NAMSS Hall of Fame Nomination Statement Regarding Chris Giles I am nominating Christina Giles, MS, CPMSM, for induction into the NAMSS Healthcare Hall of Fame. Chris meets all of the five eligibility criteria as she has served as a teacher, mentor and leader in the Medical Staff Services profession for many years. Chris has successfully worked at seven organizations within the healthcare industry and has held the titles of Director, Associate Consultant, Consultant & Principal, Senior Consultant, and Independent Consultant and Speaker (please refer to her resume for more information). She was co-founder of the Massachusetts Association of Medical Staff Services (MAMSS) and also served as President. Chris then went on to serve as a member of the NAMSS Education Council, the Governance, Management and Manpower Committee, was elected as Regional Representative on the NAMSS Board, and was faculty for NAMSS for approximately 23 years which is outstanding. Chris also served as an NCQA surveyor, a CQI instructor, and as an expert witness in negligent credentialing law cases. For El-Centro College, Chris served as faculty teaching medical staff services professionals so they could earn their college degrees in this specialized field. For the New England Health Care Assembly, she was faculty and Chair of the Credentialing Certificate Program and developed the curriculum as well. In addition, she has developed many other educational training programs over the years. She has co-authored two books and published articles in “Healthcare Review” and the “Journal of Hospital Marketing”. For HcPro, she served as an advisory editorial board member for the “Credentialing and Peer Review Legal Insider” and also the Credentialing Resource Center publications. These are just a few examples of her assuming leadership positions in the healthcare industry outside of her own organization or company, her willingness to share her expertise with her peers/colleagues, and her ability to influence and effect change within the industry. In addition to her various jobs within healthcare and her many years of experience, she has owned two businesses: Medical Staff Solutions and C. Giles and Associates. These two businesses have helped numerous hospitals, MCOs, PHOs, CVOs, group practices, nursing homes and home nursing services. Chris was also the co-founder and partner in Edge-u-Cate, LLC which was just another venue for her to share her knowledge and expertise for the benefit of others. I can personally attest to the fact that I know of at least five women who have went on to assume leadership positions within the field due to her mentorship, myself included. I am sure there are many more I do not know about. Chris is definitely viewed as a role model and top leader within the industry by her peers. In summary, I feel as many others I know do, that Chris has a high level of knowledge on various topics within the medical staff services profession. She is an excellent teacher, mentor, role model, and overall has made significant contributions to the Medical Staff Services profession for many years. She truly deserves this award!
Excellent organizational, facilitative and communication skills, ability to liaison with multi levels of an organization in planning and initiating required change;
Development of educational/training programs, excellent presentation/teaching skills;
Team project Manager
Proven aptitude for problem recognition, definition and expeditious solution/follow through
Ability to interpret and apply organizational and regulatory agency rules, regulations, policies
Ability to assess organizational needs and develop required policies and procedures
PROFESSIONAL EXPERIENCE Provision of consulting services to hospitals, managed care organizations, group practices/PHO’s and credentialing
verification organizations concerning: assessment of and revision to credentialing processes, assessment of and revision to policies and procedures, medical staff bylaws, rules and regulations, development and provision of educational and orientation programs for medical staff officers or leaders and staff; restructuring of medical staff committees and performance improvement processes, staffing assessments, redefining work processes, training of credentialing personnel, credentials committees and medical staff leaders
Expert witness in legal credentialing cases
Project Manager overseeing implementation of change in processes, training of personnel and revising necessary accompanying documents.
Surveyor for National Committee on Quality Assurance (NCQA) for credentialing verification organizations
nationwide. Faculty Member for National Association of Medical Staff Services Continuous Quality Improvement instructor, providing resources to Medical Staff in movement from Quality
Assurance to Performance Improvement. Chair of Credentialing Certificate Program Committee - sponsored by The Healthcare Assembly - Developed
curriculum and serve as faculty. Development of credentialing process and procedures for a health care system with its various components: hospital,
MCO, PHO, large group practice, nursing homes and home nursing service, inclusive of medical and allied health professionals, assessment of appropriate computer requirements.
