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HomeMy WebLinkAboutMINUTES - 02141995 - 1.65 TO: BOARD OF SUPERVISORS FROM: Mark Finucane, Health Services Director 1 Contra DATE. January 25, 1995 Costa County SUBJECT: CHANGES TO MEDICAL STAFF BYLAWS SpECWIC REOUEST(S)OR RECOYYEMCAT101/(S)&BMXGROUIID AMD.1U WV--A1TIOM RECOMMENDAnON: Approve the amendments to the Medical Staff Bylaws and Rules and Regulations. Detailed amendments showing deletions and insertions are attached. BACKGROUND: Changes to the bylaws were undertaken for several reasons: Revisions to Sections 4.7-2,4.7-4,8.2,8.7.1 and 9.3-2 create a separate division for Family Nurse Practitioners within the Department of Ambulatory Family Medicine. They also add the Director of Nursing and the Director of Ambulatory Care Nursing to the Medical Executive Committee. Deletion of the Ambulatory Review Committee because its functions have been taken over by individual departments. Changes to 9.13-2 expands membership on Medical Quality Assurance Committee to include representation from all services,from new committees,and to delete representation from previously discontinued committees. Sections 7.2 and 8.6 through 8.7-2 clarify and standardize election procedures for Medical Staff Officers and Department and Division chairs. They also delete Orthopedics as a separate division within the Department of Surgery at the request of the Department of Surgery. Section 14.7 defines voting eligibility in department and Medical Staff elections Section 15.3 applies principles set forth in 14.7 to Bylaws amendments. Section 5.6 establishes late processing fees for reappointment to bring the Medical Staff into compliance with JCAHO regulations. Section 9.20 changes reporting responsibility for the Cancer Committee to reflect the deletion of the Ambulatory Review Committee(see above). Section 8.3-1 and 8.3-2 clarify assignment to primary and secondary departments Rules and Regulations changes were undertaken to change Medical Records co-signature requirements and to reflect the fact that the Medical Staff has chosen to adopt the Personnel form for use in evaluating members at times of reappointment. These changes were approved by the Medical Executive Committee on Jan.23, 1995,and also by the active Medical Staff by mailed ballots. They also were reviewed by County Counsel. FISCAL IMPACT: None. CONTINUED ON ATTACHMENT: Y NAT RE RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE APPROVE OTHER SIGNATURE(S): 1 ACTION OF BOARD ON FEB 1 4 APPROVED AS RECOMMENDED �_ OTHER VOTE OF SUPERVISORS 1 HEREBY CERTIFY THAT THIS IS A TME UNANIMOUS (ABSENT ) AND CORRECT COPY OF AbV ACTION TAKEN AYES: NOES: AND ENTERED ON THE MINUTES OF THE BOARD ABSENT: ABSTAIN: is. OF SUPERVISORS ON THE DATE SHOWN. C4fttctp.rwn: Steven C. Tremain, M.D. FEB �� CC: Mark Finucane ATTESTED l� 95 Frank Puglisi PHIL BATCHELOR,CLERK OF THE BOARD OF Steven-C. Tremain, M.D. SUPERVISORS AND COUNTY ADMINISTRATOR BY ,DEPUTY 4.7-2 PREROGATIVES Each member of the affiliate staff shall be entitled to: (d) be appointed to any committee except the Medical Exectitive eon 111 littee.I The affiliate staff member shall not have the right to vote unless that right is granted by the Medical Staff President at the time of the committee appointment. 4.7-4 LIMITATION Affiliate staff members shall not be eligible to hold office in this Medical Staff organization nor shall they be eligible to vote on matters presented at general and special meetings of the Medical Staff, departmental meetings, division or committee meetings except as provided in 4.7-2(d). Affiliate staff members shall not be eligible to vote in division meetings except that affiliate staff members of the Mid-Level Practice Division of the Department of Ambulatory Family Medicine shall be eligible to hold office and vote on matters within the scope of their practice presented at meetings of the Mid-Level Practitioner Division of the Department of Ambulatory Family Medicine. 8.2 CURRENT CLINICAL DEPARTMENTS AND DIVISIONS The current Clinical Departments and Divisions are: (a) Ambulatory Family Medicine 1. Divisions: 9 East County ii) Central County iii) West County iv Mid-Level Practice 8.7-1 QUALIFICATION 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 certified by an appropriate specialty board, or affirmatively establish through the privilege delineation process that he/she 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. The Division Head for the Division of Mid-Level Practice shall be a member of the Affiliate Staff. 