HomeMy WebLinkAboutMINUTES - 01251994 - 1.68 TO: BOARD OF SUPERVISORS
FROM: Mark Finucane, Health Services Director - =':* Contra
Costa
DATE:
County
SUBJECT: December 14, 1993
CHANGES TO MEDICAL STAFF BYLAWS
SPECIFIC REOUEST(S)OR RECOMMENDATIONS)&BACKGROUND AND JUSTIFICATION
RECOMMENDATION:
Approve the amendments to the Medical Staff 13ylaws Detailed amendments showing deletions and insertions
are attached.
BACKGROUND:
Changes to the bylaws were undertaken for several reasons:
✓ To comply with JCAHO criteria.
✓ To follow recommendations by CMA to afford legal protection.
✓ To clarify existing practices.
✓ To modify language.
✓ To reflect changes in organizational structure.
These changes were approved by the Medical Executive Committee and also by the Medical Staff as a whole
by mailed ballots. They also were reviewed by County Counsel.
FISCAL IMPACT:
None.
CONTINUED ON ATTACHMENT: YES SIGNATURE
RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE
APPROVE OTHER
SIGNATUREM:
ACTION OF BOARD ON oZS/ g f54 APPROVED AS RECOMMENDED X OTHER
VOTE OF SUPERVISORS
I HEREBY CERTIFY THAT THIS IS A TRUE
_X UNANIMOUS (ABSENT ) AND CORRECT COPY OF Aid ACTIC"d TAKEN
AYES: NOES: AND ENTERED ON THE MINUTES OF THE BOARD
ABSENT: ABSTAIN: OF SUPERVISORS ON THE DATE SHOWN.
Contact Person: Steven C. Tremain, M.D.
arr TED
CC: Mark Finucane , Director, Health ServicePHIL TCHELOR,CLERK OF THE BOARD OF
_
SUPERVISORS AND COUNTY ADMINISTRATOR
BY DEPUTY
SUMMARY OF BYLAWS CHANGES
3.1 Nature of Membership
To clarify privileges and restrictions of clinical psychologists.
3.5 Basic Responsibilities
To include FNPs, residents and other members of the health care team.
4.2 The Honorary Medical Staff
To clarify restrictions on practice by honorary medical staff members.No substantive change.
4.4-1 Qualifications (of courtesy staff)
(d) Language modification only
(f) To clarify requirement for meeting attendance
5.5 Application procedure
These changes specify that applications go to the Credentials Committee, which affords
protection from discovery.Changes were recommended by the California Medical Association.
6.3-2 Basis for Privileges Determination
Wording change to comply with JCAHO criteria.
6.8-1 Circumstances
Changes Medical Staff Secretary to Credentials Coordinator to comply with CMA
recommendations above.
6.8-3 Termination
Adds reference.
Article VII
Changes length of term of office of president, president-elect and past president. Deletes
positions of East and West County representatives to reflect reorganization.
8.1 Organization of Clinical Departments and Divisions
Adds approval procedure.
8.6-2 Qualifications
Clarifies qualifications of Department Heads
8.6-2 Selection atut 8.6-3 Term of Office
Increases the terms of department heads to two years and calls for actual elections by secret
ballot every other year.
8.7 Division Heads
Makes requirements and terms of division heads the same as department heads.
9.3-2 Composition
Changes composition of the Medical Executive Committee.
9.22 Bioethics Committee
Creates a hospital bioethics committee
10.2-3 Executive session
Allows ex-officio members to attend executive sessions if the chair requests.
10.3-1 Staff Meetings
Defines quorum for meetings to remove officers. Allows for mail ballots for other business.
14.1 Rules and Regulations
Specify annual review of rules and regulations, as suggested by JCAHO.
14.7 Requirements for Elections and Votes within Committees and Departments
New section specifying election rules within departments and committees.
15.3 Medical Staff Action
Allows bylaws to be amended by mail ballot with a quorum for such balloting to be a third
of the active staff.
