Quality Monitoring Program Resources

Medical Direction & Medical Staff Bylaws

Overview

The DADS Quality Assurance and Improvement vision for medical direction in LTC is that

Every facility will have an effective medical director and medical staff bylaws.

Ideally, the medical director serves as the leader of the medical staff ensuring physician accountability through applicable policies and procedures. However, medical directors currently have little authority over physicians practicing in long term care facilities.[1] Therefore, establishing medical staff bylaws is essential in order to improve the effectiveness of medical direction. Staff bylaws define the duties and responsibilities of the medical director as well as the medical director's relationship to other staff.

Federal Requirements

The Federal Nursing Home Reform Act of 1987 defines the primary functions of the medical director as oversight of resident care policies and coordination of medical care in the nursing facility.[2] Resident care policies include the following aspects of patient care:

Admissions, transfers, and discharges
Infection control
Use of restraints
Physician privileges and practice
Responsibilities of non-physician health care workers in resident care, emergency care and resident assessment and care planning
Accidents and incidents
Ancillary services such as laboratory, radiology and pharmacy
Use of medication
Use and release of clinical information
Overall quality of care

The medical director's medical care coordination role involves:

Monitoring and ensuring implementation of resident care policies, and providing oversight and supervision of physician services and medical care of residents;
Overseeing the overall clinical care of residents to ensure that care is adequate and effective;
Evaluating reports of possible inadequate medical care and taking appropriate action to remedy problems; and
Assuring the support of essential medical consultants as needed.

The American Medical Directors Association (AMDA) Model Care Facility provides a sample framework for responsibilities of medical directors and structure of medical staff. The major components of the framework include the purpose, rationale and primary responsibilities of the medical director and administrator; and the scope of medical direction.[3] The model also specifies a structure for and expectations of the medical staff.

State Requirements

The State of Texas does not have detailed state requirements for medical direction. Maryland is the first state to implement state-specific requirements, and these can serve to further define the roles of medical direction and medical staff bylaws.[3,4,5,6]

Requirements for Maryland's Medical Directors

Qualifications

Responsibilities

Physician Responsibilities in Maryland Nursing Facilities

Physician responsibilities in long-term care (attending physicians)

Physicians' clinical responsibilities in nursing home care

Issues in Medical Direction

Several factors should be considered in implementing medical direction and medical staff bylaws.[1,3,5,6,7,8,9,10,11,12,13]

The importance of the management role of the medical director.[13]
The medical director must be an effective manager of a diverse medical staff. The medical director should be able to anticipate, address and resolve problems before they result in inadequate professional performance. In particular, the medical director should be able to identify specific reasons for attending physicians not meeting performance standards and take appropriate actions to address performance problems. Effective medical direction can serve as a facility risk management tool by avoiding adverse resident outcomes that stem from sub-optimal medical or nursing care. A medical director's core management functions can include:
- Identifying performance expectations and explaining the reasons for these expectations.
- Explaining how to fulfill these expectations.
- Identifying criteria for measuring satisfactory fulfillment of expectations.
- Determining whether performance expectations are being met.
- Providing feedback to staff members who are trying to meet those expectations.
Structure of medical staff and bylaws (physician accountability).
The design of a medical staff model depends on the care objectives of individual facilities. Consider whether your facility needs:
- A flexible or restricted panel of contracted physicians.
- Organized or informal medical staff.
- Full- or part-time contract physicians.
- On-call or as needed contract physicians.
- Provision of routine or periodic visits by contracted physicians.
- Care on-site or through community-based medical coverage.
A closed medical staff model may be the most appropriate for some facilities. Physicians in a closed staff tend to visit residents more frequently and may be more effective in their treatment of residents.[14,15] An organized medical staff includes bylaws that specify roles and responsibilities, officers, committees, rules and regulations, and regular meeting schedules, which can promote physician accountability.[13] A non-organized or informal staff makes performance measurement and improvement more difficult to achieve.[16]
Resistence to specific requirements for medical directors and attending physicians.

