Medical Staff bylaws update aligns our hospitals with CMS and Joint Commission requirement

Nov 9, 2019

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

Standardizing these key provisions will make it much easier for physicians and APPs practicing at multiple hospitals to get through the credentialing and privileging processes at each hospital where they practice. We expect to gain efficiencies. The Medical Staff Bylaws for each hospital have been redlined and are under review by the MECs. Each medical staff will have the opportunity to review the changes before voting on them by the end of the year.

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.