An Act To Provide For The Autonomy Of Hospital Medical Staffs

Text of legislation filed by MMS for the 2015-16 session of the Massachusetts Legislature:


SECTION 1.  Chapter 111 of the General Laws is hereby amended by inserting after section 57D the following new sections: --

Section  57E.  Definitions.

(1)  “Governing Board” means the Board of Trustees, the Board of Directors or the equivalent, of an individual hospital. A governing board of a corporation owning or controlling multiple hospitals may not serve as a governing board for the purposes of this section.

(2)  “Hospital” means any hospital licensed under section 51 of this chapter.

(3)  “Medical staff” means those physicians and other health care professionals who are privileged to attend patients in a hospital.

Section  57F.  Purpose. 

The Legislature hereby finds and declares that:

(1)  Providing quality medical care in individual hospitals in the Commonwealth depends on the mutual accountability, interdependence, and responsibility of the medical staff and the hospital governing board for the proper performance of their respective obligations;

 (2)  The final authority of a hospital’s governing board may be exercised for the responsible governance of the hospital or for the hospital’s business, but this final authority may only be exercised with a reasonable belief that the medical staff has failed to fulfill a substantive responsibility in matters pertaining to the quality of patient care;

(3)  It would be a violation of the medical staff’s self-governance and independent rights for the hospital’s governing board to assume a duty or responsibility of the medical staff precipitously, unreasonably, or in bad faith;

(4)  The specific actions that would constitute bad faith or unreasonable action on the part of either the medical staff or the hospital’s governing board will always be fact-specific and cannot be precisely described in statute;

(5)  The provisions set forth in this section and sections 57E to 57G inclusive do nothing more than provide for the basic independent rights and responsibilities of a self-governing medical staff;

(6)  Ultimately, a successful relationship between a hospital’s medical staff and its governing board depends on the mutual respect of each for the rights and responsibilities of the other.

Section 57G.  Requirements.

(1)   The medical staff's right of self-governance shall include, but not be limited to, all of the following:

 (a)  Establishing, in medical staff bylaws, rules, or regulations, criteria and standards, consistent for medical staff membership and privileges, and enforcing those criteria and standards;

 (b)  Establishing, in medical staff bylaws, rules, or regulations, clinical criteria and standards to oversee and manage quality assurance, utilization review, and other medical staff activities including, but not limited to, periodic meetings of the medical staff and its committees and departments and review and analysis of patient medical records;

 (c)  Selecting and removing medical staff officers;

 (d)  Assessing medical staff dues and utilizing the medical staff dues as appropriate for the purposes of the medical staff;

 (e)  The ability to retain and be represented by independent legal counsel at the expense of the medical staff;

(f)  Initiating, developing, and adopting medical staff bylaws, rules, and regulations, and amendments thereto, subject to the approval of the hospital’s governing board, which approval shall not be unreasonably withheld.

(2)        The medical staff bylaws shall not interfere with the independent rights of the medical staff to do any of the following, but shall set forth the procedures for:

(a)  Selecting and removing medical staff officers;

(b)  Assessing medical staff dues and utilizing the medical staff dues as appropriate for the purposes of the medical staff;

(c)  Establishing the ability to retain and be represented by independent legal counsel at the expense of the medical staff.

(d)  Establishing the ability of an existing med staff to reorganize and redefine its own governance structure as appropriate.

(e) Establishing the ability of all properly licensed and hospital credentialed  physicians involved in patient care to be eligible for a voice and vote in organized medical staff self-governance.

(f) The formation of the medical staff as a representative democracy where members personally participate with voice and vote in the decision making and election of their representatives.

(3)        With respect to any dispute arising under this section, the medical staff and the hospital’s governing board shall meet and confer in good faith to resolve the dispute.  Whenever any person or entity has engaged in or is about to engage in any acts or practices that hinder, restrict, or otherwise obstruct the ability of the medical staff to exercise its rights, obligations, or responsibilities under this section, the Superior Court, on application of the medical staff, and after determining that reasonable efforts, including reasonable administrative remedies provided in the medical staff bylaws, rules, or regulations, have failed to resolve the dispute, may issue appropriate relief, including but not limited to injunctive relief while the matter is under dispute.   

SECTION 2.  This Act shall take effect on October 1, 2015.

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