HomeMy WebLinkAboutMINUTES - 08062013 - C.120RECOMMENDATION(S):
Approve the attached changes to the Medical Staff Bylaws and Rules & Regulations, as recommended by the Medical
Executive Committee, the Joint Conference Committee and Health Services Director.
FISCAL IMPACT:
None.
BACKGROUND:
To come into compliance and consistency with current regulations and practices in relations to electronic medical
records and hospital committee work changes are necessary to the Medical Staff Bylaws and Rules and Regulations.
The Medical Staff Bylaws and the Joint Commission require that changes to the Medical Staff Bylaws and Rules &
Regulations be approved by the Board of Supervisors.
CONSEQUENCE OF NEGATIVE ACTION:
The Medical staff will have to use Medical Staff Bylaws and Rules and Regulations that are outdated.
CHILDREN'S IMPACT STATEMENT:
Not Applicable.
APPROVE OTHER
RECOMMENDATION OF CNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE
Action of Board On: 08/06/2013 APPROVED AS RECOMMENDED OTHER
Clerks Notes:
VOTE OF SUPERVISORS
AYE:John Gioia, District I Supervisor
Candace Andersen, District II
Supervisor
Mary N. Piepho, District III
Supervisor
Karen Mitchoff, 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: August 6, 2013
David Twa, County Administrator and Clerk of the Board of Supervisors
By: June McHuen, Deputy
cc: D Gary, T Scott, Cheryl Goodwin
C.120
To:Board of Supervisors
From:William Walker, M.D.
Date:August 6, 2013
Contra
Costa
County
Subject:Medical Staff Bylaws and Rules & Regulations
ATTACHMENTS
Rules and Regulations - Marked up copy
Rules and Regulations - Clean copy
Bylaws - marked up copy
Bylaws - clean copy
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20123 Medical Staff Rules and Regulations
Contra Costa Regional Medical Center & Health Center
20123 Medical Staff Rules and Regulations
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20123 Medical Staff Rules and Regulations
Contra Costa Regional Medical Center & Health Center 20123 Medical Staff Rules and
Regulations Table of Contents
General Rules ............................................................................................................................. 3
Medical Records ........................................................................................................................ 3
Completion of Records .............................................................................................................. 3
Elective Surgery ......................................................................................................................... 5
Delinquency .............................................................................................................................. 5
Outpatient Records .................................................................................................................... 7
Medical Orders .......................................................................................................................... 7
CPR ........................................................................................................................................... 9
Disaster Assignments ................................................................................................................ 9
Consultation Policy .................................................................................................................... 9
Operating Room Policies .......................................................................................................... 9
Supervision of House Staff ..................................................................................................... 10
On-Call Response Time .......................................................................................................... 11
Processing and Delivery of Blood Products ............................................................................. 11
Collection and Expenditures of Medical Staff Funds ............................................................. 12
Medical Staff Evaluation and Development ........................................................................... 14
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20123 Medical Staff Rules and Regulations
These Rules and Regulations are adopted pursuant to Article 15 of the Medical Staff Bylaws. These Rules
use the same Definitions as the ones described in the Bylaws. The Rules specifically include those
policies and procedures that are referenced herein.
1. General Rules
a. Admissions
i. All admissions of patients are subject to rules delineated in the Medical Staff Bylaws,
specific department policies and Hospital Policy 543 - Admission of Patients.
b. Continuous Responsibility for Patients
i. Inpatient
1. The attending physician is responsible for the complete and continuing care
of his/her patients. He/she is required to keep appropriate personnel informed
as to where he/she can be reached in case of emergency and shall designate
at least one physician to render emergency or other necessary patient care if
he/she is not available. Each patient shall be reassessed daily.
ii. Outpatient
1. Primary Care Providers are responsible for their panel of patients as
described in the Ambulatory Care Policy 1016 - Case Management.
c. Medical Records
i. General Provisions
1. Abbreviations
a. An “Unacceptable Abbreviations List” is posted throughout the
hospital and clinics. Copies may be obtained from Medical Records.
2. Records Belonging to Health Services Department
a. Refer to Hospital Policy 501- Access to, Removal of and Retention
of Medical Records. All medical records and other records relating to
the admission, care and discharge of a patient are the property of the
Contra Costa County Health Services Department and may be
removed from the Health Services Department's jurisdiction and
safekeeping only in accordance with a subpoena, court order or other
statute. In case of readmission of any patient, all previous records
shall be available to the attending physician.
3. Electronic Signature
a. Approved electronic signature of medical records is acceptable for
chart completion.
ii. Completion of Records
1. Inpatient Records
a. Responsibilities of the Members of Medical Staff and General
Provisions
2. Content of Staff Entry
a. The attending physician shall be responsible for preparing a
complete medical record for each patient as described in Hospital
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20123 Medical Staff Rules and Regulations
Policy 516 - Medical Record Content. This record shall include at
least the following minimum information.
b. Patients shall be discharged only upon the order of the attending
physician or another physician acting as his/her representative. At
the time the patient is discharged, the attending physician shall
complete the medical record, indicate the reason for admission, state
the final diagnosis, record treatment and/or procedures performed,
describe the condition of the patient on discharge, including specific
comparison with condition on admission and any specific
instructions given the patient and/or family (e.g., diet, medication,
physical activity and follow-up care). When pre-printed instructions
are given to the patient, the record should so indicate and a sample of
the instruction sheet in use at the time must be kept on file in the
Medical Records Department. All medical record entries must be
signed and dated.
c. When a patient has been hospitalized for 72 hours or more, a dictated
discharge summary is required. in order to complete the chart. A
dictated discharge summary is not required for newborn infants who
have uncomplicated courses and who are hospitalized for more than
72 hours solely for the reason that the mother is continuing inpatient
post-partum or postoperative care.
d. All surgery performed shall be fully described by the operating
surgeon in the patient's medical record. Such description shall
include a detailed account of the technique used, identification of
tissues and foreign material removed, if any, and a description of the
findings. Such description shall be dictated done immediately after
surgery is concluded. A brief written interim operative note shall be
placed in the medical record immediately after surgery is concluded.
if the complete note is not immediately visible in the electronic
health record.
e. At the discretion of the attending physician, tissues and foreign
materials removed in surgery shall be submitted, together with
adequate clinical information, to the pathologist on duty. The
Pathology Department may establish appropriate guidelines.
f. In addition to the operating surgeon's report, the record of every
operation involving use of an anesthetic other than local shall include
a proper anesthetic record and a post-anesthetic follow-up report.
f. Standards for History and Physical Examination.
g. The complete history and physical examination (H&P), as
required for the patient's medical record, shall be completed within 24
hours after admission of the patient, and, in case a patient is admitted for
surgery, shall be completed prior to the time surgery is done. When the
history and physical examination is dictated, a holding note must be
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20123 Medical Staff Rules and Regulations
recorded in the medical record at the time of examination. A history and
physical may be performed up to 30 days in advance provided a durable
and legible copy is inserted into the inpatient medical record no later than
24 hours after admission and is updated as appropriate.
h.g. 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.)
a. The scheduling surgeon must schedule the patient for a
pre-op H&P to be done within 30 days prior to the
surgery. The surgeon must clearly enter in the medical
record:
i. The procedure being scheduled and type of
anesthesia;
ii. The surgical indications;
iii. Whether the patient is to be admitted following
the surgery.
b. 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.
c. A History and Physical shall be done on all pre-op
patients in one of three formats—an approved Medical
Records Form, a dictated H&P, or a written H&P.
d.c. Pre-op lab work should be scheduled within two
weeks prior to surgery.
e.d. 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.
3. Delinquency
a. 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.
