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HomeMy WebLinkAboutMINUTES - 05211996 - C78,41 TO: BOARD OF SUPERVISORS k6m: William Walker, M•.D.; Healtt ,Services Director 1 Contra _ Costa} ' OATS. April 11, 1996 County SUBJECT: CHANGES TO MEDICAL STAFF BYLAWS AND RULES AND REGULATIONS &PEC0C REOUEST(S)OR R>ECOM>AEMAT10M('S)i SAMGROUND AND.I MWICATIOM RECOMMENDATION: Approve changes in the Medical Staff Bylaws and Rules and Regulations Section 3.6 is a new anti-harassment provision in the Medical Staff Bylaws that is strongly recommended by the CMA and is consistent with County policy regarding harassment. Section 6.10 is a new section of the Bylaws that was strongly recommended by a variety of emergency agencies so that during a disaster,such as an earthquake,where providers may not be able to travel to the hospital where they have privileges,those providers could come to our facility to assist with disaster management. Section 9.7 reflects changes which have occurred in the Patient Care Policy Committee's purpose and composition. Two deletions from the "Definitions" section of the Bylaws reflect the reorganization of the Department of Family Medicine and the deletion of regional directors. Section 5.7-2 The clause deleted is unnecessary Section 7.5-3 The change increases clarity Section 9.15 - The Operating Room Committee has voted to change its name to more clearly define its scope. Section 9.21 gives formal Bylaws status to the Perinatal Morbidity and Mortality Committee,which has been operating informally for many years. Section 11.3-4 Information is included in the Rules and Regulations. In addition,the following changes are proposed: 1. The Department of Ambulatory Family Medicine has voted to change its name to Department of Family Medicine. This change would be made throughout the Bylaws. 2. Typographical errors creating no substantive change will be corrected throughout Rules and Regulations Changes: After the most recent JCAHO visit,the Autopsy Policy was changed to comply with JCAHO guidelines. A further change would allow a registered pharmacist to take verbal orders from physicians. FISCAL IMPACT: None. CONTINUED ON ATTACHMENT: Y NAT RE RECOMMENDATION OF ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE APPROVE OTHER SIGNATURE($): ACTION OF BOARD ON May 21, 1996 APPROVED AS RECOMMENDED X OTHER VOTE OF SUPERVISORS 1 HEREBY CERTIFYTHAT THIS IS A TRUE UNANIMOUS (ABSENT______j AND CORRECT COPY OF ArV ACTION TAKEN . AYES: 1,3 , 4 , & 5 NOES: None AND ENTERED ON THE MINUTES'OF THE BOARD ABSENT: None ABSTAIN: 2 OF SUPERVISORS ON THE DATE SHOMM. Contact Person: CC: ATTESTED May 21, 1996 St even C. Tremain, M.D. CHELOR.CLERK OF THE BOARD William Walker, M.D. E SORSAN, (NIS T R - Frank Pu lisp, COU County Administrator County Counsel 3.6 HARASSMENT PROHIBITED 3.6-1 Statement of Policy The Medical Staff is committed to providing a workplace free of sexual harassment as well as unlawful harassment based upon age, ancestry, color, marital status, medical condition, mental disability, physical disability,national origin, race, religion,gender, or sexual orientation. The Medical Staff does not tolerate harassment by Medical Staff members of resident Physicians, support staff, county employees, patients, or other Medical Staff members. 3.6-2 Harassment Defined Harassment is unwelcome verbal, visual, or physical conduct that creates an intimidating, offensive or hostile working environment or that interferes with work performance. Such conduct constitutes harassment when: Sal Submission to the conduct is made either an implicit or explicit condition of employment: (b,) Submission to or resection of the conduct is used as the basis for an employment decision: or c) The harassment unreasonably interferes with work performance or creates an intimidating, hostile or offensive work environment. Harassing conduct can take many forms and includes, but is not limited to, slurs, jokes. statements,gestures,pictures, or cartoons regarding a person's age, ancestry, color, marital status, medical condition, mental disability, physical disability, national origin, race, religion. gender or sexual orientation. Sexually harassing conduct in particular includes all of these prohibited actions as well as requests for sexual favors,conversation containing sexual comments, and unwelcome sexual advances. 3.6-3 Investigation and Corrective Action Every complaint of harassment will be investigated thoroughly and promptly and the Medical Staff will attempt to keep the investigation confidential. The Medical Staff will not tolerate retaliation against anyone who reports harassing conduct. If the Medical Staff determines that harassment occurred.the Medical Staff will take corrective action up to and including termination of Medical Staff privileges or membership. Invesfigafions and corrective action of harassing conduct shall be in accordance with Articles XI and XII of these Bylaws. Current 3.6 becomes 3.7 6.10 PRIVILEGES IN THE EVENT OF AN EMERGENCY As DEFINED IN GOVERNMENT CODE SECTION 8558 (a) Physicians and Non-Physician Practitioners During an emergency of any degree defined in Government Code Section 8558, physicians and non-physician practitioners (hereafter referred to collectively as practitioners)who are not members of this Medical Staff may be granted emergency temporary privileges provided the practitioner provides a copy of his/her current California license to practice, a photo identification, and the name(s) and telephone C.7g number(s)of hosoRal(s)where he/she has current privileges. Emergency temporary privileges may