HomeMy WebLinkAboutMINUTES - 07222008 - C.119 sE -L
TO: BOARD OF SUPERVISORS (��,,� � Contra
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CostaFROM: William Walker, M.D., Health Services Director ;: r
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By: Jacqueline Pigg, Contracts Administrator
'4 COUN"�
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DATE: July 02, 2008 County
SUBJECT: Bylaws Amendment
SPECIFIC REQUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION
RECOMMENDATION:
Support and authorize proposed amendments to the Medical Staff Bylaws Rules & Regulations of Contra
Costa Regional Medical Center and Health Centers to satisfy state licensure regulations, as well as comply
with imposed standards of Contra Costa Regional Medical Center and Health Centers Medical Staff Bylaws.
FISCAL IMPACT:
No Fiscal Impact
BACKGROUND:
The Performance Improvement Committee (PIC) convened, discussed and agreed on the proposed
changes to the Medical Staff Bylaws Rules & Regulations. The proposed changes would include
modifications to reappointment guidelines, clarification in definitions, grammatical adjustments, title
changes, updates to clinical departments and divisions.
CONTINUED ON ATTACHMENT: X_YES SIGNA URE:
RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE
i/kPPROVE OTHER
SIGNA URE(S): !'
ACTION OF BOARD ON APPROVE AS RECOMMENDED OT/AER
VOTE OF SUPERVISORS
V I HEREBY CERTIFY THAT THIS IS A TRUE
UNANIMOUS (ABSENT ) AND CORRECT COPY OF AN ACTION TAKEN
AND ENTERED ON THE MINUTES OF THE BOARD
AYES: NOES: OF SUPERVISORS ON THE DATE SHOWN.
ABSENT: ABSTAIN: 1 7
ATTESTED(v� !-oC_, C;2tr-)b
JOHN CUCLEN,CL RK OF THE BOARD OF
Contact Person: Jeff Smith MD (370-5113) SUPERVISORS AND COUNTY ADMINISTRATOR
Cc: CCRMC Admin 2500 Alhambra , + _
Health Services Dept (Contracts)
BY: l�/WY�Y/ yWy ,DEPUTY
Proposed Changes to the Bylaws and Rules
The following changes have been proposed to the Medical Staff Bylaws and Rules. They have been approved by
the MEC and County Counsel.
1. Changes in the membership of PIC
With reorganization and other changes, it is recommended that several changes be made in the
membership of PIC. The Terms of the Physician Chair and the Medical Staff representative are also
clarified.
2. Requires that Reappointnwnt Packets be turned in three 3 months before the end of the
current term instead of monthe in advance. (t re)
JCAHO and other regulators require that Medical Staff members be reappointed every two years. We
currently send out the reappointment packets six(6) months in advance, but allow members to turn
them in up to one(1) month before their appointment expires. Since it takes over two (2) months to
gather all the material, have the department head review the application and have action by the
credentials committee, MEC and the Board,these members are not reappointed before their term
expires. JCAHO no longer allows an extension of appointment while the reappointment is being
processed and even temporary privileges for this purpose are being questioning.
The Credentials committee, along with our consultant Marjorie Margolis, recommends the following:
1. Continue to send the reappointment packets out 6 months in advance, but require that they be
returned 3 months in advance.
2. Adjust the late processing fees accordingly. A$50 per month penalty would start if the packet
were not completed within 1 month.
3. Notify the department chair if the member is delinquent
4. Remove old,no longer acceptable language about the extension of appointment.
3. Shifts East Countv DFM into an Antioch-Brentwood Division and a Pittsburg-Bay Point
Division.
As the Population of East County has mushroomed,the number of Family Medicine Clinics has greatly
increased. East County DFM not only has more Family Medicine clinics than any other Division, it
also has twice as many clinic sites. Splitting East County DFM into two divisions should allow each
Division to function better.
4. Makes the Ambulatory Quality Improvement Committee a standing Medical Staff Committee.
Ambulatory Quality Improvement Committee used to be a subcommittee of PIC. As the importance of
Ambulatory Quality Improvement is increasing, and more resources are devoted to it, MEC now
recommends that it be a standing Medical Staff committee. This amendment spells out the purpose
and composition of the committee.