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20123 Medical Staff Rules and Regulations
4. Disciplinary Proceedings
a. Process
i. Automatic initiation of disciplinary proceedings for the
responsible practitioner will occur as soon as a chart
becomes delinquent.
ii. A letter will be sent to the practitioner responsible for the
delinquent records, signed by the Medical Staff President.
iii. The letter shall state:
1. The list of delinquent records;
2. 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.
iv. 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
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. . . . . . . . . . . . . . . . . 6 hours after conclusion of anesthesia.
“Complete” recovery note. . . . . . . . . . 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;
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.
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20123 Medical Staff Rules and Regulations
appropriate Department Heads, the Executive Director of the
Hospital, the Director of Medical Staff Affairs, and the
Residency Director as appropriate.
b. Further Sanctions
i. 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.
5. Operative Reports Co-Signatures
a. Co-signatures are required on all resident operative reports.
6.5. Outpatient Records
a. 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 A provider note must be completed or
dictated within 24 hours.
b. If notes are dictated, a brief, legible, handwritten note is also
required, including the assessment plan. Plan must include new
medications prescribed. Dictated notes must be signed within 30
days after the visit and are delinquent on the 31st. day.
c.b. If their only delinquent records are unsigned outpatient dictations,
members will not be suspended until after 14 days.
d. 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.
7.6. Outpatient notes should contain the following elements:
a. Patient identification.
b. Date of visit
c. Relevant history or pertinent update of the illness or injury.
d. Physical findings, if applicable.
e. Results of tests and other studies, if applicable.
f. Diagnostic assessment.
g. Treatment plan, including prescriptions.
h. Results of treatment rendered during the visit, if applicable.
i. Patient teaching, including instructions given to the patient and/or
family and follow-up care.
j. Providers are required to have a legible signature on all notes and
prescriptions or a name stamp must be used.
k. Outpatient charts should contain an up-to-date database, including
allergies and medication list. This is the responsibility of the primary
care provider.
l.j. The primary care provider should acknowledge all consultations in
the medical record.
d. Medical Orders
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20123 Medical Staff Rules and Regulations
i.iii. Inpatient
1. All orders must be rewritten reconciled when a patient is transferred into or
out of the Critical Care units (ICU and IMCU). All prior orders in those
circumstances shall be void.
a. All orders for treatment shall be in writing. Under this rule, an order
shall be considered to be in writing if Orders can be dictated or
telephoned to a health professional listed below and later signed by
the attending physician, or, in case of treatment required in the
absence of the attending physician, by the physician then responsible
for the patient's care. Verbal orders shall be accepted and entered
written by a licensed nurse, occupational therapist, physical therapist,
licensed respiratory therapist or speech therapist, registered
pharmacist or registered dietician only and such action will be
limited to urgent circumstances.
b. Verbal orders are not valid for orders to limit or remove lifesaving
procedures.
c. There are no routine or standing orders regarding patient care or
ordering of diagnostic tests. There may be sheets used as
"guidelines," e.g., "CCU" orders or "TPN" orders, but the members
of the Medical Staff must specify which orders apply each time.
ii.iv. Outpatient
1. Outpatient orders should be written entered in the medical records. Any
verbal orders must be co-signed by the M.D or FNP within 24 hours.
e. Orders for Drug Therapy:
i. Inpatient
1. Antibiotics are rewritten every Wednesday or are automatically stopped;
2. Narcotics and hypnotics must be rewritten every seventy-two (72) hours or
are stopped;
3. Anticoagulation orders
a. Heparin--Every twenty-four (24) hours, except low dose
subcutaneous heparin;
b. Warfarin--Every three (3) days
c. IV fluids must be rewritten every 24 hours
ii. Outpatient
1. Outpatient prescriptions are generally valid for one year after the date
written. Prescriptions can be written or phoned or faxed into the patient’s
choice of pharmacy.
f. Automatic Stop Orders for Inpatient Respiratory Therapy:
i. Automatically stopped after five (5) days.
g. Laboratory Orders:
i. Inpatient
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20123 Medical Staff Rules and Regulations
1. There can be no open-ended order for lab tests, and all orders should specify
a stop date. Tests ordered daily or more frequently can be ordered for a
maximum of seven (7) days. Tests ordered less frequently than daily can be
ordered for a maximum of one (1) month.
ii. Outpatient
1. Standing orders for tests are valid for a maximum of six months. Providers
are expected to call the CCRMC lab to cancel standing orders if they are no
longer needed or to revise orders. Standing orders can be issued or renewed
by using the Standing Order Lab Form.
2. Tests will be canceled if the lab does not receive the specimen within 48
hours of the expected collection time. An exception is timed or serial
specimens (i.e., Outpatient stool occult blood and sputum).
h.e. CPR
i.v. Although a "Basic CPR" certificate is not required for Medical Staff membership, it
is strongly encouraged for all those physicians in patient care. Individual
Departments may require it for membership.
i.f. Disaster Assignments: Refer to the Hospital Disaster Plan
i.vi. Contra Costa Regional Health Center & Health Centers maintains a disaster plan
based upon the Hospital Emergency Incident Command System (HEICS) which
delineates the administrative structure for disaster responses. Each individual
Department also has in place disaster and evacuation plans.
ii.vii. Employed members of the Medical Staff are designated automatically as disaster
workers in the event of a disaster. Other members of the Medical Staff are eligible to
participate in disaster work, as is volunteer staff under the guidelines of disaster
credentialing as delineated in the Medical Staff Bylaws.
j.g. Consultation Policy
i.viii. Specific requirements for consultation are set forth in Department policy manuals and
by delineation of Privileges. In addition, all providers are expected to seek
consultation and advice whenever they encounter a situation in the course of caring
for a patient in whom they are not confident of their own ability or knowledge. They
should also seek consultation when it becomes evident that the patient is not
comfortable with the diagnosis or management of his or her problem. Consultation
may be obtained from Members of the Staff who are privileged to care for the
problem for which the advice is sought, and his or her report shall be included in the
medical record. The consultation report should be placed in the medical record.
ii.ix. Except where consultation is precluded by emergency circumstances, the attending
physician shall consult with another qualified physician in all of the following cases:
1. All major surgical cases in which the patient is not a good risk.
2. In all cases in which the diagnosis is obscure or in which there is doubt as to
the best therapeutic measures to be utilized.
k.h. Operating Room Policies
i.x. Consents:
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20123 Medical Staff Rules and Regulations
1. Except in cases of emergency, no surgery shall be performed except pursuant
to written informed consent from the patient or his/her legal representative,
and all other persons, if any, from whom consent is required.
ii.xi. Requirements Prior to Surgery:
1. Except in cases of grave emergency, all of the following shall be completed
and properly recorded by the time surgery is commenced:
a. History and physical examination;
b. Pre-operative diagnosis;
c. All necessary Laboratory and X-ray work;
d. Pre-anesthetic evaluation in all cases receiving a general anesthetic.
2. If, in any surgical cases, the foregoing requirements are not met prior to the
time scheduled for surgery, the operation shall be canceled by the Operating
Room Supervisor or designee and rescheduled unless the attending physician
states in writingdocuments that such delay would be detrimental to the
patient.
iii.xii. Prompt attendance of surgeon and attendants: Surgeons and attendants must be in the
operating room and ready to commence surgery at the time scheduled.
l.i. Supervision of House Staff
i.xiii. House staff shall have appropriate supervision present at all times regardless of
patient complexity or house staff proficiency capabilities. This supervision shall be
accessible and available particularly when house staff capability is exceeded.
ii.xiv. Inpatient Supervision
1. House staff shall identify a Medical Staff member as the attending of record
on the admission orders of all patients admitted to the hospital. All critically
ill patients admitted by the house staff shall be discussed with an attending
physician. Teaching rounds shall be held daily. Junior house staff shall
receive closer attending supervision, proficiency monitoring and patient care
responsibilities whenever possible. After hours supervision shall be provided
by either in-house Medical Staff coverage or Department-dependent call
mechanisms.
