McLaren Greater Lansing Rules of the Department of Emergency Medicine ARTICLE I. PURPOSE AND ORGANIZATION

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1 McLaren Greater Lansing Rules of the Department of Emergency Medicine ARTICLE I. PURPOSE AND ORGANIZATION 1.1 PURPOSE The purpose of the Department of Emergency Medicine shall be to perform the organizational responsibilities incumbent upon Professional Staff departments as prescribed in the Bylaws and specific to the practice of Emergency Medicine, including credentialing, recredentialing, peer review and quality assessment/improvement activities, emergency physician coverage, operational policies, and the evaluation of equipment, service, and facility needs. (Ref. Bylaws, Article XIII) 1.2 ORGANIZATION The Department of Emergency Medicine is established to conform with Article XIII of the Bylaws. ARTICLE II. DEPARTMENT MEMBERSHIP 2.1 NATURE OF THE DEPARTMENT MEMBERSHIP The Department of Emergency Medicine shall consist of Members of the Professional Staff who meet the qualifications for Department Members and who have been recommended to the Department of Emergency Medicine by the Credentials Committee and Professional Staff Executive Committee (PSEC) and appointed by the Board of Trustees. 2.2 ASSIGNED ALLIED HEALTH PROFESSIONALS Allied Health Professionals with specified service authority to provide dependent services will be those recommended by the Credentials Committee and PSEC and appointed by the Board of Trustees and assigned to the Department in accordance with established policy and as consistent with the Special Policy for Allied Health Professionals of the Bylaws. 2.3 BASIC QUALIFICATIONS FOR MEMBERSHIP Members/Applicants of the Department shall meet the basic qualifications for membership on the Professional Staff. Initial Approval: 12/95 Page 1

2 2.3.2 Members/Applicants of the Department shall engage primarily in the practice of Emergency Medicine Members /Applicants eligibility for appointment in the Department of Emergency Medicine is based upon documented evidence of training and experience. Specific consideration will be given, but not limited to, evidence of the following: Members/Applicants must complete an emergency medicine residency program approved either by the Accreditation Council for Graduate Medical Education (ACGME), the American Osteopathic Association (AOA), or the Royal College of Physicians and Surgeons of Canada Members/Applicants of the Department who are fellowship trained, if requesting privileges to apply skills obtained in such a fellowship program, must be eligible to sit for the certifying examination in the applicable specialty board recognized by the ACGME or AOA. If the ACGME or AOA does not accredit the fellowship and no specialty board exists, the member/applicant must submit the program curriculum, procedure logs and a signed attestation from the Program Director that the practitioner met the program requirements Members/Applicants must provide documentation of previous practice experience and demonstrated competency. 2.4 OTHER GENERAL REQUIREMENTS Members initially appointed to the Department must satisfactorily complete the observation requirements of the Department as defined in Article VIII of these Rules Initial applicants will be interviewed by the Department Chairman. 2.5 BASIC RESPONSIBILITIES OF DEPARTMENT MEMBERSHIP Primary responsibilities of Members of the Department will be as defined in the Bylaws Members will participate in good faith in the provision of professional emergency medical services sufficient to meet the needs of the Department Active Members will support the observation system of monitoring Department Members Members of the Department or Members of the Professional Staff who possess privileges within the Department must participate in the quality assessment/improvement and peer review activities of the Department Department Members will actively participate as faculty of the emergency medicine residency and carry their proportionate share of the teaching responsibilities as assigned by the Chairman. Initial Approval: 12/95 Page 2

