AKRON CHILDREN'S HOSPITAL MEDICAL STAFF BYLAWS, POLICIES, AND RULES AND REGULATIONS MEDICAL STAFF RULES AND REGULATIONS

Transcription

1 AKRON CHILDREN'S HOSPITAL MEDICAL STAFF BYLAWS, POLICIES, AND RULES AND REGULATIONS MEDICAL STAFF RULES AND REGULATIONS July 1, 2012

2 GENERAL RULES G1. Patients shall be attended by their own private Medical Staff members. Patients who have no attending Medical Staff member shall be accepted by and become the responsibility of members of the Medical Staff on service in the department or division to which the nature of the illness of the patient indicates assignment according to applicable policies and procedures. G2. Members of the Medical Staff retain responsibility for the continuous care and supervision of each patient in the hospital for whom he/she is providing services. Members who are not available for patient care responsibilities must make suitable arrangements with another Medical Staff member to act as substitute. Members who are collaborating physicians for Advance Practice Nurses cannot leave their patients solely in the care of the Advance Practice Nurse. In case of failure to make such arrangements, the case will be referred to the Medical Staff member on service. G3. This hospital provides professional graduate medical education. The extent of participation of residents in patient care is defined in the medical staff policy entitled Supervision of Residents and Fellows in Training Programs and by each department involved in graduate medical education. Each departmental policy and procedure manual describes the lines of command and the graded nature of responsibilities. In furtherance of the Hospital's quality assurance and peer review functions, the medical staff policy provides for communication between the Medical Education Committee, Medical Performance Improvement Committee, Medical Staff Executive Committee, and Board of Trustees regarding matters of quality of patient care and resident education. G4. Medical staff members admitting private patients shall be held responsible for giving such information as may be necessary to assure the protection of other patients from those who are a source of danger from any cause whatsoever, or to assure protection of the patient from self-harm. G5. In situations where a member of the Medical Staff is participating in a contractual relationship with The Hospital, termination of said contract shall not constitute termination of the individual's Medical Staff privileges, unless otherwise specifically provided in said contract. These Bylaws are not a part of, and are not to be used in interpreting any contract under which any member of the Medical Staff is participating with The Hospital, including, but not limited to, the Hearing and Appellate Review Procedure under Article IX of these Bylaws. G6. A consultant must be qualified in a field in which he/she is sought. The status of the consultant is determined by the Medical Staff Executive Committee on the basis of an individual's training, experience, and competence. A satisfactory consultation includes examination of the patient and the record. A written

3 opinion signed by the consultant must be included in the medical record. The patient's Medical Staff member is responsible for requesting consultations when indicated. The reason for consultation must be clearly stated. It is the duty of the Medical Staff through its Department Chairpersons, Division Directors and Medical Staff Executive Committee to make certain that members of the Staff do not fail in the matter of calling for consultations as needed. G7. Health care providers are distinguished into two categories, dependent and independent practitioners. Independent practitioners are all individuals permitted by Ohio law and by the Hospital to provide patient care services independently (without supervision by a physician) within the Hospital. All independent practitioners have delineated clinical privileges. Dependent practitioners are individuals who provide medical care under supervision. The determination of status of any given practitioner group, i.e. dependent or independent, or change in status from dependent to independent, is made by the Medical Staff Executive Committee and the Board of Trustees. Presently, independent practitioners are physicians, dentists, psychologists, podiatrists, certain advanced practice nurses, physician assistants and certain qualified laboratory scientific staff. Dependent practitioners include, but are not limited to: certified registered nurse anesthetists, scrub persons, perfusionists, speech-language pathologists, audiologists, genetics counselors and surgical assistants. Certified registered nurse anesthetists practice under the direct supervision of an anesthesiologist. Most dependent practitioners are Hospital employees. Non-Hospital dependent practitioners may be free lance, physician's employees, or practitioners providing contracted patient care. Physician's assistants and certified registered nurse anesthetists are credentialed, privileged, and re-privileged through the medical staff process. Other dependent practitioners are credentialed and authorized to provide care through Hospital processes. G8. All licensed independent practitioners must make formal application for delineated clinical privileges in their respective fields. These applications shall be evaluated by the Credentials Committee and acted on by the Medical Staff Executive Committee and the Board of Directors. G9. Dependent practitioners who are not Hospital employees must make application to the Hospital to provide patient care. Hospital managers and directors are responsible for determining the appropriate qualifications and competence to provide the patient care requested and for providing an orientation that covers the care provider's responsibilities. Hospital managers and directors are responsible for ensuring a consistent standard of care through job descriptions, performance evaluations, and maintenance of applicable current licensure/certification. G10. Administrative physicians desiring appointment to the Medical Staff with or without clinical privileges will follow the same processes for appointment and reappointment as outlined in Credentials Committee policies and procedures.