be granted only by the President of the Medical Staff, or his/her designee, and the Administrator, or his/her designee, jointly. An Emergency Privileges Coordinator (Coordinator) will be designated by the Administrator or his/her desiqnee if the Coordinator designated by the Hospital Disaster Plan is unavailable. The Coordinator shall review and copy/record the required information/documents and record the time and date emergency temporary privileges were requested by the practitioner. If possible,the Coordinator will contact the California Medical Board (or other applicable board) to verify the practitioner's license and that the practitioner's license is in good standing. If possible, the Coordinator will verify privileges at other facilities. If all of these telephone calls cannot be completed in a timely manner, the Medical Staff President and the Administrator may still -grant emergency temporary privileges so long as the practitioner's license is in good standing. The Coordinator shall maintain a written record of all information obtained from and about each practitioner seeking emergency temporary privileges. (b) Physician Assistants During an emergency of any degree defined in Government Code Section 8558, physician assistants may be granted emergency temporary privileges, provided the physician assistant provides a copy of his/her current California license to practice, a photo identification, and the name and telephone number of his/her supervising Physician. Emergency temporary privileges may be granted only by the President of the Medical Staff, or his/her designee, and the Administrator, or his/her designee. kin!! . The Coordinator shall review and copy/record the required information/documents and record the time and date emergency temporary privileges were requested. If possible. the Coordinator will contact the California Medical Board to verify the Physician assistant's license and that the license is in good standing. If possible,the Coordinator Wil contact the physician assistant's supervising physician. If all of these telephone calls cannot be completed in a timely manner.the Medical Staff President and the Administrator may still grant emergency temporary privileges so long as the Physician assistant's license is in good standing. The Coordinator shall maintain a written record of all information obtained from and about each physician assistant seeking emergency temporary privileges. The Contra Costa County Health Officer shall designate and assign a physician who is a credentialed member of the Medical staff to supervise no more than five (5) physician assistants who have been granted emergency temporary privileges. If practical,the physician assistant's supervising phvsician may also provide supervision to the physician assistant either personally or electronically, but in the event of conflicting instructions,the instructions of the phvsician designated and assigned by the Contra Costa County Health Officer shall prevail and shall be followed by the Physician assistant. The Coordinator shall maintain a written record of the name(s) of each temporary supervising physician and the temporary physician assistant(s) he/she is assigned to supervise. u Termination of Emergency Temporary Privileges All emergency temporary privileges shall automatically terminate when the emergency is ended. The Administrator or his/her designee, in his/her sole discretion, shall determine when the emergency is ended. If any information is received that suggests a practitioner or a physician assistant may not be capable of rendering C •7g services in an emergency or the rendering of emergency services is otherwise inappropriate, the Medical Staff President or his/her designee may immediately rescind the emergency temporary privileges of the practitioner or Dhvsician assistant. There shall be no right to a hearing or any other review of a decision to rescind the emergency temporary privileges of any practitioner or physician assistant, regardless of the reason for the rescission. 9.7 PATIENT CARE POLICY AND EVALUATION COMMITTEE 9.7-1 Purpose and Meetings The Patient Care Policy and Evaluation Committee (PCP&EC) monitors, assesses and recommends improvements to the MEC for: amnually feviews, amd reeemirmemds to the MEG: (a) The clinical and medical records policies and rules of the Medical Staff and of its inpatient clinical units and diagnostic and therapeutic support services (including OR/R-RPAR, ER, CCUs, etc.); (b) Medical-related aspects of infection control policies; .Lc. Pharmacy and therapeutics policies and practices:and Blood and blood product usage policies and practices. The committee also acts as liaison with Nursing and Administration for review and coordination of policies, procedures, rules and regulations under joint Medical Staff-Administration or Medical Staff-Nursing purview and coordinates its activities with those of the Ambulatory Policy Committee. The PCP&EC receives quality assurance findings suggestive of or requiring changes in the said policies and practices, and formulates, or directs the formulation of, specific changes. It serves as a forum for identifying and discussing problems in the delivery of patient care services and in the observance of patient's rights. The PCP&EC meets monthly and reports to the MEC. Whenever appropriate, monitoring findings and recommendations will be reported to the Medical Quality Assurance Committee and to the individual clinical departments. 