130.026 Medical Staff Rights and Responsibilities Bill of Rights

130.026

130.026 Medical Staff Rights and Responsibilities Bill of Rights: The Texas Medical Association adopts the following medical staff rights and responsibilities as TMA policy:

TMA recognizes the following fundamental responsibilities of the medical staff:   

  • The responsibility to provide for the delivery of high-quality and safe patient care, the provision of which relies on mutual accountability and interdependence with the hospital’s governing body; 
  • The responsibility to provide leadership and work collaboratively with the hospital’s administration and governing body to continuously improve patient care and outcomes;
  • The responsibility to participate in the hospital’s operational and strategic planning to safeguard the interest of patients, the community, the hospital, and the medical staff and its members; 
  • The responsibility to establish qualifications for membership and fairly evaluate all members and candidates without the use of economic criteria unrelated to quality, and to identify and manage potential conflicts that could result in unfair evaluation;
  • The responsibility to establish standards and hold members individually and collectively accountable for quality, safety, and professional conduct; and 
  • The responsibility to make appropriate recommendations to the hospital’s governing body regarding membership, privileging, patient care, and peer review. 

TMA recognizes that the following fundamental rights of the medical staff are essential to the medical staff’s ability to fulfill its responsibilities: 

  • The right to be self-governed, which includes but is not limited to (1) initiating, developing, and approving or disapproving of medical staff bylaws, rules, and regulations; (2) selecting and removing medical staff leaders; (3) controlling the use of medical staff funds; (4) being advised by independent legal counsel; and (5) establishing and defining, in accordance with applicable law, medical staff membership categories, including categories for nonphysician members;
  • The right to advocate for its members and their patients without fear of retaliation by the hospital’s administration or governing body;
  • The right to be provided with the resources necessary to continuously improve patient care and outcomes; 
  • The right to be well informed and share in the decisionmaking of the hospital’s operational and strategic planning, including involvement in decisions to grant exclusive contracts or close medical staff departments; 
  • The right to be represented and heard, regardless of the voting rights of the physician as outlined by the medical staff bylaws, at all meetings of the hospital’s governing body; and 
  • The right to engage the hospital’s administration and governing body on professional matters involving their own interests. 

TMA recognizes the following fundamental responsibilities of individual medical staff members, regardless of contractual or independent status: 

  • The responsibility to work collaboratively with other members and with the hospital’s administration to improve quality and safety; 
  • The responsibility to provide patient care that meets the professional standards established by the medical staff;
  • The responsibility to conduct all professional activities in accordance with the bylaws, rules, and regulations of the medical staff; 
  • The responsibility to advocate for the best interest of patients, even when such interest may conflict with the interests of other members, the medical staff, or the hospital; 
  • The responsibility to participate and encourage others to play an active role in the governance and other activities of the medical staff;
  • The responsibility to participate in peer review activities, including submitting to review, contributing as a reviewer, and supporting member improvement. 

TMA recognizes that the following fundamental rights apply to individual medical staff members, regardless of contractual or independent status, and are essential to each member’s ability to fulfill the responsibilities owed to his or her patients, the medical staff, and the hospital: 

  • The right to exercise fully the prerogatives of medical staff membership afforded by the medical staff bylaws, which right may not be waived as a condition of employment or medical staff privileges; 
  • The right to make treatment decisions, including referrals, based on the best interest of the patient, subject only to review by peers;
  • The right to exercise personal and professional judgment in voting, speaking, and advocating on any matter regarding patient care or medical staff matters, without fear of retaliation by the medical staff or the hospital’s administration or governing body;
  • The right to be evaluated fairly, without the use of economic criteria, by unbiased peers who are actively practicing physicians in the community and in the same specialty;
  • The right to full due process before the medical staff or hospital takes adverse action affecting membership or privileges, including any attempt to abridge membership or privileges through the granting of exclusive contracts or closing of medical staff departments;
  • The right to immunity from civil damages, injunctive or equitable relief, and criminal liability when participating in good faith peer review activities; and
  • The right to be free of “sham peer reviews” and manipulation of medical staff bylaws by hospitals attempting to silence or inhibit the voicing of physician concerns regarding the advocacy of their patients. (CHSO Rep. 2-A-18).  

Last Updated On

August 14, 2018