4 G11. Adverse Information Regarding Medical Staff Members. Information about the conduct, performance and competence of Medical Staff Members is handled through Medical Staff Policies which include the Professional Conduct Policy, Impaired Practitioner Policy, and the Peer Review Policy. G12. Confidentiality of Information: a. The records of the Medical Staff and its committees responsible for the evaluation and improvement of the quality of patient care rendered in the Hospital shall be maintained as confidential. b. Access to such records shall be limited to duly appointed officers, committees, and employees of the Medical Staff for the sole purpose of discharging Medical Staff responsibilities and subject to the requirement that confidentiality be maintained. c. Information which is disclosed to the governing body of the Hospital or its appointed representatives shall be maintained by the recipient as confidential. d. Medical Staff members can review their credentials files in accord with Credentials Committee Policies and Procedures. Personal letters of reference are considered confidential. e. Information contained in Medical Staff, department, division, or committee minutes, files, and records, including information regarding any member or applicant to this Medical Staff, shall be confidential. The disclosure of information from such documents other than when required by law or with the consent of the member or applicant may be made only with the express approval of the Medical Staff Executive Committee or its designee. f. Any breach of confidentiality of the discussions or deliberations of Medical Staff departments, divisions, or committees, except in conjunction with another hospital, professional society, or licensing authority, or as required by law, is outside appropriate standards of conduct for this Medical Staff. If it is determined that such breach has occurred, the Medical Staff Executive Committee may undertake such corrective action as it deems appropriate. G13. Subject to the approval of the Medical Staff Executive Committee, each department may formulate its own Rules and Regulations for the conduct of its affairs and the discharge of its responsibilities. Such Rules and Regulations shall be consistent with these Bylaws, the Rules and Regulations of the Medical Staff as incorporated in the Bylaws, and other policies of The Hospital. G14. New appointees to the Medical Staff are required to attend orientation to Hospital policies, including those pertaining to confidentiality of patient information and compliance, and to complete training on use of the Hospital electronic medical

5 record prior to exercising clinical privileges, except for temporary privileges which may be exercised upon the grant of privileges, in accordance with the Credentialing Policy. Other exceptions and modifications to this rule may be made by the President of the Medical Staff in his or her discretion. CLINICAL RULES C1. Psychiatric treatment must be offered to all patients who have attempted suicide or have taken a chemical overdose. That such services were at least offered must be documented in the patient's record. C2. Therapeutic abortion or sterilization for male or female patients is permitted for medical reasons after concurring consultations by two members of the Medical Staff, one from the Department of Pediatrics and one from the Department of Surgery, and a consultation from a practitioner in the field of specialty practice represented by the medical condition for which the procedure is recommended. No one of the above consultants shall be the one performing the procedure. C3. A uterine cytologic examination (generally a pap smear) for detection of cancer shall be offered every female inpatient 18 years or over. That such services were at least offered must be documented in the patient's record. C4. The use and reasons for special treatment procedures such as restraint, seclusion, behavior modification procedures and other special treatment procedures used for children and adolescents shall be documented in the patient's medical record. Written guidelines governing the use of these procedures shall be included in the policies and procedures of the patient care units. C5. All anesthesia care, or the administration of anesthetics to patients will be provided only by individuals with delineated clinical privileges. This includes all anesthesia, i.e., general, spinal, or other major regional anesthesia, as well as surgery or other invasive procedures requiring intramuscular, intravenous, or inhalation sedation anesthesia that may result in the loss of the patient's protective reflexes. C6. All patients undergoing procedural sedation will be monitored as described in The Hospital's Procedural Sedation and Analgesia Policy. PHYSICIAN ORDERS P1. All orders for patient care shall be in writing, dated, and signed by the attending Medical Staff member.