5. Removes the UPPR Committee from the bylaws. This committee no longer functions.
6. Allows Pre-Operative Histories and Physicals to be done 30 days in advance. Regulations have
changed to allow a pre-operative history and physical to be done up to 30 days in advance, so long as a
history and physical update is done just before surgery. This change gives us more flexibility.
Proposed revisions to the CCRMC Medical Staff Bylaws, Rules &Regulations
March 2008 Page I of 8
i
t s
9.3-11 Performance Improvement Committee
9.3-11-1 Purpose and Meetings
The Performance Improvement Committee(PIC)has the authority and responsibility for
implementing and directing the Quality Management Program for the Hospital and Clinics. It is
responsible for setting the quality management standards,determining criteria by which care will
be measured,setting priorities for which aspects of care will be monitored, and analyzing the
quality of care studies, indicator77s,utilization reports, grievances,survey data and risk
management information. A systematic,multidisciplinary improvement process is followed. It
develops an annual plan for performance improvement activities(Quality Management Plan).
9.3-11-2 Composition
The Performance Improvement Committee includes the following members:
(a) A Physician Chairperson, appointed by the Medical Staff President, subject to MEC approval;
The Physician Chair will serve for approximately three(3)years (in addition to one(1)year
as chair elect), with the term ending 1 year after the approximately triennial Joint
Commission Survey.
(b) a Physician Chair-Elect appointed by The Medical Staff President, subjet to MEC approval,
will be appointed after the triennial "unannounced"Joint Commission survey. He/She will
take over as chair one(1)year after the survey
(c) the Medical Staff President;
(d) the CCRMC Executive Director;
(e) the Director of Systems Redesign/Senior Medical Director;
(f) the Chief Nursing Officer;
(g) the Director of Ambulatory Services;
(h) the Director of Ancillary Services;
(i) the Manager-ef Qiaa4y Management,
the Director of Patient Safety and Performance Improvement;
G) the Manager-of Ut:lizatien Reyie A;
the Chair,Ambulatory Quality Improvement Committee
(k) ;
the Facilities Manager,
(1) the Dir-eetef of GFitisal Care Ser-viee
the Past Medical Staff President,
(m) the Residearay Program Di eete
r
the Chair of the Patient Care Policy and Evaluation Committee, and
(n) two Medical Staff Physician representatives, appointed by the Medical Staff President, subject
to MEC approval.
Proposed revisions to the CCRMC Medical Staff Bylaws, Rules cPc Regulations
March 2008 Page 2 of 8
5.3.2 Term of Appointment, Extensions, and Failure to File Reappointment Application
Except as otherwise provided in these Bylaws, initial appointments to the Medical Staff shall be
until the applicant's second birthday after the initial provisional appointment. Reappointments
shall be for a period of two years.
Failure to file a complete and timely application for reappointment shall result in the automatic
termination of the Member's membership Privileges and prerogatives at the end of that term.
uniess Fnefribership is extended by the Me.7iGal Exe6utiv e Ge fi....:
5.3.3 Extension of n.,p eifit, n
if it appears that an pli ..t: f fe ill et be fiill � ,d 1, theexpir-atie
date f the AA ffibeappointment, f&r.weasseeniss .,thio.-_than due to the reappiiGant's failure
Genimittee and the Bear-d of Supef-,,isers shall appreve a time, an-d-Member speeifk extensien ef
not 6r-eate a vested right in the N4ember-fer eentinued appointment t4ough the efitir-e next teFm bu4
5.4 Application Procedure
5.4.1 Application
Application for Medical Staff membership must be submitted directly to the Credentials
Committee 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 the policies and resolutions relating to clinical practice in the
Hospital and Health Centers.
5.4.2 Application Content
Every applicant, except Resident staff applicants, must furnish the following
information and documentation:
(a) undergraduate, medical school, and postgraduate training, including the name of each
institution, degrees granted,program completed, and dates attended;
(b) all currently valid medical, dental,podiatric and other professional licensures or
certifications,and Drug Enforcement Administration registration(with exceptions
determined by Credentials Committee action when the applicant will not be prescribing
medication) and any other controlled substances registration, with the date and number of
each;
(c) specialty or sub-specialty board certification and/or 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 judgment 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);
Proposed revisions to the CCRMC Medical Staff Bylaws, Rules & Regulations
March 2008 Page 3 of 8
5.5 Reappointment and Requests for Modifications of Staff Status or Privileges
Applications for reappointment are due 440 150 days prior to the expiration of a Member's term.
