Re-forming the traditional organization medical staff.

The winds of change are blowing strong through the U.S. health care system. Congress, the White House, and state governors are kicking around the political football of "health care reform." Some large companies, tired of seeing profits eroded by health care costs, are directly providing health care services to their employees. Emphasis on health maintenance disappoints disease-oriented physicians' expectations of being firmly in control of the system. On any given day, millions more Americans need help with simple (primary) health care problems than require coronary bypass grafts. That (recently rediscovered) fact is causing power struggles between specialists and generalists, making cooperative efforts difficult. Users fear that provider greed and federal fumbling might make care undependable in either a single-payer or a managed competition model. Hospitals are rushing to give doctors money to stake a claim, they believe, to doctors' geographic domains and to their patients.

Beneath the surface of this upheaval, a variety of difficult issues await resolution, among them the question of what to do with the traditional, two-bylaws model, legalistically oriented "organized medical staff" in U.S. medical centers.

The physician executive must be aware of this issue and its ramifications, for two reasons. The physician executive will be looked to as a resource, expected to recommend how much of what kind of change is needed, and what initial steps should be taken. And the physician executive must be alert to the emotional nature and potential explosiveness of this issue. While forward-looking physicians are no longer interested in "bylaws revisions," frequent meetings, and other trappings of die traditional "organized medical staff," traditional-thinking physicians may vigorously defend the status quo.

Here is a "quick-reference primer" for the busy physician executive to use when asked to participate in medical staff restructuring efforts.

What is the traditional organized

medical staff?

The organized medical staff is one of two entities created by provisions in governing body bylaws. (The other is the hospital auxiliary). This "single organized medical staff" is required for accreditation by the Joint Commission on Accreditation of Healthcare Organizations,[1] whose 22-member board includes seven representatives from the American Medical Association, and seven from the American Hospital Association. An organized medical staff is also required by state institutional licensing agencies. Activities of the organized medical staff are further governed by a supplementary document called "medical staff bylaws.[2]

Some traditional-thinking physicians and their attorneys still argue with the above characterization. They prefer the illusion that the organized medical staff is as independent from the medical center's organizational structure as is the county medical society and exists to serve the same physician-protective political functions.

What are the intended purposes and

functions of the traditional organized

medical staff?

Since 1919,[3] the governing body and the public have depended on the organized medical staff to ensure, insofar as is humanly possible, the basic qualifications and current dependable performance of physicians privileged to attend patients at the medical center. Today, specific charges of the organized medical staff include establishment of systems for confirming practitioners' qualifications ("credentialing"), developing and using conclusions about the current performance of medical staff members ("quality/performance improvement"), providing coordinated input to decisions of the medical center's executive staff and board, providing continuing medical education opportunities, and offering opportunities for collegial interaction.

Why change?

Shortcomings of the existing organized medical staff model are legendary. Traditional structure has been bureaucratic, consisting of a "horizontally organized" system of committees. Individual medical staff leaders who act without coming to a committee and asking, "May I? are accused of "disenfranchising" grass roots medical staff members. Authority is so diffused that true resolution of issues is less common than "cyclical referral" between committees. (While most physicians favor less committee work, many also still fear the notion of a single responsible individual acting for the group.)

Traditional methods of accomplishing medical staff functions have long been the target of criticism. For years, only physicians could attend official meetings of committees of the organized medical staff. "Executive sessions" (meaning without representatives of medical center administration) were commonplace. Expressions o disappointment with the unique system of evaluating physician performance ("peer review") are nothing new. As long ago as 1953, it was noted that clinical conferences and meetings of clinical departments "accomplish a general analysis of professional work" of the medical staff, but "do not provide a true picture of the professional efficiency of individual members of the medical staff."[4] Physician fears and lack of understanding of both organizational and legal theory resulted in capture of organized medical staff functions by attorneys and consultants, to the detriment of both physicians and the medical center.

