Opinion ID: 1704973
Heading Depth: 1
Heading Rank: 5

Heading: The Hospital Governance Law

Text: The HGL is composed of seven separate sections. For purposes of our analysis, however, we will focus on sections 1, 5, and 6. [15] Section 1 sets forth the Legislature's intent to provide consolidation of the Board's power, authority, duty, and ultimate responsibility under existing statutes in the areas of medical staff and clinical privileges and discipline, and compliance with statutorily mandated peer review, risk management, and quality assurance activities. Section 1 also provides that if the Board's bylaws conflict with the Medical Staff Bylaws, the Board's bylaws will always prevail with respect to medical staff privileges, quality assurance, peer review, and contracts for hospital-based services. [16] Section 5 provides the Board with the right to reject or modify a medical staff recommendation or take action independent of the medical staff in the areas of medical staff membership, clinical privileges, peer review, and quality assurance under stated circumstances. Section 5 also reiterates that if the bylaws of the Board and the medical staff conflict, the bylaws of the Board will control with respect to medical staff privileges, quality assurance, peer review, and contracts for hospital-based services. [17] Finally, section 6 of the HGL contains the detailed procedures to be followed when the Board seeks to modify a medical staff recommendation or where the medical staff has failed to act after a Board request in the areas of medical staff membership, clinical privileges, peer review, or quality assurance. [18] Under section 6 of the HGL, the Board's independent action on a medical staff recommendation is subject to a fair hearing process. If, after the fair hearing, the board determines corrective or disciplinary action is necessary, proposed board action is then recommended to a conference committee made up of three members of the governing board and three members of the medical staff. If the conference committee recommends other action, the HGL provides that the Board shall not unreasonably reject that recommendation, but the Board's decision on the matter will be final if the conference committee agrees or if the conference committee reaches no majority decision.