Applications that are not complete at 39 90 days prior to the expiration of a term are not processed and the
membership automatically expires at the end of the term. Applications completed between 44N 150 days
and 30 90 days from the end of a term are charged a late fee as noted in the Rules. Onee an applioant has
At least five n►eaths 180 days prior to the expiration date of the current staff appointment(except for
temporary appointments), a reapplication form developed by the Medical Executive Committee shall be
mailed or delivered to the Member. The completed application form and Medical Staff dues are due 150
days prior to the expiration date. The Department Chair will be notified if the member is delinquent. Each
Medical Staff Member shall submit to the Credentials Committee the completed application form for
renewal of appointment to the staff and for renewal or modification of clinical privileges. The
reapplication form shall include all information necessary to update and evaluate the qualifications of the
applicant including,but not limited to,the matters set forth in Section 5.4.2 as well as other relevant
matters. Upon receipt of the application,the information shall be processed as set forth commencing at
Section 5.4.5. In addition,the Department head will review the applicant's QA profile if there is one.
A Medical Staff Member who seeks a modification of Clinical Privileges may submit such a request at any
time upon a form developed by the Medical Executive Committee,except that such application may not be
filed within one year of the time a similar request has been denied.
5.5.1 Effect of Application
The effect of an application for reappointment or modification of staff status or privileges is the same as
that set forth in Section 5.4.4
5.5.2 Standards and Procedure for Review
When a staff Member submits the first application for reappointment,and every two years thereafter,or
when the Member submits an application for modification of staff status or Clinical Privileges,the Member
shall be subject to an in-depth review generally following the procedures set forth in Section 5.4.5.
5.6 Leave of Absence from the Medical Staff
A Member may request a leave of absence not to exceed two years. No leave is effective unless and until
approved by the Medical Executive Committee. At the end of the leave the Member must apply for
reinstatement. The Member must provide information regarding his or her relevant activities during the
leave of absence if the MEC so requests. During the period of leave,the Member shall not exercise
Privileges at the Hospital, and membership rights and responsibilities shall be inactive. The obligation to
pay dues,if any,shall continue during the leave unless waived by the Medical Executive Committee.
5.6.1 Reinstatement after a Leave
Failure,without good cause,to request reinstatement of Membership at least 30 days prior to the
end of an approved leave shall be deemed a voluntary resignation from the Medical Staff. The
Medical Executive Committee shall make recommendations concerning reinstatement of the
Member's Membership and Privileges to the Governing Body for final action.
Proposed revisions to the CCRMC Medical Staff Bylaws, Rules &Regulations
March 2008 Page 4 of 8
1.15 Collection and Expenditures of Medical Staff Funds
1.15-1 Application Fees
Each application may be assessed an application processing fee. This fee shall be Two
Hundred Dollars ($200) and shall also be considered as payment of any dues, for which
the applicant shall be liable during the period of the initial appointment, should the
applicant be appointed to the staff.
In the event that the applicant is not accepted,no portion of this application fee shall be
refunded. In special circumstances as defined by the Credentials Committee and the
Medical Executive Committee,this application fee may be waived
1.15-2 Medical Staff Dues
The Medical Executive Committee shall have the power to determine the amount of
annual dues. The following dues are currently in effect:
Active Staff: -$100 for each two-year reappointment
Courtesy Staff: $50 for each two-year reappointment
The application fee is considered payment of dues for the provisional staff and, therefore,
no further dues shall be collected until the time of the first reappointment. No dues shall
be charged to members of the Honorary or Resident Staff. In special circumstances as
defined by the Credentials Committee and the Medical Executive Committee, these dues
may be waived.
1.15-3 Reappointment Late Processing Fees
Pursuant to the Bylaws and the Rules, the Medical Staff is authorized to collect late
processing fees. An application for reappointment is late when less than 440 150
calendar days remain until the end of Member's term. In addition to the regular
reappointment fee, the following late processing fees are assessed:
At�A 150 days from the end of a term-$50
(may be waived in extenuating circumstances, such as vacation.)
