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HomeMy WebLinkAboutMINUTES - 11142006 - C.151 SE--L TO: BOARD OF SUPERVISORS - Contra FROM: William Walker, M.D., Health Services Director ;k Costa -= County STA COUK� DATE: Oct. 16, 2006 SUBJECT: Medical Staff Bylaws and Rules and Regulations SPECIFIC REQUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION RECOMMENDATION: Approve revisions to the Medical Staff Bylaws and Rules and Regulations. FISCAL IMPACT: None BACKGROUND: Changes were proposed to meet new regulatory standards and to reflect current practice. The Medical Executive Committee approved the changes and the active Medical Staff voted to adopt the changes. County Counsel has reviewed the proposal and has approved. CONTINUED ON ATTACHMENT:--X—YES SIGNATURE: _,LRECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE ,/'APPROVE OTHER SIGNATURES : , �9.. ACTION OF B6�DN / 4. I/ �` n6.� APPROVE AS RECOMMENDEDl/ O ER VOTE OF SUPERVISORS I HEREBY CERTIFY THAT THIS IS A TRUE UNANIMOUS (ABSENT ) AND CORRECT COPY OF AN ACTION TAKEN AND ENTERED ON THE MINUTES OF THE BOARD AYES: . NOES: OF SUPERVISORS ON THE DATE SHOWN. ABSENT: ABSTAIN: ATTESTED c JOHN CULLEN,CLERK OF THE BOARD OF Contact Person: .SO/1%r3. J U tiGJ /`1,�`t�./� SUPERVISORS AND COUNTY ADMINISTRATOR CC: P9 Iri p l,�EgKc� s BY: EPUTY WILLIAM B. WALKER, M.D. //'y"% CONTRA COSTA HEALTH SERVICES DIRECTOR REGIONAL JEFFREYSMITH, M.D. EXMEDICALCENTER EXECUTIVE DE DIRECTOR � MEDICAL CENTER HEALTH CENTERS CONTRA COSTA CONTRA COSTA STEVEN C.TREMAIN, M.D. HEALTH SERVICES HEALTH CENTERS DIRECTOR,OFFICE OF AMBULATORY CARE 2500 Alhambra Avenue SENIOR MEDICAL DIRECTOR Martinez, California 94553-3191 Ph (925) 370-5000 To: Board of Supervisors Date: Sept. 7, 2006 From: Sonia Sutherland, M.D. Re: Proposed Bylaws Medical Staff President Changes David Hearst, M.D. Chair, Administrative Affairs Committee The CCRMC Medical Staff has approved several changes to the CCRMC Medical Staff Bylaws. These have also been approved by County Counsel. The Board of Supervisors must also approve these changes before they can take effect. Please feel free to contact either one of us if you have any questions. The actual proposed changes are attached. Summary of Proposed Bylaws Changes Some of the more important changes that are being recommended include the following: 10.2 Page 21, Making Information Available to MEC After a leave of Absence, 5.4. " We incorporated CMA wording that a member must provide information regarding relevant activities during a leave of absence if the MEC requests it. 18.5 Page 45, 2.4-12. Performance Improvement Committee. Major changes were made in the purpose and, more importantly, in the composition of the Performance Improvement Committee. The committee will be much more multidisciplinary with the addition of the following: The director of Ancillary Services, the Director of Quality Management, the Manager of Utilization Review, the Director of Psychiatric Services, the Director of Critical Care Services and the Residency Program Director. 18.6 Page 46. There is a new committee — the Medical Errors and Adverse Outcome Committee. This committee will provide education, case consultation and quality improvement regarding medical errors. �' • Contra Costa Alcohol and Other Drugs Services• Contra Costa Emergency Medical Services • Contra Costa Environmental Health • Contra Costa Health Plan • Contra Costa Hazardous Materials Programs •Contra Costa Mental Health • Contra Costa Public Health • Contra Costa Regional Medical Center • Contra Costa Health Centers N 18.9 Page 55, Medical or Psychological Exam as Part of a Fair Hearing, 11.1.2. Currently applicants and members can be required to take a medical or psychological exam at the time of appointment or reappointment. This change says that the MEC can also require a medical or psychological exam as part of a formal investigation. The member is not required to pay for the exam. 20. Page 58, 12.1.12. After listing 11 actions that are grounds for a hearing, current wording states that any restriction placed on Medical Staff membership or clinical privileges is subject to a fair hearing. It was felt that this is too broad. The CMA Model Bylaws do not recommend the right to a hearing in all these cases. Therefore, the additional wording is being added stating that a restriction would be grounds for a hearing only if it was reportable to the Medical Board pursuant to Section 805. .21. Page 58, 12.2. A section on exhaustion of remedies is added. This is based on CMA recommendations stating essentially that members cannot take legal action, i.e. sue, unless they have gone through the fair hearing and other processes described in the Bylaws first. In addition, there are several other changes that are required by JCAHO, reflect what we are already doing, or are relatively minor changes: The Rules section entitled"Rules to Implement the Bylaws" is to be moved back into the Bylaws. There are two main reasons for this. First, JCAHO now requires that some of these items be in the Bylaws. In addition, JCAHO now requires that the mechanism for adopting and amending the Rules and Regulations is the same as mechanism for adopting and amending the Bylaws. Therefore, there is no longer any advantage to having some items in the Rules and Regulations. The sections of the Rules that will be moved into the Bylaws are: 2.1, Categories of the Medical Staff, 2.2, Appointment and Reappointment Procedures; 2.3, Clinical Departments; 2.4, Committees, and Section 3, Allied Health Practitioners. Other changes include: 1. Page 1 of the Bylaws, Definition #21. The definition of a resident physician has been changed to include any physician in training in an approved residency or fellowship because we now have residents from Travis and conceivably could have other residents or fellows in the future. 2. Page 6 of the Bylaws, 3.1-4-1 (f). Meeting requirements for courtesy staff members not on active staff at another hospital. We no longer have meeting requirements for any members since they are unenforceable; therefore, this section has been deleted. 3. Page 8, 3.1-5-4. This states that provisional staff members are ineligible to hold office in the Medical Staff organization. This has been deleted. It is in conflict with other parts of the Bylaws which say that department chairs can be on the provisional staff. This is a better way of doing things, since we may wish to recruit someone for department head, or have a new person serve as department head before he/she is on active staff. 4. Page 10, 3.1-7-4. This gives the duration of temporary privileges as 90 days. This is incorrect. JCAHO regulations require a different period,which is detailed in another section of the Bylaws. Therefore, this section is being deleted 5. Page 11, 3.2. General Prohibitions states that members assigned to the resident category may not hold any general Medical Staff office. This is redundant , as it is stated somewhere else and will be deleted. 6. Page 13, 5.2. The Bylaws state that a medical or psychological exam can be required of applicants for appointment or reappointment but does not state how we should agree on an examining physician. We have used the CMA Model Bylaws to give a process for selecting the examiner. 7. Page 14, 5.3.2. This is old language stating that there needs to be an extension of the member's term if the application for reappointment is still being processed. This language is no longer acceptable to JCAHO. We have added language in 5.3.3 which explains how this is done, therefore, the section in 5.3.2 is not necessary and will be deleted. 8. Page 15, 2.2-2-7 (m). We have added additional information that is collected at the time of application: any past, pending or current exclusions from a federal health care program. This is required for health plan information. In addition, if we had someone providing care at the hospital who was excluded from Medicare or Medi-Cal, it could cause serious problems for the organization; therefore, it is important that we gather this information. 8.1 Page 16, A Valid Photo ID is Required with the Application, 2.2-2-2 (n). This fulfills the JCAHO requirement of verifying that the person applying is in fact who they say they are. 9. Page 20, 2.2-2-7. This is an old process for granting privileges in an emergency. We now have an entire section giving much more detail about this. Therefore, this previous version will be deleted. 10. Page 20, 2.2-3. Our current Bylaws do not specifically give timelines for reappointment or details of how the reappointment will be processed. This additional section takes language from the CMA Model Bylaws to state when the application must be turned in and that the processing will be similar to the process for the initial appointment. 10.1 Page 21, 2.2-3. If a request for modification of clinical privileges is denied, a member may not request the same modification until one year later. 10.2 See above. 11. Page 22, 6.2.3, Privileges for Department Heads. Currently, there is no specific procedure for granting privileges for department heads, therefore a procedure is now added to the Bylaws. 12. Page 23, 6.5.1.2. Various organizations require that we query the National Practitioner Data Bank before granting temporary privileges. This has been added to our Bylaws. 12.1 Page 25, Proctoring, 6.7. Our current Bylaws and Rules do not set forth standards and procedures for proctoring. We have added the CMA recommended wording. 12.2 Pages 26-27,Disaster Privileges, 6.8. JCAHO has new standards for granting privileges in case of a disaster. The Bylaws have been changed to reflect these requirements. 