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C. Giles Resume – Page 2
EDUCATION AND TRAINING Worcester State College M.S., Human Service Management Worcester, MA Graduated University of Mass. Medical Center Management Development Program Worcester, MA Completed Davis & Elkins College B.A./French Education Elkins, West Virginia Graduated
EMPLOYMENT HISTORY June, 2014- Dec. 2016 Independent Consultant & Speaker C.Giles & Associates Nashua, NH October 2012 – June 2014 Senior Consultant
The Greeley Company Danvers, MA
January 2001 – July 2012 Co-founder and partner
Edge-u-Cate, LLC December, 1996 – October, 2012 Consultant & Principal Medical Staff Solutions Nashua, NH January 1991 - December,1996 Director, Medical Staff Services St. Vincent Hospital Worcester, MA July, 1987 - January 1991 Director, Medical Staff Services The Medical Center of Central Massachusetts Worcester, MA Sept. 1989 - 2012 Faculty Member National Association Medical Staff Services November, 1986 - July, 1987 Associate Consultant InterQual, Incorporated Marlborough, MA June, 1981 - November, 1986 Assistant for Professional Affairs University of Massachusetts Medical Center Chief of Staff's Office Worcester, MA
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C. Giles Resume Page 3
ACCOMPLISHMENTS o Developed and presented national seminars on: credentialing, management, health care law and
accreditation standards o Developed credentialing procedures for healthcare systems including hospitals, managed care
organizations, physician hospital organizations, credentialing verification organizations and nursing homes
o Co-authored two books on credentialing and privileging o Co-founder and partner of Edge-U-Cate, LLC, 2001-2012; current faculty member
o Developed credentialing and privileged procedures for advanced practice professionals for healthcare systems
o Developed appropriate documentation process to ensure compliance with ACCME requirements for continuing education programs
o Enhanced and maintained appropriate documentation process for compliance with ACGME requirements for graduate medical education programs
o Developed and revised Medical Staff Bylaws, Rules and Regulations, and policy and procedure manuals for healthcare organizations
o Overseen Implementation and maintenance of electronic databases of required practitioner information
o Revised appointment/reappointment applications, delineation of privileges forms and related letters, documents and forms
o Revised and edited manual for Medical Staff Coordinators o Developed and revised credentialing seminar materials o Participated in the development of software package to record credentialing information o Developed a referring physician office
HONORS, PROFESSIONAL ASSOCIATIONS o Elected Who's Who in American Colleges and Universities, o Certified Medical Staff Coordinator, o Member, National Association of Medical Staff Services, Mass. Association, MSS, o Elected, Northeastern Regional Representative to NAMSS Board, o Member, Education Council, NAMSS, o President, Massachusetts Association of Medical Staff Services and Co-Founder of MAMSS o Member, Massachusetts Medical Society Advisory Council on Centralized Verification Service, o National Faculty Member for NAMSS
o Faculty member for El Centro College, Dallas, TX o Editor, MED SCOPE, Medical Staff Newsletter, St. Vincent Hospital, o New England Healthcare Assembly, Credentialing Management Certificate Board
Committee Member & Chairman, o Faculty member, New England Healthcare Assembly, o Advisory Editorial Board member, Credentialing Resource Center, HcPro Publishing and Credentialing and Peer Review Insider, HcPro Publishing
PUBLICATIONS "Marketing a Physician Referral Service" - Journal of Hospital Marketing, Volume 2, No. 2,
“Credentialing Responsibility: Yours, Mine or Ours?” -Healthcare Review, Issue I, Co-Author: The Medical Services Handbook: Fundamentals & Beyond, Jones & Bartlett Publishers, Inc., 2007 and 2011 Co-Author: HealthCare Credentialing: A Guide to Practical Innovations, Wolter & Kluwer Publishers, 2007-Present
March 6, 2017 NAMSS 2025 M Street NW, Suite 800 Washington, DC 20036 Re: Christina Giles – NAMSS Healthcare Hall of Fame Nomination To Whom It May Concern: It is my privilege to be asked and subsequently to provide this letter in support of Christina (Chris) Giles’ nomination for the NAMSS Healthcare Hall of Fame. I have known Chris for almost the entire length of my career as a medical services professional; nearly 25 years. I came to know her first as an industry leader and teacher. I admired her teaching style that allowed for and encouraged my growth as it was so obviously rooted in both her love for teaching - an outward expression of her strong educational background. As time passed, I came to refer to Chris as a friend, a mentor, a professional