Medical Staff Rights, Responsibilities & Relationships:
overiding basis of the relationship between the governing body and the
medical staff is cooperation with accountability to each other in
maintaining and improving patient quality medical care.
medical staff is a legally distinct and separate, but not wholly
independent, unincorporated association of medical professionals with
inherent rights, authority and responsibilities.
- It has the right to organize and act in its own name.
has the right to write bylaws, elect officers, elect or appoint
department chairs, committees, etc., credential members, specify
sanction/appeal processes, establish standards of care, etc..
- It has the right to its own legal counsel and the right to institute legal proceedings including suits.
medical staff has a primary responsibility to the patient - not to the
hospital - and must act to protect the patient if governing
body/administration actions endanger patient care or safety.
medical staff is made up of physicians who are required to have
integrity and professionalism with the responsibility and authority to
take care of fellow humans.
- The hospital enabling statutes under
Commonwealth (Pa.) law are the basis of the creation of the medical
staff and a governing body, but neither is required to be derived from
- The governing body does not delegate to the hospital
medical staff its functions under medical staff bylaws, but the
governing body reviews medical staff bylaws to assure that they are
legally proper and reasonable, and the medical staff is conducting
itself in a fair and unbiased manner. The governing body may not
unreasonably withold or delay approval of the medical staff bylaws if
the foregoing conditions are met.
- The medical staff bylaws
should assure that the medical staff is able to perform in a smooth
expedient manner the discharge of its responsibilities and fulfill its
mission of service to patients and the community.
- Medical staff
bylaws are considered an integral part of a contract with bidirectional
accountability between the governing body and the medical staff -
neither party can unilaterally usurp rights and obligations of the other
party, such as unilateral amendment of each other's bylaws.
- Neither the governing body nor the medical staff are constrained to take actions in behalf of the other's interest.
GUEST EDITORIAL by John Malcolm, Jr. MD*
our travels around Pennsylvania helping medical staffs with updating
their bylaws, we've regularly pointed out that the Commonwealth's
regulations governing hospitals, hospital governing bodies and medical
staffs are predicated on an expected cooperative relationship between
all parties. As an example the medical staff is assigned primary
responsibility by regulation for evaluation and assurance of quality
patient care (107.1, 107.26(b)(4), 107.51, 107.52). In addition, the
governing body is required to delegate to the medical staff the
authority to carry out certain responsibilities assigned by these
regulations to the medical staff (103.4(9)). Further, the governing
body is required to provide administrative support to the medical staff
to aid its carrying out the assigned responsibilities (103.4(13)). The
role of the governing body to the medical staff is one of oversight to
assure that the medical staff is meeting its responsibilities in an
efficient, effective, appropriate and fair manner. Should the medical
staff fail to meet their assigned responsibilities, the governing body
is required to step in. For example, in practice, if the governing body
has a concern over a quality of care issue, it would alert the medical
staff of their concerns with the expectation that the medical staff
would promptly address the issue. Should the medical staff fail to act,
fail to act appropriately or the governing body does not agree with the
medical staff's action(s) - then the governing body can take further
action to remediate their concerns. The process for further action by
the governing board is spelled out in the regulations and is again based
on cooperative actions by both the medical staff and the governing body
such as an initial review by a joint conference committee composed of
equal numbers of members from the medical staff and governing body.
as noted in the adjacent column the first and overiding priority is a
cooperative relationship between the hospital's medical staff and
governing body. It is also with some concern that we have noted that
most medical staffs we have met with are only vaguely aware of, or
unaware of the content of the Commwealth's regulations governing
hospitals, their governing body/administration and their medical
staffs. We would urge medical staff's leadership to familiarize
themselves with these regulations as they review and update their
* Dr. Malcolm is a past chair of the Pennsylvania Medical Society's Organized Medical Staff Section.
Additional informational references on this topic:
Commonwealth of Pennsyvania Codes - Title 28, Part IV, Subpart B, Chapters 101, 103, 107.
"Guidelines for an Effective Medical Staff", 4th Edition, Pennsylvania Medical Society
"Physician's Guide to Medical Staff Organization Bylaws", 5th Edition, American Medical Association
"The Medical Staff Handbook", 3rd Edition, The Joint Commission