Strong bylaws and an independent self-governing medical staff protect patient care

Medical staff self-governance is a vital part of a carefully crafted system designed to ensure the delivery of quality patient care. This system recognizes that the hospital’s medical staff is the only body with the medical expertise and daily experience unique to that hospital necessary to conduct the quality assurance activities that are integral to patient safety. 

The California Medical Association (CMA) has intervened in medical staff situations—most recently, the events at Tulare Regional Medical Center, where the autonomy of the medical staff was threatened, harming patient care and leading to the closure of the hospital.

Medical staff bylaws are the cornerstone for effective medical staff self-governance and provide the necessary legal and professional structure for medical staff operations, organized medical staff relations with board of directors/trustees, and relations with applicants to and members of the organized medical staff. The bylaws define the mechanism by which the medical staff will fulfill its responsibilities to ensure that proper standards of medical care and ethical practices are established and maintained. With properly drawn bylaws, the medical staff becomes a smoothly operating unit, much better able to serve the needs of the community.

It is important for medical staffs to periodically review, and if necessary update their bylaws, rules and regulations, and other governing documents.  Periodic analysis of the medical staff bylaws is critically important to ensure compliance with current standards, as well as legal and practice developments.

In addition to maintaining strong bylaws, CMA has identified 10 steps medical staffs can take to achieve and/or maintain self-governance and provide a common set of expectations between the medical staff and hospital. This will in turn: 1) increase compliance with Joint Commission and legal standards; and 2) reduce conflict and confusion, allowing medical staffs and hospitals to focus on what they do best—deliver safe, quality care to patients.

10 Steps to a Strong, Self-Governing Medical Staff

1. Secure an independent attorney: If possible, independent legal counsel should be secured to represent the medical staff.
2. Control medical staff funds: Dues should be adequately structured and all medical staff funds should be controlled by the medical staff.
3. Govern yourselves: Be governed by your bylaws and not by documents the medical staff did not approve.
4. Have an ombudsman: The bylaws committee, if properly constituted, should serve as a self-governance ombudsman.
5. Select medical staff leaders: The medical staff should be governed and represented by individuals that the medical staff selects and pays.
6. Avoid actual conflicts of interest: Decision-making must be in the best interests of the medical staff and patient care.
7. Be transparent: Provide medical staff members with the information they need to participate meaningfully in medical staff affairs.
8. Take ownership of quality: Medical staffs must exercise their right to protect quality or they will lose it.
9. Be involved with the hospital: The hospital’s business is the medical staff’s business.
10. Manage disputes fairly: Have a fair dispute resolution mechanism.

For a legal opinion concerning a specific situation, consult your personal or medical staff attorney.  For information on other legal issues, use CMA’s online health law library or refer to the California Physician’s Legal Handbook (CPLH). CPLH is a comprehensive health law and medical practice resource containing legal information including current laws, regulations and court decisions that affect the practice of medicine in California. Written and updated by CMA’s Center for Legal Affairs, CPLH is available in an eight-volume, softbound print format, or as an online subscription to cplh.org.  Access to cplh.org is complimentary for medical staffs who are members of the CMA Organized Medical Staff Section (OMSS).