“Board members should not usurp the role of management and should not micromanage,” according to The Joint Commission standard LD.01.03.01. This article provides insight into why ensuring a hospital’s board stays within its governance role is not only a best practice, but also reduces risk. Key areas of concern include employment/Human Resource issues, workers compensation matters, medical staff and credentialling concerns, professional liability matters, and privacy issues.

Board members are often tempted to get involved in employment issues when approached by staff or community members. When board members do get involved in an HR matter, it is often to 1) take action against an employee who the board member sees as being unfit for their job; or 2) do a favor for a friend by promoting them for a position or promotion. While a board member may genuinely want to help, the only individuals who should be involved in any employment decisions are the HR director and the hospital administrator/CEO.

Employee discipline is a legal issue, and board members lack necessary training to investigate, make an HR analysis, ensure consistency across the organization, and avoid deviations from other HR decisions. The board member can become a witness resulting in EEOC interviews, depositions in litigation instituted by the employee/prospective employee, and testifying at trial (potentially against the hospital). When action is taken against an employee, a board member’s involvement could lead to allegations against the board member personally of discrimination, harassment, hostile work environment, and even public intimidation. Often the hospital’s directors’ and officers’ coverage does not cover these claims. On the other hand, if the board member advocates for an employee, it can undermine the work of the HR director and administrator, expose the hospital to liability, and implicate his/her fiduciary relationship of loyalty to the hospital. If an employee or potential employee contacts a board member, the best practice is for the board member to respond simply, “I don’t get involved in personnel matters.”

Board members should avoid involvement in workers’ compensation matters, as they are carefully governed by state law. Actions or comments made by board members can accidentally violate the workers comp insurance policy and even cancel coverage.

The board must also be mindful of its unique role in medical staff matters. The Health Care Quality Improvement Act (HCQIA) and state law, including La. R.S. 13:3715.3, grant certain protections, including qualified immunity in suits brought by physicians, as long as the medical staff bylaws are precisely followed. An individual board member can incur personal liability by becoming involved outside of strict compliance with the bylaws. The hospital and those participating in the medical staff process can also lose immunity from a lawsuit. Historically, defamation actions by physicians have garnered significant jury awards, and there may be no insurance coverage for either the board member or the hospital.

In one 2013 Louisiana case, Granger v. Christus Health Central Louisiana, the hospital was ultimately exonerated on appeal. However, a jury initially awarded almost $4 million to a cardiac surgeon who had behavioral and quality issues. Through the peer review processes, the physician’s privileges were initially suspended, but the suspension was lifted. He received a letter of reprimand and six months of supervised probation, and was required to attend anger management. When the physician failed to comply, his privileges were revoked. He sued on the procedural issue of whether he should have received a hearing. The Court considered, for purposes of HCQIA immunity whether the Medical Executive Committee acted “without malice and the reasonable belief that such action is warranted by the facts.” Key facts came from a recording the physician made of his conversation with an unsuspecting board member. While the hospital was later vindicated when both the jury verdict and lower court decisions were reversed on appeal, the case serves as a cautionary tale for board members: confidentiality is crucial, and board members should not stray outside of their role.

If a board member is contacted regarding a medical staff matter, the appropriate response is “I don’t discuss medical staff matters.” The board member should direct the individual to the hospital administrator or Medical Executive Committee chair. If the board member receives a complaint or has his/her own concerns about a physician’s behavior or quality of care, he/she should bring the matter to the attention of the hospital administrator.

Similarly, board members may have concerns about an alleged instance of medical malpractice. These matters are within the purview of the hospital’s Risk Management Department and board members should avoid involvement. Any response other than “I don’t get involved in risk management matters” risks a waiver of confidentiality protections under La. R.S. 13:3715.4. The hospital may have to disclose information that it could otherwise protect from discovery. Further, the board member could become a witness, with their special status giving extra weight to their testimony. Further, when a board member become a witness against the hospital, it implicates the duty of loyalty to the hospital.

