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HomeMy WebLinkAboutMINUTES - 08281990 - 1.51 BOARD OF SUPERVISORS FROM: Mark Finucane, Health Services Director QoElhh,I C Ira Costa DATE' July 23, 1990IRE7 Cou "ta1 SUBJECT: BYLAW CHANGES SPECIFIC REOUEST(S) OR RECOMMENDATION(S) & BACKGROUND AND JUSTIFICATION RECOMMENDATION: APPROVAL FISCAL IMPACT: NONE BACKGROUND: The Medical Staff of Merrithew Memorial Hospital and Clinics has approved changes to the Medical Staff Bylaws. The changes are as follows. (See attachments) : 1. Section 4 . 5-7 (P. 15): Clarifies need for Administrator and Governing Body to act upon Medical Executive Committee recommendations regarding advancement of staff member at the conclusion of the Provisional period. 2 . Section 5.4 (A. 20) : Clarifies duration of initial appointment to the Medical Staff. 3 . Section 8. 4 (1) (p. 43) : Changes approval process of Medical Staff Departmental Rules and Regulations from President of Staff and Professional Affairs Committee of the Board to Medical Executive Committee and Professional Affairs Committee. 4 . Section 9 . 1 (P. 48) : Requires each committee to formulate Rules and Regulations, subject to the approval of the Medical Executive Committee and the Professional Affairs Committee. 5. Section 9 . 13-2 (c) (P. 581 : Clarifies membership of Medical Quality Assurance Committee. 6. Section 9. 21 (p. 62a, 62b) : Develops Critical Care Committee in compliance with JCAHO regulations. Roger Barrow, MD /to�r. - Medical Staff President Execut ve ire HospitaLlincis CONTINUED ON ATTACHMENT: YES SIGNATURE: RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD 'COMMITTEE APPROVE OTHER SIGNATUR S : ACTION OF BOARD ON APPROVED AS RECOMMENDED OTHER VOTE OF SUPERVISORS 1 HEREBY CERTIFY THAT THIS IS A TRUE x 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. ATTESTED AUG 2 8 1990 ��' County Administrator County Auditor-Controller PHIL BATCHELOR, CLERK OF THE BOARD OF Health Services Director SUPERVISORS AND COUNTY ADMINISTRATOR Hospital: Medical Staff Administration/Patty Rose Campbell, CMSC BY DEPUTY M382/7-83 -62a- public - based on survival and comparison data. The committee will also supervise the tumor registry for quality..control of abstracting, staging and reporting. The committee will conduct a minimum of two patient care evaluation studies annually, one to include survival data. The committee will meet at least quarterly or more often as needed and reports to the Patient Care Monitoring Committee. Y.20-2 COMPOSITION The cancer committee includes; (a) Chairperson appointed by the Medical Staff President, subject to Medical Executive Committee approval . (b) Tumor Board Chairperson (who may also serve as Cancer Committee Chairperson). (c) Six (6) additional medical staff members including repre- sentation from Internal Medicine, Surgery, OB-GYN, Pathology, Hematology/Oncology, and Family Practice. (d) Field Liaison Physician. (e) Representation from Administration, Social Services and Nursing, all without vote. (f) The cancer registrar who will act as staff to the Cancer Committee, without vote. Y.21 CRITICAL CARE COMMITTEE Y.21-1 PURPOSE AND MEETINGS The Critical Care Committee (CCC) is a multi-disciplinary committee which oversees the quality, safety, and appropriate- ness of patient care services provided within the Critical Care Unit (CCU). The CCC, in consultation with the Patient Care Policy Committee, shall develop written policies and procedures which shall guide the provision of patient care including, but not limited to; criteria for patient admission to and discharge from the CCU (including priority determination); guidelines for providing specialized patient care to patients who require such care but who, for pre-determined reasons (e.g. contagious disease) or for unforeseen reasons (e.g. when patient load exceeds optimal operational capacity) cannot be cared for within the CCU; guidelines for transferring and referring patients who require services not provided by the CCU; guide- lines for circumstances under which consultation is required; the role of the Resident Staff in the CCU; and guidelines for appropriate orientation, in-service training, and continuing medical and nursing education. As appropriate and as necessary, the CCC shares information with the Medical Quality -58- (c) President-Elect of the Medical Staff, or the President of the Medical Staff during any period in which the office of President- Elect is vacant, with vote. (d) Physician representative from Psychiatric Quality Assurance activities, appointed by the Chairperson of the Medical Quality Assurance Committee, with vote. (e) Administrator, without vote. (f) Director, Hospital Quality Assurance Program, without vote. Y.14 UTILIZATION REVIEW COMMITTEE Y.14-1 PURPOSE AND MEETINGS The Utilization Review Committee! develops and oversees implementa- tion and operation of the utilization review (UR) plan relating to inpatient, ambulatory and clinical support services, makes utiliza- tion decisions as required under, the plan, analyzes utilization pro- files and evaluates the effectiveness of the UR program. Physician members of the committee act as the physician advisors required by the