At 99 120 days from the end of a term—$50 more for a total penalty of$100
(may not be waived.)
At 60 90 days from the end of a term-$50 more for a total penalty of$150,
At N 90 days, all fees must be paid in full and application must be complete or
reappointment application is not processed and the membership is deemed to have
expired automatically at the end of the term.If the member submits a new application for
membership in the medical staff within six (6) months of the expiration of the
appointment, he/she must pay the$150 penalty in addition to the application fee.
Proposed revisions to the CCRMC Medical Staff Bylaws, Rules & Regulations
March 2008 Page 5 of 8
8.1.1 Current Clinical Departments and Divisions
The current Clinical Departments and Divisions are:
(a) Family Medicine
1. Divisions:
i) East Gec f4y Antioch-Brentwood
ii) Geral Getm+y Pittsburg-Bay Point
iii Central County
iv) West County
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8.9 Election of Division Heads
8.9.1 In April of each election year,the active Medical Staff of the applicable division shall elect a
Division Head as set forth.
8.9.2 Family Medicine West County and Antioch-Brentwood Divisions shall elect Division Heads in
even-numbered years;Family Medicine Central County and Pittsburg-Bay Point Divisions shall
elect Heads in odd-numbered years
Proposed revisions to the CCRMC Medical Staff Bylaws, Rules & Regulations
March 2008 Page 6 of 8
9.3-3 Ambulatory Quality Improvement Committee
9.3-3-1 Purpose and Meetings
The Ambulatory Quality Improvement Committee (AQIC) has the authority and responsibilityfor
implementing and directing management and quality improvement in the CCRMC health centers.
AOIC coordinates with the Performance Improvement Committee and other groups for-quality
projects that extend beyond the health centers. AQIC is responsible for setting the quality
standards, determining criteria by which care will be measured, setting priorities for which
aspects of care will be monitored and analyzing the quality of care studies, indicators, utilization
data, grievances, survey data and risk management information. A systematic multidisciplinary
improvement process is followed. AQIC meets monthly(at least 10 times a year). All departments
that provide ambulatory services will report their quality indicators to AQIC at least annually
9.3-3-2 Composition
The Ambulatory Quality Improvement Committee includes the following members, supplemented
by guests from Safety and Performance Improvement SPI)and reporting departments as indicated
(a) A physician Chairperson appointed by the Medical Staff President subject to MEC approval.,
(b) The Ambulatory Care Administrator,
(c) A representative for Ambulatory Care Nursing,
(d) The Performance Improvement Committee (PIC) Chair,
(e) A representative from the Department of Family Medicine,
(17 A representative from Obstetrics/Gynecology,
(g) A representative from Pediatrics,
(h) A representative from Dental,
(i) Other medical staff departments as desired by the chair,
6) Safety and Performance Improvement (SP1)Ambulatory Care Nurses,
(k) A representative for the CCHP Quality Management Department.
Proposed revisions to the CCRMC Medical Staff Bylaws, Rules & Regulations
March 2008 Page 7 of 8
1.3-2(a)(3) Special Standards for Elective Surgery
The following procedure is to be followed when scheduling a patient for either elective
outpatient surgery or elective surgery to be done on the day of admission.
For General or Regional Anesthesia
i) The scheduling surgeon must schedule the patient for a pre-op H&P to be
done within-7 30 days prior to the surgery.
ii) The surgeon must clearly enter in the medical record:
• The procedure being scheduled and type of anesthesia;
• The surgical indications;
• Whether the patient is to be admitted following the surgery.
iii) It is the responsibility of the surgeon scheduling the procedure to obtain
informed consent from the patient at the time it is scheduled,having
explained the risks and benefits to the patient.
iv) A History and Physical shall be done on all pre-op patients in one of three
formats—either an approved Medical Records Form,a dictated H&P,or a
written H&P.
V) Pre-op lab work should be scheduled within two weeks prior to surgery.
vi) The pre-op H&P and all ordered tests will be reviewed by the anesthesiologist
prior to surgery. The provider performing the H&P and/or the primary care
provider may be consulted in evaluating abnormal results prior to
cancellation of surgery.
Proposed revisions to the CCRMC Medical Staff Bylaws, Rules &Regulations
March 2008 Page 8 of 8