There has been resistance to having and enforcing specific requirements for medical directors and attending physicians.[3] Some commonly voiced concerns appear below.

CONCERN: Nursing facilities do not control and therefore cannot be responsible for what physicians do.

Physician accountability is an integral part of liability risk management in physician group practices, hospitals and other care delivery systems in which physicians are medical staff but not necessarily employees. In LTC facilities, as in the aforementioned systems, the entire system is affected by the liability risks of individual staff members. Thus, failure to ensure physician accountability in LTC reflects inadequate understanding of the underlying issues and a failure to use proven management approaches - not some attribute inherent in physicians or their work.

CONCERN: Physicians do not need regulations to practice adequately.

Regulation comes about precisely because the desired outcomes have not been produced in the absence of regulation.

CONCERN: Requirements are used to dictate how physicians should practice medicine.

The purpose of requirements is to reduce random practice variations that do not improve the quality of resident outcomes. Such standardization, based on clinical evidence, is rational and desirable. There is no reason why ignorance of evidence-based practice should be allowed to cause harm.

CONCERN: Physicians should not have to obtain continuing medical education as medical directors.

Medical direction is a complex job requiring many skills, including leadership and administrative skills, not taught in medical school or any aspect of physician training.
Other issues concerning medical directors and attending physicians.

The position of Medical Director is not always fully utilized nor adequately compensated. Some medical directors of nursing homes are not paid for their work.[9] Compensation issues in medical direction may reflect federal and state budget constraints as well as perceptions concerning the value of the work itself.[3,10,11]

Practical Guide to Quality Improvement

Successful medical direction accomplishes the following:[12,13,17,18,19,20,21,22]

Defines clearly the functions and responsibilities of the medical director, as well as the facility and medical staff.
Organizes medical staff and bylaws to meet the facility and resident needs.
Provides educational resources on medical direction and medical staff bylaws to the facility administrator, nursing staff, medical director, and members of the medical staff.
Uses a Utilization Review Committee to help the medical director with his or her legal responsibilities, as well as to review alleged cases of substandard medical care.
Designates a team of care providers to assist the medical director.
Implements and evaluates the model of medical direction and medical staff bylaws according to facility and resident needs.
Assesses the effectiveness of medical direction and staff bylaws on the actual improvement of resident care.

Part I. Define the Medical Director's Responsibilities and Medical Staff Bylaws

Review the characteristics of your facility's residents to determine specific care needs.
Identify care processes and facility practices needed to address the problems and risks of the residents in accordance with evidence-based best practices.
Identify the specific physician roles and responsibilities that are needed to provide optimal resident care.
Establish physician performance standards that address these roles and responsibilities.
Measure actual physician performance to establish a baseline for improvement efforts.
Use evidence-based management principles and practices that affect performance to improve physician performance.
Identify the responsibilities of the medical director relative to both physicians and the facility.
Identify your facility's responsibilities relative to the medical director and attending physicians in order promote improvement of medical staff performance.

Part II. Implement Medical Direction and Medical Staff Bylaws

Draft the staff bylaws for medical director and medical staff in your facility according to the considerations in Part I.
Organize a Utilization Review Committee consisting of the facility administrator, nursing and other departmental directors, attending physicians, medical staff and the medical director.
Send the bylaws to the Utilization Review Committee for review and comment, and then revise them accordingly.
Educate all pertinent facility personnel (e.g., administrators, nursing staff, medical director and members of the medical staff) about the finalized bylaws.
Implement the bylaws, review performance, and collect data to monitor the effectiveness of medical direction and medical staff model in achieving specific resident outcome improvements.
Have physicians practicing at the facility sign a Physician Practice Agreement that explains the conditions for obtaining and retaining medical practice privileges at your facility.

