St. Vincent Implements 2024 Medical Staff Clinical Rules
Janis Langohr, MD, St. Vincent Bylaws Committee Chair, shares the following update:
Providers should be aware of two recent changes to their workday. The first is the implementation of the St Vincent Regional Hospital Medical Staff 2024 Clinical Rules. The second is the Medical Records Completion Policy which is a companion to Clinical Rule 10 regarding appropriate and timely completion of medical records. Both documents were recently completed by the Bylaws (Rules) Committee and MEC. The Market Board affirmed the changes on Aug. 19, 2024.
The rules were created from a SCL (now Intermountain Health) template provided to the Rules Committee in 2023. The template was grounded in Montana and Federal (CMS) laws to ensure compliance of the hospital and its associated providers with the law. The job of the Bylaws (Rules) Committee was to ensure that the rules met the requirements of our bylaws and reflected the current culture and work practice of the providers at Saint Vincent Regional Hospital.
As a result, the new rules should fit seamlessly into a provider’s workflow and should not significantly affect current practice or the expectation of call obligations. Many of these rules have already been incorporated into EPIC, note templates, pharmacy practice, and the call panel.
Highlights of the rules and changes:
The 2024 rules reflect the increased role of APPs in healthcare delivery.
Consent for Medical and Surgical Procedure (Rule 2) incorporates Montana law in obtaining consent when the patient cannot do so, especially with end-of-life issues.
Consultations (Rule 3) incorporates the language of the Emergency Medical Treatment Active Labor Act (EMTALA) regarding on-call physicians and APPs. Although this Rule is highly prescriptive and complex, it should have little effect on how individual providers and their teams currently take calls and respond to emergencies.
Discontinuing Life-Sustaining Treatment (Rule 7) is heavily based in law and has greater detail than previous renditions. The rules committee received considerable assistance from spiritual care and the ICU in crafting and editing Rule 7. It is a good teaching tool for all those involved in end-of-life care.
Medical Records (Rule 10) works together with the Medical Records Completion policy to streamline the process for handling delinquent medical records by integrating the services of Health Information Management (HIM) and the Medical Staff Office (MSO). The sanctions for recurrent violations of this policy are driven by Rule 10 and include automatic suspension and termination from the medical staff for repeat offenders. It is therefore advisable to complete medical records in a timely fashion. Rule 10 takes its authority from our Bylaws Article XIII which addresses Automatic and Administrative Actions.