Department of Medicine - Rules and Regulations

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BAYSHORE COMMUNITY HOSPITAL

Department of Medicine - Rules and Regulations

BAYSHORE COMMUNITY HOSPITAL

DEPARTMENT OF MEDICINE

RULES AND REGULATIONS

1. DEFINITION:

The Department of Medicine will be composed of all internists, general/family practitioners and other medical subspecialists. Although psychologists will be members of the Podiatry and Psychology Staff, they will fall under the jurisdiction of the Department of Medicine.

Chair

The Chair of the Department must hold the rank of Full Attending or Senior Attending in good standing and be Board Certified in the appropriate specialty. The Chair will be elected for a two (2) year term at a departmental meeting held in September. This term of office will commence on January 1 of the following year. A Chair be re-elected for another two (2) year term and then must remain out of office for a period of one term.

Vice Chair

The Vice Chair of the Department of Medicine shall be chosen by the Department Chair.

The election of Chair and appointment of Vice Chair are subject to approval by the Executive Committee of the Medical Staff, and the Board of Trustees.

2. APPOINTMENTS:

Appointment to the Medical Service is accomplished by application to the Staff, recommendation by the Department Chair and approval by the Credentials Committee, Executive Committee of the Medical Staff, and Board of Trustees. At the time of approval by the Credentials Committee, the Chair of the Department will recommend the rank of the incoming physician. All new applicants will be evaluated by the Department Chair prior to appearance at the Credentials Committee. At that time, the Chair will ascertain whether or not the doctor intends to become a fully functioning member of the Hospital and Medical Staff and utilize Bayshore Community Hospital as his/her primary hospital. The Chair and the applicant will decide whether he/she should be placed on the Regional or Active Staff. If a physician has six (6) or more admissions or provides services to twenty-five (25) or more hospital-based patients, he/she will be asked to assume the responsibilities of an Assistant Attending on the Active Staff.

All initial appointments to the Staff shall be provisional/probationary appointments.

Provisional appointments shall be for a period of twelve (12) months which may be extended once for an additional twelve (12) months. The practitioner shall be notified, in writing, by his/her respective Department Chair when the provisional period is to be extended. If, after the extension of the provisional period has expired, a practitioner is not appointed to the Staff, the Staff appointment shall be deemed to be terminated.

3. RANKS:

Ranks will be recommended by the Chair of the Department of Medicine who will utilize the procedures outlined in the Medical Staff Bylaws to have these recommendations confirmed.

a)  Assistant Attending

Assistant Attending is the usual entering rank for full-time Department of Medicine physicians and Carries with it the responsibilities of being present in the hospital or providing equivalent coverage for any hours assigned. Assistant Attendings are expected to attend all Department meetings and to participate in hospital functions related to patient care.

b)  Associate Attending

The rank of Associate Attending is available for those physicians who have served as Assistant Attending for a minimum of at least one year. This rank will be considered for those who have demonstrated excellence in emergency care performance. The rank is not automatic and attitude will be considered by the Chair when promoting a physician to this rank.

c)  Full Attending

In order to achieve Full attending status, the physician must be Board Certified in the appropriate specialty and filed in the medical staff office, and must have served a minimum of one year as an Associate Attending. The Physician must fulfill all of the requirements and obligations and show more than an active interest in the hospital.

4. PRIVILEGES:

Clinical and special privileges will be extended to all members of the Department of Medicine in accordance with their recognized skills, training, established precedence and according to delineation of privileges.

The Chair of Medicine will review the documents presented by the applicant to include specifically his/her training and experience in each area of medicine for which the applicant intends to ask for privileges. These documents should be specific insofar as

experience in the given area is concerned, whether by number of cases or length of time spent on a particular service and recommendations from the Chairs of Services.

When privileges for certain special procedures are requested, the physician must provide documentation indicating attendance at courses or performance of the procedures at other institutions. After approval by the Chair of Medicine, the recommendation for approval will be presented to the Credentials Committee, Executive Committee of the Medical Staff, and Board of Trustees. The recommendation will include guidelines for supervision of the new procedure by an appropriate subspecialist appointed by the Chair of the Department of Medicine.

