Documenting roles and responsibilities.

Documenting Roles and Responsibilities

A hospital medical director (*1) needs to have a contract that spells out his or her duties and responsibilities and reporting relationships, and that contains the basic provisions ordinarily found in executive employment contracts, dealing with subjects such as compensation, vacation and sick leave, termination, retirement, insurance coverage, job-related expense reimbursement, professional advancement expenses, performance and salary review, etc. Even with a comprehensive employment contract, the issue of what needs to be done to recognize the medical director in the governance documents of the institution--the hospitals bylaws and the medical staff bylaws--remains. Hospital bylaws usually contain detailed statements of the duties of the institution's chief executive. Frequently, the chief executive is a corporate office, although this status is not essential. Other hospital executives whose positions are described in the corporate bylaws may also be corporate officers, but it is not essential.

The hospital medical director is ordinarily perceived as an executive employee. The issue of whether o grant the status of corporate officer to the medical director would only arise as a practical matter at an institution in which the chief executive has been granted corporate officer status. It would be very unlikely that a corporate office of medical director would exist in the absence of the chief executive's being a corporate officer.

Even if the medical director is not a corporate officer, it does not mean that a hospital governance document should not contain one or more provisions that describe the medical director's role and responsibilities. It is necessary to consider whether the medical staff bylaws or the corporate bylaws is a more appropriate document in which the address the responsibilities and functions of the medical director. The staff bylaws are the governance document created through the joint action of the medical staff and the hospital board and serve as the definitive document governing the medical affairs of the institution. It is my experience that the medical staff bylaws usually contain the basic provision concerning the medical director's position. The medical director's role and responsibilities are described in two different, but not mutually exclusive, ways in the bylaws. One is by including a provision such as the following:

Medical Director

Selection

The medical director, who shall meet the qualifications for active medical staff membership, shall be appointed by the board after consultation with the medical executive committee.

Duties

The medical director shall:

* Develop, coordinate, and implement all aspects of educational and research activities of the medical staff.

* Coordinate the functioning of the medical staff and assist in the implementation and enforcement of the hospital bylaws, hospital policies, and the bylaws and rules and regulations of the medical staff.

* Provide leadership in coordination of medical and administrative policies of the hospital and the medical staff.

* Act as an advsor to the medical executive committe in all professional matters of the hospital.

* Serve as an ex officio member of all medical staff committees.

* Carry out such additional duties as are specified:

- In the medical staff bylaws and rules and regulations.

- In the position description established by the board.

- By the board or the executive committee of the board by resolution or any other decision process.

Clinical Functions

The medical director, to perform clinical functions, must hold an appointment in the active or the consulting category. Such appointment and reappointment shall be made in the manner set forth in the medical staff bylaws for any other applicant to, or member of, the medical staff.

Removal

The board may remove the medical director from such office, subject to the provisions of the contract between the medical director and the hospital. A recommendation to remove the medical director may be made by the medical executive committee for consideration by the board.

As one can readily note, this provision covers more than the medical director's duties. Than statement of duties is rather unspecific, and the most important language with regard to duties (the bulleted items above) recognizes that other provisions of the medical staff bylaws and provisions in the staff rules and regulations may or will contain specific statements of authority and responsibilities. These specific statements are the second way of expressing the role of the medical director.

In considering specific responsibilities and authority of the medical director that may be included in medical staff bylaws and rules and regulations, the following should be given attention:

* Granting temporary privileges. A full credentials process cannot always be concluded before a new physician's services may be desired or needed at the hospital in connection with a pending application for appointment, a request for privileges to care for a specific patient, or granting of locum tenens status. The credentialing process in such circumstances can be assigned by the laws to the medical director. In the case of an applicant for appointment and privileges, this does not bind the hospital to act favorably; it only provides an opportunity for the applicant to practice while the full credentialing process is taking place.

In connection with temporary privileges, the authority should also be give to the medical director to terminate temporary privileges based on an assessment of the performance and conduct of the practitioner granted such privileges. Such authority can be, and usually is, also granted to the relevant department chairperson and/or the chief of staff.

* Corrective action. The medical director should be given specific authority in the bylaws to initiate corrective action by submitting a request to the appropriate staff committee, usually the medical executive committee. Such a provision should be accompanied by another provision stating that, if the medical executive committee declines to pursue any request for corrective action, the medical director, on his or her own initiative, may commence a formal investigation for the purpose of determining whether corrective action is warranted, and thereby continue the corrective action process.