Attachments
Proposed Changes to Medical Staff Bylaws
Additions are underlined; deletions are st-r-ueli cul.
3.1 Nature of Membership
No physician,dentist,podiatrist,s)inieal psychologist,or affiliate, including those in a medical
administrative position by virtue of a contract with the Hospital, shall admit or provide
medical or health-related services to patients in the Hospital see definition,Page 1,Item 1ij
unless he or she is a member of the medical staff or has been granted temporary privileges
in accordance with the procedures set forth in these bylaws. No licensed clinical psychologist
shall treat patients at Merrithew Memorial Hospital,Mental Health Crisis Services,Richmond
Psychiatric Emergency or any Contra Costa County Detention Facility, including any juvenile
detention facility, unless he/she is a member of the medical staff. Licensed clinical
psychologists employed by the County of Contra Costa who do not treat patients at any of
the above-listed locations/facilities may, but need not, be members of the medical staff.
Appointment to the medical staff shall confer only such clinical privileges and prerogatives
as have been granted in accordance with the bylaws.
3.5 Basic Responsibilities of Membership
(g) working cooperatively with staff members, nurse practitioners, residents, nurses, hospital
administration, and other members of the health care team so as not to adversely affect
patient care;
4.2 The Honorary Medical Staff
. . . Honorary staff members shall not be eligible to admit, care for or consult on patients, to vote,
to hold office, or to serve on standing Medical Staff committees.
4.4-1 Qualifications
The courtesy staff shall consist of practitioners, each of whom:
(d) . . . (in any eyen!Dentists holding only General Dentistry, Endodontia,Periodontia,
or Orthodontia privileges are exempt from this requirement},
f Courtesy staff members who are not on the active staff of another licensed hospital
and practice patient care an average of four hours a week or more shall have the
same meeting attendance requirements as active staff (10.8-1). Those practicing
patient care fewer than four hours a week shall have these attendance requirements
if deemed appropriate by their department chair.
5.5 Application Procedure
5.5-1 Application
Application for Staff membership must be submitted directly to the Credentials Committee
by the applicant in writing and on such form as approved by the Medical Executive
Committee. . . .
5.5-5 Processing the Application
(a) Verification of Information. The application is submitted to the M
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SGGrGtaf), Credentials Committee Coordinator. The
Credentials Committee Coordinator verifies the references, licensure and other
qualification evidence submitted and promptly notifies the applicant of any problems
in obtaining the information required. . . .
When the application is completed as defined in Section 5.5-5(b), the A4edicalsta
£€
SP.Gr-etaty Credentials Committee Coordinator transmits the applications and all
supporting materials to the Head of each Department in which the applicant seeks
privileges.
(k) Time Periods for Processing.
b. Credentials Committee Coordinator 30
days.
5.6 Reappointment Procedures and Requests for Modifications of Staff Status OR PRIVILEGES
5.6-1 Application
(a) . . . In addition, the Credentials Committee will seek information from the Quality
Assurance Committee regarding quality assurance activities of the applicant. This
Quality Assurance information will be integrated into the decision regarding
reappointment and reprivile in .
63-2 Basis for Privileges Determination
. . .The elements to be considered in making determinations regarding privileges, whether in
connection with periodic reappointment or otherwise, shall include education, training,
GliRiG^t judgmeat, por€er-mango€ a suff-iciontnumber—o€
der.umeme.d_ re-sults -of thG patient Gare maRitering and eihof quality FG;,iow, Gvaluatioi4, aj4d
and current
clinical competence as fudged by observation and monitoring. . . .
6.8-1 Circumstances
(b) Care of Specific Patients: . . . In such urgent situations, the grantor of such
privileges shall notify the Credentials Coordinator of such
action no later than the next regular working day.
6.8-3 Termination
The Administrator or the President of the Medical Staff
(a) must,on the discovery of any information or the occurrence of any event of a nature
which raises question about a practitioner's professional qualifications or ability to
exercise any or all of the temporary privileges granted, and
(b) may at any other time, after consultation with the chairperson of the department
responsible for supervision,
terminate any or all of a practitioner's temporary privileges, provided that where the life or
well-being of a patient is determined to be endangered, the termination may be effected by
any person entitled under Section 11.2-1 to impose summary suspensions under these Bylaws.