9.7-2 Composition The Patient Care Policy and Evaluation Committee includes: (a) Chairperson appointed by the Medical Staff President as outlined in the Medical Staff Bylaws subject to MEC approval; (b) At least 6-8 staff members selected to be representative of major clinical areas; (c) Representative of Nursing Service; (d) Director of Pharmacy ad-hoc for Pharmacy and Therapeutic function; (el Representative from Pathology Department ad hoc for blood and blood product review function: (e) Chairperson of Infection Control and Safety Committee of the Hospital; (f) Representative of Administration responsible for policy committee support without .79 vote; (g) Nursing supervisor/coordinators for specialty units invited on an ad-hoc basis without vote; (h) Representatives of other clinical services and professional,technical, administrative support staff participate as consultants in relevant areas of expertise ad-hoc without vote; (1) Director of Medical Records quarterly and as needed without vote. oversee the e"i9:.._l ae fiy:t:_s of the sate'Re .-9ed"ipa, .,r:_:.... Pittsburg; 5.7-2 Termination of Leave At least 30 days prior to the termination of the leave of absence, or at any earlier time, the Medical Staff member may request reinstatement of privileges by submitting a written notice to that effect to the Medical Executive Committee. The staff member shall submit a summary of relevant activities during the leave, if the executive committee so requests. The Medical Executive Committee shall make a recommendation concerning the reinstatement of the member's privileges and prerogatives,amd the pfeeedtife pfavieleel im Seetiems S.q thfough 5.4 shall be fe"ewed. 7.5-3 Past President The Past President shall have the same duties and responsibilities as the President-Elect. These will mat be eemfiietimg Positions beeause the Pafft President will be in affiee elufing the fifst sex miomths of the Section 8.3-2 Assignment to Secondary Departments 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. 9.8-2 Composition The Ambulatory Policy Committee includes: (a) A Chairperson appointed by the Medical Staff President,subject to MEC approval; (b) Th limie: The division chairs of the Department of Familv Medicine: 9.15 Operating Room Invasive Procedures Committee c .7g 9.15-1 Purpose and Meetings The GR Gammattee Invasive Procedures is a multi-disciplinary committee which oversees operative and other invasive procedures provided within the OpefflfiR@ fOOMS 0 Merrithew Memorial Hospital and Clinics. The committee will oversee and coordinate the following processes: (a) selecting appropriate procedures; (b) preparing the patient; (c) monitoring the patient during and after the procedure; and (d) discharging the patient from the service or setting. The committee will oversee and coordinate the monitoring and improving of operative and invasive procedures by systematic measurement of the above mentioned processes and search for areas of improvement. The committee, in consultation with the individual departments and appropriate Medical Staff Committees,will develop written policies and procedures which shall guide the above processes. The committee is the forum where the interdepartmental operational issues of the surgical services will be coordinated among the various departments and disciplines involved. Such issues include, but are not limited to, the scheduling of cases, the mechanism for adding extra cases, defining on-call responsibilities, etc. The committee will assist the represented departments in reviewing equipment and capital improvement needs and make recommendations regarding the prioritization of resources. The committee will report to the Medical Quality Assurance Committee. Thfeugh jdRe 4995, the eemmittee eheir also will pfesent regular updates eR the eernmiftee's pfegfess to the Medieel Emeet Staff depaftmemts of aneillefy gefviee depaftmemts. Meetimgs will be held at least quarterly. 11.3-4 Medical Records Members of the Medical Staff are required to complete medical records within such reasonable time as may be prescribed by the Medical Executive Committee. Failure to comply with the Medical Executive Committee policies regarding completion of medical records is criteria for suspension or other corrective action. , 9,21 PERINATAL MORBIDITY AND MORTALITY(PM&M)COMMITTEE 9.21-1 Function The Perinatal Morbidity and Mortality Committee (PM&M) is an inter-disciplinary committee which monitors perinatal outcomes. It is intended to complement the quality assurance activities of the departments of Pediatrics and Obstetrics and Gynecology by focusing on those cases whose management involves both obstetrical and pediatric issues. The PM&M reports to the Departments of OB/Gvn and Pediatrics. 9.21-2 Composition The Perinatal Morbidity and Mortality Committee consists of: (a) All members in good standing of the Departments of Ob/Gvn and Pediatrics. Attendance obligations are established by the individual departments: Nurse Program Manager for the Perinatal Unit,Clinical Nurse Specialists for maternity and nursery and the RN Case Coordinator are members, all with voting privileges, (c) Regularly invited members, all without vote, include: L Consultant perinatologist: 21 Consultant neonatologist: 3) Any member of the Department of Ambulatory Medicine having obstetrical privileges: 4) Any member of the resident staff presently assigned to the Pediatrics or OB/Gvn services or with a particular interest in a case being discussed: Any member of the nursing staff with a particular interest in a case being discussed. (The Nurse Program Manager or his/her designee will maintain a file of confidentiality agreements signed by all non-physician attendees.)