2. All “No CPR” orders written entered by house staff shall document
concurrent discussion with Medical Staff.
3. Medical Staff co-signatories are needed for all resident physicians for the
following medical records and documents:
a. Inpatient History and Physical
b. Pre-anesthesia Evaluation
c. Consultative Reports
d. Procedure Notes and Operative Reports
c. Discharge Summaries and Transfer out of Hospital Notes
4. Medical Staff co-signatories are needed for first-year resident physicians for
the Written Discharge Summary.
5.4. The attending staff physician shall be responsible for review and correction
of resident physician and medical student record entries.
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20123 Medical Staff Rules and Regulations
6.5. All student medical student record entries must be co-signed by a staff
member or a second- or third-year resident.
iii.xv. Outpatient Supervision
1. More detailed and specific house staff supervision rules and policies are
located in the specific Department rules and regulations manual of Contra
Costa Regional Medical Center. A copy of these policies is also located in
the residency office.
a. Prescriptions
i. All unlicensed residents must have all prescriptions co-
signed.
b. Family Medicine Clinics
i. All family medicine residents must have a Department of
Family Medicine member with appropriate privileges
assigned to supervise and precept them. This preceptor must
be immediately available and have adequate time for
teaching.
i.ii. All medical record entries by medical students must be co-
signed by a provider with privileges.
c. Specialty Clinics
i. A staff physician will directly supervise all residents
working in a specialty clinic. First-year residents are
expected to discuss all patients with their supervising
physician before the patient leaves and have their charts
signed.
ii.i. Second- and third-year residents should discuss most cases
with their supervising physician. The supervising physician
should be identified on the consultation.
iii.ii. All medical record entries by medical students must be co-
signed by a staff physician or a second- or third-year
resident. provider with privileges.
m.j. On-Call Response Time:
i.xvi. Departments shall determine and monitor appropriate on-call procedures for their
specific services.
n.k. Processing and Delivery of Ordered Blood Products
i.xvii. Blood products ordered by any physician shall be provided by the Blood
Bank/Transfusion Service without delay. If questionable indications for transfusion
are felt to be present, the pathologist, while processing of this order proceeds without
delay, will attempt to discuss this issue with the ordering physician. If, after
discussion, the pathologist still believes the request to be questionable, he/she will
report this case to the appropriate Department or committee for review.
ii.xviii. The physician who has primary responsibility for the patient has the final say in
decision-making, although we encourage a team approach utilizing dialogue between
the clinician and the transfusion service.
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20123 Medical Staff Rules and Regulations
o.l. Collection and Expenditures of Medical Staff Funds
i.xix. Application Fees
1. Each application may be assessed an application processing fee. This fee
shall be Three Hundred Dollars ($300) 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.
2. 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.
ii.xx. Medical Staff Dues
1. The Medical Executive Committee shall have the power to determine the
amount of biannual dues. The following dues are currently in effect:
a. Active Staff: $200 for each two-year reappointment
b. Courtesy Staff: $100 for each two-year reappointment
2. 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.
iii.xxi. Reappointment Late Processing Fees
1. 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 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:
a. At 150 days from the end of a term - $50 (may be waived in
extenuating circumstances, such as vacation);
b. At 120 days from the end of a term—$50 more for a total penalty of
$100 (may not be waived);
c. At 90 days from the end of a term-$50 more for a total penalty of
$150,
d. At 60 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.
iv.xxii. Expenditure of Funds
1. The Medical Executive Committee shall determine the method of
disbursement of Medical Staff funds. The Medical Executive Committee
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20123 Medical Staff Rules and Regulations
may appoint a Medical Staff Funds Advisory Committee to advise the
Medical Executive Committee regarding such expenditures.
2. If an Advisory Committee is appointed, it shall study the various possible
uses for the funds and recommend specific expenditures, including specific
dollar amounts, to the Medical Executive Committee on an annual basis or
more often as appropriate.
3. The Medical Executive Committee shall retain ultimate control of these
funds. The Medical Executive Committee may deposit these funds in any
accounts it deems suitable.
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20123 Medical Staff Rules and Regulations
a. Any account shall have the following co-signers:
i. The Medical Staff President
ii. The Medical Staff President-Elect
iii. The Immediate Past President of the Medical Staff
iv. The Chair of the Administrative Affairs Committee
v. Two Medical Staff Coordinators as designated by the
Medical Executive Committee
b. Any two (2) of these co-signers may disburse Medical Staff funds
provided at least one signer is a Member of the Medical Staff. Any
disbursement of funds greater than Two Hundred Fifty Dollars
(>$250) must be approved in advance by the Medical Executive
Committee. Any disbursement of funds of Two Hundred Fifty
Dollars or less ($250) may be authorized by any two (2) of the
cosigners listed above. Any such disbursement of funds without the
advance approval of the Medical Executive Committee must be
reported to the Medical Executive Committee by the Medical Staff
President at the next regularly scheduled Medical Executive
Committee meeting.
p.m. Medical Staff Evaluation and Development
i.xxiii. Each Member of the active Medical Staff shall be reviewed no less often than every
two years 11 months by his/her Department Head on a form approved by the Medical
Executive Committee. The purpose of this evaluation shall be to facilitate verbal and
written documented communication between the Department Head and the Staff
Member in an attempt to acknowledge the Staff Member's areas of excellence and to
identify those areas, which can be improved.
ii.xxiv. The Medical Staff President shall evaluate the Department Heads in the same manner
after consultation with the Members of his/her department. If the Department Head is
also the Medical Staff President, an individual designated by the Credentials
Committee shall evaluate him or her.
iii.xxv. Upon completion, the evaluator and the Medical Staff Member shall meet face to
face and each receives a copy of the evaluation, with an additional copy to be placed
in the individual's credentials file. The copy in the credentials file shall be used by the
Credentials Committee during the reappointment process. The Staff Member may
request modification of this evaluation or may submit to the credentials file a
statement to respond to the evaluation.
iv.xxvi. This evaluation shall be sent to the credentials file and the information in the
credentials file shall be used for Medical Staff purposes only.
2. Medical Staff Policies
a. Autopsy Policy
b. Treatment with Non-approved Drug(s) Policy
i. Refer to polices of the Institutional Review Committee
c. Peer Review Confidentiality Form
d. Furnishing of Medications by Nurse Practitioners
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20123 Medical Staff Rules and Regulations
e.d. Policy on Provider Communication
3.2. Other Policy Manuals
a. From time to time, policies are legally created and adopted by the Governing Body, the
Administration, Nursing, and particular administrative departments. To the extent that these
policies are not in conflict with the Medical Staff Bylaws, the Rules, or Medical Staff
Policies, the Medical staff shall abide by the extraneous policy. If these extraneous policies
are in conflict with the Bylaws, the Rules, or Medical Staff Policies, the Medical Executive
Committee shall review the conflicting policies and recommend appropriate changes. When
the extraneous policies have a negative impact upon the quality of patient care, the Medical
Executive Committee shall also review the policy and make appropriate recommendation to
assure quality care. In all cases, the Medical Staff must abide by the requirements of the
Bylaws and the Rules.