colleague, a co-presenter, and, even later, as her supervisor. Because of this background, I believe that I am in a very unique position to provide comments in support of her nomination. (On a personal note, Chris continued to teach me even while reporting to me - for this I will always be grateful.) Chris has been a steadfast role model in the industry for many years. She is well known through her time as a volunteer for NAMSS in a variety of leadership roles, as faculty for NAMSS, through the development and implementation of Edge-U-Cate programs, the creation and delivery of her own educational programs, and later, the primary developer of robust educational content for The Greeley Company. A thorough and intense researcher Chris is diligent in her approach to delivering both formal and informal education to her peers and medical services professionals regardless of their level of experience. She is also well known to the field as an author, having written several publications over the course of her career. The functions performed by medical services professionals and credentialing and privileging processes have benefited and improved through Chris’ contributions as a consultant. I’ve witnessed firsthand her ability to ‘right the ship’ of highly dysfunctional medical staff services departments and to do so with understanding of all the cultural and operational challenges that may impede sustainable success. For the reasons noted above and many more, I am honored to support Chris’ nomination for the NAMSS Healthcare Hall of Fame. Please do not hesitate to contact me if you need additional information. Regards,
Sally J Pelletier, CPMSM, CPCS Advisory Consultant and Chief Credentialing Officer The Greeley Company (617)365-5722
350 South Grand Avenue
Two California Plaza
Suite 3400
Los Angeles, CA 90071-3427
213.928.9800
Fax 213.928.9850
Philadelphia Boston Washington, D.C. Los Angeles New York Pittsburgh
Detroit Berwyn Harrisburg Orange County Princeton Silicon Valley Wilmington
www.pepperlaw.com
Mark A. Kadzielski direct dial: (213) 928-9820 direct fax: (800) 589-4728
It is my distinct pleasure and privilege to write in support of your nomination to the NAMSS Hall of Fame.
I have known you for almost all of your professional career. We have spoken at many NAMSS conferences during that time. I have also had the opportunity in the past decade to collaborate with you as co-author of our book, HEALTH CARE CREDENTIALING: A Guide to Innovative Practices. Your incredible hard work in preparing this book for publication, and in working diligently on our annual supplements since its publication, has been inspiring.
Throughout our relationship your strong sense of professionalism has always demonstrated itself.
You are a truly dedicated medical staff services professional, and have significantly contributed to the increased respect this profession has achieved in health care today. I am proud to support your nomination.
Warmest personal regards,
MARK A. KADZIELSKI MAK/hp
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Excerpt from the Medical Staff Services Handbook:
Fundamentals & Beyond, Jones & Bartlett Publications, Inc., 2007 and 2011
Chapter 4: Medical Staff Bylaws and Related Documents
Christina W. Giles, CPMSM, MS
“These will be your Bible—do not go anywhere without them!”
Truer words were never said with regard to medical staff bylaws―this is best practice advice for all
medical staff services and credentialing professionals.
Although in most organizations, bylaws are referred to as a necessary evil; a document described as
legalistic, lengthy, unclear and difficult to understand, the reality is that you will not be successful in your
job if you do not have useful, well-written bylaws and related documents, policies, and procedures. If you
have been working in medical staff services for any period of time, you know that eventually many key
issues discussed at medical staff committee and/or department meetings or questions from medical staff
leaders can be answered by researching the bylaws, rules and regulations, or related documents.
The bylaws, rules and regulations, and policies and procedures provide a written outline of the medical
staff’s structure and function along with the medical staff’s responsibility in accomplishing the goals,
mission, and vision of the organization.1 These documents contain the different components and specificity
of the medical staff structure. The policies and procedures contain detailed how-tos providing the MSP an
opportunity to follow procedures that have been well established and that are compliant with Joint
Commission on Accreditation of Healthcare Organizations (JC) standards, as well as state, federal, and
hospital requirements.
DEFINITIONS
Defining the names given to each kind of document will help identify what each contains.
