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Home My WebLink AboutMINUTES - 08091994 - 1.54 TO: BOARD OF SUPERVISORS FROM: Mark Finucane, Health Services Director '!f Contra Costa DATE: August 2, 1994 County SUBJECT. CHANGES TO MEDICAL STAFF BYLAWS SPECIFIC REOUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION RECOMMENDATION: Approve the amendments to the Medical Staff Bylaws. Detailed amendments showing deletions and insertions are attached. BACKGROUND: Changes to the bylaws were undertaken for several reasons: 9.15 and 9.17 Patient Care Monitoring'Committee and Clinical Department Evaluation Committee. These committees have been deleted by the Medical Quality Assurance Committee as their functions have been assumed by the various departments. Thus it was necessary to delete these to be consistent with our current practice. 9.20 Cancer Committee. The American College of Surgeons,which accredits our cancer program,requires that all members of these multi- disciplinary committees vote on committee matters. At the request of the Cancer Committee,the cancer registrar and the administration representative will now have votes on this committee. This has little impact in reality since, in general,decisions on this committee are made by consensus. 10.8 Attendance Requirements. This amendment to 10.8-1 simply clarifies this section and makes it consistent with other sections in that each member of the courtesy staff who works four or more hours per week and is not a member of a medical staff of another hospital must abide by the attendance requirements of active staff. These changes were approved by the Medical.Executive Committee and also by the Medical Staff as a whole by mailed ballots. They also were reviewed by County Counsel. FISCAL IMPACT: None. CONTINUED ON ATTACHMENT: YES SIGNATURE r RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE APPROVE OTHER SIGNATURE(S): ACTION OF BOARD ON APPROVED AS RECOMMENDED OTHER VOTE OF SUPERVISORS I HEREBY CERTIFY THAT THIS IS A TRUE UNANIMOUS (ABSENT ) AND CORRECT COPY OF AN ACTIO`J TAKEN AYES: NOES: AND ENTERED ON THE MINUTES OF THE BOARD ABSENT: ABSTAIN: -Z-- OF SUPERVISORS ON THE DATE SHOWN. Contact Person: Frank Puglisi ATTESTED CC: Frank Puglis i.- - PHIL BATCH R, CLERK OF 7H BOARD OF Steven C. Tremain, M.D. SUPERVISOR AND COUNTY ADMINISTRATOR Director, Health Services Dept. _nn BY � ( ,Ll L ,, j DEPUTY PATIENT CARE MeNTORwa eemmm:r:rEE 9.15-1 Purpose and MeeteiMs gatheiing, and analpes displays for surgical indications monitming, blood tise and t,ansfusion i evievv, antibiotic a,id other d,tig use revievv, patient infection mo, ig and assigned to it. It monitors and enfor lits elating to adequacy, completeness • Pediatrics.9.i 5-2 eoinposition T- ie Feme hic tides, (C) Fou, addutwona' Medical Staff membens, including epresentation fio... at leas Staff.9.17-1 Purpose and Meefings I 1ple,, ei itation of spec.al studies of the quality of ca.e provided and in t!ie use of patient fli,d*i,gsof4iipat*eiitdepait,iie,itiiioibffidDtya,idiiioita'etyi-ev*ews. It also couidillates tile ra'uatmuiiaiidiiiui,Dto,mi,gofcaiepi-ovmdedDiit'ievciiDousspeLffia' cclitvaieas. The einuiperson, andio, to relevant clinical units of the (a) ei airpe,son appointed by tlie el aw,pe,son of the meAe,subject to mEe • (d) Rep.esentative fI on.Ad milliSh atiul 1,without vote. (e) E)thei men.be.s with specia I expeitise as necessary on a, ad-hoe basis,without vote 9.20 CANCER COMMITTEE 9.20-2 Composition The cancer committee includes: (e) Representation from Administration, Social Services and Nursing, all without vote. (f) The cancer registrar,who also will act as staff to the Cancer Committee,withoat vote. 10.8 ATTENDANCE REQUIREMENTS 10.8-1 Staff Meetings Except as stated below, each member of the active staff during the term of appointment who are entitled to attend meetings under Article IV and each member of the courtesy staff subject to 4.4-1(f) shall be required to attend: (a) At least 50 percent of general staff meetings duly convened pursuant to these Bylaws, and (b) At least 50 percent of all meetings of each department,division, and committee of which he or she is a member. Members of staff categories other than active staff shall be required to attend such other meetings as may be determined by the Medical Executive Committee. 9.15' Operating Room Committee 9.15-1 Purpose and Meetings The OR Committee is a multi-disciplinary committee which oversees operative and other invasive procedures provided within the operating rooms of Merrithew Memorial Hospital and clinics. The committee will oversee and coordinate the following processes: ► Selecting aavpropriate procedures: ► Preparing the atienfi ► Monitoring theap tient during and after the procedure: and ► Discharging the gatient from the service or setting. The committee will oversee and coordinate the monitoring and improving of operative and invasive procedures]2y systematic measurement of the above mentioned processes and search for areas of improvement. The committee, in consultation with the individual departments and appropriate Medical Staff Committees,will develop written volicies and procedures which shallua ide the above processes. The committee is the forum where the interdepartmental operational issues of the surgical services will be coordinated among the various departments and disciplines involved. Such issues include, but are not limited to,the scheduling of cases,the mechanism for adding extra cases,defining on- call responsibilities. etc. The committee will assist the represented departments in reviewing equipment and capital improvement needs and make recommendations regarding the prioritization of resources. The committee will reportto the Medical Quali Assurance Committee. Through June 1995,the committee chair also will esent regular updates on the committee's progress to the Medical rp Executive Committee. As appropriate and as necessary the committee will share information with other Medical Staff departments or ancillary service departments. Meetings will be held at least quarterly. 9.15-1 Composition a) A representative from the Anesthesia Department A representative from the Surgery Department (c) A_representative from the OB/GYN Department A representative from the Orthopedic Division or another surgicalspecialty area The nurse manager overseeing the OR and post-anesthesia recovery unit (f A representative from the post-anesthesia recovery unit nursing staff LgI A_representative from the operating room nursing staff A representative from the clinic nursing staff who works in a clinic which prepares atients for sur-ciery Q A staff member from the Quality Management Department who will function as quality coach for the committee (non-voting) Other invitedug ests as aagpropriate(non-voting) One of the above medical staff members will be appointed as chairperson by the Medical Staff President sub'ect to MEC approval.