2013 Medical Staff Rules and Regulations
Contra Costa Regional Medical Center & Health Center
2013 Medical Staff Rules and Regulations
2013 Medical Staff Rules and Regulations
Contra Costa Regional Medical Center & Health Center 2013 Medical Staff Rules and
Regulations Table of Contents
General Rules ............................................................................................................................ 1
Medical Records ........................................................................................................................ 1
Completion of Records .............................................................................................................. 1
Elective Surgery ......................................................................................................................... 3
Delinquency .............................................................................................................................. 3
Outpatient Records .................................................................................................................... 4
Medical Orders .......................................................................................................................... 4
CPR ........................................................................................................................................... 6
Disaster Assignments ................................................................................................................ 6
Consultation Policy .................................................................................................................... 6
Operating Room Policies .......................................................................................................... 6
Supervision of House Staff ....................................................................................................... 7
On-Call Response Time ............................................................................................................ 8
Processing and Delivery of Blood Products ............................................................................... 8
Collection and Expenditures of Medical Staff Funds ............................................................... 8
Medical Staff Evaluation and Development ........................................................................... 10
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Med Staff Rules and Regs 2013 changes accepted
These Rules and Regulations are adopted pursuant to Article 15 of the Medical Staff Bylaws. These Rules
use the same Definitions as the ones described in the Bylaws. The Rules specifically include those
policies and procedures that are referenced herein.
i. General Rules
a. Admissions
i. All admissions of patients are subject to rules delineated in the Medical Staff Bylaws,
specific department policies and Hospital Policy 543 – Admission of Patients.
b. Continuous Responsibility for Patients
i. Inpatient
a. The attending physician is responsible for the complete and continuing care
of his/her patients. He/she is required to keep appropriate personnel informed
as to where he/she can be reached in case of emergency and shall designate
at least one physician to render emergency or other necessary patient care if
he/she is not available. Each patient shall be reassessed daily.
ii. Outpatient
a. Primary Care Providers are responsible for their panel of patients as
described in the Ambulatory Care Policy 1016 – Case Management.
c. Medical Records
i. General Provisions
a. Abbreviations
i. An “Unacceptable Abbreviations List” is posted throughout the hospital
and clinics. Copies may be obtained from Medical Records.
b. Records Belonging to Health Services Department
i. Refer to Hospital Policy 501- Access to, Removal of and Retention of
Medical Records. All medical records and other records relating to the
admission, care and discharge of a patient are the property of the Contra
Costa County Health Services Department and may be removed from the
Health Services Department's jurisdiction and safekeeping only in
accordance with a subpoena, court order or other statute. In case of
readmission of any patient, all previous records shall be available to the
attending physician.
c. Electronic Signature
i. Approved electronic signature of medical records is acceptable for chart
completion.
ii. Completion of Records
a. Inpatient Records
i. Responsibilities of the Members of Medical Staff and General Provisions
a. Content of Staff Entry
i. The attending physician shall be responsible for preparing a
complete medical record for each patient as described in
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Hospital Policy 516 - Medical Record Content. This record
shall include at least the following minimum information.
b. Patients shall be discharged only upon the order of the attending
physician or another physician acting as his/her representative.
At the time the patient is discharged, the attending physician
shall complete the medical record, indicate the reason for
admission, state the final diagnosis, record treatment and/or
procedures performed, describe the condition of the patient on
discharge, including specific comparison with condition on
admission and any specific instructions given the patient and/or
family (e.g., diet, medication, physical activity and follow-up
care). When pre-printed instructions are given to the patient, the
record should so indicate and a sample of the instruction sheet in
use at the time must be kept on file in the Medical Records
Department. All medical record entries must be signed and
dated.
c. When a patient has been hospitalized a discharge summary is
required.
d. All surgery performed shall be fully described by the operating
surgeon in the patient's medical record. Such description shall
include a detailed account of the technique used, identification of
tissues and foreign material removed, if any, and a description of
the findings. Such description shall be done immediately after
surgery is concluded. A brief interim operative note shall be
placed in the medical record immediately after surgery is
concluded if the complete note is not immediately visible in the
electronic health record.
e. At the discretion of the attending physician, tissues and foreign
materials removed in surgery shall be submitted, together with
adequate clinical information, to the pathologist on duty. The
Pathology Department may establish appropriate guidelines.
f. In addition to the operating surgeon's report, the record of every
operation involving use of an anesthetic other than local shall
include a proper anesthetic record and a post-anesthetic follow-
up report.
Standards for History and Physical Examination. The complete history
and physical examination (H&P), as required for the patient's medical
record, shall be completed within 24 hours after admission of the patient,
and, in case a patient is admitted for surgery, shall be completed prior to
the time surgery is done. When the history and physical examination is
dictated, a holding note must be recorded in the medical record at the
time of examination. A history and physical may be performed up to 30
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days in advance provided a durable and legible copy is inserted into the
inpatient medical record no later than 24 hours after admission and is
updated as appropriate.
a. 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.)
a. The scheduling surgeon must schedule the patient for a
pre-op H&P to be done within 30 days prior to the
surgery. The surgeon must clearly enter in the medical
record:
i. The procedure being scheduled and type of
anesthesia;
ii. The surgical indications;
iii. Whether the patient is to be admitted following
the surgery.
b. 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.
c. A History and Physical shall be done on all pre-op
patients Pre-op lab work should be scheduled within
two weeks prior to surgery.
d. 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.
2. Delinquency
a. 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.
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3. Disciplinary Proceedings
a. Process
i. Automatic initiation of disciplinary proceedings for the
responsible practitioner will occur as soon as a chart
becomes delinquent.
ii. A letter will be sent to the practitioner responsible for
the delinquent records, signed by the Medical Staff
President.
iii. The letter shall state:
1. The list of delinquent records;
2. 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.
iv. 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
Document Time Delinquent
Discharge Summary. . . . . . . . . . . . . . . 13 days post discharge.
Inpatient History/Physical. . . . . . . . . . . . . . . . . 24 hours post admission.
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. . . . . . . . . . . . . . . . . 6 hours after conclusion of anesthesia.
“Complete” recovery note. . . . . . . . . . 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;
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.
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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.
b. Further Sanctions
i. 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.
4. Outpatient Records
a. 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. A provider note must be
completed or dictated within 24 hours.
b. If their only delinquent records are unsigned outpatient
dictations, members will not be suspended until after 14 days.
5. Outpatient notes should contain the following elements:
a. Patient identification.
b. Date of visit
c. Relevant history or pertinent update of the illness or injury.
d. Physical findings, if applicable.
e. Results of tests and other studies, if applicable.
f. Diagnostic assessment.
g. Treatment plan, including prescriptions.
h. Results of treatment rendered during the visit, if applicable.
i. Patient teaching, including instructions given to the patient
and/or family and follow-up care.
j. The primary care provider should acknowledge all consultations
in the medical record.
d. Medical Orders
i. Inpatient
a. All orders must be reconciled when a patient is transferred into or out of the
Critical Care units (ICU and IMCU).
i. Orders can be dictated or telephoned to a health professional listed below
and later signed by the attending physician, or, in case of treatment
required in the absence of the attending physician, by the physician then
responsible for the patient's care. Verbal orders shall be accepted and
entered by a licensed nurse, occupational therapist, physical therapist,
licensed respiratory therapist or speech therapist, registered pharmacist
or registered dietician only and such action will be limited to urgent
circumstances.
a. Verbal orders are not valid for orders to limit or remove
lifesaving procedures.
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b. There are no routine or standing orders regarding patient care or
ordering of diagnostic tests.
ii. Outpatient
1. Outpatient orders should be entered in the medical records. Any verbal
orders must be co-signed by the M.D or FNP within 24 hours.
e. CPR
i. Although a "Basic CPR" certificate is not required for Medical Staff
membership, it is strongly encouraged for all those physicians in patient care.
