HomeMy WebLinkAboutMINUTES - 05112010 - C.71RECOMMENDATION(S):
Approve the attached changes to the Medical Saff Bylaws and Rules & Regulations as
recommended by the Medical Executive Committee and by the Health Services Director.
FISCAL IMPACT:
None.
BACKGROUND:
The Joint Commission on Accreditation of Healthcare Organizations requires Board of
Supervisors approval for changes to the Medical Staff Bylaws. The following modifications
were reviewed and approved by the Medical Executive Committee:
APPROVE OTHER
RECOMMENDATION OF CNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE
Action of Board On: 05/11/2010 APPROVED AS RECOMMENDED OTHER
Clerks Notes:
VOTE OF SUPERVISORS
AYE:John Gioia, District I
Supervisor
Gayle B. Uilkema, District II
Supervisor
Mary N. Piepho, District III
Supervisor
Susan A. Bonilla, District IV
Supervisor
Federal D. Glover, District V
Supervisor
Contact: Anna Roth, 370-5101
I hereby certify that this is a true and correct copy of an action taken and entered on the minutes of the Board
of Supervisors on the date shown.
ATTESTED: May 11, 2010
David J. Twa, County Administrator and Clerk of the Board of Supervisors
By: Katherine Sinclair, Deputy
cc: Tasha Scott, Barbara Borbon, Cheryl Goodwin
C.71
To:Board of Supervisors
From:Tasha Scott, Health Services
Date:May 11, 2010
Contra
Costa
County
Subject:Changes to Medical Staff Bylaws
BACKGROUND: (CONT'D)
Add fellows to the resident and fellow staff.1.
Change the composition of the Interdisciplinary Practice Committee2.
Change the requirements for when dictations must be electronically signed.3.
Substitute the title "Director of Nursing" for "Chief Nursing Officer".4.
ATTACHMENTS
G:\C&G DIRECTORY\NON CONTRACTS\Summary of Bylaws Changes 3-4-10.pdf
G:\C&G DIRECTORY\NON CONTRACTS\~5640394.pdf
March 4, 2010
Proposed Bylaws and Rules and Regulations Changes
The following changes have been recommended by the Medical Executive Committee and approved by
County Council. They were approved by a vote of the Medical Staff and by the Joint Conference
Committee. A copy of the actual changes is attached.
1. Add fellows to the resident and fellow staff.
Now that we have fellows, the Bylaws are being revised to clarify that fellows have the same
qualifications, prerogatives, responsibilities, and application process as residents. (Bylaws
Sections 3.1.5 and 5.4.2).
2. Change the composition of the Interdisciplinary Practice Committee.
Interdisciplinary Practice Committee establishes policies and procedures for practice by non-
medical staff members such as nurse practitioners, optometrists, and others. The composition of
the committee will be changed as follows to comply with state requirements and to be sure the
membership is appropriate for the issues addressed. (Bylaws Section 9.3.9.2).
The IPC shall consist of:
(d) the Director of Ambulatory Care, if not serving as the representative of
Administration;
(e) two additional physicians, appointed by the Medical Staff President
Executive Committee;
(g) an FNP representative selected by the FNPs; MEC and
(f) (h) one or more licensed or certified health professionals other than
registered nurses who are performing or will perform functions requiring
standardized procedures will be appointed by the IPC Chair on a
temporary basis when issues pertaining to their functions are discussed.
3. Change the requirements for when dictations must be electronically signed.
Now that we are dictating more, we need to clarify when these dictations must be signed.
a. Clarifies that all inpatient dictations must be signed within 13 days and they are
delinquent after the 14th day. (Rules and Regulations 1.3.2.6.).
b. Changes the Rules and Regulations to state that outpatient dictations must be signed
within 30 days instead of the current 13 days. Also, members will not be suspended for
an unsigned outpatient dictation until it is delinquent 14 days instead of the current 7
days. (Rules and Regulations 1.3.2.10).
4. Substitute the title Director of Nursing for Chief Nursing Officer.
a. With the restructuring, we no longer have a Chief Nursing Officer. We will have a
Director of Nursing, or someone functioning as the director of nursing, who will assume
those tasks.
MARCH 4, 2010
PROPOSED BYLAWS CHANGES
3.1.5 Resident/Fellow Staff
3.1.5.1 Qualifications for Residents/Fellows. The resident/fellow staff consists of
Members, each of whom:
(a) meets the qualifications for Medical Staff membership set forth in the
Bylaws;
(b) is a graduate of a medical school approved by the American
Association of Medical Colleges and is a participant in an approved
residency or fellowship program.
3.1.5.2 Prerogatives. Each Member of the resident/fellow staff is 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;
(d) be appointed to any committee except the Medical Executive
Committee. The resident/fellow staff member shall not have the right
to vote unless that right is conferred by the Medical Staff President at
the time of the committee appointment;
(e) if licensed, apply for provisional status on the Medical Staff without
relinquishing his or her resident status with regard to these Bylaws.
3.1.5.3 Responsibilities. Each member of the resident/fellow staff is responsible for the
following:
(a) carrying out the basic responsibilities of Medical Staff membership set
forth in the Bylaws and Rules;
(b) contributing to the organization and administrative affairs of the
Medical Staff by participating on staff, in the departments, and on
committees as reasonably requested, and by participating in fulfilling
such other staff functions as are reasonably requested.
