Part 2: Making Bylaws Fit Unique Systems - CMS Compliance for Multi-Hospital Systems

Rick Curtis, CEO of The Center for Improvement in Health Quality (CIHQ), spoke with us recently about the change in the Medicare Conditions of Participation (CoP)’s requirements for a certified, integrated medical staff. This included great advice for becoming CMS compliant, along with the process for integrating bylaws and the role of leadership.

In Part 1, we discussed the four main medical staff requirements for CMS compliance . The key takeaway was the importance of having mechanisms in place which help address the unique in-system issues of integrated, multi-hospital systems. Modern hospital systems are complicated, so it is important to make sure hospitals are able to best serve the needs of their unique communities with their specialized services.

To help multi-hospital systems meet compliance for integration, a simple majority vote is required. Once the votes are in and the staff agrees that they want to proceed with integration, bylaws must be adjusted to encompass the network.

Adjusting Bylaws into a Unified System

Having common bylaws is key to the proper governance of an integrated medical staff. The bylaws must address:

  • Governance
  • Appointment
  • Credentialing
  • Privileging
  • Oversight
  • Peer review
  • A process that guarantees certain rights

After integrating, step one is for the medical staff to create a common document of bylaws that tells medical staff members when their membership is first granted and if they renew, their right to vote to opt-in or out. This must be communicated after each new hire or membership.

The difficulty the majority of multi-hospital systems run into is when it comes to addressing the uniqueness of the previous bylaws. There are many variations that can exist within the health system, and all must be taken into account in the new document.

Integrating Bylaws in Unique Hospital Variations

Although bylaws must be all-encompassing, it’s important to remember the uniqueness in the variations, which must be present in the bylaws. When these details are overlooked, providers within the system may be granted a privilege that they were never able to perform. This lack of uniqueness is what historically causes problems during medical emergencies.

The best solution during the tricky adjustment of bylaws is to have a mechanism in place that handles policy disputes. This is especially important for multi-hospital systems where a physical governing body can’t simultaneously be present at every hospital.

One Medical Staff, One Leader

A unified medical staff requires a unified medical staff leader. To function as a single staff, there needs to be one official authority that has absolute authority in making all of the decisions. However, this doesn’t exclude a system from having committees at each hospital who oversee the execution or quality of certain tasks.

A quick note here: Keep in mind that a multi-hospital system may decide to have multiple, separate medical staffs. There still needs to be one leader per medical staff, so if there are 5 separate medical staffs, each one needs its own leader – making 5 total leaders. 

It’s also important to note, that the leading authority doesn’t have to physically practice at every hospital, but they must be an active consultant within their system. If external authorities or agencies appear at one hospital and the leading authority is at another, the leader must make themselves available – either in person or via other face-to-face communication (i.e. Skype or a webinar). This active, direct consultation must occur at least twice a year as proof that they are aware of everything going on within their system.

Feeling a bit stressed by all that responsibility? Don’t worry, it is possible to rotate the leadership position, as long as the terms are defined in the bylaws. For larger multi-hospitals, it may be ideal to rotate leadership positions between the heads of massive hospitals.

Sum It Up:

In Rick’s webinar series, we learned about the four main medical staff requirements for CMS compliance and the challenges of uniting a multi-hospital system with unique members. We’ve also discussed adjusting bylaws to best-fit the credentialing necessities of these unique system members.

For more information about CMS for Multi-Hospital Systems and Integrated Medical Staff Offices, check out our symplr education series webcast with Rick Curtis. To learn more about simple and effective solutions for the credentialing process, schedule a Demo with symplr today!

MS for Multi-Hospital Systems & Integrated Medical Staff Offices


Melissa Outlaw

About the Author
Melissa Outlaw

Melissa Outlaw is a Vice President, Customer Success with symplr. Melissa and her team assist clients in learning and implementing our provider management software - credentialing, privileging, peer review, quality and event reporting applications. She supports clients in benchmarking current internal practices, identifying potential efficiencies, then driving the integration of technology with process improvement to reduce time of service and operating expenses. She works extensively with decentralized, multi-facility organizations in transitioning to a shared service center as well as assisting healthcare organizations bridge the gap between procedures performed by a provider and their privileges granted.

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