Individual Departments may require it for membership.
f. Disaster Assignments: Refer to the Hospital Disaster Plan
i. Contra Costa Regional Health Center & Health Centers maintains a disaster plan
based upon the Hospital Emergency Incident Command System (HEICS) which
delineates the administrative structure for disaster responses. Each individual
Department also has in place disaster and evacuation plans.
ii. Employed members of the Medical Staff are designated automatically as disaster
workers in the event of a disaster. Other members of the Medical Staff are
eligible to participate in disaster work, as is volunteer staff under the guidelines
of disaster credentialing as delineated in the Medical Staff Bylaws.
g. Consultation Policy
i. Specific requirements for consultation are set forth in Department policy manuals
and by delineation of Privileges. In addition, all providers are expected to seek
consultation and advice whenever they encounter a situation in the course of
caring for a patient in whom they are not confident of their own ability or
knowledge. They should also seek consultation when it becomes evident that the
patient is not comfortable with the diagnosis or management of his or her
problem. Consultation may be obtained from Members of the Staff who are
privileged to care for the problem for which the advice is sought, and his or her
report shall be included in the medical record. The consultation report should be
placed in the medical record.
ii. Except where consultation is precluded by emergency circumstances, the
attending physician shall consult with another qualified physician in all of the
following cases:
a. All major surgical cases in which the patient is not a good risk.
b. In all cases in which the diagnosis is obscure or in which there is doubt
as to the best therapeutic measures to be utilized.
h. Operating Room Policies
i. Consents:
1. Except in cases of emergency, no surgery shall be performed except
pursuant to written informed consent from the patient or his/her legal
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representative, and all other persons, if any, from whom consent is
required.
ii. Requirements Prior to Surgery:
2. Except in cases of grave emergency, all of the following shall be
completed and properly recorded by the time surgery is commenced:
a. History and physical examination;
b. Pre-operative diagnosis;
c. All necessary Laboratory and X-ray work;
d. Pre-anesthetic evaluation in all cases receiving a general
anesthetic.
3. If, in any surgical cases, the foregoing requirements are not met prior to
the time scheduled for surgery, the operation shall be canceled by the
Operating Room Supervisor or designee and rescheduled unless the
attending physician documents that such delay would be detrimental to
the patient.
iii. Prompt attendance of surgeon and attendants: Surgeons and attendants must be in
the operating room and ready to commence surgery at the time scheduled.
i. Supervision of House Staff
iv. House staff shall have appropriate supervision present at all times regardless of
patient complexity or house staff proficiency capabilities. This supervision shall
be accessible and available particularly when house staff capability is exceeded.
v. Inpatient Supervision
4. House staff shall identify a Medical Staff member as the attending of
record on the admission orders of all patients admitted to the hospital.
All critically ill patients admitted by the house staff shall be discussed
with an attending physician. Teaching rounds shall be held daily. Junior
house staff shall receive closer attending supervision, proficiency
monitoring and patient care responsibilities whenever possible. After
hours supervision shall be provided by either in-house Medical Staff
coverage or Department-dependent call mechanisms.
5. All “No CPR” orders entered by house staff shall document concurrent
discussion with Medical Staff.
6. Medical Staff co-signatories are needed for all resident physicians for the
following medical records and documents:
a. Inpatient History and Physical
b. Pre-anesthesia Evaluation
c. Consultative Reports
d. Procedure Notes and Operative Reports
7. Discharge Summaries and Transfer out of Hospital NotesThe attending
staff physician shall be responsible for review and correction of resident
physician and medical student record entries.
8. All medical student record entries must be co-signed by a staff member
or a second- or third-year resident.
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vi. Outpatient Supervision
9. More detailed and specific house staff supervision rules and policies are
located in the specific Department rules and regulations manual of
Contra Costa Regional Medical Center. A copy of these policies is also
located in the residency office.
a. Prescriptions
i. All unlicensed residents must have all prescriptions co-
signed.
b. Family Medicine Clinics
i. All family medicine residents must have a Department
of Family Medicine member with appropriate privileges
assigned to supervise and precept them. This preceptor
must be immediately available and have
adequate time for teaching.
ii. All medical record entries by medical students must be
co-signed by a provider with privileges.
c. Specialty Clinics
i. A staff physician will directly supervise all residents
working in a specialty clinic. First-year residents are
expected to discuss all patients with their supervising
physician before the patient leaves Second- and third-
year residents should discuss most cases with their
supervising physician. The supervising physician should
be identified on the consultation.
ii. All medical record entries by medical students must be
co-signed by provider with privileges.
j. On-Call Response Time:
i. Departments shall determine and monitor appropriate on-call procedures for their
specific services.
k. Processing and Delivery of Ordered Blood Products
i. Blood products ordered by any physician shall be provided by the Blood
Bank/Transfusion Service without delay. If questionable indications for
transfusion are felt to be present, the pathologist, while processing of this order
proceeds without delay, will attempt to discuss this issue with the ordering
physician. If, after discussion, the pathologist still believes the request to be
questionable, he/she will report this case to the appropriate Department or
committee for review.
ii. The physician who has primary responsibility for the patient has the final say in
decision-making, although we encourage a team approach utilizing dialogue
between the clinician and the transfusion service.
l. Collection and Expenditures of Medical Staff Funds
i. Application Fees
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a. Each application may be assessed an application processing fee. This fee
shall be Three Hundred Dollars ($300) 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.
b. 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.
ii. Medical Staff Dues
a. The Medical Executive Committee shall have the power to determine the
amount of biannual dues. The following dues are currently in effect:
i. Active Staff: $200 for each two-year reappointment
ii. Courtesy Staff: $100 for each two-year reappointment
b. 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.
iii. Reappointment Late Processing Fees
1. 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 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:
a. At 150 days from the end of a term - $50 (may be waived in
extenuating circumstances, such as vacation);
b. At 120 days from the end of a term—$50 more for a total
penalty of $100 (may not be waived);
c. At 90 days from the end of a term-$50 more for a total penalty of
$150,
d. At 60 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.
iv. Expenditure of Funds
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a. The Medical Executive Committee shall determine the method of
disbursement of Medical Staff funds. The Medical Executive Committee
may appoint a Medical Staff Funds Advisory Committee to advise the
Medical Executive Committee regarding such expenditures.
1. If an Advisory Committee is appointed, it shall study the various
possible uses for the funds and recommend specific
expenditures, including specific dollar amounts, to the Medical
Executive Committee on an annual basis or more often as
appropriate.
2. The Medical Executive Committee shall retain ultimate control
of these funds. The Medical Executive Committee may deposit
these funds in any accounts it deems suitable.
3. Any account shall have the following co-signers:
i. The Medical Staff President
ii. The Medical Staff President-Elect
iii. The Immediate Past President of the Medical Staff
iv. The Chair of the Administrative Affairs Committee
v. Two Medical Staff Coordinators as designated by the
Medical Executive Committee
b. Any two (2) of these co-signers may disburse Medical Staff funds
provided at least one signer is a Member of the Medical Staff. Any
disbursement of funds greater than Two Hundred Fifty Dollars (>$250)
must be approved in advance by the Medical Executive Committee. Any
disbursement of funds of Two Hundred Fifty Dollars or less ($250) may
be authorized by any two (2) of the cosigners listed above. Any such
disbursement of funds without the advance approval of the Medical
Executive Committee must be reported to the Medical Executive
Committee by the Medical Staff President at the next regularly scheduled
Medical Executive Committee meeting.
m. Medical Staff Evaluation and Development
i. Each Member of the active Medical Staff shall be reviewed no less often than every
11 months by his/her Department Head on a form approved by the Medical
Executive Committee. The purpose of this evaluation shall be to facilitate verbal
and documented communication between the Department Head and the Staff
Member in an attempt to acknowledge the Staff Member's areas of excellence and
to identify those areas which can be improved.