• Bylaws are a governance framework document that establishes the roles and responsibilities of a
body and its members.2
• Medical staff bylaws are regulations and/or rules adopted by the organized medical staff and the
governing body of an organization for internal governance and for defining rights and obligations
of various officers, persons, or groups, within the organized medical staff’s structure.3
• A policy is defined by Webster’s dictionary as a statement of fact that refers to a standard to be
maintained; management or procedure based primarily on material interest; or a definite course or
method of action selected from among alternatives and in light of given conditions to guide and
determine present and future decisions; or a high-level overall plan embracing the general goals and
acceptable procedures of a governing body.4
• A procedure is defined by Webster’s dictionary as a set of instructions on how the policy will be
achieved; a particular way of accomplishing something; a series of steps followed in a regular
definite order; a traditional or established way of doing things.4
• A rule is a prescribed guide for conduct or action, a written regulation governing procedure or
controlling conduct.4
• A regulation is an authoritative rule dealing with details or procedure.4
2
Some medical staffs also have separate departmental rules and regulations. These documents typically
contain the specifics of treating patients in that particular specialty, specialty specific privileging criteria,
or state and federal requirements.
Based on various court interpretations there continues to be uncertainty as to whether the bylaws
constitute a contract—a document binding on the parties that agree to them—between the medical staff
and the hospital or health care entity that approves and signs them. (See further discussion in Chapter 18.)
The AMA has a policy stating that “The medical staff bylaws are a contract between the organized
medical staff and the hospital.”5 The JC 2009 standards require that “The organized medical staff and
governing body work collaboratively, clearly reflecting recognized roles, responsibilities and
accountabilities . . . The Medical Staff Bylaws create a system of rights and responsibilities between the
organized medical staff and the governing body and between the organized medical staff and its
members.”6 JC standards also currently require that the governing body approve and comply with the
medical staff. Neither body may unilaterally amend the medical staff bylaws or rules and regulations.7 One
may infer from the above standard that since neither the medical staff or the governing body can amend the
bylaws or rules and regulations without the other group’s input, this (these) documents are a contract that
cannot be changed by just one party. There have been various court cases representing both sides of this
issue. (See Chapter 18 written by Joanne P. Hopkins, Esq.)
MEDICAL STAFF BYLAWS AND RELATED MANUALS
JC outlines in the hospital accreditation standards what the medical staff bylaws should include. The
Centers for Medicare and Medicaid (CMS) also outline what should be in medical staff bylaws in the
hospital Conditions of Participation. Both documents should be maintained in the office as resource
material. See Table 4-1, which provides a comparison of CMS and JC requirements concerning the content
of medical staff bylaws as well as NCQA’s requirements for content of policies and procedures.
Many medical staffs have separated the bylaws document into multiple documents including a:
credentials manual, organization manual, fair hearing plan, rules and regulations, and policies and
procedures. If more than one document is developed, all the documents should be defined in the initial
definition of the medical staff bylaws as “related documents or manuals” of the bylaws. For example, the
definition of medical staff bylaws may appear as:
Medical staff bylaws or bylaws means the bylaws of the medical staff. Related manuals means any one
or more of the following documents as appropriate to the context and shall be considered as included in
the bylaws:
• Medical staff credentials manual
• Medical staff fair hearing plan
• Organization manual
• General rules and regulations—policies and procedures of the medical staff
The reasoning behind separating the documents is based on the time and effort it takes to amend them.
Traditionally, medical staff bylaws required that the active medical staff (or all those designated the right
to vote) must vote on any and all revisions. Some bylaws even require one or two “readings,” and the
medical staff must receive the proposed revisions 30–45 days prior to voting on the changes. By separating
contents into different manuals, the manuals of the bylaws can include a more timely and easier to achieve
revision process. For example, the credentialing procedures that may be influenced by state, federal, and
accrediting body requirements, and the organizational structure, such as the numbers of
departments/divisions and medical staff committees, could be included in manuals in which the
3
amendment process is achieved in a more timely manner such as presentation to the medical executive
committee for vote and then to the governing body. Up until 2005 it appeared that JC was willing to accept
this alternative approach of creating multiple documents with some of them containing a shorter, more
direct amendment process. However, the reader should be aware that revised JC language published in
2005 appears to be very specific in terms of what items need to be included in the actual bylaws document.