If one or more members of the Medical Staff desire privileges that differ significantly from the scope of practice implied by the privileges already granted to that (or those) individuals, such individuals should make application to the Director of his/her Department for such privileges, in writing.

The Chair of the Department will then (with the aid of an ad hoc committee which he/she will appoint if he/she so desires):

a) for new procedures or expanded scope of care at this institution,

make a recommendation to the Credentials Committee regarding

the advisability of granting the privileges and, where indicated, the

cost efficiency of such care.

b) provide the Credentials Committee with proposed criteria for the

granting of privileges for the new procedure or expanded scope of care.

c) make an individual recommendation to the Credentials Committee

regarding the practitioner requesting the privileges.

d) propose a mechanism to the Credentials Committee for enhanced

monitoring and evaluation of clinical performance and outcomes.

The Credentials Committee will then act upon the aforementioned matters and refer its

recommendations to the Executive Committee and then to the Board of Trustees of the Hospital for final action.

If the privileges “cross over” departmental or service lines, the application will be reviewed by the Chair of each of the involved departments. If the Chair of the department fails to make any recommendations within sixty (60) days, the application may be referred by the individual practitioner to the Medical Executive Committee.

Should the decision by the Executive Committee be unfavorable to the requesting practitioner, he/she may appeal the decision through the usual due process described in the Bylaws

When the privileges requested have been approved by the Executive Committee, the new privileges will be recorded in the practitioner’s privilege record and distributed in the usual manner.

The Chair (or designee) of the Member’s Department shall transfer the suspended Member’s patients then in the Hospital to the care of another Member, when feasible, considering the wishes of the patient.

At the time of biennial reappointment to the Staff, appraisal of a physician’s competency to perform certain procedures will be carried out. Consideration will be given to recency of performance of the procedure, postgraduate courses, continuing medical education, and other educational material which may have a bearing on the competency of the physician’s performance.

Members of the Department of Medicine may appeal and oppose changes of status of their privileges according to the mechanisms described in the Bylaws of the Medical Staff of Bayshore Community Hospital.

Renewal of privileges in the Department of Medicine will be based on consideration of the following:

a) Basic medical knowledge

b) Professional judgment

c) Sense of responsibility

d) Ethical conduct

e) Competence and skill

f) Cooperativeness, ability to work with others

g) Use of hospital facilities

h) Appearance

i) History and physical exam taking

j) Record keeping

k) Case presentations

l) Patient management

m) Physician-Patient relationship

n) Ability to understand/speak English

o) Participation in Medical Staff affairs

p) Physical and mental capabilities

q) Continuous professional education

r) Prompt and timely completion of medical records

s) Attendance at hospital Quarterly Staff, department/section and

committee meetings

t) Reasonable usage of hospital facilities

Additionally, renewal of privileges will be affected by citation by:

a) Utilization Review

b) Multi-Disciplinary Peer Review Committee

c) Infection Control Committee

d) Executive Committee

5. SUPERVISION:

Every new physician who comes into the Medical Service will have a period of supervision, the duration of which will vary. The supervision consists of having any Assistant, Associate, or Full Attending member on the Medical Service review

the patients being taken care of by the new member of the Medical Staff to check on the follow-up care and management of the patient during the hospital stay, including any special procedures that will be done by the new doctor. For each new physician, various factors and circumstances have to be taken into consideration. A physician may be removed from supervision by the Department Chair on the advice of the supervising physicians who have participated in the supervisory period. This notification will be in writing to the Chair of Medicine.

6. ELECTION FOR DEPARTMENT DIRECTOR:

The Department Chair will appoint a Nominating Committee to consist of not less than three (3) members, with a Chairman who will actively seek nominations beginning sometime after July l. By September 1, a panel of nominees will be selected by this Committee and posted. All interested members will be screened. Only physicians who are Full Attending and who are qualified to vote and not on suspension will be considered. No nominations will be obtained from the floor at the September Department of Medicine meeting.