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7.1 General Officers of the Staff
7.1-1 Identification
The general officers of the Staff are:
RGgieRaj
7,�2 RA4 OT7 QF;LF1Tr_T:
fir ;ao -r.,
PF9-Sid GRt Falx,.* One
P;4otpr Ridopt (ln
Regienal gyre tat —9116
Q";C'p'r.p' ;4s;gumct office- in tho first day of the M@diral Staff year- fell wing their- GIGGtien (july ,
Of- Each officer sep,eg until the Gnd of hisAef wr-m and- uwtil a ig e_foewd,
7:2 aOf F344i;t And Wert County Regional Repr-ownwtivps
(a) Wee-440H. Tho E;44 and I lest COURty vWgional Re, rhwApR
F-GgiGllal GIGGti0n by majority vew cam by those Acai C% staff ma.
immediately h-ev.ve-en the twe candidates rweiving the, highest pumbpr- of vpteg
(b) Nomination- Neminmiens fe; regional rpp;Gspnta!ivp. Gan be made by any MGB4bp.F
Of 1110 _AGt;.,P Staff Wh SC, r Gl;n;..al r aG!i..Q the sAMA Fegion S the
e
7.2 Attainment and Succession of Office
7.2-1 of President, President-Elect and Past President
(a) E!2gjk,,.. The Prp-gident Blest shall he 114.12.or.P Q, and is shosen, from
ho h@ld Wlpwing the , rterl.. meeting ;., April and pFier to T„I., 4 st ,f that
fir if RG GAnfl;dAW for o gwon effiGe, r- riv .rote on tho f;rot
f'
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one year, and at the ropolusiop Af the, one,year- wFm, shall AttAiA 4he office,
of Sisl tt�
(a) Term of Office: The election for the office of President-Elect shall take
place in January. The person who receives the majority of the votes cast is
the President-Elect and shall immediately assume the office. On July 1 of
that same year,the President-Elect shall assume the office of President. The
President shall serve one one-year term, but may be reelected to a second
one-year term. At the conclusion of the President's term(s) of office, the
President shall assume the office of Past-President.
Should the incumbent President be nominated for, and choose to seek, a
second one-year term, the incumbent President will be listed on the ballot
in the annual January election along with all other nominated candidates.
Should the incumbent President be reelected, the office of President-Elect
shall remain vacant until the next January election.
(b) Nomination: The Administrative Affairs Committee (AAC) serves as the
nominating committee. It convenes in November or December ;
election-ysar-s for the purpose of nominating one or more qualified
candidates for the office of President-Elect. Nominations may also be made
from the floor at the Ap44 January quarterly meeting by a member of the
Active Staff in good standing. Any such floor nomination must be seconded
by a member of the Active Staff in good standing and accompanied by
evidence of the nominee's willingness to be nominated.
(c) Election: The President Elect shall be an M.D. or D.O. and is chosen, from
among the candidates nominated under Section 7.2-1(b), by uluk;tion by
. '45' VOW GaSt by thesG Active Staff ii4 good standing 19y serr-et ballet
balloting as defined in Section 15.3.
meeting i n„r;i and r r toJul), ist of thatyeai:. Elections shall occur
annually in January of each year. The Medical Staff President may serve
two consecutive one-year terms. If no candidate for a given office receives
a majority vote on the first ballot, a runoff election is held immediately
between the two candidates receiving the highest number of votes. The
President Elect shall serve , and at the r-oneJusion of th
year- ter-fn, from the time of election until July 1 of that year, at which time
he or she shall attain the office of President.
:A�_Qr=L PRESIDEATT
,
beginning and ending his/heF term in odd rube-od years.