Board members should also be aware of the risks of breaches of confidentiality under the Health Insurance Portability and Accountability Act (HIPAA). HIPAA can be implicated where an unauthorized individual accesses records out of curiosity relating to a family member or an incident in the community, or to check up on either a patient or a physician. Discussing a patient’s health information without the patient’s authorization with a physician or other hospital staff member can also implicate HIPAA.

In the event of a HIPAA breach, the hospital is obligated to self-disclose the breach to both the patient and the government, and may be exposed to potential fines and penalties. Penalties under HIPAA for a person who knowingly obtains or discloses individually identifiable health information in violation of the privacy rule can include a criminal penalty of up to $50,000 per event and up to one year in prison.

Hospital board members should limit their role to oversight of management and operations and advising management on key issues, without micromanaging or usurping management’s role. When approached about matters outside of their scope, a board member best avoids trouble by responding: “I don’t get involved in personnel/medical staff/risk management matters.”

“Board members should not usurp the role of management and should not micromanage,” according to The Joint Commission standard LD.01.03.01. This article provides insight into why ensuring a hospital’s board stays within its governance role is not only a best practice, but also reduces risk. Key areas of concern include employment/Human Resource issues, workers compensation matters, medical staff and credentialling concerns, professional liability matters, and privacy issues.

Board members are often tempted to get involved in employment issues when approached by staff or community members. When board members do get involved in an HR matter, it is often to 1) take action against an employee who the board member sees as being unfit for their job; or 2) do a favor for a friend by promoting them for a position or promotion. While a board member may genuinely want to help, the only individuals who should be involved in any employment decisions are the HR director and the hospital administrator/CEO.

Employee discipline is a legal issue, and board members lack necessary training to investigate, make an HR analysis, ensure consistency across the organization, and avoid deviations from other HR decisions. The board member can become a witness resulting in EEOC interviews, depositions in litigation instituted by the employee/prospective employee, and testifying at trial (potentially against the hospital). When action is taken against an employee, a board member’s involvement could lead to allegations against the board member personally of discrimination, harassment, hostile work environment, and even public intimidation. Often the hospital’s directors’ and officers’ coverage does not cover these claims. On the other hand, if the board member advocates for an employee, it can undermine the work of the HR director and administrator, expose the hospital to liability, and implicate his/her fiduciary relationship of loyalty to the hospital. If an employee or potential employee contacts a board member, the best practice is for the board member to respond simply, “I don’t get involved in personnel matters.”

Board members should avoid involvement in workers’ compensation matters, as they are carefully governed by state law. Actions or comments made by board members can accidentally violate the workers comp insurance policy and even cancel coverage.

The board must also be mindful of its unique role in medical staff matters. The Health Care Quality Improvement Act (HCQIA) and state law, including La. R.S. 13:3715.3, grant certain protections, including qualified immunity in suits brought by physicians, as long as the medical staff bylaws are precisely followed. An individual board member can incur personal liability by becoming involved outside of strict compliance with the bylaws. The hospital and those participating in the medical staff process can also lose immunity from a lawsuit. Historically, defamation actions by physicians have garnered significant jury awards, and there may be no insurance coverage for either the board member or the hospital.

In one 2013 Louisiana case, Granger v. Christus Health Central Louisiana, the hospital was ultimately exonerated on appeal. However, a jury initially awarded almost $4 million to a cardiac surgeon who had behavioral and quality issues. Through the peer review processes, the physician’s privileges were initially suspended, but the suspension was lifted. He received a letter of reprimand and six months of supervised probation, and was required to attend anger management. When the physician failed to comply, his privileges were revoked. He sued on the procedural issue of whether he should have received a hearing. The Court considered, for purposes of HCQIA immunity whether the Medical Executive Committee acted “without malice and the reasonable belief that such action is warranted by the facts.” Key facts came from a recording the physician made of his conversation with an unsuspecting board member. While the hospital was later vindicated when both the jury verdict and lower court decisions were reversed on appeal, the case serves as a cautionary tale for board members: confidentiality is crucial, and board members should not stray outside of their role.

