METHODIST HEALTH SYSTEM

MEDICAL STAFF POLICY MANUAL

Immediate Prior Version: July 25, 2006

Current Version Approved by:

MDMC Executive Committee: January 9, 2007

MCMC Executive Committee: January 12, 2007

Corporate Medical Board: January 16, 2007

Board of Directors: January 23, 2007

ARTICLE 1 - INTRODUCTION 1

ARTICLE 2 - PURPOSES 1

ARTICLE 3 - DEFINITIONS 1

ARTICLE 4 - MEDICAL STAFF APPOINTMENT 1

4.1 Nature of Medical Staff Appointment 1

4.2 Qualifications for and Terms, Conditions and Responsibilities of Appointment 1

4.2.1 Qualifications for Appointment 1

4.2.2 Professional Liability Insurance 2

4.2.3 Responsibilities of Appointment 2

4.2.4 Authority to Appoint 2

4.2.5 Terms of Appointment 2

4.2.6 Provisional Status 3

4.2.6.1 Applicability 3

4.2.6.2 Continuation, Evaluation and Termination of Provisional Status 3

4.2.6.3 Orientation Process 4

4.2.7 Primary System Hospital Affiliation 4

4.2.8 Applicant’s Obligations 4

4.2.9 Participation in Teaching Programs as Teaching Staff 4

4.2.9.1 Appointment Process 4

4.2.9.2 Degree of Care/Management of Patient by House Staff 5

4.2.10 Compliance with Privacy Regulations 5

4.2.10.1 Adoption of Privacy Notice 5

4.2.10.2 Approval of Restrictions and Limitations 5

4.2.10.3 No Information Patients 5

4.2.10.4 No Effect on Legal Regulations 5

4.3 Ethics and Ethical Relations 6

4.3.1 Conflict of Interest 6

4.3.1.1 Purpose 6

4.3.1.2 Definitions 6

4.3.1.3 Procedures 7

4.4 Scope of Clinical Privileges 8

4.5 Peer Review 8

4.5.1 Purpose 8

4.5.2 Objective 8

4.5.3 Guidelines 9

4.5.4 Privileged Committee Function 9

4.5.5 Definition 9

4.5.6 Process 9

ARTICLE 5 - APPOINTMENT OF INITIAL APPLICANT AND REAPPOINTMENT 12

5.1 Disclosures 12

5.2 Burden of Proof 12

5.3 Application and Initial Appointment 12

5.3.1 Initial Application 12

5.3.2 Corporate Credentials Committee Function 14

5.3.3 Corporate Medical Board Responsibilities 14

5.3.4 Favorable Recommendation by the Corporate Medical Board 15

5.3.5 Deferral of Application 15

5.3.6 Adverse Recommendation by Corporate Medical Board 15

5.3.7 Final Action by Board of Directors 16

5.3.8 Eligibility for Appointment after Adverse Recommendation 16

5.3.9 Expedited Review Process for Initial Applicants 16

5.3.9.1 Purpose and General Requirements 16

5.3.9.2 Expedited Processing Procedure 17

5.3.9.3 Criteria for Applying Process 17

5.3.10 Scheduled Review of Provisional Status for Active Category of Membership 17

5.4 Medical Staff Re-Appointment Process 19

5.4.1 Practitioners' Obligation 19

5.4.2 Reappointment Application Process 19

5.4.3 Department and Corporate Credentials Committee Review 21

5.4.4 Corporate Medical Board Responsibilities 23

5.4.5 Favorable Recommendation by the Corporate Medical Board 23

5.4.6 Deferral of Application 23

5.4.7 Adverse Recommendation by Corporate Medical Board 23

5.4.8 Final Action by Board of Directors 24

5.4.9 Eligibility for Reappointment After Adverse Recommendation 24

5.4.10 Reappointment Criteria 24

5.4.11 Conditional Reappointment 25

5.5 Leave of Absence 25

5.5.1 General Leave of Absence 25

5.5.2 Leave of Absence for Military Service 26

5.5.3 Inactive Status for Illness 26

5.6 Modification of Appointment 26

ARTICLE 6 - CLINICAL PRIVILEGES 27

6.1 Request for Privileges by Initial Applicants and Provisional Appointees 27

6.2 Re-determination of Privileges 27

6.3 Requests for New or Additional Privileges 27

6.3.1 Purpose 27

6.3.2 Policy 27

6.3.3 Definitions 28

6.3.3.1 General Procedure 28

6.3.3.2 New Privilege 28

6.3.3.3 New Technology 28

6.3.3.4 Special Procedure 28

6.3.4 Procedure 28

6.4 Privileges Granted to Dentists 30

6.5 Privileges Granted to Podiatrists 30

6.6 Temporary Privileges 30

6.6.1 Temporary Privileges for Initial Applicant 30

6.6.2 Locum Tenens Privileges 31

6.6.3 Temporary Privileges for Specialized Teams 31

6.6.4 Temporary Privileges for the Care of a Specific Patient 31

