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TO: BOARD OF SUPERVISORS
Contra Costa County
FROM: William Walker, M.D.
DATE: April 29,2044
SUBJECT:
Medical Staff Bylaws,,Rules and Regulations
SPECIFIC REQUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUS'T'IFICA'T'ION
The Medical Staff of Contra Costa Regional Medical Center has proposed changes to its
current Bylaws and Rules and Regulations. The changes were deemed necessary because
of changing regulations; technology and practice. The revisions were approved by a vote
of the active Medical Staff and reviewed by County Counsel. The proposal is attached.
CONTINUED ON ATTACHMENT: -1-YES SIGNATURE.
.IMCOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE:
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VOWF SUPERVISORS: I HEREBY CERTIFY THAT THIS IS A TRUE AND CORRECT
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BY , ( ,DEPUTY
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Section 14.1 of Bylaws (page 30)
New Language:
The Medical Staff must annually review these Rales and Regulations. The
procedure for adopting, amending, and repealing these Rules and
Regulations is set forth in Article 95 of the Bylaws. Once a rule or
regulation is adopted or amended by the Governing Body, it is effective
and governs applicants and members of the Medical Staff.' if thre is a
conflict between the Bylaws and the Rules and Regulations, the Bylaws
prevail. The process set forth in Article 15 of the Bylaws is the sole method
for the initiation, adoption, amendment, and repeal of Medical Staff Rules
and Regulations.
ITEM B
Section 15.4 of Bylaws (page 31)
New language:
Bylaws changes adopted by the Medical Staff shall not become effective
until approved by the governing body. Neither the Medical Staff nor the
Governing Body may unilaterally amend the Medical Staff Bylaws or Rules
and Regulations.
ITEM C
Section 6.5.1.1 (page 9)
New language:
After receipt of'a completed application for appointment, including a
request for specific privileges, an applicant may be granted temporary
privileges for an initial period of 60 days while the application is being
processed! If the processing of the completed application by the Medical
Staff requires more than 60 days, the temporary privileges ma be extended
for up to an additional 60 days at the discretion of the Medical Staff
President or hislher designee. Temporary privileges shall automatically'
terminate at the end of a maximum of 920 days, 'unless earlier terminated in
accordance with the Medical Staff Bylaws andlor the Rules.
ITEM D
Section 6.5.1.2 (page 9)
New language
Temporary privleges/Circumstances
Important patient Care, Treatment and Service Need
After receipt of an application for appointment, including a'request for
specific privileges, and applicant may be granted temporary privileges for
the purposes of important patient care, treatment or service need, for an
initial period of 50 days while the application is being processed. The
Medical Staff must be able to verify the applicants current licensure and
competence, or temporary privileges are denied. If the processing of the
completed application by the Medical Staff requires more than 60 days, the
temporary privileges may be extended for up to an additional 60 days'at the
discretion of the Medical Staff President or hislher designee. Temporary
privileges shall automatically terminate at the end of maximum of 120`
days, unless earlier terminated in accordance with the Medical Staff Bylaws
andlor the Rules.
ITEM E
Bylaws section 12.3.6 '(second paragraph added to original)
A medical staff member does not have the right to view or use peer review
information of other practitioners as part of the fair hearing process.
ITEM"F
New language:
Bylaws section 7.3 to 7.3.5
Attainment of Office
7.3.1 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 two-year term,
but may be reelected to a second consecutive term. At the
conclusion of the President's term(s) of office, the President shall
assume the office of Past-President.
7.3.2 Should the incumbent President be nominated for, and choose to.
seek, a second two-year term, the subsequent election will be held in
January of the.second year of the incumbent President's term.
Should the incumbent President be reelected, the office of President-
Elect shall remain vacant until the next January election for
President.
7.3.3 Nomination. The Medical Executive Committee shall nominate
qualified candidates for the office of President-elect as specified in
the Rules. Each nominee must be an M.D. or D.O. Nominations may
also be madefrom the floor at the October 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
goad standings and accompanied by evidence of the nominee's
willingness to be nominated.
