BILL ANALYSIS                                                                                                                                                                                                    



                                                                  SB 1456
                                                                  Page  1

          SENATE THIRD READING
          SB 1456 (Kuehl)
          As Amended  August 23, 2004
          Majority vote

           SENATE VOTE  :   Vote not Relevant
            
           ENVIRONMENTAL SAFETY     5-2                                    
           
           -------------------------------- 
          |Ayes:|Laird, Chu, Levine,       |
          |     |Lowenthal, Hancock        |
          |     |                          |
          |-----+--------------------------|
          |Nays:|Aghazarian, Leslie        |
          |     |                          |
           -------------------------------- 
           SUMMARY :  Clarifies the medical staff's right of self-governance  
          and makes various findings and declarations.  Specifically,  this  
          bill  :   

          1)Requires the medical staff's right of self-governance to  
            include, but not be limited to, all of the following:

             a)   Establishing in medical bylaws, rules or regulation,  
               criteria and standards consistent with the medical peer  
               review process, for medical staff membership and  
               privileges;

             b)   Establishing in medical staff bylaws, rules or  
               regulations, clinical criteria and standards to oversee and  
               manage quality assurance, utilization review, and other  
               medical staff activities including, but not limited to,  
               periodic meetings of the medical staff and its committees  
               and departments and review and analysis of patient medical  
               records;

             c)   Selecting and removing medical staff officers;

             d)   Assessing medical staff dues and utilizing the medical  
               staff dues as appropriate for the purposes of the medical  
               staff;

             e)   The ability to retain and be represented by independent  
               legal counsel at the expense of the medical staff, provided  








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               that medical staff at the University of California have the  
               right to retain and be represented by independent legal  
               counsel at the expense of the medical staff upon approval  
               by the Regents of the University of California or their  
               designee in accordance with the bylaws of the Regents,  
               which approval shall not be unreasonably denied; and,

             f)   Initiating, developing, and adopting medical staff  
               bylaws, rules and regulation, and amendments thereto,  
               subject to approval of the hospital governing board, which  
               approval shall not be unreasonably withheld.

          2)Prohibits the medical bylaws from interfering with the  
            independent rights of the medical staff to do any of the  
            following, but requires the procedures for:

             a)   Selecting and removing medical staff officers;

             b)   Assessing medical staff dues and utilizing medical staff  
               dues as appropriate for the purposes of the medical staff;  
               and,

             c)   The ability to retain and be represented by independent  
               legal counsel at the expense of the medical staff.

          3)Requires, that with respect to any dispute arising, the  
            medical staff and hospital governing board to meet and confer  
            in good faith to resolve the dispute.  Allows a superior court  
            of any county to issue an injunction, writ of mandate, or  
            other appropriate order whenever a person or entity has  
            engaged in or is about to engage in any acts or practices that  
            hinder, restrict, or otherwise obstruct the ability of the  
            medical staff to exercise its rights, obligations, or  
            responsibilities, as specified.  

          4)Makes legislative findings and declarations on the following:

             a)   That providing quality medical care in hospitals depends  
               on the mutual accountability, interdependence, and  
               responsibility, of the medical staff and the hospital  
               governing body for the proper performance of their  
               respective obligations;

             b)   That the governing board of a hospital must act to  
               protect the quality of medical care provided and the  








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               competency of its medical staff, and the responsible  
               governance of the hospital in the event that the medical  
               staff fails in any of its substantive duties or  
               responsibilities, and nothing in this bill undermines their  
               authority.  The final authority of the hospital governing  
               board may be exercised for the responsible governance of  
               the hospital or for the conduct of the business affairs of  
               the hospital but such final authority may only be exercised  
               with a reasonable and good faith belief that the medical  
               staff has failed to fulfill a substantive duty or  
               responsibility in matters pertaining to the quality of  
               patient care.  Specifies that it would be a violation of  
               the medical staff's self-governance and independent rights  
               for the hospital governing board to assume a duty or  
               responsibility of the medical staff precipitously,  
               unreasonably, or in bad faith; and,

             c)   That the specific actions that would constitute bad  
               faith or unreasonable action on the part of either the  
               medical staff, or hospital governing board will always be  
               fact specific and cannot be precisely described in statute,  
               and that the provisions set forth herein do nothing more  
               than provide for the basic independent rights and  
               responsibilities of a self-governing medical staff.   
               Specifies that a successful relationship between a  
               hospital's medical staff and governing board depends on the  
               mutual respect for the rights and responsibilities of the  
               other.

          5)Makes the bill's enactment contingent on the passage of SB  
            1325.

           EXISTING LAW  : 

          1)Provides for the licensing and regulation of physicians and  
            surgeons by the Medical Board of California in the Department  
            of Consumer Affairs.

          2)Requires a licensed general or specialized hospital with five  
            or more physicians on its medical staff to have rules adopted  
            by its board of directors to govern the operation of the  
            hospital, and the rules to include the following:

             a)   Provision for the organization of licensed physicians  
               within the hospital into a formal medical staff with  








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               appropriate officers and bylaws, and with staff  
               appointments on an annual or biennial basis;

             b)   Provision that membership on the medical staff shall be  
               restricted to physicians and other licensed practitioners  
               competent in their respective fields and worthy in  
               professional ethics.  Prohibits the division of profits  
               from professional fees and such division is cause for  
               exclusion from the staff;

             c)   Provision that the medical staff is self-governing with  
               respect to the professional work performed in the hospital;  
               that the medical staff meet periodically and review and  
               analyze at regular intervals their clinical experience; and  
               the medical records of patients to be the basis for such  
               review and analysis; and,

             d)   Provision that adequate and accurate medical records be  
               prepared and maintained for all patients.

          3)Requires a licensed general or specialized hospital, having  
            less than five physicians on its medical staff to have rules  
            adopted by its board of directors to govern the operation of  
            the hospital, and the rules to include the following  
            provisions:

             a)   That membership on the medical staff shall be restricted  
               to physicians and other licensed practitioners competent in  
               their respective fields and worthy in professional ethics.   
               Division of profits from professional fees in any manner is  
               prohibited and any such division is cause for exclusion  
               from the staff; and,

             b)   That adequate and accurate medical records be prepared  
               and maintained for all patients.

          4)States that it is unprofessional conduct if the rules for the  
            medical staff and hospital are not adopted.

           FISCAL EFFECT  :  According to the Assembly Appropriations  
          Committee staff, this bill will have minor, if any, state costs.

           COMMENTS  :  This bill is substantially similar to the provisions  
          of SB 1325 (Kuehl), pending with the Governor, but includes  
          clarifying amendments dealing with the medical staff of  








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          University of California (UC) hospitals.  The amendments  
          indicate that UC medical staff's right to retain and be  
          represented by independent legal counsel must be approved by the  
          Regents of the UC or its designee in accordance with the bylaws  
          of the Regents.  UC believes these amendments are necessary to  
          address the unique relationship between the University and its  
          faculty physicians and make this bill consistent with the bylaws  
          governing the University.  UC specifies that its faculty  
          physicians enjoy certain rights and privileges that are not  
          common to other medical staff including access to legal counsel  
          under the UC Regents' Bylaws and Standing Orders, the provision  
          of medical malpractice insurance, and benefit of internal  
          grievance processes designed to address and resolve quality  
          issues and concerns.  Without the amendments, the provisions of  
          the SB 1325 would have an adverse impact on the relationship of  
          faculty physicians and the UC Board of Regents or its designees.  
             


           Analysis Prepared by  :    Rosielyn Pulmano / HEALTH / (916)  
          319-2097 


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