In reaction to the revised standard published in 2005, there were multiple issues raised to JC concerning
the difficulty of compliance with the new standard language. As a result, JC stated that they would not
survey for compliance with the revised language in the new element of performance for that standard until
January 2007:
Implementation of a new requirement for Medical Staff standard MS.1.20 has been delayed until
January, 2007. The new Element of Performance (EP 19) would require that the medical staff and the
governing body agree on the following:
• The issues that must be addressed in the medical staff bylaws.
• The criteria used to identify the issues that must be addressed in the medical staff bylaws.
• The process used for joint adoption/approval of other issues that are addressed in the rules,
regulations, and policies.
The intent of EP 19 is to create a collaborative and systematic, yet flexible, adoption process. The
proposed EP evoked serious concerns from the field, which see the new requirement as prescriptive
and burdensome, requiring an extensive review of existing medical staff bylaws and other documents.
Delaying implementation allows further exploration and possible modifications that would address
these concerns. MS.1.20 originated from the 2004 reformatting of the standards. Following confusion
in the field regarding the intent of MS.1.20, EP 19 was developed.”8
An example of the “multiple manual” approach would be the bylaws containing the “nuts and bolts” of the
medical staff organization; the credentials manual containing the specifics about the appointment,
reappointment, and privileging processes; the organization manual containing the listing of
departments/divisions and committees; and the rules and regulations containing the specifics about how to
admit, transfer, care for and discharge patients, and any operating room requirements and medical records
requirements. The policies and procedures would include such things as: licensed independent practitioner
health and well being, code of behavior, medical staff peer review, practitioner interview,
sedation/analgesia, and so on. Some medical staffs want the fair hearing and appellate procedures included
in the bylaws; others would prefer that a separate document be established. Either way, the two
sections/documents that would still be voted upon by the whole medical staff are the bylaws and the fair
hearing and appellate review procedures. Figure 4-1 depicts a traditional bylaws table of contents. There is
no specific method for separating these topics into manuals, but many legal counsels who support the idea
of separation of the documents would be able to advise what items to include in which documents.
CMS and accrediting body requirements for what needs to be in the medical staff bylaws should be
reviewed annually to determine if there have been any revisions to the requirements. Figure 4-2 provides
excerpts from bylaws about related manuals; Figure 4-3 is a sample table of contents for a medical staff
organization and functions manual. Figure 4-4 is a sample table of contents for medical staff rules and
regulations.
After reading this chapter, take the time to review your institution’s medical staff bylaws and identify
the CMS requirements as well as any accrediting body standards relevant to medical staff bylaws with
which you must comply. This will familiarize you with your documents, as well as assist you in reviewing
them for compliance with external standards. In addition, obtain a copy of the hospital’s bylaws and
compare the language in the medical staff section of the hospital bylaws to relevant wording in the medical
4
staff bylaws—there should not be any discrepancies. The medical staff bylaws are typically revised more
often than the hospital bylaws, and discrepancies can often occur within the two documents.
The most important thing to remember about bylaws and related manuals is that they must always
reflect current structure and practice of the medical staff. These should be considered “living” documents,
in that they will be used by many people on a continual basis; therefore, they must be current and reflect
compliance with state, federal, and accrediting body requirements as well as current practice in the
hospital.
MEDICAL STAFF BYLAWS AND RELATED MANUALS REVISION PROJECT
The revision process should be handled by taking a project management approach. First the key
stakeholders in this process should be identified: key medical staff leaders, the whole medical staff,
hospital administration, the MSSP and other internal administrative managers or directors, the governing
body, and legal counsel. Typically, the medical staff organization is allowed a great deal of creative
freedom in developing the medical staff documents. Some medical staffs prefer “vague” language that
allows more freedom when making decisions when issues arise. Other medical staffs prefer very specific
language that clearly spells out what to do in a particular situation. Most medical staff service professionals
favor the latter because it is helpful to have a definitive bylaw, rule, regulation, or policy statement to refer
to when a particular issue is raised.
As noted above, the bylaws provide a description of the current structure and practice of a particular
medical staff. Each institution and its medical staff organization also has its own culture. Oftentimes it is
possible to “see” within the document language the type of relationship that exists among the medical staff,
hospital administration and the board of trustees.