UR plan. The URC meets at least monthly and reports to the Medical Quality Assurance Committee. Y.14-2 COMPOSITION The Utilization Review Committee includes: (a) Chairperson, appointed by the Chairperson of the MQAC, subject to MEC approval . (b) At least 6-8 additional Medical Staff members, selected to pro- vide broad representation from the Medical Staff. (c) At least one representative from Administration, without vote. (d) Director of Social Services, without vote. (e) Representative from Nursing, without vote. (f) Representative from Finance, without vote. (g) Representative from Quality Assurance Department, without vote. (h) Director of Medical Records, without vote. e -48- ARTICLE IX COMMITTEES 9.1 DESIGNATION Medical staff committees shall include but not be limited to, the medical staff meeting as a committee of the whole, meetings of departments and divisions, meetings of committees established under Article IX, and meetings of special or ad hoc committees or subcommittees created by the MEC or the committees established under this Article (pursuant to this Article) or by departments (pursuant to Section 8.4(1 ). The committees described in this Article shall be the standing committees of the medical staff. Special or ad hoc committees may be created by the Medical Executive Committee to perform specified tasks. Each committee shall formulate recommendations for committee rules and regulations reasonably necessary for the proper discharge of its responsibilities, subject to the approval of the MEC and the Professional Affairs Committee. Unless otherwise specified, the chairpersons and members of all committees shall be appointed by and may be removed by the Medical Staff President, subject to consultation with and approval by the Medical Executive Committee. Medical staff committees shall be responsible to the Medical Executive Committee. Y.2 GENERAL PROVISIONS 9.2-1 TERMS OF COMMITTEE MEMBERS Unless otherwise specified, committee members shall be appointed for a term of l year, and shall serve until the end of this period or until the member's successor is appointed, unless the member shall sooner resign or be removed from the committee. 9.2-2 REMOVAL If a member of a committee ceases to be a member in good standing of the medical staff, fails to meet committee attendance requirements, or suffers. a loss or significant limitation of practice privileges, or if any other good cause exists, that member may be removed by the Medical Executive Committee, in consultation with the committee chairperson. 9.2-3 VACANCIES Unless otherwise specifically provided, vacancies on any committee shall be filled in the same manner in which an original appointment. to such committee is made; provided however, that if an individual who obtains membership by virtue of these bylaws is removed for cause, a successor may be sele-ted by the Medical Executive Committee. -43- (e) reviewing and evaluating departmental adherence to: (1) medical staff policies and procedures and (2) sound principles of clinical practice; (f) coordinating patient care provided by the department's members with nursing and ancillary patient care services; (g) submitting written reports as necessary to the medical executive com- mittee concerning; (1) the department's review and evaluation activi- ties, actions taken thereon, and the results of such action; and (2) recommendations for maintaining and improving the quality of care pro- vided in the department and the hospital ; (h) meeting at least monthly for the purpose of considering patient care review findings and the results of the department's other review and evaluation activities, as well as reports on other department and staff functions; (i ) establishing such committees or other mechanisms as are necessary and desirable to perform properly the functions assigned to it; (j ) taking appropriate action when important problems in patient care and clinical performance or opportunities to improve care are identified; (k) accounting to the medical executive committee for all professional and medical staff administrative activities within the department; (1 ) formulating recommendations for departmental rules and regulations reasonably necessary for the proper discharge of its responsibilities subject to the approval of the MEC and the Professional Affairs Committee. (m) planning and conducting, in cooperation with the Residency Director, a program of instruction, supervision, and evaluation of Residents, 8.5 FUNCTIONS OF DIVISIONS Subject to approval of the medical executive committee, each division shall perform the functions assigned to it by the department chairman. Such functions may include, without limitation, retrospective patient care reviews, evaluation of patient care practices, credentials review and pri- vileges delineation, and continuing education programs. The division shall transmit regular reports to the Department Head on the conduct of its assigned functions. -20- 5.4 DURATION OF APPOINTMENT AND REAPPOINTMENT Except as otherwise provided in these bylaws, initial appointments to the medical staff, except the Resident staff, shall be until the applicant's second birthday after the initial provisional appointment. Reappointments shall be for a period of 2 years. Initial appointments to the Resident staff shall be for the duration of residency training. 