3.1.5.4 Limitation. Resident/fellow staff members shall not be eligible to hold office in
this Medical Staff organization nor shall they be eligible to vote on matters
presented at general and special meetings of the Medical Staff, departmental
meetings, division meetings, or committee meetings except as specifically
provided in the Bylaws.
9.3.9.2 Composition
The IPC shall consist of:
(a) a physician chairperson, appointed by the Medical Staff President,
subject to MEC approval;
(b) the Chief Nursing Officer;Director of Nursing
(c) the Administrator or designee;
(d) the Director of Ambulatory Care, if not serving as the representative of
Administration
(e) two additional physicians, appointed by the Medical Staff President;
Executive Committee
(f) two additional registered nurses, appointed by the Chief Nursing
Officer; Director of Nursing and
(g) an FNP representative selected by the FNPs; and
(f)(h) one or more licensed or certified health professionals other than
registered nurses who are performing or will perform functions
requiring standardized procedures. will be appointed by the IPC Chair
on a temporary basis when issues pertaining to their functions are
discussed.
Formatted: Bullets and Numbering
Formatted: Bullets and Numbering
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 one (1) year after the approximately
triennial Joint Commission Survey;
(b) A Physician Chair-Elect appointed by The Medical Staff President,
subject 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 Director of Nursing;
(g) the Director of Ambulatory Services;
(h) the Director of Ancillary Services;
Contra Costa Regional Medical Center
& Health Center
2008 Medical Staff Rules and Regulations
CHANGES
Contra Costa Regional Medical Center & Health Centers
2008 Medical Staff Rules and Regulations
2
1.1.1.1. Delinquency
All charts must be complete by the 13th day post discharge and will be delinquent on
the 14th day post discharge if not complete. A "complete medical record" is defined
as one that meets all criteria set forth.
Document Time Delinquent
Written Discharge Summary 13 days post discharge
Inpatient History/Physical 24 hours post admission
Written Operative Report Immediately post-surgery
Dictated Operative Report Immediately after surgery
Pre-anesthesia evaluation
(timed note)
Must be completed prior to being
placed under anesthesia unless extreme
emergency
Post/PAR Anesthesia
(Timed note)
"Early" PAR note
"Complete" recovery note
6 hours after conclusion of anesthesia
48 hours after conclusion of anesthesia
Verbal orders Authenticated by 24 hours for IV Fluid
or IV drug orders; all others within 48
hours
Other inpatient documentation as required
by law, including:
(a) Diagnostic and therapeutic orders;
(b) Clinical observations and results
of therapy;
(c) Reports of procedures, tests, and
their results; and
(d) Conclusions at the termination of
care.
(e) All inpatient dictations
At hospital discharge
Must be signed within 13 days and are
delinquent after the 14th day
Formatted
Contra Costa Regional Medical Center & Health Centers
2008 Medical Staff Rules and Regulations
3
1.3.2.9 Disciplinary Proceedings
Process
Automatic initiation of disciplinary proceedings for the responsible practitioner will occur
as soon as a chart becomes delinquent.
A letter will be sent to the practitioner responsible for the delinquent records, signed by
the Medical Staff President.
The letter shall state:
The list of delinquent records;
That failure to complete delinquencies within 7 days will result in suspension
of all Medical Staff Privileges and Staff Membership by the Medical Staff
President until the stated delinquent charts are completed.
If delinquent records referred to in the letter are not completed within seven days,
the Medical Staff President shall immediately suspend all Medical Staff
Privileges and Membership until the delinquent charts are properly completed.
The Medical Staff President will notify the appropriate Department Heads, the
Executive Director of the Hospital, the Director of Medical Staff Affairs, and the
Residency Director as appropriate.
Further Sanctions
Any suspended practitioner shall be reported to the Performance Improvement
Committee by the Medical Staff President and this information will be placed in
the practitioner's permanent quality assurance profile.
Any practitioner suspended for 30 days or more during any calendar year may be
reported to the Medical Board of California by the Medical Staff President.
1.3.2.9 Operative Reports Co-Signatures
Co-signatures are required on all resident operative reports.
1.3.2.10 Outpatient Records
Providers are encouraged to chart as soon as possible after a visit. At a minimum,
the diagnosis and treatment plan shall be charted at the time of the visit. Charting
must be completed or dictated within 24 hours.
Contra Costa Regional Medical Center & Health Centers
2008 Medical Staff Rules and Regulations
4
If notes are dictated, a brief, legible, handwritten note is also required, including
the assessment and plan. Plan must include new medications prescribed. Dictated
notes must be signed within 13 30 days after the visit and are delinquent on the
31st 14th day.
If their only delinquent records are unsigned outpatient dictations, members will
not be suspended until after 14 days.
Notes must be legible. If a provider’s handwriting is difficult to read as
determined by the Department Chair, he/she might be required to dictate notes. In
the event of a dispute, Performance Improvement Committee will have the final
say in legibility.
Formatted
Formatted: Bullets and Numbering