9.3 MEDICAL EXECUTIVE COMMITTEE 9.3-2 COMPOSITION The MEC consists of: (m) Medical Director of the Mental Health Division, Director of Quality Management Department, the Chief Resident, The Director of Nursing and the Director of Ambulatory Care Nursing as�ppointecHTg t'te Medical Staff P.eswdent, all ex-officio and without vote. 9.13-2 Composition The Medical Quality Assurance Committee includes: (a) A Chairperson, appointed by the Medical Staff President, subject to MEC approval; (b) Chairpersons of the Utilization Review, Patient eare monito,ing, , Critical Care. and Risk Management Committees; (c) President-Elect of the Medical Staff, or the President of the Medical Staff during any period in which the office of President-Elect is vacant,with vote; (e) Additional physician representation as necessary to assure that the Departments of Surgery,Medicine,Anesthesia, Emergency, Pediatrics, OB/GYN,Ambulatory Family Practice Medicine, Geriatrics, Pathology, Diagnostic Imaging and Psychiatry, as well as the four divisions of Ambulatory Family Medicine and the Detention Facility providers have at least one member, with vote, on the Medical Quality Assurance Committee. i epresen itation through the men ibers'Hp cui, position outlined (a)through (d) above; (f) Administrator,with vote; (g) Director, Hospital Quality Assurance Program,without vote. 7.2 ATTAINMENT AND SUCCESSION OF OFFICE 7.2-1 Of President-Elect, President and Past President (a) Term of Office: The election for the office of President-Elect shall take place in damxary April. 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 consecutive 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 darttiary April election along with all other nominated candidates. Should the incumbent President be reelected,the office of President-Elect shall remain vacant until the next dantim yr 6R12 election. (b) Nomination: The Administrative Affairs Committee (AAC) serves as the nominating committee. It convenes in November oi Becember January or February for the purpose of nominating one or more qualified candidates for the office of President- Elect.Each nominee must be an M.D.or a D.O.Nominations may also be made from the floor at the 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. Nominations may also be submitted to the chair of the Administrative Affairs Committee. The last day to nominate a candidate is March 1. (c) Election: The PI esident-Elect the candidates,ion iinated tinder Sertim i 7.2-1 (b� above by electici i by balloting as defined On Seebon 14.7. Elections sholl oertir annually in dantimy of each year The Medical Staff Presidei it I-,ic,7 serve two coi isectitive oi ie-yea, te,,i is. If i eu an ididate, P.eside.it--Elartsia'lseivefiuiiit'ietuIiieofele!L,tgoi. tii-.ta'dtilyI of that yeai, at which The President-Elect is chosen from among the candidates nominated under Section 7.2-1 (b) above by election as defined in Section 14.7. Candidates for Medical Staff President-Elect may submit a written statement not to exceed two pages to the Medical Staff Office no later than close of business on March 3rd. On or before March 7th.the Medical Staff Office shall mail to all active members of the Medical Staff a list of the candidates for Medical Staff President-Elect, accompanied by the candidates' statements, if any. AAvproximately 30 days, but no less than 25 days, before the April meeting of the Medical Executive Committee.the Medical Staff Office shall mail ballots to all active members of the Medical Staff. In order for a ballot to be counted, it must be returned to the Medical Staff Office no later than close of business on the 11th day before the April meeting of the Medical Executive Committee. The ballots shall be counted by the Medical Staff President and at least one other member of the Medical Executive Committee, unless the Medical Staff President is a candidate.. In that event, the Medical Executive Committee shall designate a second member of the Medical Executive Committee to count ballots. As soon thereafter as possible.the Medical Executive Committee shall notify all candidates of the election results. Thereafter, but at least seven calendar days before the April meeting of the Medical Executive Committee. the Medical Executive Committee shall post, or otherwise disclose to the Medical Staff, the election results. 8.6 DEPARTMENT HEADS 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 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 4.3-1. 8.6-2 Election In Jtm April_of each election year,the active medical staff of the applicable Department shall elect a Department Head as set forth in Section 14.7.vv a 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. The Medical Staff President shall request nominations for Department Head at the January Quarterly Medical Staff meetina and at the applicable Department meeting. Nominations may be made only to the current Department Head and to the Medical Staff President. The last day to nominate a candidate for Department Head is March 1 St. Candidates may submit a written statement not to exceed two pages to the Medical Staff Office no later than close of business on March 3rd. The Medical Staff Office shall mail a list of candidates to all active members of the Medical Staff in the affected department no later than March 7th. The list shall be accompanied by the candidates'statements, if any. Approximately 30 days, but no less than 25 days, before the April meeting of the Medical Executive