6.6.5 Special Requirements for Temporary Privileges 32

6.6.6 Termination of Temporary Privileges 32

6.7 Emergency Privileges 32

ARTICLE 7 - CORRECTIVE ACTION 33

7.1 Corrective Action 33

7.2 Summary Suspension 33

7.3 Automatic Suspension or Revocation 33

7.4 Precautionary Administrative Suspension 33

7.5 MHS Practitioner Conduct Policy 33

7.5.1 Policy 33

7.5.2 Definitions 33

7.5.3 Procedure for Reporting and Handling Apparent Violations 34

7.5.3.1 Reporting the Incident 34

7.5.3.2 Documentation of the Incident 35

7.5.3.3 Investigation of the Incident 35

7.5.3.4 Review with the Practitioner 36

7.5.3.5 Conduct of a Level I Review 36

7.5.3.6 Conduct of a Level II Review 37

7.5.3.7 Conduct of a Level III Review 37

7.5.3.8 Conduct of a Level IV Review 37

7.5.3.9 Letters of Admonishment and Conditional Conduct Letters 38

7.5.3.10 Practitioner Advocate 38

7.5.3.11 Documentation of the Meeting with the Practitioner 38

7.5.3.12 Outline of Formal Disciplinary Measures 38

7.5.3.13 Exoneration of Practitioner 39

7.5.3.14 Exclusion of Practitioner from the Hospital Facilities 39

7.5.3.15 Responsibility for Sponsored and/or Employed Individuals 39

7.5.3.16 Presence of Counsel at Reviews 39

7.5.3.17 Confidentiality and Protection from Discovery 39

7.5.3.18 Order of Review 40

7.5.3.19 Retention of Records 40

7.5.3.20 The Corporate Credentials Committee Responsibility 40

7.5.3.21 Time of the Essence 40

ARTICLE 8 - FAIR HEARING PROCEDURE 40

ARTICLE 9 - MEDICAL STAFF CATEGORIES 41

9.1 Types of Categories 41

9.2 Active Membership 41

9.2.1 Category Description; Qualifications; Rights; & Responsibilities Active Status I 41

9.2.2 Active Status II (Without Privileges) 41

9.2.3 Senior Active Status 41

9.3 Affiliate Category 42

9.3.1 Consulting Affiliate 42

9.3.2 Sponsored Attending Affiliate 42

9.3.3 Honorary Affiliate 42

9.3.4 Departmental Affiliate 42

9.3.5 Temporary Affiliate 42

9.3.6 Courtesy Affiliate 42

9.4 Administrative and Medical Staff Functions 43

9.5 House Staff 43

ARTICLE 10 - ALLIED HEALTH PROFESSIONALS 44

10.1 Relationship to Medical Staff 44

10.2 Categories, Qualifications, Application Process, Monitoring, and Identification 44

10.2.1 Categories 44

10.2.1.1 Allied Health Associates 44

10.2.1.2 Allied Health Assistants 44

10.2.2 Qualifications 44

10.2.3 Application Process 44

10.2.4 Monitoring of Approved Applicants 45

10.2.5 Identification 45

10.2.6 Suspension and Exclusion of Allied Health Professionals 45

10.2.7 Sponsoring Practitioner’s Responsibilities 45

ARTICLE 11 - MEDICAL STAFF ORGANIZATION AND OFFICERS 47

11.1 Officers of the Medical Staff 47

11.1.1 Annual Stipend 47

11.1.2 Source of Funds 47

11.1.3 Control of Funds 47

ARTICLE 12 - CORPORATE MEDICAL STAFF COMMITTEES 48

12.1 Composition and Appointment 48

12.2 Authority to Delegate 48

12.2.1 Special Committees 48

12.2.2 Standing Special Committees 48

12.3 Corporate Medical Board 48

12.4 Corporate Graduate Medical Education Committee 48

12.5 Other Corporate Medical Staff Committees 48

12.5.1 Corporate Bylaws and Policies Committee: 48

12.5.2 Corporate Credentials Committee 49

12.5.3 Medical Staff Health Subcommittee 49

12.5.3.1 Creation 49

12.5.3.2 MHS Practitioner Health Policy 50

12.5.4 Corporate Clinical Ethics Committee 54

12.5.4.1 System Hospital Clinical Ethics Consult Teams 55

12.5.5 MHS Medical Staff Policy and Guidelines Committee 56

12.5.6 Corporate Health Information Management Committee 57

ARTICLE 13 - SYSTEM HOSPITAL MEDICAL STAFF COMMITTEES 58

13.1 Composition and Appointment 58

13.2 Authority to Delegate 58

13.2.1 Special Committees 58

13.2.2 Standing Special Committees 58

13.3 Executive Committee 58

13.4 Succession & Leadership Committee 58

13.5 Other System Hospital Medical Staff Committees 58

13.5.1 Professional Care Audit/Review Committee 58

13.5.2 Utilization Management Committee 60

13.5.3 Medical Staff Quality Council 61

ARTICLE 14 - MEDICAL STAFF CLINICAL DEPARTMENTS AND SECTIONS 62

