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A systemwide Work Group of physicians and medical staff leaders from various hospitals met for several weeks this spring and summer on a project to ensure all Intermountain Hospital Medical Staff Bylaws align with current State, Federal (CMS) and Joint Commission regulations and standards, and align across hospitals on key provisions, where possible. Better coordination and standardization will make it easier for physicians and APPs to be able to obtain medical staff status at any or multiple Intermountain hospitals. This improved physician and APP access is particularly important for those providing TeleHealth clinical services or coverage at multiple locations.
During the initial review process, we discovered several areas within our Medical Staff Bylaws that would benefit from standardization. The Work Group recommended, to a Steering Committee, aligned language and other changes for the following key areas/provisions:
Medical Staff Categories
- Standardized categories to Active, Active Referral, Courtesy, Consulting, Telemedicine Status, Emeritus Status, Advance Practice Providers (if they’ve been added to the medical staff), Allied Health Professionals
- Standardized rights and responsibilities
Application, Appointment and Reappointment Procedures
- Shortened the detail included in the general bylaws and suggested that details be moved to a policy. If policy does not exist, we provided a template that will be updated once changes have been accepted.
Qualifications for Appointment
- Standardized language around eligibility
- Standardized composition of the medical staff
- Standardized board eligibility language to make it more general
- Recommended that board eligibility details be moved to policy and departmental rules and regulations
Officers of the Medical Staff
- Recommended to eliminate secretary treasurer where present
- Standardized the selection process for the president
- Standardized the language around roles and responsibilities, to ensure delineation between President of the Medical Staff and Medical Director
Department Chairs
- Ensured roles and responsibilities language corresponded with Joint Commission language
Policy on Discipline, Corrective Actions and Related Matters (including the Fair Hearing Plan
- For bylaws that contained the entire policy, the details were moved to a policy and standardized language represented the bylaw
- Language added to bylaws that did not contain the various possible disciplinary actions
If you have questions, please reach out to your hospital medical director or medical staff coordinator, or contact Susan DuBois, AVP Office of Physician and APP Professional Affairs or Paul Krakovitz, MD, VP, Chief Medical Officer, Specialty-Based Care.