Committee.the Medical Staff Office shall mail ballots to all the active Medical Staff members within the affected department. In order for a ballot to be counted,it must be returned to the Medical Staff Office no later than close of business on the 11th day before the April meeting of the Medial Executive Committee. The ballots shall be counted by the Medical Staff President and at least one other member of the Medical Executive Committee, unless the Medical Staff President is a candidate. In that event.the Medical Executive Committee shall designate a second member of the Medical Executive Committee to count ballots. As soon thereafter as possible. the Medical Executive Committee shall notify all candidates of the election results. Thereafter, but at least seven calendar days before the April meeting of the Medical Executive Committee.the Medical Executive Committee shall post, or otherwise disclose to the Medical Staff, the election results. The newly elected Department Heads shall be reviewed for approval by the Medical Executive Committee at its April meeting. The elected Department Head is thereafter subject to approval of 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. Vacancies due to any reason shall be filled for the unexpired term by election by department members as soon as possible. No later than Aprif zle Uf evic i year-, tie I'viedica Staff Piesident sliall notify aim applicable 8.6-3 Term of Office The term of office of Department Heads is two Medical Staff years. Each assumes office on the first day of the Medical Staff year, except that a Department Head appointed to fill a vacancy assumes office immediately upon appointment. Each Department Head serves until the end of his/her term and until a successor is elected, unless he/she sooner resigns or is removed from office. A Department Head is eligible to succeed himself/herself. 8.6-4 Removal After election and ratification,removal of a Department Head from office may occur for cause by a two-thirds vote of the Medical Executive Committee or a two-thirds vote of the department members on active staff. 8.6-5 Duties Each Department Head shall have the following authority, duties and responsibilities: (a) act as presiding officer at departmental meetings; (b) report to the Medical Executive Committee and to the Medical Staff President regarding all professional and administrative activities within the department; (c) generally monitor the quality of patient care and professional performance rendered by members with clinical privileges in the department through a planned and systematic process;oversee the effective conduct of the patient care, evaluation, and monitoring functions delegated to the department by the Medical Executive Committee; (d) prepare and transmit to the appropriate authorities, as required by these Bylaws, recommendations concerning appointment, reappointment, delineation of clinical privileges, and corrective action with respect to practitioners or affiliates holding membership or exercising privileges or services in the Department; (e) annually review, and amend as necessary, Department policies and procedures; (f) participate in managing the Department through cooperation and coordination with nursing and other patient care services and with Administration on all matters affecting patient care,including personnel,equipment,facilities,services, and budget; (g) endeavor to enforce the Medical Staff Bylaws, rules, policies and regulations within the department; (h) appoint acting Department Head during any absence; (i) assure all Department functions, as stated in Section 8.4, are performed; Q) perform such other duties commensurate with the office as may from time to time be reasonably requested by the Medical Staff President or the Medical Executive Committee. (k) plan and conduct, as requested by and in cooperation with the Residency Director, a program of instruction, supervision, and evaluation of Residents. 8.7 DIVISION HEADS 8.7-1 Qualification 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 certified by an appropriate specialty board, or affirmatively establish through the privilege delineation process that he/she 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 Election Eviel, Bivision I lead sl ia" be elected by t'ie Bivisim, ie,, bei s on active staff. subject to the approval of the BeP31111101 it I lead, the MEe ,,.d t'ie Bei ector of Medical Staff Aff-aii s. If t'ie Be.ectur of Medica Staff Affai.s clues not app,ove , Eftsim j I lead, sheilie wall discass tire any reason shall be filled foi the m texpired tern. by electioi i by divisivi, i, en ibe,s cis sou,, as possible. In April of each election year,the active medical staff of the applicable division shall elect a Division Head as set forth in Section 14.7. Ambulatory Family Medicine West and 6rthopedics the Mid-Level Practitioner Division shall elect Division Heads in even-numbered years,Ambulatory Family Medicine Central and East shall elect heads in odd-numbered years. The