7. VOTING PRIVILEGES

Voting privileges for Medical Staff elections shall be granted in accordance with the Bylaws, Rules and Regulations of the Medical Staff of Bayshore Community Hospital.

8. PEER REVIEW AND QUALITY MONITORING:

The Department will perform regular quality monitoring. This quality monitoring will include Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) as outlined in Section III of the Medical Staff Rules and Regulations.

Focused Professional Practice Evaluation (FPPE)

A FPPE will be conducted in the following situations:

1. For all new department members. The FPPE occurs during the period in
which the new practitioner is on supervision.

2. When a practitioner requests a new privilege.

3. When any other below triggers are met:

·  A single event that resulted in a mortality or caused significant harm;

·  A single event that may/can cause significant harm if repeated;

·  An identified pattern that has negatively impacted on the health of the patient;

·  An identified pattern that has the potential to adversely impact on the health of the patient;

·  Complaints by patients, family members or designated legal representatives of a patient regarding care/treatment.

·  Deviation from an expected range of values resulting from PI data collection.

·  Adverse or negative performance trend over six consecutive months of Ongoing Professional Practice Evaluation (OPPE).

·  Repeated failure to follow hospital or medical staff policy.

·  Notice from any regulatory or peer review agency

4. When conducting a review, any or all of the following aspects may be considered

·  Through patient care, medical/clinical knowledge

·  Practice based learning and improvement

·  Interpersonal communication skills

·  Professionalism

·  Systems based practice

·  Patient safety

·  Medical management

·  Medication use

·  Patient outcomes data

5.  Resources to utilize –

Data may be gathered from:

·  Chart review

·  Direct observations

·  Statistical reviews

·  Proctoring

·  Peer references

·  Interviews

Reviews will be conducted in-house unless it is determined that for reasons of conflict or insufficient expertise that an outside reviewer is required. This decision may be made by the departmental Chair, the chairperson of the Multi-Disciplinary Peer Review committee, or the chairperson of the committee.

At the conclusion of the investigative process the appropriate medical staff PI committee will assign an alpha identifier to each event as follows:

A / Routine/Acceptable Care
B / Non-Routine/Acceptable Care
C / Routine or Non-Routine/Questionable Care/Questionable variation from evidence based medical care
D / Non-Acceptable Care/Variation from evidence based medical care
E / Inadequate Documentation

Corrective action plans are required whenever a variance from the standard of care has resulted in an adverse patient event and/or demonstrated a pattern of sustained non compliance has occurred.

The corrective action plan shall be developed with the guidance of the VP for Medical Affairs, the Multi-Disciplinary Peer Review Committee and the appropriate chief of service.

The Corrective action plan shall be specific for the event, contain achievable actions, goals, and a timeframe for compliance and reporting of progress to the appropriate committee/subcommittees as designated. See Medical Staff Bylaws, Article IX, Corrective Action.

Ongoing Professional Practice Evaluation (OPPE) - Periodic performance reviews of all current medical and affiliated staff will be conducted. This also will include physician assistants and nurse practitioners. OPPE data will be collected and placed in the physician’s file for review by the departmental Chair or his designee. Available data will be reviewed every six months and may come from various sources and reports. Not all reports will be required to be reviewed simultaneously.

The following data may be reviewed:

·  Information acquired through periodic chart review

·  Direct observation

·  Monitoring of diagnostic or treatment techniques

·  Discussion with other individuals involved in the care of the patient including consulting physicians, nursing and administrative personnel

·  Reports compiled medical records, obtained by extraction from the EMR or data collection agency, or other hospital departments.

·  Other sources as deemed appropriate.

Aspects of OPPE to be considered may include, but should not be limited to, any of the items below:

·  Medical assessment and treatment of patient

·  Adverse privileging decision

·  Use of medications.

·  Use of blood and blood components

·  Appropriateness and outcome of operative and other procedures.

·  Appropriateness and clinical practice patterns including length of stay, denials, avoidable days.