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Home My WebLink AboutMINUTES - 07251989 - 1.63 svl 1-003 TO: BOARD OF SUPERVISORS FROM: Mark Finucane, Director CVlltra Health Services Department Costa DATE: June 19, 1989 C SUBJECT: Adoption of the Amendments to the Medical Staff Bylaws V SPECIFIC REQUEST(S) OR RECOMMENDATIONS) & BACKGROUND AND JUSTIFICATION I. RECOMMENDED ACTION: Approve, adopt and authorize the Chair to execute on behalf of the Board, the amendments to the Medical Staff Bylaws of the Contra Costa County Health Services Department' s, Merrithew Memorial Hospital and Clinics. The Medical Staff Bylaws were originally approved by the Board of Supervisors on November 29, 1988. The amendments are as follows: Amendment A: Department Head Privileges Amendment B: Governing Body Signatures Amendment C: Annual Review of Bylaws Amendment D: Extend Presidential term for two years II. FINANCIAL IMPACT: None. III. BACKGROUND/REASONS FOR RECOMMENDATION: The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) requires that the Medical Staff Bylaws under which the medical staff of an institution operates be approved by the Governing Board of that institution. These Bylaws conform to the accreditating body' s standards. Additionally, the amendments have been reviewed by County Counsel 's Office, and it was recommended that these amendments be approved by the Governing Body. CONTINUED ON ATTACHMENT; _ YES SIGNATURE: 1"'^ RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE APPROVE OTHER SIGNATURE S : Y ACTION OF BOARD ON APPROVED AS RECOMMENDED L OTHER VOTE OF SUPERVISORS 1 HEREBY CERTIFY THAT THIS IS A TRUE UNANIMOUS (ABSENT ) AND CORRECT COPY OF AN ACTION TAKEN AYES: NOES: AND ENTERED ON THE MINUTES OF THE BOARD ABSENT: ABSTAIN: OF SUPERVISORS ON THE DATE SHOWN. cc: CC: Health Services Department ATTESTED _ J U L 2 5 1989 Hospital - Medical Staff Office ---- County Administrator PHIL BATCHELOR, CLERK OF THE BOARD OF SUPERVISORS AND COUNTY ADMINISTRATOR M382/7-83 BY �� p DEPUTY AMENDMENT A SECTIONS 6.3-3 and 6.3-4 These sections have been revised as shown below to prohibit Department Heads from granting their own privileges. Currently the Department NW ds grant their own privileges, subject to the review of the Credentials CommittgLT, the Medical Executive Committee, and the Governing Body. This Amendment would change the process so that the Chair of the Credentials Committee would grant Department Head's privileges, subject to the above review processes. It is expect that, where appropriate, the Chair of the Credentials Committee will see input from other staff members. 6.3-3 PRIVILEGES OF DEPARTMENT HEADS Privilege requests by Department Heads shall be individually reviewed and acted upon by the Chairperson of the Credentials Committee. Department Heads shall not grant Privileges to them- se ves. in the event that the Chairperson of the Credentials Committee is also a Department Head, the Medical Staff President shall act upon this individual 's privilege requests. 6.3-4 PROCEDURE All requests for clinical privileges shall be processed pursuant to the procedures outlined in Article V, except that requests for privileges by a Department Head shall not be acted upon by his/her- self, but rather by the Chairperson of the Credentials Committee as stated in Section 6.3-3 above. AMENDMENT B SECTIONS 8.4(L), 9.2-5(b), 14. 1 This amendment meets the JCAHO requirement that the Governing Body or its designee review and sign all Medical Staff, Department, and Conte Jtee Rules and Regulations, and Policies and Procedures. 6.4 FUNCTIONS OF DEPARTMENTS Tr The general functions of each department shall include: (1 ) formulating recommendations for departmental rules and regulations reasonably necessary for the proper discharge of its responsibilities subject to the approval by the Medical Staff President, n� d the Professional Affairs Committee. 9.2-5 DUTIES OF THE COMMITTEE CHAIRPERSON Each committee chairperson shall have the following authority, duties, and responsibilities: (a) act as presiding officer at committee meetings; (b) annually review, and amend as necessary, committee policies and procedures, subject to the approvalof the Medical Staff President and the Professional Affairs Committee. 14.1 RULES AND REGULATIONS The medical staff shall initiate and adopt such rules and regulations as it may deem necessary for the proper conduct of its work and shall periodically review and revise its rules and regulations to comply with current medical staff practice. Recommended changes to the rules and regulations shall be submitted to the Medical Executive Committee for review and evaluation prior to presentation for consideration by the medical staff as a whole under such review or approval mechanism as the medical staff shall establish. Following adoption by the Medical Staff and approval by the Professional Affairs Committee, such rules and regulations shall become effective. Applicants and members of the -medical staff shall be governed by such rules and regulations as are properly initiated and adopted. If there is a conflict between the bylaws and the rules and regulations, the bylaws shall prevail . The mechanism described herein shall be the sole method for the initiation, adoption, amendment, or repeal of the medical staff rules and regulations. AMENDMENT C SECTION 15. 1 This amendment meets the JCAHO requirement that the Bylaws state that the Medical Staff has a mechanism to review the Bylaws at least annially. ARTICLE XV ADOPTION AND AMENDMENT OF BYLAWS 15. 1 ANNUAL REVIEW These Bylaws shall be reviewed annually by the Medical Executive Committee. S - • 4 AMENDMENT D ARTICLE VII This amendment changes the term of the Medical Staff President from one to two years, effective with the incoming President as of July 1, 1989. The President- Elect would be elected one year prior to the beginning of the next term of President, and shall serve as a back=up to the President during that year. The Past President shall serve for one year after the completion of his/her term as President, and shalt serve as a back-up to the President during that year. Thus, it would look like this: 7/89 (7/90) 7/91 (7/92) 7/93 (7/94) LPast-Presiden (BerIetti )_ I I Past-Presiders PRESIDENT (Barrow) J L (Barrow)_ _ President _ Past- LElt_ _ 1I PRESIDENT I L ecPresident _ President Elect _ _ 1I PRESIDENT JLPresident E1gt_ _ _ _ As shown above, with this proposal the election for President Elect would be held every two years. Thus, there would be no election this summer; the next election would be in May of 1990. This amendment was proposed by Drs. Berletti , Hobert and Tremain, the three most recent Medical Staff Presidents, and endorsed by Dr. Wille, the President just prior to these three individuals. The primary reason cited for this amendment was that the office of President is becoming more complicated each year because of more intensive outside regulatory intervention. Furthermore, it was felt that more continuity was needed as we make the decisions necessary to move into a new hospital . Recent Presidents all stated that they did not fully understand the nature of their duties until they had held the office for at least 5 - 6 months. -89- AMENDED BY THE Medical Staff on: V ( I 19 M ��& to (Year e cal Staf Presi ent JUL 2 5 1989 APPROVED by the Governing Board on: 19 (Month TTateT / i ear airgerson Phil Batchelor,Crerk of the Board of Supervisors and County Administrator er o t e Governing o y ccs �1