3 2.5.6 Members on duty in the Emergency Department will make every reasonable effort to consult the primary physician of each admitted patient prior to admission All patients presenting themselves to the Emergency Department will be evaluated by either the emergency physician, patient s attending physician, or designee. Unlicensed Members of the house staff must receive concurrence of treatment from either the emergency physician on duty or the attending physician Admitting orders for patients admitted to the hospital to an inpatient service through the Emergency Department will be the responsibility of the admitting physician. ARTICLE III. APPOINTMENTS AND REAPPOINTMENTS 3.1 GENERAL PROCEDURE Appointments are provisional in nature for a period of twelve (12) months as governed by Article V of the Bylaws. 3.2 DEPARTMENTAL REVIEW The Department will review, investigate, and consider each completed application for appointment, reappointment, request for additional privileges, or modification of Professional Staff status and will adopt and transmit a written recommendation to the PSEC, through the Credentials Committee, and the Board of Trustees noting specific recommendations, any conditions attached to the recommendation, and statement of rationale for such recommendation. (Ref. Bylaws, Section 6) If additional information is required during the Department s review process, the Chief Executive Officer (CEO), or his designee, will be notified, and the CEO will make such request of the applicant. (Ref. Bylaws, Section and 6.3) For stated cause, the Department may defer action on an application. 4.1 GENERAL CONDITIONS ARTICLE IV. CLINICAL PRIVILEGES Delineation of a Member s clinical privileges will be governed by the Bylaws, General Rules, and Department Rules The Department will maintain a Core Privilege Form, subject to PSEC and Board of Trustees approval. Initial Approval: 12/95 Page 3

4 4.2 CREDENTIALING Determination of clinical privileges will be made based on documented evidence of training and experience and other indicators of the applicant s competence Prior to performing new techniques/procedures, the applicable credentialing must occur. Please refer to the Practitioner Apprenticeship in Established Techniques/Procedures and Privileging for New Techniques/Procedures located in the General Policies of the Bylaws. 4.3 SCOPE OF CLINICAL PRIVILEGES The scope of clinical practice within the Department of Emergency Medicine will include the diagnosis and treatment of patients presenting to the Department and the necessary procedure related to this practice. Requests for specific clinical privileges will be submitted on the prescribed Core Privilege Form. 4.4 ADDITIONAL PRIVILEGE REQUESTS Additional privileges may not be requested in conjunction with reappointment and must be submitted on the acceptable request form. A request will not be considered complete unless accompanied by supporting documentation as may be applicable. 4.5 CONDITIONS OF CLINICAL PRIVILEGES Observed clinical performance and results of quality assessment/improvement and peer review activities will be considered General conditions for observation and provisional status of initially appointed clinical privileges include observation as defined in Article VIII of these Rules. ARTICLE V. QUALITY IMPROVEMENT AND PEER REVIEW 5.1 QUALITY IMPROVEMENT PLAN Under the direction of the Department Chairman, the Department will develop a written annual plan delineating the quality improvement and peer review activities to be performed by the Department subject to the approval of the PSEC and as consistent with accreditation standards and the institution s goals The Quality Improvement Plan will be evaluated on an annual basis to assess the results of activities and recommendations and to consider modifications and/or revisions. Initial Approval: 12/95 Page 4

5 6.1 DESIGNATION OF OFFICERS ARTICLE VI. OFFICERS As consistent with the Bylaws, the officials of the Department will include a Chairman and a Vice Chairman. 6.2 QUALIFICATIONS The Chairman and Vice Chairman will be Active or Emeritus Members of the Department The Chairman and Vice Chairman will be Board Certified in Emergency Medicine. Non- Board Certified Active or Emeritus Members who have been practicing Emergency Medicine for five (5) years will be considered to have Board equivalence for purposes of eligibility to hold office in the Department The Chairman and Vice Chairman will be Members who have demonstrated leadership and management capabilities and agree to assume the responsibilities of the respective offices as defined in the Bylaws and these Rules. 6.3 TERM OF OFFICE The term of office for the Chairman and Vice Chairman will be for a period of two (2) years as consistent with the Bylaws and concurrent with the term of elected officers of the Professional Staff. 6.4 ELECTION PROCEDURE As consistent with the Bylaws, the Chairman and Vice Chairman will be elected by twothirds (2/3) majority vote of the Active Members of the Department. 6.5 NOMINATING COMMITTEE A Nominating Committee consisting of a minimum of three (3) Active Members will be appointed by the Chairman in July of the last year of his term. A slate of officers will be finalized in September for communication to Members of the Department. At that time, additional nominations (of qualified Members who agree) may be submitted in writing for addition to the slate of nominees Elections will be held at the November Department meeting. Nominations will be accepted by the floor at that time. Written ballots will be cast. Initial Approval: 12/95 Page 5

