HomeMy WebLinkAboutMINUTES - 11191996 - C148 PD: BOARD OF SUPERVISORS
FROM: William Walker, M,.D,.i Health Services Director 1 Contra
_ Costa
DATE: October 17, 1996 County
SUBJECT: CHANGES TO MEDICAL STAFF BYLAWS
SPECWIC REOUEST(S)OR RE (S)i aACKGROUMD AND A TWKA- TM
RECOMMENDATION:
Approve changes in the Medical Staff Bylaws
The attached proposed changes to the Bylaws were approved by the Administrative Affairs Committee on Aug. 23, 1996,and the
Medical Executive Committee on Sept. 16, 1996. The active Medical Staff approved the changes on Oct. 14 and County Counsel
has reviewed them. New language is underlineddeleted text is stmek attt.
Section 4.1 creates a temporary staff status. That was recommended by the CMA surveyors in order to clarify the roles of those
clinicians with only temporary privileges.
Section 8.4 satisfies JCAHO requirements and also clarifies that peer review may be conducted at the division level.
Section 9.2-1 clarifies terms of committee chairs.
Section 9.4 was changed at the request/suggestion of County Counsel. The second paragraph has been moved from the section
describing functions of the Medical Executive Committee. It was felt to be more appropriate in this section.
Sections 9.10 and 9.11 reflect current practice.
Section 10.8 clarifies meeting attendance requirements:
Section 12.3-3 attempts to make time frames reasonable:
Section 14.7-2 clarifies eligibility to vote: „
FISCAL IMPACT:
None.
CONTINUED ON ATTACHMENT: YES SIGNATURE
RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE
APPROVE OTHER
SIGNATURES):
ACTION OF BOARD ON IS I S ]9 ( APPROVED AS RECOMMENDED �_ OTHER
VOTE OF SUPERVISORS
_ 1 HEREBY CERTIFY THAT THIS IS A TRUE
---- UNANIMOUS (ABSENT�
T, � AND CORRECT COPY OF AV ACTION TAKEN
AYES: I,III,IV,V NOES: AND ENTERED ON THE MINUTES'OF THE BOARD
ABSENT:---------- ABSTAIN: TT OF SUPERVISORS ON THE DATE SHOWN.
ContW Peen: Steven C. Tremain., M.D.
CC: William Walker, M.D. ATTESTED PHIL BATCHELOR,CLERK O�1rHE r ARD OF
Steven C. Tremain, M.D.
Frank P Tremain,
_ SUPERVISORS AND COUNTY ADMINISTRATOR
By A. ,DEPUTY
Board of Supervisors
October 17, 1996
Changes to Medical Staff Bylaws
4.1 THE MEDICAL STAFF
The Medical Staff shall be divided into the active, courtesy, provisional, resident, honorary, temporary and
affiliate categories.
4_8 Temporary Staff
4.8-1 Qualifications
Temporary staff shall consist of members,each of whom:
Lal Meets the Qualifications for Medical Staff membership set forth in Section 3.2:
Has been granted temporary privileges under section 6.8 and is not currently on the active,
courtesy, provisional, resident or affiliate staff:
4.8-2 Prerogatives
Each member of the temporary staff shall be entitled to:
(a) Provide such specifically designated patient care services as are -granted to him or her by
Section 6.8:
Attend meetings of the staff in the department of which he/she is a member and any staff and
hospital educational proarams.
4.8-3 Responsibilities
Each member of the temporary staff is responsible for the following:
(a) Carrying out the basic responsibilities of Medical Staff membership set forth in Section 3.5:
providing for the continuous care and supervision of each patient in the Hospital for whom
he/she is providing services, including arranging for care and supervision in his/her absence
and outside of his/her area of professional competence:
(c) providing consultation,supervision, and monitoring of patients,when requested:and
(d) attending meetings of the Medical Staff, his/her department, and committees of which he/she
is a member in accordance with Article X.
4.8-4 Limitations
Temporary staff members are not eligible to hold office in this Medical Staff or-ganization nor are they
eligible to vote on matters presented at general and special meetings of the Medical Staff,
departments,divisions,or committees. Temporary staff status shall automatically terminate at the end
of the initial 90-day temporary privilege period unless it is renewed by the administrator upon the written
concurrence of the Medical Staff President and the appropriate department chair persons in
accordance with section 6.8-1 (a). If temporary staff status is granted so that a practitioner may
exercise temporary clinical privileges for the care of one or more specific patients in accordance with
section 6.8-1 (b),temporary staff status shall terminate upon the discharge of said patient(s) from the
hospital. In the event that a practitioner's temporary clinical privileges are terminated in accordance
with section 6.8-3 (b), said practitioner's temporary staff status is also deemed terminated and the
practitioner is thereafter entitled to the procedural rights afforded by Article XII.
8.4 FUNCTIONS OF DEPARTMENTS
The general functions of each department shall include:
(a) conducting patient care reviews for the purpose of analyzing and evaluating the quality and
appropriateness of care and treatment provided to patients within the department. The department
shall routinely collect information about important aspects of patient care provided in the department,
periodically assess this,information and develop objective criteria for use in evaluating patient care.
Patient care reviews shall include all clinical work performed under the jurisdiction of the department,
regardless of whether the member whose work is subject to such review is a member of that
department. Information gathered by other Medical Staff committees may be used to aid a
department's efforts to meet this responsibility;
(h) meeting at least monthly ten times a year for the purpose of considering patient care review findings
and the results of the department's other review and evaluation activities, as well as reports on other
department and staff functions;the divisions within the Department of Family Medicine may conduct
peer review at division meetings. in which case those meetings meet the criteria for this requirement.