5.5 APPLICATION PROCEDURE 5.5-1 APPLICATION Application for Staff membership must be submitted by the. applicant in writing and on such form as approved by the Medical Executive Committee. Prior to the application being submitted, the applicant will be provided access to a copy of the Medical Staff Bylaws, the Rules and Regulations of the Staff and its Departments and Divisions, and summaries of other policies and resolutions relating to clinical practice in the hospital and clinics. 5.5-2 APPLICATION CONTENT Every applicant, except Resident staff applicants, must furnish complete information on the following: (a) undergraduate, medical school , and postgraduate training, including the name of each institution, degrees granted, program completed, dates attended; (b) all currently valid medical , dental , podiatric and other pro- fessional licensures or certifications, and Drug Enforcement Administration verification (with exceptions determined by Credentials Committee action when the applicant will not be prescribing treatment) and any other controlled substances registration, with the date and number of each; (c) specialty or sub-specialty board certification, recertification; (d) health impairments (including alcohol and drug dependencies), hospitalizations, and institutionalizations, if any, which may affect the applicant's ability in terms of skill , attitude and judgement to perform professional and medical staff duties; (e) professional liability insurance coverage and information on malpractice claims history and experience (suits and settlements made, concluded and pending); (f) any pending or completed action involving denial , revocation, suspension, reduction, limitation, probation, non-renewal or voluntary relinquishment (by resignation or expiration) of: license or certificate to practice any profession in any state or country; Drug Enforcement Administration or other controlled substances registration; membership or fellowship in local , state,.O national professional organizations; faculty membership at any medical or other professional school ; staff membership -15- Committee may extend the provisional staff status for an additional ` period of up to 12 months, which determination shall not be subject to review pursuant to Articles XI or XII. In no event shall the total provisional staff status of a member exceed twenty-four (24) months. At the conclusion of provisional staff status, further staff status is determined as stated in Section 4.5-7. 4.5-7 ACTION AT CONCLUSION OF PROVISIONAL STAFF STATUS. (a) If the provisional staff member has satisfactorily demonstrated his or her ability to exercise the clinical privileges ini- tially granted and otherwise appears qualified for continued medical staff membership, the member shall be eligible for placement in the active, Courtesy or affiliate staff, as appropriate, upon recommendation of Medical Executive Committee. The Administrator and the Governing Body shall act upon this MEC recommendation. Should any disagreement occur between the MEC, the Administrator, and the Governing Body, resolution shall occur in compliance with Section 5.5-5 (i ). (b) in all cases, the appropriate department shall advise the Credentials Committee, which shall make its report to the Medical Executive Committee which, in turn, shall. make its recommendation to the Professional Affairs Committee regarding a modification or termination of clinical privileges, or term- ination of medical staff membership. 4.6 RESIDENT STAFF 4.6-1 QUALIFICATIONS FOR RESIDENTS. The resident staff shall consist of members, each of whom: (a) meets the qualifications for medical staff membership set forth in Section 3.2; (b) is a graduate of an approved medical school and is a partici- pant in an approved residency or fellowship program. 4.6-2 PREROGATIVES. Each member of the resident staff shall be entitled to. (a) admit patients under appropriate supervision and direction of the program director, and the Head of the department in which he/she is exercising privileges; (b) exercise clinical privileges under appropriate supervision and direction of the program director and Head of the department in which he/she is exercising privileges; (c) attend meetings of the Medical Staff and, if invited, the departments to' which he/she is currently assigned; -62b- Y.21-1 PURPOSE AND MEETINGS (CONT): Assurance Committee and its subordinate committees. The CCC shall meet at least quarterly and reports to the Patient Care Policy Committee. The Chairperson (or his/her designee) shall serve as the Director of the CCU. 9.21-2 COMPOSITION The CCC includes: (a) At least one member each from the Department of Anesthesia, Medicine, and Surgery, one of whom shall be appointed chairperson by the President of the Medical Staff, subject to MEC approval , with vote. (b) The nursing supervisor of the Critical Care Unit, with vote. (c) The Residency Director, or his/her designee, with vote. (d) The Director of Cardiopulmonary Services, or his/her designee. (e) A member of the Resident Staff.