If a board member is contacted regarding a medical staff matter, the appropriate response is “I don’t discuss medical staff matters.” The board member should direct the individual to the hospital administrator or Medical Executive Committee chair. If the board member receives a complaint or has his/her own concerns about a physician’s behavior or quality of care, he/she should bring the matter to the attention of the hospital administrator.

Similarly, board members may have concerns about an alleged instance of medical malpractice. These matters are within the purview of the hospital’s Risk Management Department and board members should avoid involvement. Any response other than “I don’t get involved in risk management matters” risks a waiver of confidentiality protections under La. R.S. 13:3715.4. The hospital may have to disclose information that it could otherwise protect from discovery. Further, the board member could become a witness, with their special status giving extra weight to their testimony. Further, when a board member become a witness against the hospital, it implicates the duty of loyalty to the hospital.

Board members should also be aware of the risks of breaches of confidentiality under the Health Insurance Portability and Accountability Act (HIPAA). HIPAA can be implicated where an unauthorized individual accesses records out of curiosity relating to a family member or an incident in the community, or to check up on either a patient or a physician. Discussing a patient’s health information without the patient’s authorization with a physician or other hospital staff member can also implicate HIPAA.

In the event of a HIPAA breach, the hospital is obligated to self-disclose the breach to both the patient and the government, and may be exposed to potential fines and penalties. Penalties under HIPAA for a person who knowingly obtains or discloses individually identifiable health information in violation of the privacy rule can include a criminal penalty of up to $50,000 per event and up to one year in prison.

Hospital board members should limit their role to oversight of management and operations and advising management on key issues, without micromanaging or usurping management’s role. When approached about matters outside of their scope, a board member best avoids trouble by responding: “I don’t get involved in personnel/medical staff/risk management matters.”

“Board members should not usurp the role of management and should not micromanage,” according to The Joint Commission standard LD.01.03.01. This article provides insight into why ensuring a hospital’s board stays within its governance role is not only a best practice, but also reduces risk. Key areas of concern include employment/Human Resource issues, workers compensation matters, medical staff and credentialling concerns, professional liability matters, and privacy issues.

Board members are often tempted to get involved in employment issues when approached by staff or community members. When board members do get involved in an HR matter, it is often to 1) take action against an employee who the board member sees as being unfit for their job; or 2) do a favor for a friend by promoting them for a position or promotion. While a board member may genuinely want to help, the only individuals who should be involved in any employment decisions are the HR director and the hospital administrator/CEO.

Employee discipline is a legal issue, and board members lack necessary training to investigate, make an HR analysis, ensure consistency across the organization, and avoid deviations from other HR decisions. The board member can become a witness resulting in EEOC interviews, depositions in litigation instituted by the employee/prospective employee, and testifying at trial (potentially against the hospital). When action is taken against an employee, a board member’s involvement could lead to allegations against the board member personally of discrimination, harassment, hostile work environment, and even public intimidation. Often the hospital’s directors’ and officers’ coverage does not cover these claims. On the other hand, if the board member advocates for an employee, it can undermine the work of the HR director and administrator, expose the hospital to liability, and implicate his/her fiduciary relationship of loyalty to the hospital. If an employee or potential employee contacts a board member, the best practice is for the board member to respond simply, “I don’t get involved in personnel matters.”

Board members should avoid involvement in workers’ compensation matters, as they are carefully governed by state law. Actions or comments made by board members can accidentally violate the workers comp insurance policy and even cancel coverage.

The board must also be mindful of its unique role in medical staff matters. The Health Care Quality Improvement Act (HCQIA) and state law, including La. R.S. 13:3715.3, grant certain protections, including qualified immunity in suits brought by physicians, as long as the medical staff bylaws are precisely followed. An individual board member can incur personal liability by becoming involved outside of strict compliance with the bylaws. The hospital and those participating in the medical staff process can also lose immunity from a lawsuit. Historically, defamation actions by physicians have garnered significant jury awards, and there may be no insurance coverage for either the board member or the hospital.