Part III. Evaluate Medical Direction and Medical Staff Bylaws

Identify resident care processes and resident outcomes sensitive to medical director and medical staff performance.
Set improvement goals for these care procesess and resident outcomes.
Use the facility Quality Assurance Committee to objectively measure progress toward these improvement goals.
Provide progress feedback to the facility administration and medical director.
Have the medical director regularly provide performance feedback to attending physicians with consideration to the following components:
- The purpose of the communication.
- The circumstances (e.g., privilege renewal, periodic evaluation, recent episode) for the communication.
- Performance expectations and criteria for conclusions concerning performance.
- A summary of conclusions about performance or explanation of which actions or inactions are consistent or inconsistent with expectations.
- A recommendation concerning what the physician could do to meet expectations.
- The possible consequences of failure to improve.
- The manner of subsequent communications.
- (See an example of physician communication about specific performance issues.)
Consult the Quality Assurance Committee concerning performance problems and any allegations of improper medical practice.

Related Licensure and Certification Tags

The following deficiencies may be cited for inadequate physician accountability. The deficiency list is representative rather than exhaustive.

Program

Licensure Tags (State)

Certification Tags (Federal)

Nursing Facilities

19.1917 (2)	F 520 Quality assessment and assurance
19.403 (3)	F156 Notice of rights and services
19.403 (f)	F154 Fully informed concerning medical condition
19.408 (2)	F166 Grievances
19.502 (a)	F177 Transfer and discharge
19.601 (a)	F221 Resident behavior and facility practices
19.601 (a)	F223 Abuse
19.601 (C)	F224 Staff treatment of residents
19.701	F240 Quality of life
19.901 (12)(A)	F329 Unnecessary drugs
19.1910 (a)	F514 Clinical records
19.1907 (a)(b)(1)(2)	F501 Medical director
19.1902 (a)(b)	F493 Governing body
19.901 (2)	F492 Compliance with State, Federal and Local laws
19.1901	F490Administration

ICFs/MR

M0015 90.42 (c)	W319 Ensure 24 hour physician services
M0015 90.42 (c)	W320 Develop medical care plan for client who needs 24 nursing care
M0015 90.42 (c)	W321 Integrate medical care plan with Individual program plan
M0015 90.42 (c)	W322 Preventive and general care
M0015 90.42 (c)	W323 Evaluation of vision and hearing
M0015 90.42 (c)	W324 Immunizations
M0015 90.42 (c)	W325 Routine Laboratory Screenings
M0015 90.42 (c)	W326 Special studies as needed
M0015 90.42 (c)	W327 Tuberculosis control
M0015 90.42 (c)	W328 Use of physician assistant or nurse practitioner
M0015 90.42 (c)	W329 Physician role in initial program plan
M0015 90.42 (c)	W330 Physician review and update of plan

Assisted Living

There are no tags related to medical direction in assisted living facilities.

Additional Resources (including online resources)

The resources listed below are provided solely as a convenience to our users. These may include publications from government, professional, for-profit, and non-profit sources. Some of these sources may have financial ties to industry. DADS does not control the content of these resources, and the opinions and recommendations provided there are those of the authors and do not necessarily reflect the position of QAI or DADS.

Online

Synopsis of Federal Regulations in the Nursing Facility - Implications for Attending Physicians and Medical Directors, Revised February 2000.

AMDA Position Paper on Quality Pharmaceutical Care

Role and Responsibilities of the Medical Director in the Nursing Home

In Print

Levenson SA. Clinical and Administrative Policies for the Medical Director and Attending Physicians. 1997. Heaton Resources (Med-Pass, Inc.).

Levenson SA. Medical Direction in Long-Term Care - A Guidebook for the Future (2nd Edition). 1993. Durham, North Carolina: Carolina Academia Press.

Levenson SA. Medical Direction in Long-Term Care - A Clinical and Administrative Guide. 1988. Maryland: National Health Publishing.

Pattee JJ, Otteson OJ. Medical Direction in the Nursing Home - Principles and Concepts for Physician Administrators. 1991. Minneapolis, Minnesota: North Ridge Press.