6 6.6 RESPONSIBILITIES OF OFFICERS Chairman The Chairman will be responsible for establishing, supervising, and directing the patient care rendered in the Department The Chairman will be the presiding officer of the Department s meetings The Chairman will be responsible for carrying out responsibilities and functions as designated in the Bylaws and will serve as the representative of the Department on the PSEC The Chairman will appoint special committees The Chairman will be an Ex-Officio Member of Department committees unless otherwise designated Vice Chairman The Vice Chairman will perform activities as delegated by the Chairman and will be the Department s representative in the absence of the Chairman. ARTICLE VII. COMMITTEES 7.1 The Department membership will meet at a minimum quarterly. Appointed Nursing and Administrative representatives will serve as Ex-Officio Members at these meetings. 7.2 An executive or management committee may be established by the Chairman. ARTICLE VIII. OBSERVATION REQUIREMENTS 8.1 OBSERVATION PROTOCOL Newly appointed Members of the Department are provisional and are subject to satisfactory completion of the observation requirements of the Department. 8.2 PROCEDURE Observers are assigned by the Chairman. There will be observers for each newly appointed Member. The extent of observation will be at the discretion of the Chairman and dependent on the level of training of the newly appointed Member. At a minimum, eighteen (18) charts (three [3] per shift) will be retrospectively reviewed by the observer(s). In most cases, direct observation of performance will be required until the Initial Approval: 12/95 Page 6

7 observer(s) are satisfied that the Member s level of competence meets Department standards. The process will be completed within the first six (6) months of appointment Completion of Observation: Upon completion of observation requirements, the observer(s) will review and evaluate the Member s performance and will make a conclusive recommendation in writing to the Department Chairman for consideration Upon receipt of a recommendation, the Department will consider the written recommendation and will forward its written recommendation to the PSEC through the Credentials Committee to: (1) Recommend approval without further observation; (2) Extend the observation period for stated cause; or (3) Recommend that the Member s request be denied and/or that Professional Staff membership be terminated. The reasons for denial/revocation of appointment and/or clinical privileges will be explicitly stated Failure of a provisional Member to complete observation requirements within the designated time period will result in re-evaluation of the application for appointment and/or clinical privileges Any Professional Staff Member with observation status may, in writing or in person, request extension of the observation period or reconsideration of his application. Extensions of the observation period will not extend such time beyond two (2) years from the initial appointment date Professional Staff Members who fail to complete the observation requirements due to inactivity may reapply for Professional Staff membership and/or clinical privileges. ARTICLE IX. MEETINGS AND ATTENDANCE REQUIREMENTS 9.1 DEPARTMENT MEETINGS The Department will meet at a minimum quarterly at a time and place as established by the Chairman in consultation with Department Members. 9.2 QUORUM As consistent with the Bylaws Members eligible to vote and present, but at least three (3), will constitute a quorum. 9.3 DEPARTMENT MEETING ATTENDANCE REQUIREMENTS Meeting attendance requirements will be consistent with the Bylaws and General Rules. Initial Approval: 12/95 Page 7

8 9.3.2 Each Members of the Active Category shall be encouraged to attend at least fifty percent (50%) of Department meetings. ARTICLE X. ADOPTION AND AMENDMENT 10.1 DEPARTMENT RESPONSIBILITY AND AUTHORITY The Department will have the responsibility and delegated authority to formulate, adopt and recommend Rules and Amendments for the Department of Emergency Medicine after recommendation to the PSEC and subject to the approval of the Board of Trustees Endorsement of a two-thirds (2/3) majority of the eligible voting Members is required AMENDMENT Upon recommendation to the PSEC and subject to the approval of the Board of Trustees these Rules may be amended by a two-thirds (2/3) majority of the eligible voting Members of the Department PERIODIC REVIEW OF DEPARTMENT RULES These Rules will be reviewed at least every two (2) years GLOSSARY Terms utilized in the context of these Rules will be consistent with Article II Definitions of the Bylaws ADOPTION The foregoing Rules were adopted and recommended to the PSEC and the Board of Trustees in accordance with and subject to the Professional Staff Bylaws. ADOPTED AND APPROVED: Chairman, Department of Emergency Medicine Professional Staff Executive Committee Board of Trustees Date Date Date Initial Approval: 12/95 Page 8