7.3.4 Election. The President-Elect is chosen from among the nominated
candidates by election as defined in these Bylaws. 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 December 3rd, On or before December 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.. Approximately 30 days, but no
less than 25 days before the January meeting of the Medical
Executive Committee, the Medical Staff Office shall mail ballots to all
active members of the Medical Staff`:
7.3.5 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 19th day before the
January meeting of the Medical Executive Committee. The Medical
Staff President and at least one other member of the Medical
Executive Committee shall count the ballots, 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 January meeting of the Medical Executive Committee, the
Medical Executive'Committee shall post, or otherwise disclose the
election results to the Medical Staff.
ITEM G
Proposed language;
Section 2.2-2-3'References {page 20 of the`rules'and regulations}
The applicant must include the names of at least three (3) professionals currently
licensed and practicing in the same discipline as the applicant, not currently or
about to become corporate or business partners with the applicant in
professional practice or personally related to him/her, who have personal
knowledge of the applicant's current clinical ability, competency, ethical
character, health status and ability to work cooperatively with others and who will
provide specific written comments on these matters, and letters of
recommendation for staff membership.
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privileges may be granted on an emergent basis to handle immediate
patient care needs.
6.8.1 Declaration of Disaster
The hospital disaster plan mustbe implemented prior to
consideration of granting disaster privileges.
6.8.2' Individuals Responsible for Granting Disaster Privileges
The Medical Staff President or his/her designee(s), or the
Administrator or hislher designee(s) are responsible for granting
disaster privileges. Under the disaster plan, and in the absence of
the above persons or designees, the incident commander, or his/her
designee(s), is the individual responsible for granting disaster
privileges'until the above persons or designees are present to carry
out the function of granting disaster privileges.
6.8.2.1 Responsibilities of Individuals Granting Disaster Privileges
Disaster privileges may be granted on a case-by-case basis,
and the responsible individual, at his or her discretion, is,;not
required to grant privileges to any individual.
6.8.3 Identification Requirements for Disaster Privileges
Disaster privileges may be granted upon the presentation of
any of the following items:
(a) A current picture hospital ID card
(b) A current license to practice and a valid picture ID
issued by a state, federal, or regulatory agency
(c) Identification indicating that the individual is a member
of a Disaster Medical Assistance Team (DMA T)
(d)` Identification indicating that the individual has been
granted authority to render patient care, treatment, and
services in disaster circumstances (such authority
having been granted by'a federal, state,;or municipal
entity)
(e) Verification of identity and qualifications by current
hospital or medical staff member(s) with personal
knowledge of the practitioner's identity and
qualifications.
6.8.4 Disaster Identification
Practitioners granted disaster privileges shall be identifiable to
other staff by the wearing of a disaster identification badge.
6.8.5 Management of Persons Granted Disaster Privileges
Persons granted disaster privileges will be assigned duties
either by the granting authorities as defined in:6.8,2, or if
assigned to a specific department, by the department chair or
his/her designee. In the absence of these persons, the
incident commander may assign duties or delegate this
responsibility to person(s), identified in the disaster plan, who
are responsible for designation of duties:
Disaster privileges are automatically terminated when the
disaster plan is deactivated Disaster privileges maybe
revoked at any time or for any reason by the Medical Staff
President,Administrator, department chair, or their
designee(s).
6.8.6 Verification Process
As soon as practical, when the immediate situation is under
control, the granting autorides or their designees will verify
credentials and privileges of those,persons granted disaster'
privileges. The verification process is a high priority, and the
process is identical to that for temporary privileges granted for
important patient care needs as delineated in section 6.5.1.2 of
the Bylaws. A practitioner's disaster privileges may be
immediately terminated in the event that any information
received through the verification process indicates any
adverse information or suggests that the person is not capable
of rendering services in an emergency.;