Autumn is an excellent time for hospitals to review and update their Professional Staff Rules and Regulations (“Rules and Regulations”).

Rules and Regulations are an important regulatory and risk management tool for hospitals. Along with a hospital’s by-laws, policies and procedures, Rules and Regulations help to ensure that the hospital is able to meet its statutory duties; its quality of care obligations; and its responsibilities to patients, staff and visitors, by articulating the hospital’s expectations for how its credentialed professional staff will conduct themselves.

Rules and Regulations should not be static documents. To be effective, they need to continuously evolve to reflect current expectations for professional staff. While it is up to each organization to determine the topics and issues addressed through its Rules and Regulations, the following key questions should be asked in any review:

  • Are your Rules and Regulations consistent with applicable law?
  • Are your Rules and Regulations consistent with your current by-laws and how your professional staff is organized?
  • Is it clear who the Rules and Regulations apply to?
  • Do your Rules and Regulations accurately reflect your expectations of the professional staff to whom they apply?
  • Is there duplication or, even worse, inconsistency between your Rules and Regulations and hospital policy or procedure?
  • Is compliance with Rules and Regulations entrenched in your appointment and credentialing processes? Specifically, is commitment to abide by the Rules and Regulations a condition of initial and ongoing appointment to your hospital’s professional staff? Is failure to comply grounds for discipline, up to and including suspension of privileges or refusal to reappoint where warranted?
  • Do your Rules and Regulations clearly communicate the expectations of professional staff, and are they readily available for reference?
  • Are your Rules and Regulations enforced? Even if they meet all of the requirements above, Rules and Regulations will not be effective if they are not enforced.

Pursuant to the Public Hospitals Act (Ontario) and its related Hospital Management Regulation (“Regulation 965”), the hospital’s board is responsible for establishing the Rules and Regulations after receiving and considering the recommendations of the hospital’s medical advisory committee (or of the professional staff advisory committee, where such entity has been established in lieu of a medical advisory committee).

We recommend that Rules and Regulations be reviewed and updated regularly, ideally at least once every three years. A review should also be undertaken in conjunction with any regulatory changes, legal decisions (such as court decisions or coroner’s recommendations), substantive amendments to the professional staff by-laws, changes to best practice, or changes to related organizational policy and procedure.