13. Page 28, 7.3. Previous language for election of the Medical Staff President was somewhat confusing. This spells out in a clearer manner our current procedure for electing and re-electing a Medical Staff President. 14. Page 29, 7.5.2, Regarding Removal of a Medical Staff Officer. Previously, a vote had to be taken at a special meeting called for this purpose with a quorum present. It is very difficult to have a quorum (half of the active staff) physically present at a special meeting. This would remove the requirement of a meeting so that removal could also be done by a mail-in ballot. 15. Page 30, 8.1. Current Bylaws state that each department must have a chair and a vice chair. This is not our current practice; therefore, this requirement was deleted. 16. Page 30, 8.1. We take language from the CME Model Bylaws to clarify how a department might be divided into divisions. 17. Page 31, 8.4, functions of departments—The current Bylaws do not spell out the functions of departments in detail. We have taken language from the CMA Model Bylaws to delineate the functions of the departments. 18. Page 32, 8.5, Department Heads—We have added several requirements to the functions of the Department Heads. These are (m) through (u). This is a JCAHO requirement and we have little choice but to make those changes. 18.1 Page 38, 2.4-1-1. The purpose of the Administrative Affairs Committee has been changed. The requirement that it supervises Medical Staff compliance with accreditation and assists the Disaster Committee were deleted since it no longer performs these functions. 18.2 Page 39, 2.4-2-2. The purpose and composition of the Ambulatory Policy Committee was changed in minor ways to reflect current practice. 18.3 Page 40-41, 2.4-4-1. The purpose and composition of the Cancer Committee was changed in minor ways to reflect current practices. 18.4 Page 43, 2.4-10. The Invasive Procedures Committee was deleted. Its functions have, for the most part, been taken over by Perioperative Committee, a subcommittee of PIC. 18.5 See above. 18.6 See above. 18.7 Page 50, 2.4-17. The Risk Management Committee no longer exists. Its function has been taken over by PIC. 18.8 Page 50. The Unsatisfactory Patient/Provider Relationship Committee (UPPR) is now described in the Bylaws. It has been in existence for many years. 18.9 See above. 19. Page 57, 11.3.5, Professional Liability Insurance. We do require professional liability insurance to protect the county. Therefore, the phrase "if any is required"has been deleted. 20. See above. 21. See above. 22. Page 59, 12.2.2.5, Judicial Review Committee. A sentence was added stating that the Medical Executive Committee shall designate one of the members of the Judicial Review Committee as chair. Previously, there was a description of the chair, but no description of how the chair was chosen. 23. Page 69, Article 15 has been renamed"Adoption and Amendment of the Bylaws and Rules and Regulations." Currently, there was no description of how the Rules and Regulations are amended. By JCAHO requirements, they must be adopted and amended by the same process as adoption and amendment of the Bylaws, therefore, the appropriate changes have been made. 24. Page 69, 15.3.2. This states that if there are any proposed changes to the Bylaws or the Rules and Regulations, rather than sending a copy of all these pages to every member with the ballot, we can just make a copy of the proposed changes available. This is our current practice. Summary of Proposed Changes to the Rules and Regulations A. Page 1, 1.3-1 (a). We no longer have an approved abbreviation list; we.have only an unacceptable abbreviation list and, therefore, the appropriate changes were made in the Rules B. On Page 1, 1.3-1 (b) Signature Stamps. We no longer use signature stamps, therefore this section was deleted. C. Page 5, 1.3-2 (a) 5: A practitioner who has been suspended for 30 days or more for not completing medical records may be reported to the Medical Board of California, depending on the particular circumstances. Therefore, this section was changed appropriately. D. Page 5, 1.3-2 (a) 7—DRG forms. We no longer use DRG forms. Therefore, this reference was removed. E. Page 9, 1.12-2 (b). First-year residents are no longer required to discuss all their patients with the preceptor or to have all charts co-signed. Therefore, this section has been deleted. F. Page 9, 1.13 Medical Screening Exam. Regulations have changed and a medical screening exam is no longer required under all the circumstances listed; therefore, this section has been deleted. Guidelines for medical screening examinations are in administrative policies at this time. G. Page 11, 1.16-4. This makes reference to the Secretary of the Medical Executive Committee, however, there is no secretary to the Medical Executive Committee. Therefore, the reference was changed to the Medical Staff President.