Medical Staff President shall request nominations for division head at the January Quarterly Medical Staff meeting and at the applicable division meeting. Nominations may be made only to the current Department Head and to the Medical Staff president. The last day to nominate a candidate for division head is March 1 St. Candidates may submit a written statement not to exceed two pages to the Medical Staff Office no later than close of business on March 3rd. The Medical Staff Office shall mail a list of candidates to all active members of the Medical Staff in the affected division no later than March 7th.The list shall be accompanied by the candidates'statements, if any. Approximately 30 days, but no less than 25 days, before the April meeting of the Medical Executive Committee,the Medical Staff Office shall mail ballots to all the active Medical Staff members within the affected division. In order for a ballot to be counted,it must be returned to the Medical Staff Office no later than close of business on the 11th day before the April meeting of the Medial Executive Committee. The ballots shall be counted by the Medical Staff President and at least one other member of the Medical Executive Committee, unless the Medical Staff President is a candidate. In that event,the Medical Executive Committee shall designate a second member of the Medical Executive Committee to count ballots. As soon thereafter as possible, the Medical Executive Committee shall notify all candidates of the election results. Thereafter, but at least seven calendar days before the April meetina of the Medical Executive Committee.the Medical Executive Committee shall post, or otherwise disclose to the Medical Staff, the election results. The newly elected division heads shall be reviewed for approval by the appropriate Department Head prior to the April meeting of the Medical Executive Committee and by the Medical Executive Committee at its April meetina. The elected division head is thereafter subject to approval of the Medical Exectitive emninittee and the Director of Medical Staff Affairs. In the event that the elected division head is not approved by either the Department Head,the Medical Executive Committee or the Director of Medical Staff Affairs, a new election shall be conducted as soon as possible. If the Department Head or 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 anv reason shall be filled for the unexpired term by election by division members as soon as possible. 8.7-3 Tenn Each Bivision I lead sl all se,ve a twolea, tei i,, vvl iiel, evii mides vvit'. the Medical Staff yew hum office or lose Medical Staff inembeiship or cliniCal privileges in tha�dwvision. Bivision Vads shall be eligible to succeed then iselves. The term of office of division heads is two Medical Staff years. Each assumes office on the first day of the Medical Staff year,except that a division head elected to fill a vacancy assumes office immediately upon election. Each division head serves until the end of his/her term and until a successor is elected,unless he/she sooner resigns or is removed from office. A division head is eligible to succeed himself/herself. 8.7-2 Election Each Division Head shall be elected by the Division members on active staff,subject to the approval of the Department Head, 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 Wes en'-s shall elect a Division Head in even-numbered years. Ambulatory Family Medicine Central and East shall elect Division Heads in odd-numbered years. 14.7 REQUIREMENTS FOR ELECTIONS OF MEDICAL STAFF PRESIDENT,DEPARTMENT HEADS,DIVISION HEADS AND FOR BYLAWS AMENDMENTS Elections. A" elections for Medical Staff President, Bepciftinent I leads, Bivision I 'ends, Regional Repre-sentatives and any other Medical Staff puSitiOlIS Shall be by secret ballot by active staff Within t'iecippiupi-mcttedepaitiiieiit ,d*v*s*uii, region, etc. Election shall be by niajuiity vote of those ba cast. If,to candidate fo. a given office,eceives a ,naim ity vote on the first ballet, a ,tinoff electi0i, sl 14.7-1 Elections by Secret Ballot: All elections shall be by secret ballot. 14.7-2 Eligibility to Vote: Only "active" members of the Medical Staff may vote in elections Governed by these bylaws. An "active" member of the Medical Staff is one who has been approved for active status by the Governing Body on or before the day ballots are mailed and • whose reappointment status is current and in accordance with Section 5.6. All active members of the Medical Staff are eliaible to vote in all elections for medical Staff President-Elect and for changes to the Medical Staff Bylaws. All active members of the Medical Staff who are assigned membership in departments and/or divisions in accordance with Section 8.3 and who have met all attendance requirements in their assigned department and/or division during the last twelve (12) month period are eligible to vote in all elections for Department Head in their assigned department(s) and for division head in their assigned division(s). 