Medical staff bylaws generally reflect the “culture” of the medical staff. While many standard
provisions are typically included in bylaws, certain other provisions, not necessarily legal but essential,
will generally be included. The degree of governing body control, role of legal counsel, the level of
medical staff authority or representation on board committees, and the approach to medical staff
corrective action are indications of institutional culture. No specific approach or culture is preferable,
but different cultures will generally result in different bylaw provisions.9
Typically the MSP is charged with the responsibility of assisting the medical staff in its job of reviewing
and revising the medical staff documents. Often, the MSSP is the person who actually drafts proposed
language and then presents the new language to the bylaws committee and/or legal counsel who may revise
as necessary. A major bylaws revision project is quite an undertaking and takes many weeks or months of
work. Some hospitals prefer to hire a consultant and outside legal counsel to draft the documents and assist
the medical staff in working through the new language. There are so many legal issues involved in medical
staff activities today; it is always helpful to have legal counsel assistance or at least review prior to
finalizing any revisions. A major revision project is also an opportunity to consider changing or revising
not only language but perhaps structure or organizational details of the organized medical staff, especially
if the organization has become too bureaucratic or complicated. Such changes could include a reduction in
the number of departments, medical staff committees, or staff categories; a lengthening of the medical staff
officer and department chairs’ terms of office; reduction in meeting attendance requirements; or
simplification of the bylaws amendment process. The redesign of the medical staff has to take place first;
the preparation of revised documents that describe the redesign would be the last step in the process.
The impact of proposed changes should be aired, examined, discussed, and negotiated with key
members of the medical staff, hospital administration and the governing board. “Working” the proposed
revisions in this manner should preclude any unexpected opposition.
5
Medical staff professionals should maintain an ongoing bylaws and medical staff document revision
file in which all relevant articles or findings that need to be discussed by the bylaws committee or medical
staff officers are maintained. Any recommendations for changes from a medical staff member, department,
or committee should also be maintained, researched, and then presented to the committee for
consideration. Members of the governing body may also submit requests for bylaws revisions that must be
considered by the medical staff. The MSP and medical staff leaders have to be constantly aware of changes
in state and federal law and in the JC and CMS hospital requirements that might affect the medical staff
organization, its structure, and how it is currently functioning. The MSSP should develop appropriate
liaisons and include monthly research on helpful Web sites or use health care–related newsletters to
capture these prospective changes and issues (e.g., contacts at the local or state medical societies, state
hospital association, state association of medical staff services, and the National Association of Medical
Staff Services). In addition, monthly checks with the Federal Register for changes in federal law should
become part of the work process (www.acess.gpo.gov). The American Health Lawyers Association
(www.healthlawyers.org) has a helpful Web site, as do Horty, Springer and Mattern, P.C.
(www.hortyspringer.com—go to health law library); the American Hospital Association (www.aha.org),
and the American Medical Association (www.ama-assn.org).
REVIEWING THE AMENDMENT PROCESS
The bylaws amendment process should be defined in the bylaws. Amending the document typically
requires a review and recommendation from the bylaws and medical executive committees, advance notice
of proposed revisions to the active medical staff (or those with voting prerogatives), specific voting
procedures as outlined in the bylaws document (which may include a voice, secret ballot, mail ballot, show
of hands, or proxy vote), a majority vote of those allowed to vote, and approval by the governing board.
Review your institution’s bylaws amendment process and identify any opportunities for improvement
in this process; i.e., can this process be simplified?
• Consider changing the time frame for providing notice of proposed revisions to the whole medical
staff to 15 days, instead of 30 or 45.
• Consider changing the required vote of majority of members able to vote to majority of members
able to vote and present at the meeting held for the purpose of acting on revisions.
• Consider also allowing for a mail ballot, distributed 14 working days prior to deadline. An
affirmative vote may be cast by marking the ballot “yes” or by discarding the ballot. A negative
vote may be cast by marking the ballot “no” and returning. To be adopted an amendment must
receive a majority of the votes cast.
• Consider allowing the MEC to have the power to adopt such amendments that are technical or legal
modifications or clarifications, reorganization or renumbering, or amendments made necessary
because of punctuation, grammar, or spelling errors. Such amendments shall be effective
immediately and shall be permanent if not disapproved by the medical staff or the board within 60
days of adoption by the MEC.
MAJOR CONSIDERATIONS FOR A MEDICAL STAFF BYLAWS REVISION PROJECT