In one 2013 Louisiana case, Granger v. Christus Health Central Louisiana, the hospital was ultimately exonerated on appeal. However, a jury initially awarded almost $4 million to a cardiac surgeon who had behavioral and quality issues. Through the peer review processes, the physician’s privileges were initially suspended, but the suspension was lifted. He received a letter of reprimand and six months of supervised probation, and was required to attend anger management. When the physician failed to comply, his privileges were revoked. He sued on the procedural issue of whether he should have received a hearing. The Court considered, for purposes of HCQIA immunity whether the Medical Executive Committee acted “without malice and the reasonable belief that such action is warranted by the facts.” Key facts came from a recording the physician made of his conversation with an unsuspecting board member. While the hospital was later vindicated when both the jury verdict and lower court decisions were reversed on appeal, the case serves as a cautionary tale for board members: confidentiality is crucial, and board members should not stray outside of their role.

If a board member is contacted regarding a medical staff matter, the appropriate response is “I don’t discuss medical staff matters.” The board member should direct the individual to the hospital administrator or Medical Executive Committee chair. If the board member receives a complaint or has his/her own concerns about a physician’s behavior or quality of care, he/she should bring the matter to the attention of the hospital administrator.

Similarly, board members may have concerns about an alleged instance of medical malpractice. These matters are within the purview of the hospital’s Risk Management Department and board members should avoid involvement. Any response other than “I don’t get involved in risk management matters” risks a waiver of confidentiality protections under La. R.S. 13:3715.4. The hospital may have to disclose information that it could otherwise protect from discovery. Further, the board member could become a witness, with their special status giving extra weight to their testimony. Further, when a board member become a witness against the hospital, it implicates the duty of loyalty to the hospital.

Board members should also be aware of the risks of breaches of confidentiality under the Health Insurance Portability and Accountability Act (HIPAA). HIPAA can be implicated where an unauthorized individual accesses records out of curiosity relating to a family member or an incident in the community, or to check up on either a patient or a physician. Discussing a patient’s health information without the patient’s authorization with a physician or other hospital staff member can also implicate HIPAA.

In the event of a HIPAA breach, the hospital is obligated to self-disclose the breach to both the patient and the government, and may be exposed to potential fines and penalties. Penalties under HIPAA for a person who knowingly obtains or discloses individually identifiable health information in violation of the privacy rule can include a criminal penalty of up to $50,000 per event and up to one year in prison.

Hospital board members should limit their role to oversight of management and operations and advising management on key issues, without micromanaging or usurping management’s role. When approached about matters outside of their scope, a board member best avoids trouble by responding: “I don’t get involved in personnel/medical staff/risk management matters.”

“Board members should not usurp the role of management and should not micromanage,” according to The Joint Commission standard LD.01.03.01. This article provides insight into why ensuring a hospital’s board stays within its governance role is not only a best practice, but also reduces risk. Key areas of concern include employment/Human Resource issues, workers compensation matters, medical staff and credentialling concerns, professional liability matters, and privacy issues.

Board members are often tempted to get involved in employment issues when approached by staff or community members. When board members do get involved in an HR matter, it is often to 1) take action against an employee who the board member sees as being unfit for their job; or 2) do a favor for a friend by promoting them for a position or promotion. While a board member may genuinely want to help, the only individuals who should be involved in any employment decisions are the HR director and the hospital administrator/CEO.

Employee discipline is a legal issue, and board members lack necessary training to investigate, make an HR analysis, ensure consistency across the organization, and avoid deviations from other HR decisions. The board member can become a witness resulting in EEOC interviews, depositions in litigation instituted by the employee/prospective employee, and testifying at trial (potentially against the hospital). When action is taken against an employee, a board member’s involvement could lead to allegations against the board member personally of discrimination, harassment, hostile work environment, and even public intimidation. Often the hospital’s directors’ and officers’ coverage does not cover these claims. On the other hand, if the board member advocates for an employee, it can undermine the work of the HR director and administrator, expose the hospital to liability, and implicate his/her fiduciary relationship of loyalty to the hospital. If an employee or potential employee contacts a board member, the best practice is for the board member to respond simply, “I don’t get involved in personnel matters.”

Board members should avoid involvement in workers’ compensation matters, as they are carefully governed by state law. Actions or comments made by board members can accidentally violate the workers comp insurance policy and even cancel coverage.

