California Medical Association Resolutions
FROM HOWARD L. LANG, MD

Coincident with the series of articles on medical staff self-governance appearing in Southern California Physician, the 2007 California Medical Association House of Delegates addressed similar issues.

Specifically, Reference Committee F dealt with a crucial medical staff self-
governance issue--peer review. The peer review process is the source of much concern since it is becoming apparent that it is being subverted to accomplish ends other than peer review's original purpose--to protect patients and provide due process for physicians.

Delegates introduced numerous resolutions regarding peer review. They covered:
1. The Lumetra peer review study mandated by the state.
2. The requirements that Lumetra is placing on hospitals to provide peer review records.
3. Sham peer review.
4. Arbitration in peer review as an option to the judicial review committee.
5. The composition of the judicial review committee.
6. A new approach to peer review that would move the judicial review committee from a specific hospital to a different venue.
7. Peer review to protect patients and provide due process for physicians.

The Reference Committee artfully combined all of the above into one resolution (608a-07), which was adopted and requires a report to the 2008 CMA House of Delegates. That meeting in October ought to be very interesting!

The house also adopted a resolution asking the American Medical Association to review the Health Care Quality Improvement Act to determine whether the act can be improved to reduce the opportunity for a hospital board or its medical staff to use the peer review process as a retaliatory weapon against a physician or for a primary economic purpose. The goal is to increase the likelihood that the peer review process is structured to ensure fairness and justice.

Exclusive contracting is another area where medical staff self-governance has been subverted by hospital boards and administrations. The house adopted a resolution that: (1) the selection, performance evaluation, and any change in retention or replacement of hospital-based contracted physicians be done with the advice of the medical staff, and (2) the CMA support legislation that requires hospital governing bodies to abide by the advice and consent of the medical staff regarding hospital-based physician contracts.

Since exclusive contracting does directly involve quality of care and the medical staff has prime responsibility in this area, it is quite appropriate that any actions in exclusive contracting be done with the advice and consent of the medical staff.

This overview of resolutions regarding medical staff self-governance should not be viewed as a summary of all the resolutions and actions by the house. However, the emphasis the group gave this topic highlights the importance of strengthening the power of medical staffs statewide.

Dr. Lang is a former CMA president and a Scottsdale, Ariz.-based consultant to medical staffs nationwide.

American Medical Association Principles
FROM BRIAN JOHNSTON, MD

In November, the American Medical Association House of Delegates passed an important resolution offering guidance to medical staffs--"Principles for Strengthening the Physician-Hospital Relationship." The document is at www.ama-assn.org/ama1/pub/upload/mm/21/i07rep-d.pdf. Where did it come from and why is it important?

The document stems from attempts in 2003 and 2004 by the American Medical Association and the American Hospital Association to set down basic principles upon which both parties could agree. The goal was to reduce the friction and rancor in hospital-medical staff relations, which were draining both goodwill and resources in communities across the nation. Unfortunately, AHA members rejected a carefully negotiated document, which halted the efforts.

The AMA Organized Medical Staff Section then took the principles back and revised them, with input from private medical staff attorneys, past OMSS chairs, AMA legal counsel and the AMA board, before bringing them to the house, where they were adopted and became AMA policy.

The principles now speak to physicians across the country, defining the relationship of the medical staff to the hospital and board. They speak to hospitals, to the Joint Commission, and to the Centers for Medicare and Medicaid Services on behalf of physicians. They set down our role, duties and obligations.

We are primarily responsible for quality of care, quality improvement and patient safety, based upon our knowledge and expertise, and based upon our duty to patients. We are self-governing, which entails writing and amending the bylaws that set our relationship to the board and to each other. We determine staff membership, credentials and privileges, offer oversight, and conduct peer review. In so doing, we set the standards of performance.  We elect and remove our officers, handle our own financial affairs, and hire our own legal counsel. The medical staff empowers the medical executive committee and may reduce the powers it delegates to the committee.

The principles are important because a minority of hospital attorneys and hospital consultants are hostile to the medical staff, holding that it is part of the hospital (like nursing or dietary) and should be under board control. We hold that while the medical staff answers to the board on issues of quality and patient safety, it is a  self-governing body, which, by virtue of its professional expertise, vantage point and independence, provides the board invaluable insight that it could not offer from a position of subservience.

Dr. Johnston is a member of the AMA Organized Medical Staff Section and chief of staff at White Memorial Medical Center in Los Angeles.