A final rule issued by the Centers for Medicare & Medicaid Services (CMS) in May revised the conditions of participation for hospitals and made two major changes to the hospital governance structure. Find out what hospital medical staffs need to know so you’re ready when this rule is implemented at your hospital.
The rule addresses allowing multi-hospital systems to have a unified, system-wide medical staff rather than a medical staff at each hospital. Under the May regulations, a medical staff may become part of a unified multi-hospital medical staff only if the medical staff affirmatively votes to do so. Meanwhile, medical staffs incorporated into a unified structure may “opt out” by vote at any time and re-establish a separate, hospital-specific staff.
The final rule also includes a new requirement for the hospital governing body to consult with an “individual assigned responsibility for the medical staff” at least two times per year.
The AMA Organized Medical Staff Section (OMSS) hosted a special session about the final rule during the 2014 AMA Interim Meeting.
Some of the key issues to consider include:
- Update your medical staff bylaws. CMS regulations require that the hospital board meet with the “individual assigned responsibility for the medical staff.” Your medical staff’s bylaws should specify who this person is—ideally, the president of the medical staff or the person who has been elected by staff members to lead the medical staff. The rule also requires the hospital board and medical staff to consult twice a year, at a minimum. Staff bylaws should address this communication as well.
- Be familiar with the rule’s requirements. Know the potential benefits and disadvantages if you unify with other medical staffs within the system or remain an individual medical staff. A unified system-wide medical staff could mean a stronger organization, with clinical standards developed across a greater number of peers and patients. On the other hand, unification could reduce each medical staff’s connection with or representation on the governing body. It also may mean new ways of considering community standards or hospital-specific services. If the system spans multiple states, a unified medical staff may have to make a choice of laws to determine which peer review protections will apply.
- Get the resources and assistance you need. The AMA-OMSS offers resources (log in), including issues to consider before your medical staff votes to become part of a unified system-wide medical staff as well as sample bylaw language. Medical staffs also can contact the AMA-OMSS via email to seek assistance with questions that arise as a result of these regulations.
The AMA, along with more than 80 other medical associations, sent CMS a letter on the final rule in July, asking the agency to give the rule more thought and institute an immediate delay before implementation. The AMA continues to advocate for regulations to protect the autonomy of medical staffs.