14.1 Organization 62

14.2 Other Matters Related to Medical Staff Clinical Departments 62

14.2.1 Qualifications, Selection, and Tenure of Department Chairmen 62

14.2.1.1 Qualifications 62

14.2.1.2 Term of Office 62

14.2.1.3 Method of Election 62

14.2.1.4 Removal of Departmental Officers 63

14.2.1.5 Department Officers with Contractual Relationship 63

14.2.2 Duties of Department Chairmen 63

14.2.3 Functions of Departments 64

14.2.4 Assignment to Departments 65

ARTICLE 15 - MEDICAL STAFF MEETINGS 66

15.1 Regular Meetings 66

15.2 Annual Meeting 66

15.3 Special Meetings 66

15.4 Attendance at Medical Staff Meetings 66

15.4.1 Requirements 66

15.4.2 Exclusion from Attendance Requirement 66

15.5 Notification, Quorum and Agenda 66

15.5.1 Notification 66

15.5.2 Quorum 66

15.5.3 Agenda 67

15.5.3.1 Regular Meeting Agenda 67

15.5.3.2 Special Meeting Agenda 67

ARTICLE 16 - DEPARTMENTAL AND COMMITTEE MEETINGS 68

16.1 Regular Meetings 68

16.1.1 Frequency of Meetings 68

16.1.2 Purpose and Record Requirements 68

16.1.2.1 Purpose of Meetings 68

16.1.2.2 Record of Meetings 68

16.2 Special Meetings 68

16.3 Attendance Requirements – Department and Committee Meetings 68

16.4 Other Matters Related to Department and Committee Meetings 69

16.4.1 Notification 69

16.4.2 Quorum 69

16.4.3 Committee and Departmental Manner of Action 69

16.4.4 Rights of Ex-Officio Members 69

16.4.5 Departmental and Committee Reports 69

ARTICLE 17 - RULES OF ORDER 69

ARTICLE 18 - IMMUNITY FROM LIABILITY 69

ARTICLE 19 - AMENDMENTS TO BYLAWS, POLICIES AND DEPARTMENT RULES 70

19.1 Medical Staff Bylaws 70

19.2 Policies 70

19.2.1 Process to Amend Policies 70

19.2.1.1 Requests for Amendments, Modifications and Repeal 70

19.2.1.2 Action of Medical Staff Bylaw and Policies Committee 70

19.2.1.3 Action of Executive Committee 70

19.2.1.4 Action of the Corporate Medical Board 70

19.2.1.5 Action of the Board of Directors 70

19.2.2 Notification to the Medical Staff 71

19.3 Department Rules 71

ARTICLE 20 - GENERAL PROVISIONS 71

ARTICLE 21 - ADMISSION AND DISCHARGE OF PATIENTS 72

21.1 Patient Admission 72

21.2 Types of Cases Admitted 72

21.3 Infectious Patients 72

21.4 Admission Priorities 72

21.5 Assignments by Patient Care Unit and Patient Transfers 72

21.6 General Consent to Treatment Form 73

21.7 Informed Consent 73

21.8 Utilization Review 73

21.9 Discharge of Patient 73

21.10 Pronouncement of Death 73

21.11 Autopsies 73

ARTICLE 22 - MEDICAL RECORDS 74

22.1 Responsibility for Medical Record 74

22.2 History and Physical Examination Report 74

22.3 Records by House Staff and Teaching Physician 74

22.4 Progress Notes 74

22.5 Reports 75

22.6 Consultation Content 75

22.7 Symbols and Abbreviations 75

22.8 Discharge Summary 75

22.9 Completion of the Medical Record 76

22.10 Authentication of Routine Order 76

22.11 Release of Patient Information 76

22.12 Medical Records are Property of the Hospital 76

22.13 Availability of Medical Records 76

22.14 Filing of Medical Record 77

22.15 Medical Record in the Emergency Room 77

ARTICLE 23 - GENERAL CONDUCT OF CARE 78

23.1 Definitions of Physician Roles in the Hospital 78

23.1.1 Attending Physician 78

23.1.2 Referring Physician 78

23.1.3 Primary Care Physician 78

23.1.4 Admitting Physician 78

23.1.5 Consulting Physician 79

23.1.6 Covering Physician 79

23.2 Consultations 79

23.3 Clarification 79

23.4 Orders for Treatment Shall be in Writing 80

23.5 Prescriptions During the Patient's Hospitalization 80

23.6 Laboratory Work 80

23.7 Patients Admitted for Dental Services 80

23.8 Patients Admitted for Podiatric Services 81

ARTICLE 24 - EMERGENCY SERVICES 82

24.1 Call Schedule 82

24.1.1 On-Call Practitioner Must Come To the ED When Called 82

24.1.2 Disputes Over Need to Respond 82

24.1.3 Assistance in Screening and/or Stabilization 82

24.1.4 Ability to Pay Not To Be Considered 82

24.1.5 Timely Response 82

24.1.6 Justification for Delay 83

