The Mihalik Blog

Medical Staff Bylaws

Hospital Medical Staff Bylaws seem to be getting more attention lately. You can find one example here.

The Joint Commission’s standards for Focused Professional Practice Evaluations (FPPE) and Ongoing Professional Practice Evaluations (OPPE) seem to be generating much of the interest.

The OPPE, in particular, forces hospital medical staffs to develop a process to gather objective data and to use the data in pre-established and methodologically sound ways to evaluate practitioner performance trends that affect clinical care and patient safety.

Just recently I and another consultant from The Mihalik Group developed a set of model Medical Staff Bylaws and Rules and Regulations for the United States Department of Veterans Affairs. Once approved by VA leadership, the bylaws will be made available to all VA facilities. This was an exciting project! It felt really good to be able to take TJC requirements and VA requirements and meld them into a document that provides a framework for medical staff functioning.

If you have concerns about whether your medical staff bylaws are up-to-date we can help.   

Thoughts On the New Approach to Joint Commission Survey

Today’s column is written by our senior Joint Commission consultant Mike Troncone, based on his experience with the new Joint Commission survey preparation.

I enjoyed the “old” approach to survey preparation.  About a year before a Joint Commission survey was expected, the organizations that I was involved with would begin preparations by doing a gap analysis and taking necessary corrective action so that a twelve-month track record of compliance could be demonstrated at the time of survey.  Flow charts and presentations were prepared so that we could “Wow!” the surveyors.  The hot topics and areas that were being emphasized were reviewed with all staff and our responses were carefully orchestrated.  Senior Leadership supported those efforts and was prepared to put the Joint Commission on their radar screens for a few months every three years to ensure a successful survey.

By now, almost every organization surveyed by the Joint Commission has been through some form of the new survey process and knows that the emphasis has changed considerably.  To successfully maintain accreditation, we need to operate by the book (the Accreditation Manual, that is), keep a careful inventory of identified areas in need improvement, and monitor corrective actions on an ongoing basis.  Continuous Survey Readiness is the key to sleeping well at night with the new process.

The big difference is to “be prepared,” not to prepare.  For this shift to occur, Senior Leadership must support a cultural shift.  This is a gradual process that will take some time.  Without an agreed upon direction and clear processes for achieving the shift, it is doomed to fail.  The survey coordinator will find her or himself in solitary chaos as the coordinator struggles to complete the annual PPR and be prepared for the unexpected arrival of the surveyors.

Leadership buy-in through a Continuous Survey Readiness plan, whether developed within the organization or with the help of the experts, will provide a blueprint for success.  The plan should define the role of each area of the organization in maintaining compliance with the standards and incorporate a succinct process for keeping the senior leaders informed of areas that require attention.

The standards can be viewed as guidelines for providing good care that can be implemented in a way that also makes good business sense in day-to-day operations.  Of course, this must be demonstrated before most leaders will commit organizational resources to the change.  The survey coordinator needs to develop the evidence necessary to support the shift and to define a process for achieving the shift efficiently and economically.

Advance Directives: Theory and Practice

Many of you know my business partner, Melinda Orlando.  Today’s column is one that she wrote based on personal experience. 

Joint Commission standards require hospitals to address the wishes of patients regarding end of life decisions.  Whether or not the patient has signed an advance directive must be documented in the medical record and staff must honor advance directives within limits of the law. 

Advance directives have been widely published in popular literature but may not be in common use with the very elderly population.  Mom, however, established an advance directive many yeas ago—long before she reached 93 and broke her hip.  Having observed a dear friend on life-support for a long time in a totally non-responsive state prompted her to make clear to all who would listen that this was not to be her end.  Under threat of life-long harassment from the other side, she informed her three children of her wishes, signed all of the forms, and distributed a copy of each of us. 

Prior to her recent surgery for hip pinning (the first hospitalization in 40 years), she discussed her wishes with her physicians.  In the presence of her children and husband of 69 years, she assured the surgeon and anesthesiologist that should they need to honor her advance directive, she would remember them kindly as having done the best possible to help her.  She talked about how difficult it might be to make this decision and that she trusted them and her family to do the right thing—what she wanted.  No doubt this was all adequately documented in the electronic medical record that was in use near the bedside.  Respecting patient preferences is dependent upon appropriate documentation being readily available to staff when it is needed. 

Surgery went well.  However, about an hour into recovery Mom’s blood pressure dropped and cardiac symptoms developed.  One of the best things about receiving care in a large teaching hospital is the range of staff available, from medical students to the attending physician.  This brings a variety of ideas and choices.  The down side is the eagerness to act aggressively.  Thus, we encountered a well-intended resident who insisted we proceed immediately to cardiac cath to locate and correct a possible blockage. 

Although this very type of circumstance and intervention had been discussed and rejected by Mom in this resident’s presence, he wanted to “save her life.”  The attending physician was called.  He ordered medications to maintain comfort, and observation, according to her wishes.  Mom recovered and is walking well with a walker and without evident heart problems.   

The moral of the story (from the patient’s perspective) is to have an advance directive.  Be sure and discuss your wishes with all immediate family members and with all caregivers.  It is helpful if caregivers, particularly physicians, really understand your position and get to know your feelings and beliefs; not just that you have an advance directive.  The better they understand what an advance directive means to you, the better they will be in carrying out your wishes.  It is also important to have an advocate with you at the hospital if you are not fully alert or able to express your wishes.  This is especially true following surgery when you may not be able to express yourself. 

The moral of the story (from the facility’s perspective) is to develop a system of checks and balances to be sure that caregivers follow a patient’s advance directives.  If they are not willing to do so, they should be upfront with the patient and family about their position in order to provide the opportunity for another caregiver to be chosen.  Frequent education and training on advance directives and ethical issues in care is critical for improving and maintaining staff knowledge and performance in this important area.

Melinda Orlando