Your hospital's medical staff bylaws may be creating undue medical staff burden — here's why

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.

This content is sponsored by The Greeley Company

The organized medical staff has been central to the professional life of surgeons and physicians for decades. The Joint Commission defined the organized medical staff as a hospital 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, credentialing, privileging and other issues related 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 effectively reflect cultural, regulatory and procedural change. By updating medical staff bylaws to transform physician culture and staff organization, hospitals and physicians can help achieve continual improvement. However, this requires a certain degree of buy-in from clinical staff — something many hospitals 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 delivery structures. It discusses the challenges and opportunities in redesigning staff policies and processes, and finally, it explores best practices for hospitals and medical staff leaders considering bylaws review and redesign. 

Lengthy bylaws are the last thing on a physician's mind
Physicians today face significantly greater administrative demand compared to physicians who practiced 40 years ago. The increased reporting requirements of recent federal regulations designed to drive clinical quality improvement paired with use of EHRs leave physicians facing more burdens in their workload.

The average physician now spends 50 percent 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 administrative workloads may see medical staff committee 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 become 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 maintaining 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 jargon that have little to do with the provision of quality care.

Moreover, bylaws with outdated policies and protocols typically have lengthy and time-intensive amendment processes that require quorum to pass changes. Some organizations have not updated their bylaws in decades and still operate under policies written primarily in the 1960s and 1970s.

Medical staffs typically update bylaws only when new accreditation requirements or internal issues arise that demand bylaws revision. Then, staff change a certain provision or section of the bylaws in isolation without considering the document in full, Dr. Hoppa says. Patchwork maintenance like this can lead to contradictions or redundancies buried within the bylaws, causing confusion for medical staff who consult the document for guidance.

Gaining physician buy-in during a bylaws review is integral for ensuring updates are incorporated seamlessly and effectively. Moreover, 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 complex care environment may hinder a medical staff's ability to function effectively while maintaining compliance. Major factors driving 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 particularly robust merger and acquisition market.

I. Medical staff composition
Bylaws created in the 1960s often fail to reflect 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 hospitals 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, including advanced practice nurses, physician assistants, pharmacists and psychologists.  

"Outdated bylaws don't account for vital clinicians in today's care delivery system," Dr. Hoppa says.

II. Increased physician employment
The trend of younger physicians seeking employment 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 hospitals rose 50 percent between 2012 and 2015, accounting for 38 percent of all practicing physicians 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 physician and non-physician members, not just independent interests, Dr. Hoppa says.

Economic uncertainty under healthcare reform has driven many physicians to seek employment. But physician lifestyle preferences also figure in the trend toward employment among young and mid-career physicians. About 42 percent of physicians who reported seeking hospital employment said they primarily sought to escape the administrative burdens associated with independent practice, according to The New England Journal of Medicine.

"[Younger physicians] want to do what they went into medicine to do — take care of patients — and then they want to go home because they have lifestyle expectations outside their job," Dr. Hoppa says.

Young physicians who increasingly value work-life balance are less likely to attend medical staff meetings and functions scheduled before or after working hours. The absence of physicians during these meetings makes solving clinical problems and reaching quorum particularly difficult.

III. Emphasis on outpatient care settings
Increasingly today, there is a separation between clinicians supplying solely inpatient care (hospitalists) and their ambulatory counterparts.  Many of these ambulatory providers become isolated from the hospital and their inpatient colleagues.

Value-based care requires a high degree of clinical and administrative coordination between caregivers. To achieve this, Dr. Hoppa recommends medical staff consider how existing bylaws affect their ability to engage with and account for non-hospital providers. For instance, changing staff voting rules, amendment processes or committees could help staff improve relationships between physicians and non-physicians, as well as colleagues in alternative care settings.

New opportunities in updating medical staff bylaws
Medical staff bylaws must conform to federal and state legal regulations and requirements of certain accreditation groups. But medical staff organizations can also customize many bylaw items to reflect their specific organization's unique work culture, practices, demographics and values.

"Some people think there's a 'one-size-fits-all' model for bylaws," Dr. Hoppa says. "In reality, no two sets of medical staff bylaws are the same."