24.1.7 Follow-Up Care 83

24.1.8 Disciplinary Actions 83

24.1.9 Definitions 83

24.2 Disaster Plans 84

24.3 Disaster Privileges 84

24.3.1 Purpose 84

24.3.2 Policy 84

24.3.3 Procedure 84

ARTICLE 25 - GENERAL 86

25.1 Confidentiality of Medical Staff Files 86

25.2 Assessment for Medical Staff Members 86

25.3 Hospital Orientation 86

Methodist Health System Medical Staff Practitioners Notice of Privacy Practices 87

MHS Medical Staff Policies

Page - vi

MEDICAL STAFF POLICIES

ARTICLE 1 - INTRODUCTION

Pursuant to Article 19.2 of the Bylaws, the Medical Staff through the Corporate Medical Board has established certain policies and procedures to carry out further and in more detail describe the general provisions, concepts, policies, principles and obligations set out in the Bylaws. This Policy manual contains those more detailed policies and procedures, and the provisions set forth in this Medical Staff Policy Manual are the “Policies” as that term is used in the Bylaws.

ARTICLE 2 - PURPOSES

The purposes of the medical staff organization are as expressly stated in the Bylaws.

ARTICLE 3 - DEFINITIONS

Unless expressly stated otherwise, capitalized terms contained in this Policy Manual shall have the same meaning as given in the Bylaws.

ARTICLE 4 - MEDICAL STAFF APPOINTMENT

4.1 Nature of Medical Staff Appointment

The Nature of Medical Staff Appointment is as set forth in the Bylaws. Additional requirements, policies and rules related to initial application, appointment and reappoint including the process for initial application, appointment and reappointment are set forth in Article 5 of these Policies.

4.2 Qualifications for and Terms, Conditions and Responsibilities of Appointment

4.2.1 Qualifications for Appointment

In order to qualify for appointment on the Medical Staff, a Physician, Dentist, or Podiatrist must:

1.  Be licensed to practice in the State of Texas;

2.  Provide documentation establishing his or her:

(i)  background, including satisfactory experience and training,

(ii)  demonstrated competence,

(iii)  mental and physical status,

(iv)  compliance with the Bylaws, the Policies, Medical Staff rules, and MHS and System Hospital policies, and bylaws,

(v)  good character and reputation,

(vi)  adherence to the ethics of his profession, and

(vii)  ability to work with others.

The documentation must be of sufficient adequacy to assure the Medical Staff and the Board of Directors that he or she will be effective Medical Staff members and will provide a high quality of medical care in an efficient manner to any patient admitted or treated by them.

3.  As appropriate, participate in Federal and State health care programs;

4.  Possess and maintain current registrations for prescribing medications with the Drug Enforcement Agency (DEA) and Department of Public Safety (DPS) as applicable

5.  Have, at all times, professional liability insurance in amounts as specified in the Policies,

6.  Furnish proof of the insurance required,

7.  As applicable, meet the Citizenship requirements of the Medical Staff, and

8.  Provide immediate written notice to the Chief Executive Officer and the medical staff services department of any failure to renew, cancellation, reduction, denial of coverage, or other changes resulting in less coverage than is required for medical staff appointment.

No Physician, Dentist, or Podiatrist shall be entitled to appointment to the Medical Staff or to the exercise of particular clinical privileges in a System Hospital merely by virtue of the fact that he is duly licensed to practice medicine, dentistry, or podiatry in the State of Texas or any other state, or that he is a member of any professional organization, or that he has had in the past, or presently has such privileges at another hospital. Sex, race, creed, and/or national origin are not used in making decisions regarding the granting or denying of medical staff membership or clinical privileges.