9.2-1 Terms of Committee Members and Chairs
Unless otherwise specified, committee members and chairpersons shall be appointed for a term of one
Medical Staff year, and shall serve until the end of this period or until the member's successor is appointed,
unless the member shall sooner resign or be removed from the committee.
9.4 JOINT CONFERENCE COMMITTEE
9.44 Purpose and Meetings
The Joint Conference Committee constitutes a forum for the discussion of Hospital and Medical Staff
matters, and a forum for interaction between the Governing Body and the Medical Staff on such
matters as may be referred by the Medical Executive Committee or the Governing Body. The-de€nt
Genfefenee GernmMee she" meet at least semi annually amel shall transmit wfitten fepefts
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i
Board of Supervisors
October 17, 1996
Changes to Medical Staff Bylaws
Please refer to the Governing
Authority Bylaws, Article V. Joint Conference Committee. and Article VI. Bylaws and Amendments
(Attachment I of these Medical Staff Bylaws)
The MEC shall elect two representatives from its members to attend the Joint Conference Committee.
Each representative shall,serve a two-year term;one representative shall be elected in even-numbered
years,the other in odd-numbered years. Nomination and election shall take place in July, and the term
shall begin on August 1. Representatives may be removed for cause at any MEC meeting by majority
vote of the MEC and a new representative elected to complete the remainder of the term.
9.42 Gernpositiort
(a) Twe membefs of the Gaveming Body as appointed by the Gheifpersen of the Goveming Bedy-,
With-vote;
3,with vote:
,
,
(e) The Administmtef, ex-effleie and without vote:
(4) Gthef guests as invited by the Gheifpefsem, ex effleie and withatit vote.
The Ghauf of the joint Genfefenee Garnrnktee shall altemate yeafly between the Governing 13edy-aftd
9.10 ADMINISTRATIVE AFFAIRS COMMITTEE
9.10-2 Composition
The Administrative Affairs Committee includes:
(a) The Chairperson, appointed by the Medical Staff President,subject to MEC approval;
(b) At least 4-6 additional Staff members;
(c) Administrator,with vote;
(el) Ghaifpefsen of the Institutional Review Gemmittee,with ,
(e) Other members with special expertise as necessary on an ad-hoc basis,without vote.
9.11 INSTITUTIONAL REVIEW COMMITTEE
9.11-1 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 Clinics; 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 required
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 and sits
10.8 ATTENDANCE REQUIREMENTS
10.8-1 Staff Meetings
Except as stated below, each member of the active staff during the term of appointment who are
entitled to attend meetings under Article IV and each member of the courtesy staff subject to 4.4-1(f)
shall be required to attend=
(a) At least 59 jE pefeent of gemefel staff meefimgs duly eamyened pufstiamt to these Bylaws, and
(b) At least 50 percent of all meetings involving peer review activities of each department,division,
and committee of which he or she is a member.
At the discretion of the appropriate department head or committee chair, alternative mechanisms other
than physical presence may be developed to satisfy these meeting attendance requirements. The
formula for calculating attendance shall be as follows: meetings attended divided by(total peer review
meetings minus excused meetings). In order to satisfy meeting attendance requirements,this formula
must equal or exceed 50% and the numerator must equal or exceed three. Meeting attendance will
be monitored only for Medical Staff Department and Division meetings.
Members of staff categories other than active staff shall be required to attend such other meetings as
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Board of Supervisors
October 17, 1996
Changes to Medical Staff Bylaws
may be determined by the Medical Executive Committee.
12.2-3 Time and Place for Hearing
Upon receipt of a request for a hearing,the Medical Executive Committee shall schedule a hearing
and, within-f'i#teem (q 5) thirty 30 days give notice to the member of the time, place and date of the
hearing. The hearing shall commence not less than thirty(30) days nor more than ninety(90)days
from the date the notice of the hearing is mailed or otherwise delivered to the member; provided,
however,that when the member is under summary suspension,the hearing shall commence not more
than forty-five(45)days from the date the notice of the hearing is mailed or otherwise delivered to the
member under summary suspension.
12.4-3 Time, Place and Notice
If an appellate review is to be conducted,the appeal board shall,within+,r thirty 30 days after receipt
of notice of appeal,schedule a review date and cause each side to be given notice of the time, place
and date of the appellate review. The date of appellate review shall not be less than 30 nor more than
60 days from the date of such notice, provided, however, that when a request for appellate review
concerns a member who is under suspension which is then in effect,the appellate review shall be held
as soon as the arrangements may reasonably be made, not to exceed 15 days from the date of the
notice. The time for appellate review may be extended by the appeal board for good cause.
14.7-2 Eligibility to Vote: Only "active" members of the Medical Staff in "good standing" 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. amel whose
. A member in "good standing"is
one whose reappointment status is current in accordance with Section 5.6-1 (a) and who has met all
attendance requirements in his/her assigned department and/or division attendance his/her assigned department and/or division during 12 months prior to
months prior to
the election.
.m eeeafelonee with Geetiam 8.3 and who have met a" aftendamee feeluirememts in theif ass g ed
depattment amdMf division dwrimg the last twelve (12) momth pefied afe eligible to Vete im all eleetiams
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