QUESTION:
We are part of a ten-hospital system.  Each hospital medical staff has its own bylaws, policies, and rules and regulations.  While we have tried to make them consistent over time, there are still a lot of differences in our documents, including in nomenclature, appointment criteria, and the process for suspensions, investigations, and hearings.  Any suggestions??

OUR ANSWER FROM HORTYSPRINGER ATTORNEY SUSAN LAPENTA:
If it helps, you should know, you are not alone.  Most health systems grew through acquisition, one hospital at a time.  Each new hospital had its own medical staff which had their own governing documents which, of course, the medical staff was reticent to change.

At the same time, working with, maintaining, and updating multiple sets of medical staff governing documents is a herculean task.  It also creates the undesired but inevitable opportunity for the documents to become more divergent and even conflicting with time.

That is why many health systems are moving in the direction of rewriting their medical staff governing documents with a focus on the core objectives of consistency and uniformity.  The rewriting often starts with the development of template documents.  While the medical staff bylaws must live at the local level to comply with accreditation standards, starting from the same template document will result in the bylaws being almost identical throughout the system.

When it comes to other medical staff documents, you have more flexibility.  We advocate for the development and adoption of medical staff policies that live at the system level but that are implemented locally by each medical staff.  These policies typically include a system credentials policy, peer review policy, professionalism policy, and practitioner health policy.  The end result is that instead of there being different policies at each hospital medical staff, there is a single system.

An undertaking like this requires commitment, engagement, strong physician leadership, and an ability to “think outside the box.” But the rewards are long lasting.  If you are looking for a mantra to jump start your medical staff bylaws revision project, we offer the sage guidance from a system CMO:  “Our goal, across the system, is to make our medical staff documents as standardized as possible and as unique as necessary.”

If you have a quick question about this, e-mail Susan Lapenta at slapenta@hortyspringer.com.