Hospital and physician leaders may realize three major benefits from reviewing and updating their medical staff bylaws.

I. Relieve medical staff of excessive demands
Medical staffs are challenged to create an effective and efficient medical staff structure that relieves physicians of excessive administrative or time-intensive tasks, Dr. Hoppa says.

Reviewing and updating bylaws gives medical staffs the opportunity to improve physician engagement by addressing outmoded leadership and management structures. Consider the fact that young physicians who value their free-time aren't motivated to attend meetings before or after work. Communication can, and should, occur in multiple venues and in manners other than meetings.  Meetings should be reserved for substantive discussion and decision-making.  This can lead to increased engagement because the clinician feels that his or her time is being valued.  

II. Improve ability to effect meaningful change
Restructuring the medical staff organization can also help improve the organization's responsiveness. Bylaws written in the 1960s typically favored informal, voluntary leadership roles and consensus through super-majority voting. This made organizations slow to implement change.

Eliminating unnecessary committees, clearly defining physician leadership roles, vetting physician leaders and streamlining amendment processes can make medical staff organizations more responsive and capable of partnering with management to drive rapid change. 

III. Incorporate best practices
Reviewing bylaws gives medical staff the opportunity to incorporate best practices promoting high quality care in clinical workflow, Dr. Hoppa says.  

For instance, it is not required by  the CMS Conditions of Participation to perform a criminal background check on a physician applying for privileges. But to improve the appropriate evaluation of clinicians applying for privileges, many medical staff organizations have customized their bylaws to make criminal background checks a requirement during privileging.

In another example, some medical teams are replacing traditional departmentalized management structures with a broader service line approach. This broad approach helps mitigate the negative effects of working with isolated clinical departments, which may resist change when implementing continuous improvement programs.

Best practices when updating medical staff bylaws

Dr. Hoppa recommends three best practices for hospitals and medical staff leaders considering updating their medical staff bylaws.

  1. Gain physician and administrator buy-in from the start. Getting physicians engaged in bylaws review is critical. Hospital and physician leaders can address physician apathy by showing physicians how bylaws redesign benefits their daily lives.

    "First, you have to overcome physicians' fear that the redesign process will be lengthy, boring and not worth the time spent — which is incorrect," Dr. Hoppa says. "Medical staff and hospital leaders can encourage physician buy-in by educating practitioners about how healthcare is changing, and explaining why it's in their best interest to update bylaws to respond to today's challenges."

    It is also worthwhile to include legal counsel and hospital administrators in the review process. Involving local legal counsel and administrators early ensures nuanced legal requirements and hospital needs are satisfied during bylaws revision.  

    "The review process should include a wide variety of leaders and influential medical staff who can vet the issues before proposing a final version for approval by the medical staff," Dr. Hoppa says. This fosters transparency, trust and collaboration among stakeholders.

  2. Consider your resources."First, an organization must decide if it has the appropriate knowledge and time to overhaul its medical staff bylaws by itself," Dr. Hoppa says. "We've found most hospitals administrative structures are fairly lean, meaning they don't have the people required to take on a significant administrative project like overhauling their bylaws."

    Hospitals lacking resources and medical staff expertise can benefit from involving outside consultants and subject matter experts to provide additional support.

  3. Utilize industry experts. Many consulting firms offer bylaws review and design support. Since bylaws debate among physicians can get heated at times — like when discussing board recertification requirements — Dr. Hoppa recommends organizations consider consultants who are physicians.

    "The Greeley Company believes 'by docs, for docs' is the best approach to bylaws redesign," Dr. Hoppa says. "Consultants who understand the politics of physicians can help supplement the advice of legal counsel, and ensure physicians, administrators and lawyers are all happy with the final result."

Conclusion
Many of today's physicians understand that, like executive and community leaders, they must set aside self-interest if they wish to govern effectively. Providers' mission to deliver high-quality care, ensure patient safety and offer excellent service at a significantly lower cost than in the past requires a medical staff that is far more agile, responsive and adaptive. Updating medical staff bylaws to transform physician culture and staff organization can help both hospitals and physicians create a framework that fosters teamwork and supports continual improvement. 

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