Leadership has been weak. "Physician leader," in the context of the organized medical staff, is considered an oxymoron. Selection of medical staff leaders has long been the subject of inside jokes. ("Whose turn is it to take the God-awful job of department chairman? Where's Harry? On vacation? Good, then he's elected.") Until recently, one-year terms were the norm for officers and department chairs. Thousands of health care dollars are spent each year on orienting a new crop of physician leaders.

In "medical staff bylaws revision" projects, participating physicians are intensely interested in a strong "removal" provision, but, almost without exception, they reject a provision calling for evaluation of the performance of medical staff leaders.

Documentation of medical staff activities has also been criticized. Until recently, activities of the organized medical staff were documented in thick black notebooks full of essay-type minutes containing needless detail and nebulous conclusions. Summary minutes with attached data reports represent an improvement, but they perpetuate a "meeting and minutes mentality" far removed from the need for effective day-to-day leadership by individual physicians.

Cost is also an issue. The high cost of supporting "medical staff functions" is partly related to the inefficiency of the traditional organizational model. In addition, costs of preparing for focused surveys by the Joint Commission on Accreditation of Healthcare Organizations are often due to "inadequate performance" of various medical staff functions. To these costs must be added fees paid to consultants and attorneys for frequent (sometimes continuous) revision of medical staff bylaws and related documents. Legal fees occasioned by defending ill-advised actions taken by medical executive committees that do not want "lawyers, administration, and the board invading our prerogatives" must also be added

In the 1980s, the credibility of the organized medical staff was further damaged by economic contamination of the credentialing process. The original idea of credentialing, and still the public promise, is patient-protective concern for physicians' qualifications. But the reality is that credentialing is used as a weapon in the economic war between physicians, between hospitals, and between physicians and hospitals.

A few years from now, histories of the organized medical staff may suggest that the final, fatal blow to the credibility of the traditional two-bylaws model was inadvertently struck by "contract physicians" (such as radiologists and pathologists). In some instances, attorneys succeeded in obtaining court judgments that medical staff bylaws constitute a contract. Furthermore, contract physicians and their attorneys commandeered the bylaws to seek double-dip due process, once through contract rights and again through the hearing and appeals process intended to protect medical staff appointees having no other mechanism of due process. This self-serving activity is a far cry from the original intent and current public promise that the organized medical staff exists to ensure the qualifications and performance of physicians.

What is the best argument supporting

the need to change?

The argument for change most persuasive to physicians is that many physicians who once objected to medical staff reorganization now favor it! Forward-looking physicians know that the traditional structure, purposely designed to delay and resist unwelcome change, now creates a disadvantage for physicians who wish to influence and participate in the nature and degree of changes in the U.S. health care system.

What are some specific areas to be

addressed?

* The medical executive function. The medical executive function should be streamlined. In most organizations, the executive function resides in an individual rather than in a committee. Only two exceptions come to mind: condominium associations and the organized medical staff. At the Constitutional Convention in 1787, delegates sorely wanted to put the executive function in a committee, because "it was hard for any one of them to think of a single executive without thinking of a king.[5] A similar mindset explains the persistence of large medical executive committees. Constitutional delegates were finally forced to conclude that "if there should be three heads in the national executive, there could be neither vigor nor tranquility."[5] The same common sense consideration suggests that the medical executive function could be well-served by having no more than an elected medical staff president and the physician executive, working with a cabinet of three to five senior physicians with reputations for objectivity and fairness.

Such streamlining is difficult to accomplish, because a favorite fear of physicians is that they will be "disenfranchised." Smaller executive groups are only acceptable if accompanied by assurances in written operational policies that the executive group's intent is to seek input from staff members and to communicate important decisions and actions in a timely manner.

* Committee structure. Functions of the organized medical staff, even in a large medical center, can be effectively accomplished with a small medical executive committee; two small subcommittees, a qualifications (credentials) subcommittee and a performance (quality) subcommittee; and participation of physician leaders on hospital-wide committees, such as the quality/performance coordinating council (figure, below[6])

Any additional committees would be related to specific clinical activities, such as a oncology committee, or to specific functions, such as a postgraduate education committee in a medical center with accredited training programs for medical residents.