The board must also be mindful of its unique role in medical staff matters. The Health Care Quality Improvement Act (HCQIA) and state law, including La. R.S. 13:3715.3, grant certain protections, including qualified immunity in suits brought by physicians, as long as the medical staff bylaws are precisely followed. An individual board member can incur personal liability by becoming involved outside of strict compliance with the bylaws. The hospital and those participating in the medical staff process can also lose immunity from a lawsuit. Historically, defamation actions by physicians have garnered significant jury awards, and there may be no insurance coverage for either the board member or the hospital.

In one 2013 Louisiana case, Granger v. Christus Health Central Louisiana, the hospital was ultimately exonerated on appeal. However, a jury initially awarded almost $4 million to a cardiac surgeon who had behavioral and quality issues. Through the peer review processes, the physician’s privileges were initially suspended, but the suspension was lifted. He received a letter of reprimand and six months of supervised probation, and was required to attend anger management. When the physician failed to comply, his privileges were revoked. He sued on the procedural issue of whether he should have received a hearing. The Court considered, for purposes of HCQIA immunity whether the Medical Executive Committee acted “without malice and the reasonable belief that such action is warranted by the facts.” Key facts came from a recording the physician made of his conversation with an unsuspecting board member. While the hospital was later vindicated when both the jury verdict and lower court decisions were reversed on appeal, the case serves as a cautionary tale for board members: confidentiality is crucial, and board members should not stray outside of their role.

If a board member is contacted regarding a medical staff matter, the appropriate response is “I don’t discuss medical staff matters.” The board member should direct the individual to the hospital administrator or Medical Executive Committee chair. If the board member receives a complaint or has his/her own concerns about a physician’s behavior or quality of care, he/she should bring the matter to the attention of the hospital administrator.

Similarly, board members may have concerns about an alleged instance of medical malpractice. These matters are within the purview of the hospital’s Risk Management Department and board members should avoid involvement. Any response other than “I don’t get involved in risk management matters” risks a waiver of confidentiality protections under La. R.S. 13:3715.4. The hospital may have to disclose information that it could otherwise protect from discovery. Further, the board member could become a witness, with their special status giving extra weight to their testimony. Further, when a board member become a witness against the hospital, it implicates the duty of loyalty to the hospital.

Board members should also be aware of the risks of breaches of confidentiality under the Health Insurance Portability and Accountability Act (HIPAA). HIPAA can be implicated where an unauthorized individual accesses records out of curiosity relating to a family member or an incident in the community, or to check up on either a patient or a physician. Discussing a patient’s health information without the patient’s authorization with a physician or other hospital staff member can also implicate HIPAA.

In the event of a HIPAA breach, the hospital is obligated to self-disclose the breach to both the patient and the government, and may be exposed to potential fines and penalties. Penalties under HIPAA for a person who knowingly obtains or discloses individually identifiable health information in violation of the privacy rule can include a criminal penalty of up to $50,000 per event and up to one year in prison.

Hospital board members should limit their role to oversight of management and operations and advising management on key issues, without micromanaging or usurping management’s role. When approached about matters outside of their scope, a board member best avoids trouble by responding: “I don’t get involved in personnel/medical staff/risk management matters.”

“Board members should not usurp the role of management and should not micromanage,” according to The Joint Commission standard LD.01.03.01. This article provides insight into why ensuring a hospital’s board stays within its governance role is not only a best practice, but also reduces risk. Key areas of concern include employment/Human Resource issues, workers compensation matters, medical staff and credentialling concerns, professional liability matters, and privacy issues.

Board members are often tempted to get involved in employment issues when approached by staff or community members. When board members do get involved in an HR matter, it is often to 1) take action against an employee who the board member sees as being unfit for their job; or 2) do a favor for a friend by promoting them for a position or promotion. While a board member may genuinely want to help, the only individuals who should be involved in any employment decisions are the HR director and the hospital administrator/CEO.

