Becker's Hospital Review

50 Executive Briefing Sponsored by: Your Hospital's Medical Staff Bylaws May Be Creating Undue Medical Staff Burden — Here's Why Executive summary Reviewing and updating medical staff bylaws is a strategic priority for hospitals and healthcare systems aiming to provide high-quality clinical care in the time of value-based medicine. The organized medical staff has been central to the professional life of surgeons and phy- sicians for decades. The Joint Commission defined the organized medical staff as a hos- pital standard in 1951. The typical structure of a hospital-based medical staff consists of licensed hospital physicians, surgeons, and other practitioners with a rotating body of medical staff leaders who convene monthly to discuss clinical quality, peer review, cre- dentialing, privileging and other issues relat- ed to self-governance. At many hospitals, the medical staff structure undergoes minimal change or modification. But as more essential healthcare services move outside the hospital, the traditional medical staff structure must evolve to effec- tively reflect cultural, regulatory and proce- dural change. By updating medical staff by- laws to transform physician culture and staff organization, hospitals and physicians can help achieve continual improvement. How- ever, this requires a certain degree of buy-in from clinical staff — something many hospi- tals struggle to attain. This article examines why physicians may be disengaged with or indifferent to staff bylaws as well as major industry changes affecting hospital-physician alignment and care deliv- ery structures. It discusses the challenges and opportunities in redesigning staff policies and processes, and finally, it explores best practic- es for hospitals and medical staff leaders con- sidering bylaws review and redesign. Lengthy bylaws are the last thing on a physician's mind Physicians today face significantly greater administrative demand compared to phy- sicians who practiced 40 years ago. The in- creased reporting requirements of recent federal regulations designed to drive clini- cal quality improvement paired with use of EHRs leave physicians facing more burdens in their workload. The average physician now spends 50 per- cent of his or her work day entering data into EHRs and completing clerical work, nearly twice as much as the 27 percent of work hours spent interacting with patients, according to a 2016 study in Annals of Internal Medicine. Frontline physicians facing hefty administra- tive workloads may see medical staff com- mittee meetings, including bylaws meetings, as one more drain on their limited time and resources. This can make it a challenge to gain physician buy-in during medical staff functions. Many medical staff members be- come apathetic, because they feel that they are no longer in control of their own destiny. But bylaws is the one area where they should not be apathetic; the medical staff bylaws are their "constitution" for self-governance as delegated by the governing board says Mary Hoppa, MD, a senior consultant at The Greeley Company, a strategy, credentialing and compliance services firm. The medical staff is responsible for maintain- ing staff bylaws and oversees credentialing and privileging processes. Despite hospitals' best attempts, medical staff bylaws are rarely user-friendly documents. Often, bylaws are overrun with complex terms and legal jar- gon that have little to do with the provision of quality care. Moreover, bylaws with outdated policies and protocols typically have lengthy and time-in- tensive amendment processes that require quorum to pass changes. Some organiza- tions have not updated their bylaws in de- cades and still operate under policies written primarily in the 1960s and 1970s. Medical staffs typically update bylaws only when new accreditation requirements or in- ternal issues arise that demand bylaws revi- sion. Then, staff change a certain provision or section of the bylaws in isolation without con- sidering the document in full, Dr. Hoppa says. Patchwork maintenance like this can lead to contradictions or redundancies buried with- in the bylaws, causing confusion for medical staff who consult the document for guidance. Gaining physician buy-in during a bylaws re- view is integral for ensuring updates are in- corporated seamlessly and effectively. More- over, greater physician participation in bylaws reviews helps enhance hospital-physician alignment overall — an important component of success under value-based care models. Bylaws from the 1960s don't work for medical staff today Legislative and regulatory changes in the healthcare industry have transformed how hospitals and physicians deliver patient care. Traditional medical staff bylaws that don't address clinical challenges in today's com- plex care environment may hinder a medi- cal staff's ability to function effectively while maintaining compliance. Major factors driv- ing physicians to review their self-governance structures include new trends in medical staff composition and physician employment, the shift to outpatient care settings and a partic- ularly robust merger and acquisition market. I. Medical staff composition Bylaws created in the 1960s often fail to re- flect the realities of today's medical staff composition and membership needs, Dr. Hoppa says. The type of clinicians eligible for medical staff membership and hospital privileging has changed considerably in recent years. CMS revised its definition of medical staff in its final rule issued May 2012, allowing hos- pitals the flexibility to extend membership opportunities to non-physician practitioners in accordance with state law. Subsequently, medical staffs today feature a more diverse array of practitioners than ever before, in- cluding advanced practice nurses, physician assistants, pharmacists and psychologists. "Outdated bylaws don't account for vital cli- nicians in today's care delivery system," Dr. Hoppa says. II. Increased physician employment The trend of younger physicians seeking em- ployment at hospitals rather than remaining independent has also affected the role and purpose of the medical staff in physicians' professional lives. The proportion of physicians employed by hos- pitals rose 50 percent between 2012 and 2015, accounting for 38 percent of all practicing phy- sicians in 2015, according to a 2016 Physicians Advocacy Institute report. Traditional medical staff structures are challenged to transform their processes and goals to represent all phy- sician and non-physician members, not just in- dependent interests, Dr. Hoppa says. Economic uncertainty under healthcare reform has driven many physicians to seek employ- ment. But physician lifestyle preferences also figure in the trend toward employment among young and mid-career physicians. About 42 percent of physicians who reported seek- ing hospital employment said they primarily

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