6 a. The privileged attending Medical Staff member may delegate the responsibility of writing patient care orders to the appropriate house officer or consultant physician. The attending Medical Staff member may not be prohibited from writing orders on his/her patients. Further, staff membership, the holding of clinical privileges and medical staff prerogatives, shall not be made conditional upon the agreement to surrender such responsibility to the house officer. b. Verbal orders shall be dictated to a registered nurse. Other licensed health professionals may take dictated orders pertaining directly to their profession. Verbal orders shall be transcribed with date by the person to whom dictated with the name of the Medical Staff member or house officer per his or her signature. Verbal orders shall be signed according to medical staff policy and procedure. P2. When a patient is transferred to another medical staff member, a transfer order must be written. P3. The prescription for respiratory care, whether written by the patient's primary Medical Staff member or appropriate house officer or developed in consultation, shall specify the type, frequency and duration of treatment, and the type and dose of medication, including dilution ratio, oxygen concentration and precautions to be observed. A written record of the prescription and of any related consultation should be kept in the patient's medical record. In all cases, the responsible Medical Staff member or appropriate house officer must place in the patient's medical record the timely, pertinent clinical evaluation of the results of respiratory therapy. P4. Patient care provided by dependent practitioners must be ordered and supervised by a privileged Medical Staff member. The care provided must be within the scope of patient care privileges defined by the applicable Hospital department/service. All patient care given by dependent practitioners shall be documented in the patient medical record. P5. Medical Staff member's orders will be cancelled at the beginning of a surgical procedure and must be reordered in the medical record following the surgical procedure. DRUG / PHARMACY D1. Drugs used shall meet the standards of the United States Pharmacopoeia, National Formulary, New and Nonofficial Drugs, with the exception of drugs for bona fide clinical investigations. Exceptions to this rule shall be well justified and documented in writing.

7 D2. Automatic stop orders exist for narcotics at the end of each 72 hours or a definite terminating date by a Medical Staff member or appropriate house officer. For antibiotics a stop order exists at the end of a fourteen-day period. The stop date for all other prescription drugs is 30 days. Drugs should not be discontinued without notifying the medical staff member so that orders can be renewed or discontinued. By a majority vote, the Medical Staff Executive Committee may designate automatic stop orders for other drugs or therapies. MEDICAL RECORDS M1. The attending Medical Staff member shall be held responsible for the review and signature of a complete medical record for each patient. a. This record shall include identification data; unit number, if applicable; nearest relative or responsible agent; evidence of appropriate informed consent; complaint; personal history; relevant social and family history; history of present illness; physical examination; inventory of body systems; diagnostic and therapeutic orders; clinical observations; special reports, such as consultations, clinical laboratory, radiology, and others; provisional diagnosis; reason for admission; medical or surgical treatment; operative report; pathological findings; progress notes; principal and secondary diagnosis(es) and procedure(s); complications; condition on discharge or transfer; summary and discharge note; instructions given to the patient and/or his family relative to necessary follow-up care particularly in regard to physical activity limitations, medications and diet; and autopsy when available. b. All entries in the medical record shall be timed and dated. c. In addition outpatient records should also include dates of service as well as identification of other sources of medical care. d. In addition emergency medical records should include information concerning the time of arrival and by whom transported and the pertinent history of the injury or illness. e. Details relative to first aid or emergency care given to the patient prior to arrival at The Hospital may be attached to the record. f. By majority vote, the Medical Staff Executive Committee may designate other items required to constitute a complete medical record. No medical record shall be filed until it is complete, except on order of the Medical Records Committee. M2. To avoid misinterpretation, symbols and abbreviations may be used in the medical record only when they have been approved by the Medical Staff Executive Committee, and when there is an explanatory legend available to those authorized