14.7-3 Mailing Address: It is the responsibility of each member of the Medical Staff to provide the Medical Staff Office with his/her current and correct mailing address. Ballots will be mailed to the last address provided by the Medical Staff member. 14.7-4 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. 15.3 MEDICAL STAFF ACTION These Bylaws may be adopted, amended, or repealed by: (a) The affirmative vote of a majority of the active staff members in good standing present at a regular or special staff meeting at which a quorum is present(as defined in Section 10.3-1), provided that a copy of the proposed documents or amendments was given or made available to each staff member entitled to vote thereon with or at the time of notice of the meeting; or (b) The affirmative vote of a majority of ballots returned by members in good standing, provided that a copy of the proposed documents or amendments are given to each staff member entitled to vote thereon,and provided that no less than two weeks time interval exists between the date the ballot was mailed to active members and the due date of the ballot. LcJ All electiong to adopt, amend or repeal the Bylaws shall be conducted in accordance with Section 14.7. 5.6 REAPPOINTMENT PROCEDURES AND REQUESTS FOR MODIFICATIONS OF STAFF STATUS OR PRIVILEGES 5.6-1 Application (a) At feast Approximately six months prior to the expiration date of the current staff appointment(except for temporary appointments) a reapplication form developed by the Medical Executive Committee shall be mailed or delivered to the member. tf-aft date,WHtte, ,totice sl iall proi riptly be sent to the applitni it advising that tl ie application has nut been received. At least 4-5 120 days prior to the expiration date, each Medical Staff member shall submit to the Credentials Committee the completed application form for renewal of appointment to the staff for the coming two years, and for renewal or modification of clinical privileges. If an application is received by the Medical Staff Office less than 120 days before expiration of the member's current appointment,the armlication is delinquent and the member shall pay a $50 late processing fee. If an application is received by the Medical Staff Office less than 90 days before expiration of the member's current appointment,the application is delinquent and the member shall pay a total of$100 as a late processing fee. If an application is received by the Medical Staff Office less than 60 days before expiration of the member's current appointment,the application is delinquent and the member shall pay a total of$150 as a late processing fee. Under no circumstances will a delinquent processina fee be waived. Failure to pay any late processina fee will render the application incomplete and application will not be processed by the Credentials Coordinator. If an application is received by the Medical Staff Office less than 30 days before expiration of the member's current appointment or if a late processina fee is not paid at least 30 days before expiration of the member's current appointment,the member is deemed to have resigned from the Medical Staff. (Also see Section 5.6-5.) In the event a membership terminates for any reason set forth herein,the procedures set forth in Article XII shall not apply. If the member desires to reapply to the Medical Staff within one year of a resignation pursuant to this provision, applicant must be made in accordance with Section 5.5 and a new application fee must be paid along with the$150 late processing fee previously accrued and unpaid. Any member who is delinquent with his/her reappointment application is not eligible to vote in any election conduced pursuant to these Bylaws. The reapplication form shall include all information necessary to update and evaluate the qualifications of the applicant including, but not limited to,the matters set forth in Section 5.5-2,as well as other relevant matters. Upon receipt of the application,the information shall be processed as set forth in Sections 5.5-5 through 5.5-7. 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 reprivileging. 5.6-4 Extension of Appointment If an application for reappointment has not been fully processed by the expiration date of the member's appointment,the staff member shall maintain membership status and clinical privileges until such time as the processing is completed.tinlessthe If the delay is due to the member's failure to complete and return the reappointment application form or provide other documentation or cooperation in a timely manner, ffill which case the appointment shall terminate. Any extension of an appointment pursuant to this section does not create a vested right in the member for continued appointment through the entire next term but only until such time as processing of the application is concluded. 