ii. The Medical Staff President shall evaluate the Department Heads in the same
manner after consultation with the Members of his/her department. If the
Department Head is also the Medical Staff President, an individual designated by
the Credentials Committee shall evaluate him or her.
iii. Upon completion, the evaluator and the Medical Staff Member shall meet face to
face and each receives a copy of the evaluation, with an additional copy to be
placed in the individual's credentials file. The copy in the credentials file shall be
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used by the Credentials Committee during the reappointment process. The Staff
Member may request modification of this evaluation or may submit to the
credentials file a statement to respond to the evaluation.
iv. This evaluation shall be sent to the credentials file and the information in the
credentials file shall be used for Medical Staff purposes only.
n. Other Policy Manuals
i. From time to time, policies are legally created and adopted by the Governing Body,
the Administration, Nursing, and particular administrative departments. To the
extent that these policies are not in conflict with the Medical Staff Bylaws, the
Rules, or Medical Staff Policies, the Medical staff shall abide by the extraneous
policy. If these extraneous policies are in conflict with the Bylaws, the Rules, or
Medical Staff Policies, the Medical Executive Committee shall review the
conflicting policies and recommend appropriate changes. When the extraneous
policies have a negative impact upon the quality of patient care, the Medical
Executive Committee shall also review the policy and make appropriate
recommendation to assure quality care. In all cases, the Medical Staff must abide
by the requirements of the Bylaws and the Rules.
Contra Costa County Regional Medical Center
& Health Centers
Medical Staff Bylaws
Rules & Regulations
2013
medical_staff_bylaws_2012 with 2013 changes accepted
Contra Costa Regional Medical Center & Health Center
2012 Medical Staff Bylaws
Table of Contents
Article 1
Name and Purposes ...................................... 2
Article 2
Membership ................................................. 2
Qualifications ............................................... 2
Requirements & Responsibilities ................. 3
Article 3
Categories of the Medical Staff ................... 5
Article 4
Allied Health Practitioners ......................... 12
Definitions, Categories .............................. 12
Responsibilities .......................................... 13
Article 5
Procedures for Appointment
and Reappointment .................................... 14
Processing the Application ........................ 17
Reappointment and Modification
of Staff Status or Privileges ....................... 20
Leave of Absence ...................................... 21
Article 6
Privileges ................................................... 22
Limitations for Certain Members ............... 23
Temporary Privileges ................................. 23
Emergency Privileges ................................ 24
Proctoring .................................................. 25
Article 7
General Medical Staff Officers/
Qualifications ............................................. 27
Vacancies ................................................... 28
Duties ......................................................... 29
Article 8
Departments and Divisions ........................ 30
Department Heads ..................................... 33
Election ...................................................... 34
Term of Office/Functions .......................... 35
Division Heads .......................................... 35
Article 9
Committees ................................................ 37
The following Committees report to the Medical
Executive Committee:
1. Administrative Affairs
2. Ambulatory Policy
3. Cancer
4. Continuing Medical Education
5. Credentials
6. Ethics
7. Institutional Review
8. Interdisciplinary Practice
9. Joint Conference
10. Medical Errors and Adverse Outcomes
11. Medical Staff Assistance
12. Patient Safety Performance Improvement
13. Utilization Management
Appointment of Members .......................... 37
Conduct of Meetings ................................. 38
Medical Executive Committee ................... 38
Article 10
Meetings .................................................... 52
Quorum ...................................................... 53
Attendance Requirements .......................... 54
Article 11
Corrective Action ...................................... 55
Initiation and Formal Investigation ............ 55
Restriction or Suspension .......................... 56
Article 12
Hearings and Appellate Reviews ............... 59
Article 13
Confidentiality ........................................... 66
Article 14
General Provisions ..................................... 69
Dues or Assessments ................................. 69
Requirements for Elections ........................ 70
Authorization, Immunity and Releases ...... 71
Article 15
Adoption and Amendment of Bylaws
and Rules ................................................... 72
Election & Term of Office ......................... 36
medical_staff_bylaws_2012 with 2013 changes accepted
CONTRA COSTA REGIONAL MEDICAL CENTER &
HEALTH CENTERS
2012 MEDICAL STAFF BYLAWS
DEFINITIONS
The following definitions apply to these Medical Staff Bylaws:
1. Administrator means the Chief Executive Officer of Contra Costa Regional Medical Center and Health Centers
or her/his designee.
2. Chief Resident means the resident physician chosen by the residents to represent them.
3. Allied Health Practitioners (AHP) are those non-Medical Staff member practitioners described in Article 4
below.
4. Clinical Privileges or Privileges means permission, granted by this Medical Staff to members of the Medical
Staff, to provide specific diagnostic, therapeutic, medical, dental, podiatric, surgical, psychiatric or
psychological services.
5. AHP Clinical Privileges or Service Authorizations means permission granted by the Governing Body, upon the
recommendation of the Interdisciplinary Practice Committee and the Medical Staff, to provide diagnostic and
therapeutic services within the scope of the AHP’s training and expertise.
6. County means the County of Contra Costa, California.
7. Department or Clinical Department means a clinical structure of the Medical Staff as further identified in these
Bylaws.
8. Department Head means the practitioner elected or appointed, pursuant to these Bylaws to be responsible for the
function of a Clinical Department.
9. Medical Director of Contra Costa Regional Medical Center, also referred to simply as the Medical Director,
means the physician appointed by the Administrator to oversee clinical activities of the hospital.
10. Chief Medical Officer of the Health Services Department means the physician appointed by the Director of the
Health Services Department to oversee the clinical activities of the Health Services Department.
11. Ex officio means service as a member of a body by virtue of an office or position held and, unless expressly
provided, without voting rights.
12. Governing Body means the County Board of Supervisors.
13. Hospital or Medical Center means the Contra Costa Regional Medical Center and Health Centers.
14. Health Centers means the outpatient clinical facilities operated by the County where the Members of this
Medical Staff provide patient care.
15. Medical Staff Year means the 12-month period commencing on the first of July of each year and ending on the
thirtieth of June of the following year.
16. Member or Medical Staff Member means any Practitioner or Resident who has been appointed to the Medical
Staff pursuant to these Bylaws.
17. Member in Good Standing means a Member of the Medical Staff who is not under a suspension.
18. Physician means an individual with a M.D. or D.O. degree who is currently licensed to practice medicine in the
State of California.
19. Practitioner means a physician, dentist, clinical psychologist, or podiatrist who is currently licensed by the State
of California to provide patient care services.
20. Residency Director means the physician who directs the postgraduate Family Medicine training program based
at the Hospital.
21. Resident means a physician in training who is participating in a residency or fellowship approved by the
American Council of Graduate Medical Education.
22. Rules or Rules and Regulations mean the Medical Staff Rules and Regulations that are contained under separate
cover and are adopted pursuant to these Bylaws.
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8.1.1 Current Clinical Departments and Divisions
The current Clinical Departments and Divisions are:
(a) Family Medicine
1. Divisions:
i) Antioch-Brentwood
ii) Pittsburg-Bay Point
iii) Concord
iv) Martinez
v) West County
vi) Inpatient
(b) Anesthesia
(c) Emergency Medicine
(d) Surgery
(e) Pediatrics
(f) Psychiatry/Psychology
(g) Internal Medicine
1. Divisions
a. Inpatient
b. Outpatient
(h) Obstetrics & Gynecology
(i) Intensive Care Unit
(j) Diagnostic Imaging
(k) Pathology
(l) Dental
ARTICLE 9 COMMITTEES
9.1 General Provisions
9.1.1 Designation
9.1.1.1 The Medical Executive Committee and the other committees described in these
Bylaws shall be standing committees of the Medical Staff unless otherwise indicated.