Bibliography

[1] Elon RD. Omnibus budget reconciliation act of 1987 and its implications for the medical director. Clinics in Geriatric Medicine 1995;11(3):419-32.

[2] Federal Nursing Home Reform Act of 1987. Accessed November 19, 2002.

[3] Levenson SA. The Maryland regulations: rethinking physician and medical director accountability in nursing homes. Journal of the American Medical Directors Association 2002;3(2):79-94.

[4] Anonymous. Medical director responsibilities and qualifications and physician services. constmail.gov.state.md.us/comar/10/10.07.02.10.htm. Accessed April 19, 2002.

[5] American Medical Directors Association (AMDA). AMDA 2002 Membership Survey. Accessed November 29, 2002.

[6] Zimmer JG, Watson NM, Levenson SA. Nursing home medical directors: Ideals and realities. Journal of the American Geriatrics Society 1993;41(2):127-30.

[7] Fanale JE. The nursing home medical director. Journal of the American Geriatrics Society 1989;37(4):369-75.

[8] Lawhorne LW, Walker G, Zweig SC et al. Who cares for Missouri's Medicaid nursing home residents? Characteristics of attending physicians. Journal of the American Geriatrics Society 1993;41(2):454-58.

[9] Elon RE. The nursing home medical director role in transition. Journal of the American Geriatrics Society 1993;41(2):131-35.

[10] Kane RS. Factors affecting physician participation in nursing home care. Journal of the American Geriatrics Society 1993;41(6):1000-03.

[11] Kane RS. Physicians' attitudes toward nursing home practice in Milwaukee. Wisconsin Medical Journal 1993;92(4):208-11.

[12] Pattee JJ. Update on the medical director concept. American Family Physician 1983;28(6):129-33.

[13] Levenson SA. Bridge building, not rain dancing: a medical director's core management responsibilities. Journal of the American Medical Director Association 2002;3(Suppl.):S61-S69.

[14] Karuza J, Katz PR. Physician staffing patterns correlates of nursing home care: An initial inquiry and consideration of policy implications. Journal of the American Geriatrics Society 1994;42(7):787-93.

[15] Miller DB, Keller D, Woodruff S. Evaluation of an open and closed medical staff in a nursing home setting. Gerontologist 1974;14(2):158-62.

[16] Levenson SA. Medical Direction in Long-Term Care - A Guidebook for the Future (2nd Edition). 1993. Durham, North Carolina: Carolina Academia Press.

[17] Pattee JJ. History and evolution of the role of medical director. Clinics in Geriatric Medicine 1995;11(3):331-41.

[18] Levenson SA. Policy and procedure development and implementation. Clinics in Geriatric Medicine 1995;11(3):449-65.

[19] Willging P. The future of long-term care and the role of the medical director. Clinics in Geriatric Medicine 1995;11(3):531-45.

[20] Ouslander JG, Osterweil D. Physician evaluation and management of nursing home residents. Annals of Internal Medicine 1994;120(7):584-92.

[21] Elon RD. Nursing home reform and the governance of medicine: lessons from Maryland. Journal of the American Medical Director Association 2002;3(2):73-78.

[22] Elon RD. Maryland's Nursing Home Medical Director Regulations.[Letter] Journal of the American Medical Director Association 2002;2(1):37-39.

Literature Review Evidence Table

Reviewers

Peer Reviewer: Mark A. Heard, MD, CMD
Review Date: September 8, 2003
Dr. Heard practices Geriatrics in Cuero, Texas. He is a nursing home medical director who is a former President of the Texas Medical Directors Association.

Your Feedback

You may use this link to submit an anonymous evaluation of this page. DADS Quality Assurance and Improvement is interested in your comments regarding this page, whether you found it helpful, and your suggestions as to how we can make the QM Web more responsive to your needs as a provider of Long Term Care services. While we will use your ideas to improve the content of this site, please be aware that because your feedback is anonymous, QAI cannot respond to questions.

Any question that requires a reply should be sent to the QM Webmaster by using this link to send an email message.

Last updated: September 12, 2003.