Hospital Accreditation
Integrated Medical Staffs - Part Three
Posted by
on 3/31/2020 10:00:00 AM
Welcome to the third in a four part blog series on CMS' requirements for health systems that wish to have a single integrated medical staff for multiple Medicare certified or accredited hospitals. In this blog, we're going to discuss the bylaw's requirements of an integrated medical staff.
CMS interpretive guidance for §482.22(b)(4) states that a "hospital that is part of a system consisting of multiple separately certified hospitals may use a single unified and integrated medical staff (hereafter referred to as a "unified medical staff") that is shared with one or more of the other hospitals in the system."
A hospital that is part a unified medical staff must ensure that there is one set of bylaws, rules / regulations, and policies that describe the medical staff's processes for self-governance, appointment, credentialing, privileging, oversight, peer review, and due process rights guarantees. These documents must also identify each separate hospital within the health system that has elected to use a unified medical staff.
Depending on State law requirements, these documents may be in addition to or instead of hospital-specific medical staff bylaws, rules / regulations and policies. The unified medical staff's documents must not conflict with any of the specific requirements found elsewhere in the Medicare Conditions of Participation (COP) at §482.12 or §482.22, or under any other hospital COP's which assign responsibilities to the hospital's medical staff.
The unified medical staff and health system governing body may not set up bylaws that unduly restrict the rights of medical staff members at each separate hospital to vote whether to accept or opt out of a unified medical staff structure. For example, the unified medical staff:
- May not establish different criteria as to which categories of medical members have voting rights with respect to a vote to accept or opt out of a unified medical staff than are used for any other type of voting the medical staff engages in, except as required that only members holding privileges to practice at the hospital may vote.
- May not require as a condition for holding an opt-out vote, that there be a petition signed by the same number of voting members as would be required for a successful vote to opt out.
- May require for a successful acceptance or opt-out vote a "super-majority," that is, a majority that is greater than a simple majority of more than fifty percent of the medical staff members with voting rights holding privileges to practice at the hospital, so long as the same type of supermajority is otherwise required to amend the bylaws, rules / regulations, and policies.
- May not permit delegation of an opt-out decision to the unified medical staff's executive committee (MEC). This is the case even when the MEC is otherwise delegated authority to act on behalf of the medical staff.
- May establish a minimum interval between acceptance or opt-out votes, such as not permitting a vote more than once every two years. However, a minimum interval between votes longer than two years might unduly restrain the rights of the members of the medical staff and would not be permissible.
Join us for Part Four of this series in next week's blog. We'll discuss the need for a unified medical staff to address the unique concerns of each participating hospital within the health system.
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About the Author
Traci Curtis RCP, HACP
RCP, HACP
Traci Curtis is the Executive Director of Survey Operations for CIHQ. Traci has more than 15 years of experience in hospital survey preparation.
Traci's past positions include Chief Quality Officer for a multi-hospital community based health system where she was responsible for accreditation and regulatory compliance. Prior to joining CIHQ, Traci served as the Executive Director of Quality for a large regional medical center, providing executive management oversight in the areas of quality, risk, medical staff credentialing, and patient relations.
Traci received her degree in education from Pima in Tucson Arizona. She is nationally certified in healthcare accreditation, and serves on the Board of Examiners for the Healthcare Accreditation Certification Program.
Accreditation
