Dealing with the changing dynamic of the medical staff

In recent times, the organized medical staff has evolved from an almost exclusive model of community-based independent physician practitioners to include a number of other physicians who have hospital connections through employment or contract arrangements.

Historically, patient care at the hospital was administered mostly by - or under the direction of - community-based attending physicians, who did regular rounds and took call while also volunteering their time for medical staff activities.

Hospital-based medical practice was largely limited to those specialties defined by the need or advantage of having a fixed presence at the hospital, such as emergency medicine, anesthesiology, radiology and pathology.

Now, however, due to technological advances, the need for professional or institutional survival, economic impetus and personal lifestyle choices, more and more physicians are joining the medical staff as hospital employees or independent contractors. This phenomenon has manifested in the growing on-site presence of hospitalists, both in primary care specialties and in subspecialties, including neurohospitalist, OBGYN-hospitalist or pediatric hospitalist practices.

Additionally, with the ever-increasing emphasis on patient safety and quality care, hospitals are hiring full-time chief medical officers or salaried department chiefs to replace the historical model of the community-based senior medical staff member who volunteered part-time service as a director of medical affairs or of a department.

Consequences for medical staffs

This changing dynamic of the practice arrangements of physicians on hospital medical staffs has resulted in a number of issues and challenges for the medical staff as a “co-equal” partner with those responsible for carrying out the hospital’s institutional mission.

Here is a look at some of the major implications of these changes:

• Even outside of academic teaching institutions, physicians who have hospital connections through employment or contract arrangements chair many clinical departments or services.
• The medical executive committee may have a majority of these employed or contract physicians among its members.
• There is a decreased presence of community-based attending physicians on-site at the hospital, as these physicians must spend more time in their own offices to see patients and earn a living.
• We have seen a reduced influence of community-based physicians on the development of medical staff bylaws, rules and regulations, and policies, as they are able to devote only limited time to medical staff governance activities.
• There is a potential for cultural dichotomy and divided loyalties among medical staff members, and possible negative consequences for medical staff collegiality, cohesive decision-making and fair process in credentialing, peer review, corrective and disciplinary action, and hearings and appeals.
• There are greater challenges in re-credentialing medical staff members whose professional activities require less frequent on-site presence at the hospital, resulting in a diminished opportunity for credentialing committees to evaluate these members’ professional performance.
• Challenges in allocating call coverage responsibilities are increasing.
• We have seen a lessened connection or continuity for community-based physicians in the medical management of admitted patients.
• There is tighter hospital control over medical staff membership and privileges through employment contract termination provisions.

What to do?

These consequences of the changing mix of physician practice arrangements are playing out against the backdrop of federal Medicare and Medicaid and Joint Commission credentialing requirements, and medical staff bylaws that could bear updating to reflect the changing scene.

There are a variety of things that physicians and hospitals can do to meet the challenges of the evolving medical staff.

• Review and revise medical staff bylaws to provide strong support for an autonomous, self-governing medical staff.

The medical staff can be accountable for quality care and patient safety only if its self-governance is supported by governing documents, including medical staff bylaws that, consistent with legal and accreditation requirements, recognize its self-governing role within the hospital.

In particular, the medical staff bylaws should contractually bind hospital leaders to respect the medical staff’s autonomous structure and its collaborative responsibilities in areas such as credentialing, privileging, peer review and oversight over clinical quality.

No bylaws should be rewritten without regard for applicable federal and state statutes and regulations, including the Massachusetts Board of Registration in Medicine Patient Care Assessment Regulations, Joint Commission standards (including newly-finalized standard MS.01.01.01, to be effective in March 2011), and policies and guidance from organized medicine.

• Encourage an inclusive and shared culture among medical staff members from disparate practice settings.

A fractious “us-versus-them” mentality not only disserves the overall institutional patient care mission of the hospital, but also it divides the focus of the medical staff’s objectives in protecting the interests of its members.

If hospital-employed physicians understand that they have a stake in the medical staff enterprise, they are more likely to appreciate and support the legitimate concerns of their medical staff colleagues. A cohesive medical staff is best for physicians and hospital alike.

• Elect strong, competent and reasonable medical staff officers.

Regardless of their individual practice arrangements, medical staff members serve their own best interests by choosing officers who understand the importance of medical staff self-governance and autonomy, can stand up for legitimate medical staff concerns, and are able to advance the medical staff’s interests with hospital trustees and administrators through reasoned and cooperative discussion.

• Address conflicts of interest fairly, impartially and objectively.

Even though the hospital may have imposed a conflict of interest policy, it is also essential for the medical staff itself to have policies or mechanisms in place for identifying conflicting professional, economic or personal interests, and for abstention/recusal of conflicted members from participation on panels that decide core matters of medical staff membership and privileges, such as credentialing, peer review and corrective action committees, professional practice evaluation and investigation of sentinel events.

Further, the medical staff bylaws should be structured to insure adequate community-based physician representation on such panels and on other governance bodies, including participation in conflict/dispute management processes.

• Encourage free, open and reasoned communication among medical staff members and with hospital leaders.

A repressive institutional culture will exacerbate division between community-based independent physicians and hospital physicians, hindering the advancement of quality patient care.

Both medical staff and hospital leaders should work to enhance open and respectful dialogue among the medical staff around quality of care and administrative policy. All parties are well served by honest and reasoned communication.

The 21st century medical staff will continue to evolve in character and composition, as physician practice arrangements undergo constant change in the health care marketplace. The medical staff’s survival as a central and crucial player in the hospital’s institutional mission will depend on its members’ ability to meet the challenge with an enlightened and forthright perspective.

Dean P. Nicastro is an attorney at Pierce & Mandell, P.C., in Boston.  He advises and represents physicians, and physician and other health care organizations, on medical staff matters, peer review, licensure, provider credentialing and reimbursement, CME, regulatory compliance and business transactions.