REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF THE COUNTY OF SAN BERNARDINO
AND RECORD OF ACTION
March 10, 2020
FROM
WILLIAM L. GILBERT, Director, Arrowhead Regional Medical Center
SUBJECT
Title v
Revised Arrowhead Regional Medical Center Medical Staff Bylaws
End
RECOMMENDATION(S)
Recommendation
1. Approve revisions to the Arrowhead Regional Medical Center Medical Staff Bylaws Articles 1 through 14, which are on file in the office of the Clerk of the Board, as detailed in Attachment A, effective March 10, 2020.
2. Approve revisions to the Arrowhead Regional Medical Center Medical Staff Bylaws Articles 15 and 16, which are on file in the office of the Clerk of the Board as detailed in Attachment B, effective March 10, 2020.
(Presenter: William L. Gilbert, Director, 680-6150)
Body
COUNTY AND CHIEF EXECUTIVE OFFICER GOALS & OBJECTIVES
Provide for the Safety, Health and Social Service Needs of County Residents.
FINANCIAL IMPACT
Approval of these amendments to the Medical Staff Bylaws will not result in the use of Discretionary General Funding (Net County Cost) as there is no associated financial impact.
BACKGROUND INFORMATION
The Arrowhead Regional Medical Center (ARMC) Medical Staff Bylaws consist of three components: the Bylaws of the Medical Staff, Medical Staff Rules and Regulations, and the Medical Staff Committee Manual. The Medical Staff recommends that the County Board of Supervisors (Governing Board) approve the revised Medical Staff Bylaws, as documented in Attachment A and Attachment B, to be effective March 10, 2020. Medical Staff Bylaws are reviewed at a minimum of every three years, and all amendments are taken to the Board for approval as they are completed. The Governing Board is responsible for all aspects of the operation of ARMC, including the quality of medical and professional care rendered at the institution. Approval of the revisions to the Medical Staff Bylaws will provide for the safety, health, and social service needs of County residents by ensuring continued patient care services at ARMC according to the level of care established in these Bylaws.
The Medical Staff Bylaws outline the process by which the Medical Staff review and make recommendations for amendments to the Governing Board. These documents provide for self-governance, the professional and legal structure for Medical Staff operations, organized Medical Staff relations with the Governing Board, and relations with applicants and members of the Medical Staff. The Medical Staff delegated the responsibility to the Medical Staff Bylaws Committee (Bylaws Committee) to periodically review the Medical Staff Bylaws for adherence to laws, regulations, and policies. The Bylaws Committee recommended applicable amendments to the Bylaws of the Medical Staff.
The Medical Staff Executive Committee and the Active Members of the Medical Staff reviewed the recommendations of the Bylaws Committee on December 10, 2019, and are proposing amendments to the Medical Staff Bylaws as reflected in Attachments A and B, on file with the Clerk of the Board, for alignment with current healthcare practices, and compliance with the regulations of The Joint Commission (TJC), Centers for Medicare and Medicaid Services Conditions of Participation, Department of Health and Human Services, and California Code of Regulations Title 22.
Amendments to the Medical Staff Bylaws include, but are not limited to, the following:
• Attachment A
• “Article V: Appointment and Reappointment to the Medical Staff, Section 5.8 Verification of Information, Subsection 5.8.2 Incomplete Application” - Removal of language pertaining to automatic rejection of appointments if Medical Staff identifies a substantive falsification or omission on the application of physician requesting staff appointment. If ARMC Medical Staff discovers a substantive falsification or an omission, ARMC Medical Staff will provide the applicant an opportunity to provide additional information. If the requested information is not provided by the applicant, ARMC Medical Staff will instead deem the application incomplete and the applicant will not be able to join the Medical Staff.
• “Article VII: Evaluation and Corrective Action, Section 7.9 Automatic Suspension and Limitation, Subsection 7.9.7 Felony Conviction or Plea and Subsection 7.9.8 Exclusion from Governmental Program” - Addition of these subsections that state that a Practitioner who has been convicted of, or who has pleaded guilty or no contest to, a felony within the past seven (7) years shall not be entitled to apply for initial appointment to the medical staff. If an existing member is convicted of, pleads guilty or no contest to a felony the member’s medical staff membership and privileges shall be automatically suspended pending review. If felony is confirmed, the member’s staff membership and privileges shall be terminated without right to a hearing. Also, a Practitioner who is excluded as a provider from any governmental health care program may not apply for initial appointment to medical staff, and an existing member who is excluded from such a government program shall be automatically terminated.
• “Article VIII: Hearing and Appellate Review Procedure, Section 8.8 Administrative Action Hearings” - This section is removed entirely.
• “Article VIII: Hearing and Appellate Review Procedure, Section 8.12 Disputing Report Language” - This section is removed entirely.
• Attachment B
• “Article XV: Medical Staff Rules, Manuals, and Policies, Section 15.1 Amendments to Medical Staff Rules and Regulations, Manuals and Policies” - This section has been replaced entirely to state that changes to a manual or the rules and regulations may be made by a majority vote of the Medical Executive Committee; policies may also be adopted and amended by a majority vote of the Medical Executive Committee; and amendments to manual, rules and regulations or policy may also be proposed by a petition signed by at least 1/3 of active staff members.
• “Article XVI: Amendment of the Medical Staff Bylaws, Section 16.1 Procedure to Amend Bylaws, Subsection 16.1.2 Action by the Active Staff” - The subsection is changed entirely to state that proposed bylaw amendments along with electronic ballots will be emailed to active staff members. At least 25% of eligible active staff members must submit a ballot to achieve a quorum, and proposed amendments must be approved by 50% of the quorum to be adopted.
The approval process is in accordance with the Medical Staff Bylaws, Centers for Medicare and Medicaid Services Conditions of Participation, Department of Health and Human Services, California Code of Regulations Title 22, and TJC standards.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by the Medical Executive Committee (Rodney Borger, MD, Chairman, 580-6370) on December 10, 2019; County Counsel (Scott Runyan, County Counsel, 387-9022 on February 14, 2020; Finance (Amanda Trussell, Principal Administrative Analyst, 387-4773) on February 20, 2020; and County Finance and Administration (Matthew Erickson, Chief Financial Officer, 387-5423) on February 24, 2020.