August Grand Rounds – Fast Forward to the Future: Medical Staff Bylaws Update

August 8, 2023 - 1:00 pm to 2:00 pm (ET)

During this installment of Grand Rounds, we will discuss “hot topics” (including 2022-23 update!) and summarize the best practice recommendations for Medical Staff Bylaws and other Medical Staff policies that were covered throughout the course.  Take home a checklist of “best practices” for Bylaws that use to evaluate your current documents – or make improvements – right away.

Topics:

• The Joint Commission is now allowing three-year credentialing cycles! We will discuss the pros and cons of credentialing every three years vs. two years.
• In many jurisdictions, the peer review privilege is under attack. Bylaw and policy language making it clear that individuals are performing activities at the request of committees, specifying the duties of committees and their members, etc., can make all the difference when arguing that your records of peer review activities should be protected.
• Transparency is key to information sharing! Most practitioners now agree that it is reasonable and appropriate for health care providers within a system (and sometimes outside a system) to liberally share information concerning practitioners they have in common.  But, not all have established methods or policy language to support liberal sharing.  We will discuss the importance of applicant databases, push notifications, pull notifications, and policy language supporting all of these important tools.  We will also discuss notification and involvement of practitioner employers in the peer review process.
• Eligibility criteria update
• Modernize your meetings! In the wake of COVID-19, and with many Medical Staffs combining functions or unifying, the nature of meetings has fundamentally changed.  You can revise your Bylaws to provide leaders with the tools that are necessary to make meetings easier to attend and, in turn, increase participation and engagement.

Upon completion of this audio conference, participants should be able to:

1. Update the threshold eligibility criteria set forth in the Medical Staff Bylaws or related Medical Staff policies (e.g., Credentials Policy) to incorporate more stringent criteria and/or to clarify ambiguities in existing criteria to allow for easier, fairer enforcement
2. Update Bylaws language to better maximize privilege protections for credentialing and peer review information and avoid waiver of that privilege wherever possible
3. Make changes to attendance and meeting requirements to reflect more modern methods by which Medical Staff leaders conduct their activities

Faculty: Rachel Remaley

Disclaimer Statement

The information presented at this CME program represents the views and opinions of the individual presenters, and does not constitute the opinion or endorsement of, or promotion by, the UPMC Center for Continuing Education in the Health Sciences, UPMC / University of Pittsburgh Medical Center or Affiliates and University of Pittsburgh School of Medicine.  Reasonable efforts have been taken intending for educational subject matter to be presented in a balanced, unbiased fashion and in compliance with regulatory requirements. However, each program attendee must always use his/her own personal and professional judgment when considering further application of this information, particularly as it may relate to patient diagnostic or treatment decisions including, without limitation, FDA-approved uses and any off-label uses.