5.6-5 Failure to File Reappointment Application Failure without good cause to file a completed application for reappointment in a timely manner shall result in the automatic suspension of the member's admitting privileges and expiration of other practice privileges and prerogatives at the end of the current staff appointment, unless otherwise extended by the Medical Executive Committee with the approval of the Governing Body. If the member fails to submit a completed application for reappointment within 38 days past the date it was due at least 30 days prior to the expiration of the current appointment,the member shall be deemed to have resigned membership in the Medical Staff at the expiration of the current appointment. In the event membership terminates for the reasons set forth herein,the procedures set forth in Article XII shall not apply. 9.20 CANCER COMMITTEE 9.20-1 Purpose and Meetings The Cancer Committee is a multi-disciplinary committee which organizes, conducts and evaluates hospital-wide oncology services and the tumor 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 conduct monitors and screens which evaluate the quality of care our patients receive, both pre-and post-cancer therapy. The committee will ascertain if there is a need for specific educational programs—both professional and public—based on survival and comparison data. The committee will also supervise the tumor registry for quality control of abstracting, staging and reporting. The committee will conduct a minimum of two patient care evaluation studies annually, one to include survival data. The committee will meet at least quarterly or more often as needed and reports to tire Patient eme monitming eommittee. communicate as necessary with the Medical Quality Assurance Committee. 8.3 ASSIGNMENT TO DEPARTMENTS AND DIVISIONS 8.3-1 ASSIGNMENT TO PRIMARY DEPARTMENT Each member shall be assigned membership in at least one department, and to a division, if any,within such department by the Department Head. grzrrrted.A member's department assignment is determined by the department in which the member conducts the majority of his/her clinical activity. if there is no majority, then the member must submit a written request for department membership to the Credentials Committee. The Credentials Committee will forward this request with its recommendation to the Medical Executive Committee for action. The Medical Executive Committee will determine department membership. The decision of the Medical Executive Committee is final and the procedure set forth in Article XII shall not apply. 8.3-2 ASSIGNMENT TO SECONDARY DEPARTMENTS A member who Chooses may request to be a member of mere-than one, and no more than one, secondary department. In order to be a member of a secondary department, the member must be on active staff,as defined in section 4.3, and must spend at least eight hours per week in clinical activities related to the secondary department. Any disagreements regarding eligibility for an assignment in a secondary department will be determined by the Medical Executive Committee and are not subject to appeal. A member assigned to a secondary department will be allowed to vote in elections and department proceedings in that secondary department if he/she meets the requirements set forth in Sections 14.7 and 14.8. Rules and Regulations Changes D) Medical Records 3) Co-signature Requirements Medical staff co-signatories are needed for all resident physicians for the followin¢medical records and documents: a) Inpatient History and Physical b) Pre-anesthesia Evaluation C) Consultative Reports Medical staff co-signatories are needed for first-year resident physicians for the Written Discharge Summary. The attending staff physician shall be responsible for review and correction of all resident physician record entries. 10 Operative Reports: Co-signatures are required on all resident operative reports. Failure to co-sign does not make the record incomplete,but if co-signature is not done within 13 days after discharge,disciplinary proceedings set forth in I. dl 5 ii-iv of these Rules and Regulations will be initiated. 11) DRG The DRG form is a required medical record and is considered incomplete without signature. Medical Staff Evaluation and Development (Approved by the Medical Executive Committee-Feb. 1989) (Approved by the Medical Staff-March 1989) (Amended by the Medical Staff-July 1990) Each member of the active Medical Staff shall be reviewed at least once every two years 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 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. The Department Heads shall be evaluated in the same manner by the Medical Staff President after consultation with the members of his/her department. If the Department Head is also the Medical Staff President,he/she be evaluated by an individual designated by the Credentials Committee. Upon completion, the evaluator and the Medical Staff member shall meet face to face and each receive 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(Ref: Section 14.8-2 of the Bylaws). Evaluations placed in the Credentials files shall be used for Medical Staff purposes only;