* Summary suspension. The need for a hospital executive to possess authority to impose summary suspension arises when there has been serious violation of the medical staff bylaws or rules and regulations, or of hospital policies, or when it appears that a practitioner's conduct requires that immediate action be taken to protect patients, employees, or other persons in the hospital. The authority to impose a summary suspension should be granted to the medical director, as well as other officials, such as some or all of the elected officers of the medical staff and the hospital's chief executive.

* Other specific responsibilities. Many hospitals, in medical staff rules and regulations or a credentialing manual, set forth the detailed process for credentialing. This set of provisions or document may contain specific responsibilities of the medical director in connection with the process. For example, the medical director may be designated as the recipient of information that staff members possess and wish to share regarding an applicant for medical staff membership. The medical director may also be the designated recipient of information supplied by other institutions with respect to an applicant and the hospital representative to conduct an interview of each applicant for medical staff appointment or for the granting of temporary privileges.

The medical director may also be assigned the responsibility to make other determinations, such as directing that a consultation be held in view of the patient's condition, developing and maintaining the roster for emergency department backup coverage by members of the medical staff, and deciding which patients shall be admitted to, or maintained in, a special care unit when space is at a premium. In addition, the medical director may be assigned specific authority in other specifically described areas, such as those that require interaction with the hospital's legal counsel in connection with clinical and clinically related activities, including compliance with hospital consent policies, organ donation request policies, and policies relating to release of information. The issue to be resolved at each hospital is to what extent it is believed desirable to specify the responsibilities of the medical director in these matters.

In setting forth specific responsibilities, there is the important question of the extent to which parallel authority in these areas should be granted to the president or chief of the hospital's medical staff, and other officers. The answer on specific issues depends in part upon the traditions of,and "political" climate within, each hospital. For example, the authority to impose summary suspension should not be vested, in the author's opinion, only in the medical director; it also should reside with the chief of staff and department chairpersons. On the other hand, specific responsibilities in connection with the credentialing process, such as receiving the initial responses from other institutions in connection with assessments of applicants for appointments, can be given solely to the medical director.

Mention was made at the beginning of this article of the contract between the medical director and the hospital. Also addressed was the use of the medical staff and/or corporate bylaws in dealing with the role of medical director. Related to, but separate from, these two documents is a third document--the position description for the medical director. The position description serves at least two major purposes.

First, it sets forth the required qualifications and the activities the hospital expects the medical director to perform, and thus is essential to the recruitment process. Its language should indicate with some precision how the incumbent is expected to be involved with the medical staff, and thus reflect an understanding that has been reached at the institution because of the medical staff leadership's involvement in its development.

Second, because it provides greater detail regarding the functions and duties of the medical director than the aforementioned documents (parts may also be incorporated by reference in the contract), it can serve as a template that can, and should, be employed in assessing the medical director's performance. This should not be taken to mean that the position, and its description, may not be in a process of evolution at the institution, but there needs to be an understanding, at any given time, on the part of all concerned, as to what is expected of the individual holding the position in order to maintain accountability.

In the final analysis, the allocation of responsibilities between the elected leadership of the medical staff and the medical director depends on the particular situation in each institution. There is a certain amount of specific authority that, if not granted, will tend to diminish the importance of the medical director and impede his or her ability to carry out the broad responsibilities contained in the basic provision in the medical staff bylaws.

One should not discount the impact of the personal characteristics of an individual medical director on the staff's acceptance of the authority granted in the medical staff bylaws. A staff may strongly resist changes in authority based on an incumbent's relationship with the staff's elected leadership. Experience seems to indicate that the extent to which consensus between the medical staff leadership and the medical director is reached on specific issues affects successful accomplishment of the medical director's objectives.

The process of defining the authority of the medical director is an evolving one. As comfort with, and acceptance of, the presence of a medical director grows, the raising of turf issues respecting the relative authority and status of the elected medical staff leadership and the medical director are diminished. This is not to suggest that conflict is always present, even at the inception of the medical director's tenure, but it is shortsighted not to recognize that the process of establishing the authority of the medical director often can trigger or exacerbate conflict because of concern by the medical staff that its prerogatives are being circumscribed by creation of the position of medical director.

(*1) Although the title medical director is used throughout this article, the position discussed may have any of a variety of titles--vice president for medical services, vice president of medical affairs, vice president for clinical services, director of or vice president for professional services, etc.

Nathan Hershey, LLB, is Professor of Health Law, Graduate School of Public Health, University of Pittsburgh. He is also of counsel with Markel, Schafer & Means, Pittsburgh, and Post & Schell, Philadelphia.