9.1.1.2 The chairperson of the Medical Executive Committee, a standing committee, or a
Department may create subcommittees, special committees, or Ad Hoc committees,
in order to carry out specified tasks. These specified tasks must be within the scope
of authority of the committee whose chairperson created the committee. Such
committees terminate once the specified task is completed and are not standing
committees.
9.1.2 Appointment of Members to Committees
9.1.2.1 The Medical Executive Committee, on the recommendation of its chairperson, shall
appoint chairpersons and members of standing committees unless otherwise specified
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in the Bylaws. Committee members are appointed for a term of one Medical Staff
year unless otherwise specified by the Bylaws, and shall serve either until the end of
this period, until the member’s successor is appointed, or until the member resigns or
is removed from the committee.
9.1.2.2 Only Members in Good Standing of the Medical Staff may be voting members of any
Medical Staff Committee. Others individuals may be appointed to committee
positions as either Ex officio or non-medical Staff members.
9.1.2.3 For committees that are not standing committees, the person creating the committee
shall appoint chairpersons and members.
9.1.3 Removal from Committees
Unless otherwise specified in the Bylaws, committee members may be removed by the
appointing authority without cause.
9.1.4 Vacancies
Vacancies on any committee shall be filled in the same manner as an original appointment is
made.
9.1.5 Conduct of Meetings of Committees
Committee meetings shall be conducted and documented in the manner specified in these
Bylaws.
9.1.6 Attendance of Non-Members
Members in good standing of the Medical Staff who are not committee members may attend
committee meetings only with the permission of the chair of the committee.
9.1.7 Accountability
All committees of the Medical Staff are accountable to the Medical Executive Committee.
9.2 Medical Executive Committee
9.2.1 Composition
The Medical Executive Committee (MEC) consists of the following Members of the Medical
Staff as voting members:
(a) President of the Medical Staff;
(b) President-Elect;
(c) Past President;
(d) Clinical Department Heads;
(e) Division Heads
(f) The Chairpersons of the following Committees shall be voting member of the
MEC:
Administrative Affairs, Ambulatory Policy, Credentials, Patient Safety and
Performance Improvement, and Patient Care Policy and Evaluation;
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(g) Chief administrators may attend the meetings without voting rights. These
include the Director of Health Services, the Chief Executive Officer of Hospital
and Clinics, the Chief Medical Officer, the Chief Nursing Officer, the
Ambulatory Care Medical Director, the Residency Program Director and the
Medical Director of the health plan. The chairperson of the MEC may invite
other individuals to participate in the MEC meetings as non-voting guests.
9.2.2 Duties
The Medical Executive Committee shall:
9.2.2.1 perform and/or delegate performance of all Medical Staff functions in a manner
consistent with the Bylaws and the Rules;
9.2.2.2 coordinate and implement the activities of the committees and the Departments;
9.2.2.3 make recommendations regarding Medical Staff membership and privileges;
9.2.2.4 initiate and pursue disciplinary or corrective actions when indicated;
9.2.2.5 supervise the Medical Staff’s compliance with the Medical Staff Bylaws, Rules,
and policies;
9.2.2.6 supervise the Medical Staff’s compliance with County laws, rules, policies and
procedures;
9.2.2.7 supervise the Medical Staff’s compliance with state and federal laws and
regulations;
9.2.2.8 supervise the Medical Staff’s compliance with JCAHO and other applicable
accreditation and certification rules;
9.2.2.9 regularly report to the Governing Body regarding the status of Medical Staff
issues;
9.2.2.10 meet monthly to conduct Medical Staff business;
9.2.2.11 represent and act on behalf of the Medical Staff in the intervals between Medical
Staff meetings, subject only to such specific limitations as may be imposed by
these Bylaws.
9.3 Committees
In order to remain in good standing on a committee, a member must attend at least 50 per cent of the
meetings.
9.3.1 Administrative Affairs Committee
9.3.1.1 Purpose and Meetings
The Administrative Affairs Committee (AAC) fulfills staff responsibilities
relating to review and revision of Medical Staff Bylaws and related manuals and
forms and assumes the responsibilities for investigating and providing
recommendations on such other administrative policy-making and planning
matters and activities of concern to the Staff as are referred by the MEC. The
AAC oversees the Institutional Review Committee (IRC) which reviews,
approves or denies, monitors and evaluates research projects, protocols, and
clinical investigations to be conducted within the Medical Services, in
compliance with the regulations of the Food and Drug Administration and
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observing all requirements of any other applicable regulatory authorities for any
given study. The AAC may overrule a positive recommendation of the
Institutional Review Committee, but the AAC may not approve a study or the
use of an investigational agent if disapproved/denied by the IRC. The AAC
meets as needed, and reports to the MEC. When appropriate, it shares its
monitoring and evaluation findings from research projects with the Patient
Safety and Performance Improvement Committee and vice versa.
9.3.1.2 Composition
The Administrative Affairs Committee includes:
(a) a physician Chairperson, appointed by the Medical Staff President,
subject to MEC approval;
(b) at least 4-6 additional Staff Members;
(c) Administrator, with vote; and
(d) their members with special expertise as necessary on an ad-hoc
basis, without vote.
9.3.2 Ambulatory Policy Committee
9.3.2.1 Purpose and Meetings
The Ambulatory Policy Committee sets Medical Staff policy in the health
centers and acts as a liaison with Nursing and Administration for coordination of
policies and procedures under joint Medical Staff-Administration or Medical
Staff-Nursing purview.
APC develops policies to resolve issues that affect more than one Medical Staff
Department and focuses on policies and projects that relate to quality of care, the
efficiency of the health centers and patient and Staff satisfaction as well as
regulatory compliance. APC coordinates its activities with PSPIC and receives
quality assurance reports suggestive of or requiring changes in policies and
procedures from individual Medical Staff Departments and from the Ambulatory
Subcommittee of PSPIC.
9.3.2.2 Composition
The Ambulatory Policy Committee includes:
(a) a physician chairperson appointed by the Medical Staff
President, subject to MEC approval;
(b) one Staff Member from each Region;
(c) the Department Head of Family Medicine or his/her designee;
(d) representatives of the Departments of Obstetrics & Gynecology,
Surgery, Pediatrics and Medicine, with vote;
(e) other members with special expertise as needed on an ad-hoc
basis without vote;
(f) Director of Health Information Management as needed on an ad-
hoc basis without vote;
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(g) a representative of the Allied Health Professionals, without vote;
and
(h) Ambulatory Care Medical Director without vote;
(i) Chief Nursing Officer without vote.
9.3.4 Bioethics Committee
9.3.4.1 Purpose and Meetings
The Bioethics Committee provides a multi-disciplinary forum for the
development of guidelines for consideration of cases and issues having
bioethical implications; development and implementation of procedures for the
review of such cases; development and/or review of institutional policies
regarding care and treatment in cases or issues having bioethical implications;
consultation with concerned parties to facilitate communication and aid in
conflict resolution in an advisory capacity; and education of the hospital staff
regarding bioethical matters. The committee will meet regularly (at least six
times yearly) and will also provide a mechanism for other meetings as necessary
to perform the case consultation function. The committee chair will report to the
Medical Executive Committee.
9.3.4.2 Composition
The Bioethics Committee includes:
(a) a physician chairperson appointed by the Medical Staff
President subject to Medical Executive Committee approval;
(b) multi-disciplinary representation selected to represent the
various clinical services of the medical and nursing staff,
ancillary support services (such as social workers, chaplains,
etc.) and lay members. At least a third of the committee
membership will be physicians;
(c) a member representing hospital administration; and
(d) the committee may invite other professional or community lay
members to be utilized when discussing issues involving their
particular clinical, ethnic, religious or other background.
