May 9, 2019

QUESTION:        Our medical staff is considering unifying with other medical staffs within our system to become one unified and integrated medical staff.  What does this entail, what are the legal requirements and what are the advantages and disadvantages for our hospital?


ANSWER:            A multi-hospital system may have a unified, systemwide medical staff rather than a medical staff at each hospital.  In 2014, the Centers for Medicare & Medicaid Services (“CMS”) revised Section 482.22(b) of the conditions of participation for hospitals, specifically allowing the unification of medical staffs.  The regulations were revised to permit the medical staff of a hospital, which is part of a hospital system consisting of multiple, separately certified hospitals, to participate in a unified, integrated medical staff.  Under the regulations, a medical staff may become part of a unified multi-hospital medical staff only if the medical staff affirmatively votes to do so.  The medical staff at each hospital must obtain a majority vote to use a unified, integrated medical staff.  Medical staffs incorporated into a unified medical staff may “opt out” by vote at any time and re-establish a separate, hospital-specific staff.

There are, of course, pros and cons to unifying the medical staff.  Unification could produce negative results, while it may also benefit the hospitals in the long term.  Unifying the medical staff may make the system stronger, providing uniform care processes that improve overall patient care and greater resources for each individual hospital.  However, unifying the staffs may disconnect the medical staff from the governing board, which can cause major tension within the system.  There are several considerations to take into account when making this decision.

If a majority vote is obtained by each separately certified hospital’s medical staff to unify as a medical staff, it is vital to understand the CMS conditions associated with such.  Doing so will require updates to the unified medical staff’s bylaws, such as inclusion of a process by which the voting medical staff members of each separately certified hospital are advised of their right to opt out and return to a separate distinct medical staff.  CMS regulations provide that the unified medical staff’s bylaws describe processes for self-governance, appointment, credentialing, privileging and oversight, as well as its peer review policies and due process rights guarantees.  The regulations also require that the unified medical staff establish and implement policies and procedures to ensure that the needs and concerns expressed by members of the medical staff, at each hospital, are given due consideration.  This may require major overhauls to bylaws documents or minor tweaks.  We would be happy to provide you with more information as to what may be necessary.