* Choice of specific methods for accomplishing "credentialing" and developing and using performance data. CQI-influenced methods of credentialing and performance evaluation are much more efficient and physician-friendly, but no less effective, than the negative and threatening methods of the 1980s.[7]

* Selection. orientation, evaluation, and payment of medical staff leaders. Leaders with (or willing to develop) organizational and communication skills, and with a reputation for objectivity and fairness, would be selected. The method of selecting clinical department chairs would accurately reflect the dual responsibility of these positions-to individual physicians on one hand and to the physician executive and the governing body on the other. For example: two or three acceptable candidates for department chair could be selected by the department and their names forwarded to the medical executive committee. The medical executive committee could then forward its recommendations to the governing board, which would appoint the department chairs from among the candidates presented.

A method would be instituted by which the medical executive committee evaluates the performance of physician leaders regularly, such as at the end of the first year of a two-year term. Emphasis should be not on removing ineffective leaders, but on helping physician leaders sharpen their organizational skills.

Paying physician leaders for organizational duties is increasingly common, but the practice must be carefully planned and implemented.[8]

* Documents describing and governing the organized medical staff. Once, the combined contents of just three documents described the organized medical staff and its functions: board bylaws, medical staff bylaws, and rules and regulations. In the 1980s it became commonplace to develop and use additional "bylaws-related documents," such as a credentialing policy and procedure manual.

Today, a totally new approach to medical staff documents is being considered. The centerpieces are organizational and professional guidelines, with medical staff bylaws an important sidebar, to be used if needed. The central documents include a performance assessment/improvement plan, a guidelines, policies and methods manual for each clinical department, and a modernized credentialing manual, which leaders can use to accomplish CQI-influenced credentialing. Attorneys need only concern themselves with the legal matters contained in medical staff bylaws. The nature of the other documents, by declared policy, is to serve as organizational and professional guidelines, not absolute standards of behavior.[7]

Should the goal be to change the

model or to make improvements in the

existing model?

By 2010, concerns about physician qualifications, performance, and continuing education will probably be handled by descendants of today's physician/hospital organizations and integrated delivery systems, rather than by a medical center-specific," single organized medical staff." However, the immediate goal should be to make improvements in the existing model.

The Critical Key

It must be realized that "medical staff restructuring" alone may have disappointing results. Successful improvements in the medical staff organization are combinations of structural changes, adoption of recently available methods, and more committed and organizationally skilled physician leaders.

References

[1.] Accreditation Manual for Hospitals, 1994 Edition. Medical Staff Standard, pp. 65-84. Oakbrook Terrace, Ill.: Joint Commission on Accreditation of Healthcare Organizations, 1993. [2.] Thompson, R. The Medical Staff Leader's Practical Guide. Marblehead, Mass.: Opus Publications, 1992, Chapter 13, pp. 185-204. [3.] The Minimum Standard for Hospitals. Chicago, Ill.: American College of Surgeons, 1919. [4.] MacEachern, M. The Medical Staff in the Hospital, 2nd Edition. Chicago, Ill.: Physicians' Record Company, 1953, p. xiii. [5.] Van Doren, C. The Great Rehearsal: The Story of the Making and Ratifying of the Constitution of the United States. Newark, N.J.: International Press, 1982, p. 53. [6.] Thompson, R., op. cit., p. 11. [7.] Medical Staff Portfolio. Credentialing Guidelines. Policies and Methods (GPM) Manual: Part 1, Part 2. and Part 3. Dunedin, Fla.: Thompson, Mohr and Associates, Inc., 1993. [8.] "Physician Leader Payment Plan." MSP Blueprints. Dunedin, Fla.: Thompson, Mohr, Inc., 1994.

Richard E. Thompson, MD, is an author and innovator based in Dunedin, Fla. He is the author of Health Care Reform as Social Change (ACPE, Tampa, Fla., 1993), and of The Organized Medical Staff: Blueprint for Change, (The Governance Institute, La Jolla, Calif., 1993). He has successfully coordinated more than 40 medical staff restructuring projects.