8 to make entries in the medical record and to those who must interpret them. Each abbreviation or symbol should have only one meaning. Orders involving abbreviations and symbols should be carried out only if the abbreviations and symbols appear on a standard list approved by the Medical Staff Executive Committee. Final diagnosis may not contain abbreviations and symbols. M3. The medical record shall document a current history and physical examination prior to the performance of surgery with general anesthesia. M4. Records on discharged patients shall be completed within 30 days of discharge. What constitutes a complete medical record and applicable sanctions for failures to comply shall be set forth in Medical Staff policies and procedures. M5. Daily progress notes must document the attending physician has seen the patient and concurs with the treatment plan. Pertinent progress notes may be made by others so authorized by the Medical Staff, such as individuals who have been granted clinical privileges and specified professional personnel. Progress notes should be recorded at an appropriate frequency reflecting the nature and course of the hospitalization. All progress notes must be dated and signed. M6. Medical Staff members using preprinted discharge instruction sheets must have copies of the sheets filed in the Medical Records Department. M7. The use of signature stamps are prohibited. Authorized electronic signatures constitute valid signatures. M8. All records are the property of The Hospital and shall be removed from The Hospital's jurisdiction and safekeeping only in accordance with a court order, subpoena, or statute. In case of readmission of a patient, all previous records shall be available for the use of the attending Medical Staff member. M9. Reports of pathology and clinical laboratory examinations, radiology and nuclear medicine examinations or treatment, anesthesia records, and any other diagnostic or therapeutic procedures should be completed immediately and be available in the record within 24 hours of completion if possible. When a necropsy is performed, provisional anatomic diagnoses should be recorded in the medical record within 3 days, and the complete protocol should be made part of the record within 60 days. M10. All tissues and specimens removed at The Hospital shall be sent to The Hospital Pathology Department, unless authorized otherwise by the Medical Staff Executive Committee. The Pathology Department shall make such examinations as may be considered necessary to arrive at a pathological diagnosis and certify the report by written or authorized electronic signature. M11. Authenticated and dated reports of all laboratory tests should also be available promptly with the patient's medical record. Report forms should be formatted to facilitate comparison of each determination with pertinent "normal" ranges, and sequential and related analyses. Reports of quantitative analyses shall include the units of concentration or activity. M12. All electrocardiogram's excluding rhythm strips, performed outside the Division of Cardiology will be submitted to cardiology for interpretation and will become part of the patient's medical record.

9 M13. Follow-up of laboratory, imaging, or other studies/tests that are pending at the time of a hospital discharge will be the responsibility of the attending of record at the time of the patient s discharge. In the Electronic Medical Record, the results will be sent to the Attending s In-Basket, and he/she will have the option of delegating/transferring the managements of the study/test result to another provider if appropriate. SURGERY OR INVASIVE PROCEDURES S1. The Chairperson of Surgery shall have the discretionary power to cancel the surgery if the operating Medical Staff member is not ready to commence operation within 20 minutes after the time scheduled. S2. The responsible surgeon must record and authenticate a preoperative diagnosis prior to surgery. S3. Informed Consent: A surgical operation shall be performed only on consent of the patient or his/her legal representative, except in emergencies. The medical record shall contain evidence of the patient's informed consent for any procedure or treatment for which it is appropriate. This information includes the identity of the patient, the procedure or treatment to be rendered, the name(s) of the individual(s) who will perform the procedure or administer the treatment, authorization for anesthesia if indicated, an indication that alternate means of therapy and the possibility of risks or complications have been explained to the patient and authorization for disposition of any tissue or body parts as indicated. The signature of the patient, parent, or other individual empowered to give consent should be witnessed. The practitioner with clinical privileges who informs the patient and obtains the consent will be identified in the medical record if other than the attending medical staff member. S4. All operations performed shall be fully described by the operating surgeon. A hand written note shall be completed immediately post operatively before the patient is transferred to the next level of care. There must be sufficient information in the medical record to manage the patient at the next level of care. Operative reports shall be dictated within 24 hours. S5. Elective surgical procedures to be done under general anesthesia shall be canceled if the patient is found to have used illicit drugs within 24 hours of the scheduled surgery. These Rules and Regulations were adopted as part of the 2005 Bylaws. Approved by the Active Medical Staff on June 22, 2005, and the Board of Trustees on June 23, Revisions were made to these Rules and Regulations with the approval of the new Bylaws in July of Additional changes regarding EHR training and the removal of the H&P from this document to the Bylaws were made by majority vote May 2012.