:7.4 -3 U A CT PRESIDENT
73 Vacancies
A vacancy in the office of President is filled by succession of the President-Elect who serves the
remainder of the unexpired term and his/her own full term as President.
or Regional filled by appoinimp-lit of —I ac.t 14g OffiGoF by tho
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If the office of President-Elect is vacant,the
Past President serves as the Acting President pending the outcome of a special election for the office
of President to be conducted as expeditiously as possible and generally in the same manner as
provided in Section 7.2-1 (b) and (c).pFevided howevef that The MEC may determine, however, not
to call a special election if a regular election for the office is to be held within 90 days.
&Q43VQ As tho RFAgidont Mort for.thA rAmandnr of tho,4orm of the Part Pragdent ;4nd fe;full one, y
vaeant,the effice of-R—ast Presid-em sh-all be-, filled by an appointment made, by!he Mediral
Committee The appoiated Past President shall sepz@ only until ibe- President Eiler'l ig d000d, a;
P,-osid ,,,t .nd tho, f„11 A-14WY rte.-.,. ..f tl,e Arov:.1o.,♦ Eln..r
In the event of a vacancy in the office of Past President, the MEC shall appoint a member of the
MEC to serve out the remainder of the vacated term.
In the event of a vacancy in the office of President-Elect, the Medical Executive Committee shall
appoint a member of the Medical Executive Committee to serve as the acting President-elect pending
the outcome of a special election for the office of President-Elect. The special election shall be
conducted as expeditiously as possible and in accordance with Section 7.2-1 (b) and (c).
7.5 Duties of Officers
7.5-3 Past President
The Past President shall have the same duties and responsibilities as the President-Elect.
These will not be conflicting positions because the Past President will be in office during the
first six months yQaf�of the President's term, and the President Elect will be in office during
the second six months year- of the President's term.
The Regional ReP;GSP_,A1,4iPg AV_g Fesponsible. fe the, position of the. Fegienal
as well as for deGison&
8.1 ORGANIZATION OF CLINICAL DEPARTMENTS AND DTvIS1ONS
. . .When appropriate, the Medical Executive Committee may recommend to the Medical Staff the
creation, elimination, modification, or combination of departments or divisions.
Any such recommendations are subject to the approval procedure set forth in Article XV of these
bylaws.
8.6-1 Qualifications
Each department shall have a Department Head who shall be a member of the active or
provisional medical staff and shall be qualified by training m4d�� ted
demonst;awd ability certified by an appropriate specialty board or affirmatively establish,
through the privilege delineation process,that the person possesses comparable competence
in at least one of the clinical areas covered by the department. If the Department Head is
a member of the provisional staff,he/she must meet the qualifications listed in Section 4.3-1.
8.6-2 Selection
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D,rwty wf A'Udoyal Staff 4ff�9_
In June of each election year,the active medical staff of the applicable Department shall elect
a Department Head, who is thereafter subject to the approval of the Medical Executive
Committee and the Director of Medical Staff Affairs. In the event that the elected
Department Head is not approved by either the Medical Executive Committee or the Director
of Medical Staff Affairs, a new election shall be conducted as soon as possible. If the
Director of Medical Staff Affairs does not approve a Department Head, she/he will discuss
the reasons for disapproval at the next Medical Executive Committee meeting.
No later than April 30 of each year, the Medical Staff President shall notify all applicable
departments that the election of the Department Head shall be conducted in June.
The following Departments shall elect a Department Head in odd-numbered years:
Ambulatory Family Medicine, Anesthesia, Pediatrics, Rehabilitation, Internal Medicine,
Pathology and Dentistry.
The following Departments shall elect a Department Head in even-numbered years:
Emergency Medicine,Surgery,Psychiatry/Psychology,Radiology,Obstetrics&Gynecology and
Geriatrics.
8.6-3 Term of Office
The term of office of Department Heads is one two medical staff years. Each assumes office
on the first day of the medical staff year following appointments, except that a Department
Head appointed to fill a vacancy assumes office immediately upon appointment. . . .