9.3.5 Cancer Committee
9.3.5.1 Purpose and Meetings
The Cancer Committee is a multi-disciplinary committee that organizes,
conducts and evaluates hospital-wide oncology services and the cancer registry.
The committee assures that full oncology services including surgery,
chemotherapy, radiation therapy, as well as rehabilitation and hospice care are
available to all patients. The committee will develop and monitor annual goals
and objectives for clinical care, community outreach, quality improvement and
programmatic endeavors related to cancer care. The committee is responsible
for establishing and monitoring the Cancer Conference format, frequency and
multidisciplinary attendance. The committee will ascertain if there is a need for
specific educational programs — both professional and public — based on
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survival and comparison data. The committee will also supervise the Cancer
Registry for quality control of case-finding, abstracting, staging, reporting and
follow-up. The committee will conduct a minimum of two patient care
evaluation studies annually, one to include survival data. The committee will
implement at least two patient care enhancements each year. The committee will
meet at least quarterly or more often as needed and communicate as necessary
with the Patient Safety and Performance Improvement Committee. The
committee will designate one coordinator for each of the four areas of Cancer
Committee activity: Cancer Conference, quality control of the cancer registry,
quality improvement and community outreach.
9.3.5.2 Composition
The Cancer Committee includes:
1. a physician chairperson appointed by the Medical Staff President,
subject to Medical Executive Committee approval;
2. at least five (5) additional Medical Staff Members including
representation from, Surgery, Pathology, Hematology/Oncology,
Family Practice, and Diagnostic Imaging;
3. Cancer Liaison Physician;
4. representation from Administration, Social Services, Nursing, and
the American Cancer Society all with vote; and
5. the cancer registrar, who will act as staff to the Cancer Committee,
with vote.
9.3.5 Continuing Medical Education Committee
9.3.5.1 Purpose and Meetings
The Continuing Medical Education Committee (CMEC) directs the development of CME
programs for the Staff responsive to quality assurance findings and to developments
pertinent to practice at the Hospital and apprises the Staff of outside educational
opportunities. It coordinates the educational activities of the Departments and of the Staff
and Hospital Departments. The CMEC also analyzes the status and needs of, and makes
recommendations regarding, the medical library services. It meets at least quarterly and
more frequently if needed and reports on its activities to the MEC.
9.3.5.2 Composition
The CMEC includes:
(a) a chairperson appointed by the Medical Staff President, subject to MEC
approval;
(b) at least two additional Staff Members; and
(c) Medical Librarian, without vote.
9.3.6 Credentials Committee
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9.3.6.1 Purpose and Meetings
The Credentials Committee coordinates the staff credentials function by receiving and
analyzing applications and recommendations for appointment, provisional period
conclusion or extension, reappointment, clinical privileges, and changes therein, and
recommending action thereon, and by integrating quality assurance and utilization review
and monitoring, membership, and other relevant information into the individual
credentials files. It also assists in designing and participates in implementing the
credentialing procedures for Allied Health Practitioners. It meets monthly or more often
as necessary and reports to the MEC regarding the credentialing of Staff Members.
9.3.8 Informatics Advisory Committee
9.3.8.1 Purpose and meetings
The Informatics Advisory Committee provides governance in informatics and information
Technology (IT)-related clinical systems. It prioritizes issues, reports and optimization
and acts as a liaison between medical staff departments and it/clinical informatics.
9.3.8.2 Composition
A. Chief medical Informatics Officer (CMI)) who serves as chair
B. Director of Nursing Informatics
C. Director of Medical Outpatient Informatics
D. Director of Medical Inpatient Informatics
E. A representative of each department.
9.3.9 Institutional Review Committee
9.3.9.1 Purpose and Meetings
The Institutional Review Committee shall review and have authority to: approve, require
modification in (to secure approval), or disapprove all research activities within the
Hospital and Health Centers; approve, require modification in, or disapprove the use of
investigation drugs or devices in individuals (i.e. "compassionate use" cases); receive
prompt notification of the emergency use of investigational drugs or devices and approve,
require modification in or, disapprove their continued use; continue, require modifications
in or terminate any ongoing studies at intervals of not greater than 12 months;
immediately terminate or suspend any research not conducted in accordance with the
IRC's requirements or that has been associated with unexpected serious harm to subjects;
ensure all compliance with federal informed consent regulations regarding investigational
use of drugs and devices; and assure the protection of the rights and welfare of all human
subjects. The Institutional Review Committee shall meet semi-annually or more often as
necessary to fulfill its obligations. If the Institutional Review Committee disapproves of
any activity within its purview, that decision is final. The Institutional Review
Committee chairperson reports to the Administrative Affairs Committee.
9.3.9.2 Composition
The Institutional Review Committee includes:
(a) a Chairperson appointed by the Chairperson of the Administrative
Affairs Committee, subject to Medical Executive Committee approval;
(b) at least one member of each gender;
(c) at least one member from outside the medical profession;
(d) at least one non-scientist;
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(e) at least one member not affiliated with the Hospital and Health Centers;
and
(f) a total of at least five members, including representative ethnic and
cultural backgrounds, of the community.
9.3.14 Order Set Oversight Committee
9.3.14.1 Purpose and Meetings
The Order Set Oversight Committee oversees order sets, clinical content requirements,
documentation requirements, and alerts. These will be developed by the appropriate
departments(s). This Committee ensures that they are done in a proper way, in a timely manner, in
a way that works for IT, and in a way that is internally consistent. if a proposal is rejected, it is
returned to the department(s) with suggestions for revisions. The department can refer a rejection
to the MEC directly.
9.3.14.2 Composition
1. The Chief Medical Informatics Officer (CMIO) shall serve as Chair
2. The Chief Medical Officer (CMO) or designee
3. The Chief Quality Officer (CQO) or designee
4. A representative from pharmacy for a 2-year term
5. Two ambulatory providers (preferably including a member of APC) for 2-year terms.
6. An inpatient provider (preferably a member of PCP&E and an alternative for a 2-year
term.
9.3.17 Peer Review Oversight Committee
9.3.17.1 Purpose and Meetings
The Peer Review Oversight Committee will oversee the peer review that is carried out by
the departments. It will supervise the processes, help address systems issues and review
cases that involve more than one department.
9.3.17.2 Composition
1. The Medical Staff President shall sever as Chair of the Committee.
2. Each department will have at least one representative. Large departments will
have two representatives; one from inpatient and the other from outpatient.
Large departments are: Family Medicine, Internal Medicine, Surgery, and
Psychiatry/Psychology.
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14.7.1 Runoff Elections: A candidate shall be elected by a majority of the votes cast. If no
candidate receives a majority vote on the first ballot, a runoff election shall be conducted
as soon as is practical between the two candidates who received the highest pluralities. If
the runoff election results in a tie, the election shall be repeated. If there is still a tie, the
Medical Staff President will cast the deciding vote. If the election is for the Medical Staff
President, the Medical Executive Committee will decide.
14.7.2 Voting within committees and Departments: At the discretion of the Department chair,
ballots may be by voice, by hand, or by secret ballot. However, at the request of any
voting Member within that committee or department, that vote shall be by secret ballot.
Voting Members are determined in accordance with these Bylaws.
14.8 Disclosure of Interest
All nominees for election or appointment to Medical Staff offices, Department chairs, or the Medical
Executive Committee shall, at least 20 days prior to the date of election or appointment, disclose in
writing to the Medical Executive Committee those personal, professional, and financial affiliations and
relationships of which they are reasonably aware that could foreseeably result in a conflict of interest
with their activities or responsibilities on behalf of the Medical Staff.