Employee discipline is a legal issue, and board members lack necessary training to investigate, make an HR analysis, ensure consistency across the organization, and avoid deviations from other HR decisions. The board member can become a witness resulting in EEOC interviews, depositions in litigation instituted by the employee/prospective employee, and testifying at trial (potentially against the hospital). When action is taken against an employee, a board member’s involvement could lead to allegations against the board member personally of discrimination, harassment, hostile work environment, and even public intimidation. Often the hospital’s directors’ and officers’ coverage does not cover these claims. On the other hand, if the board member advocates for an employee, it can undermine the work of the HR director and administrator, expose the hospital to liability, and implicate his/her fiduciary relationship of loyalty to the hospital. If an employee or potential employee contacts a board member, the best practice is for the board member to respond simply, “I don’t get involved in personnel matters.”

Board members should avoid involvement in workers’ compensation matters, as they are carefully governed by state law. Actions or comments made by board members can accidentally violate the workers comp insurance policy and even cancel coverage.

The board must also be mindful of its unique role in medical staff matters. The Health Care Quality Improvement Act (HCQIA) and state law, including La. R.S. 13:3715.3, grant certain protections, including qualified immunity in suits brought by physicians, as long as the medical staff bylaws are precisely followed. An individual board member can incur personal liability by becoming involved outside of strict compliance with the bylaws. The hospital and those participating in the medical staff process can also lose immunity from a lawsuit. Historically, defamation actions by physicians have garnered significant jury awards, and there may be no insurance coverage for either the board member or the hospital.

In one 2013 Louisiana case, Granger v. Christus Health Central Louisiana, the hospital was ultimately exonerated on appeal. However, a jury initially awarded almost $4 million to a cardiac surgeon who had behavioral and quality issues. Through the peer review processes, the physician’s privileges were initially suspended, but the suspension was lifted. He received a letter of reprimand and six months of supervised probation, and was required to attend anger management. When the physician failed to comply, his privileges were revoked. He sued on the procedural issue of whether he should have received a hearing. The Court considered, for purposes of HCQIA immunity whether the Medical Executive Committee acted “without malice and the reasonable belief that such action is warranted by the facts.” Key facts came from a recording the physician made of his conversation with an unsuspecting board member. While the hospital was later vindicated when both the jury verdict and lower court decisions were reversed on appeal, the case serves as a cautionary tale for board members: confidentiality is crucial, and board members should not stray outside of their role.

If a board member is contacted regarding a medical staff matter, the appropriate response is “I don’t discuss medical staff matters.” The board member should direct the individual to the hospital administrator or Medical Executive Committee chair. If the board member receives a complaint or has his/her own concerns about a physician’s behavior or quality of care, he/she should bring the matter to the attention of the hospital administrator.

Similarly, board members may have concerns about an alleged instance of medical malpractice. These matters are within the purview of the hospital’s Risk Management Department and board members should avoid involvement. Any response other than “I don’t get involved in risk management matters” risks a waiver of confidentiality protections under La. R.S. 13:3715.4. The hospital may have to disclose information that it could otherwise protect from discovery. Further, the board member could become a witness, with their special status giving extra weight to their testimony. Further, when a board member become a witness against the hospital, it implicates the duty of loyalty to the hospital.

Board members should also be aware of the risks of breaches of confidentiality under the Health Insurance Portability and Accountability Act (HIPAA). HIPAA can be implicated where an unauthorized individual accesses records out of curiosity relating to a family member or an incident in the community, or to check up on either a patient or a physician. Discussing a patient’s health information without the patient’s authorization with a physician or other hospital staff member can also implicate HIPAA.

In the event of a HIPAA breach, the hospital is obligated to self-disclose the breach to both the patient and the government, and may be exposed to potential fines and penalties. Penalties under HIPAA for a person who knowingly obtains or discloses individually identifiable health information in violation of the privacy rule can include a criminal penalty of up to $50,000 per event and up to one year in prison.

Hospital board members should limit their role to oversight of management and operations and advising management on key issues, without micromanaging or usurping management’s role. When approached about matters outside of their scope, a board member best avoids trouble by responding: “I don’t get involved in personnel/medical staff/risk management matters.”