8.7 DIVISION HEADS
8.7-1 Qualifications
Each division shall have a Division Head who shall be a member of the active or provisional
Medical Staff and a member of the division which he or she is to head, and shall be qualified
d-ivis;oa. certified by an appropriate specialty board, or affirmatively establish through the
privilege delineation process that the person possesses comparable competence in at least one
of the clinical areas covered by the division. If the Division Head is a member of the
provisional staff, he/she must meet the qualifications listed in 4.3-1.
8.7-2 Selection
Each Division Head shall be elected by the Division members on active staff, subject to the
approval of the Department Head, aff4 the MEC, and the Director of Medical Staff Affairs.
If the Director of Medical Staff Affairs does not approve a Division Head, she/he will discuss
the reasons for disapproval at the next Medical Executive Committee meeting. Vacancies due
to any reason shall be filled for the unexpired term by election by
division members as soon as possible. Ambulatory Family Medicine West and Orthopedics
wi-11 shall elect Division Heads in even-numbered years. Ambulatory Family Medicine Central
and East YA4 shall elect heads in odd-numbered years.
8.7-3, Term
Each Division Head shall serve a one, two-year term which coincides with the medical staff
year or until his or her successor is chosen, unless he or she shall sooner resign or be
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removed from office or lose medical staff membership or clinical privileges in that division.
Division Heads shall be eligible to succeed themselves.
93-2 Composition
(d) —'I,we AGgienal dgf ped- on . 3
Division Heads of the Department of Ambulatory Family Medicine.
(1) Health Services Director, Health Services Medical Director, Administrator,
Director of Medical Staff Affairs, and REsidency Director, all without vote;
(in) Medical Director of the Mental
Health Division, Director of Quality Management Department, the Chief
Resident, and a nurse practitioner representative as appointed by the
Medical Staff President, all ex-officio and without vote
9.22 Bioethics Committee
9.22-1 Purpose and Meetings
The Bioethics Committee provides a multi-disciplinary forum for the development of
guidelines for consideration of cases and issues having bio-ethical 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.
9.22-2 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 the hospital administration.
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.
10.2-3 Executive Session
. . . All ex-officio members of the group shall not be present during saidssssie+}the executive
session unless requested to do so by the chairperson. . . .
103-1 Staff Meetings
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4:118 PFOR-G-AGO Of ORO half thGe W-W FRO-M.WeRs Off U10- AG-tiVO Mwdigeal Stag at a Fegular-or-speoia4
ndr-Ggulation of the, mpul-&J EtAff Ar.for the A-10.6-AlOR OF
At a special meeting to remove any medical staff officer in accordance with Section 7.4-2 of
these bylaws, the presence of one half of the total members of the active medical staff shall
constitute a quorum. For all other actions, the presence or written ballot of one third of the
total members of the active medical staff shall constitute a quorum.
14.1 Rules and Regulations
The medical staff shall initiate and adopt such rules and regulations as it may deetn necessary for the
proper conduct of its work and shall peFiedisally annually review and approve its rules and regulations
to comply with current medical staff practice. . . .
14.7 Requirements for Elections and Votes within Committees and Departments
14.7-1 Elections: All elections for Medical Staff President, Department Heads, Division
Heads, Regional Representatives and any other Medical Staff positions shall be by
secret ballot by active staff within the appropriate department, division, region, etc.
Election shall be by majority vote of those ballots cast. If no candidate for a given
office receives a majority vote on the first ballot, a runoff election shall be held
immediately between the two candidates receiving the highest pluralities.
14.7-2 Voting within committees and departments: At the discretion of the chair or the
department head, 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 Article
IV.
153 MEDICAL STAFF ACTION
These Bylaws may be adopted, amended, or repealed by:
or
b. The affirmative vote of a majority of the ballots returned by a quorum of one-third of the
active medical staff members in good standing, provided that the ballots are mailed to the
active medical stiff members at least 14 days before the ballot is due, and provided that
copies of the proposed documents or amendments are included in the mailin envelope nvelope with
each ballot.
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