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Have you looked at your professional staff rules, regulations lately?

By Kate Dewhirst

Back in the 1980s and 90s, many hospitals published medical staff “rules and regulations.” And in some cases, that package then went dormant as hospital-wide policies and procedures were introduced.

Have a look on your intranet. Do you have rules and regulations that are still on the books but have not been updated in awhile?

Professional staff rules and regulations vary significantly from hospital to hospital. Not every hospital has written professional staff rules and regulations. They are not mandatory. Instead, some rely on hospital policies and some include more detailed content in their professional staff by-laws.

If you look at the OHA/OMA Hospital Prototype Board-Appointed Professional Staff By-laws, you will see a reference to “rules and regulations”:

The Board, after consulting with the Professional Staff Association and considering the recommendation of the Medical Advisory Committee, may make Rules and Regulations as it deems necessary, including rules and regulations for patient care and safety and the conduct of members of the Medical Staff, Dental Staff, Midwifery Staff and Extended Class Nursing Staff.

If your by-laws include those words, you need to have a set of rules and regulations.

So what can you include in your rules and regulations?

Think about the following topics … are these covered somewhere in writing for your professional staff?:

  • Board privileges hearings procedures
  • Chief of Staff/Chair of the MAC selection process
  • Code of conduct
  • College reporting obligations
  • Continuing professional education expectations
  • Delegation of controlled acts
  • Disclosure of patient safety incidents
  • Dispute resolution
  • Health records content and completion
  • Job descriptions for clinical leaders (Chiefs of Department, Chief Nursing Executive)
  • Joint credentialing with other hospitals or facilities
  • Leave of absence (maternity/paternity, sabbatical/academic, medical)
  • Locum tenens appointments
  • Maintaining professional staff files – what gets stored and who can access
  • Mandatory hospital-specific training requirements
  • Medical directives
  • Most Responsible Physician or Clinician/Transfer of Care
  • Occupational health and safety policies regarding immunizations, screenings and tests
  • Office space assignments and usage
  • On-call guidelines
  • Participation on committees
  • Performance reviews
  • Professional staff human resource planning
  • Quality indicators
  • Request for change of practice including reduced practice
  • Retirement and resignation obligations
  • Social media
  • Student supervision
  • Succession planning
  • Suspension/restrictions/revocation of privileges policy
  • Utilization expectations
  • Vacations/sick days
  • Whistleblower protection

None of these topics are mandatory. But in my experience, it is helpful to have objective written rules to explain your expectations. Some of these topics may be included in your hospital-wide policies or by-laws already. No need to duplicate.

Like other standards, your professional staff rules and regulations need to be updated every three to four years and more often if there is a change in law or regulatory College standards. So, if you have not looked at them in awhile – you should take them out and make sure they reflect or are consistent with:

  • Your by-laws
  • Your mission, vision and values
  • Actual honest to goodness practice in your hospital – there is nothing worse than setting rules that are “aspirational” but no one actually meets
  • Changes in the law since you updated them last

Now, here is the challenge. Hospitals need to make these rules and regulations accessible to their doctors, dentists, midwives and nurse practitioners. Make sure you engage your professional staff members in the discussion about the rules that apply to them. You can do this informally in town halls and through departmental meetings and formally by consulting your professional staff association.

Read More at Kate Dewhirst Health Law Blog

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