Medical Staff

Medical staff membership: With responsibilities also come rights

Medical Staff Leader Insider, October 14, 2010

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Every set of medical staff bylaws includes a section on medical staff responsibilities – whether it is to provide continuous care for patients, complete medical records in a timely manner, be an ethical practitioner, or take ED call. Many other medical staffs have rights’ scattered throughout their bylaws documents, but rarely do I see a section devoted to member rights. The responsibilities of medical staff membership should come with certain membership rights – and they should extend well beyond the basic right to a fair hearing or appeal, which is mandated by the Health Care Quality Improvement Act of 1986.

Many medical staffs have certain membership rights in their documents, but usually they are not recognized as such. Almost every medical staff that elects leaders has the ability to remove them from their position. However, we think that beyond that, there are other rights it is very appropriate for medical staff members to have.

For example, when a significant number of medical staff members question an action taken by the medical executive committee (MEC) regarding any rule or policy, the medical staff should have an avenue to discuss (and possibly overturn) it. Overturning an MEC decision should not be something that can be initiated by one disaffected individual; this could create such roadblocks that the medical staff ceases to function. But if a significant number of members (the numbers to be determined by each medical staff) question an action, there should be an avenue in which this can be addressed. The same would go for any action taken by a department/clinical service. A similar mechanism could be used to initiate a general medical staff meeting to discuss issues of common interest.

The following is some sample language that could be used for these rights:

Each staff member in the active category has the right to initiate a recall election of a medical staff officer by following the procedure outlined in Section [X] of these bylaws, regarding removal and resignation from office.
Each staff member in the active category may initiate a call for a general staff meeting to discuss a matter relevant to the medical staff. Upon presentation of a petition signed by 25% of the members of the active category, the MEC shall schedule a general staff meeting for the specific purposes addressed by the petitioners. No business other than that detailed in the petition may be transacted.

Each staff member in the active category may call for a department/clinical service meeting by presenting a petition signed by 25% of the members of the department/clinical service. Upon presentation of such a petition, the department/clinical service chair will schedule a department/clinical service meeting.
Each staff member in the active category may challenge any rule or policy established by the MEC. In the event that a rule, regulation or policy is thought to be inappropriate, any medical staff member may submit a petition signed by 25% of the members of the active category. Upon presentation of such a petition, the adoption procedure outlined in Section [X] will be followed.

Proposed amendments to these bylaws may be originated by a petition signed by 25% of the members of the active category. Upon presentation of such a petition, the adoption procedure outlined in Section [X] will be followed.

This section on membership rights accomplishes two goals: 1) it recognizes and consolidates membership rights that balance membership responsibilities and 2) it can serve as a method of compliance with the new standard MS.01.01.01, EP 10, which requires hospitals to have a conflict resolution mechanism between the MEC and the organized medical staff.

Mary Hoppa, MD, MBA, CMSL, is a senior consultant at The Greeley Company, a division of HCPro, Inc. in Marblehead, MA.



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