MEDICAL STAFF RULES AND REGULATIONS TABLE OF CONTENTS

Transcription

1 MEDICAL STAFF RULES AND REGULATIONS TABLE OF CONTENTS ARTICLE I. ARTICLE II. ARTICLE III. ARTICLE IV. ARTICLE V. ARTICLE VI. ARTICLE VII. INTRODUCTION A. GENERAL RULES AND REGULATIONS AUTHORZIED BY THE MEDICALSTAFF.1 B. RULES AND REGULATIONS ORIGINATED BY THE MEDICAL EXECUTIVE COMMITTEE (MEC)...1 C. RULES AND REGUALTIONS ORGINIATED BY DEPARTMENTS...1 ADMITTING/OBSERVATION POLICY A. ADMISSION REQUIREMENTS... 2 B. EMERGENCY ADMISSIONS... 2 C. DENTAL ADMISSIONS... 2 D. PODIATRY ADMISSIONS... 3 E. ADMISSIONS FOR PSYCHOLOGICAL CARE... 3 F. OBSERVATION PATIENTS... 3 DISCHARGE POLICY AND PROCEURE A. DISCHARGE ORDERS... 3 B. REFUSAL OF TREAMENT BY PATIENTS... 3 PHYSICIAN S ORDERS AND STOP ORDERS A. PHYSICIAN S ORDERS... 4 B. AUTOMATIC STOP ORDERS....5 MEDICAL RECORD RULES A. OWNERSHIP AND AVAILABILITY... 5 B. RESPONSIBILITY OF ATTENDING PRACTITIONER... 5 C. THE MEDICAL RECORD... 6 D. COMPLETION OF RECORD E. DEFINITION OF DELINQUENT MEDICAL RECORDS... 7 F. PROCEDURE FOR SUSPENSION... 7 G. USE OF MEDICAL RECORDS FOR STUDIES... 9 STANDARDS OF CONDUCT A. DISPUTES... 9 B. PROCEDURE FOR RESOLVE DISPUTES... 9 STANDARDS OF CLINICAL CARE A. ADMITTING PATIENTS B. OPERATING AND DELIVERY ROOM HOSPITAL CODES C. EMERGENCY SERVICES ARTICLE VIII. REQUIREMENTS AND GUIDELINES FOR CONSULTATION A. GENERAL CONSULTATIONS B. PSYCHIATRIC CONSULTATIONS ARTICLE IX. ARTICLE X. SPECIAL RULES AND PROCEDURES A. AUTOPSIES B. SPECIMENS C. ACUPUNCTURE D. PATIENT RIGHTS E. PATIENT RESTRAINT POLICY PERSONAL FILES A. MAINTENANCE AND ACCESS Page

2 B. CONTENTS OF THE FILES ARTICLE XI. NATIONAL PRACTITIONER DATA BANK (NPDB) ARTICLE XII. MEMDICAL STAFF APPLICATION/REAPPOINTMENT FEE A. APPLICATION FEE B. REAPPOINTMENT FEE C. FAILURE TO PAY APPLICATIOIN/REAPPOINTMENT FEE ARTICLE XIII. COMPENSATION OF CHIEF OF STAFF AND CHIEF OF STAFF-ELECT A. AMOUNT ARTICLE XIV QUALITY IMPROVEMENT PROGRAM A. INTRODUCTION ARTICLE XV. B. QUALITY IMPROVEMENT COMMITTEE (QIC) STANDING MEDICAL STAFF COMMITTEES A. COMMITTEE COMPOSITION B. MEETING REQUIREMENTS C. COMMITTEE DUTIES D. QUORUM FOR MEDICAL STAFF MEETINGS ARTICLE XVI. IMPAIRED PRACTITIONER POLICY A. POLICY PREAMBLE B. CLASSIFICATIONS FOR IMPAIRED PRACTITIONERS C. REPORTING GUIDELINES ARTICLE XVII. CREDENTIALING POLICY A. PURPOSE B. MEMBERSHIP CRITERIA BASIC C. APPLICATION PROCESSING D. REAPPOINTMENT PROCESS E. APPLICATIONS F. EXCLUSIVE AGREEMENTS G. AUTOMATIC APPOINTMENT H. TEMPORARY PRIVILEGES I. LEAVE OF ABSENCE ARTICLE XVIII. MEDICAL STAFF OFFICE (MSO) MANUAL OF POLICIES AND PROCEDURES... 25

3 RULES AND REGULATIONS OF THE MEDICAL STAFF OF GOOD SAMARITAN HOSPITAL ARTICLE I. INTRODUCTION These Rules and Regulations will be reprinted at appropriate intervals. Any new additions or changes will be identified with the date of the effective change and the source of the change. A. GENERAL RULES AND REGULATIONS AUTHORIZED BY THE MEDICAL STAFF 1. The Medical Staff may adopt such Rules and Regulations as may be necessary to implement more specifically the general principles found in these Bylaws. These shall relate to the proper conduct of the Medical Staff, organizational activities, and shall embody the level of practice that is required of each practitioner in the Hospital. 2. Rules and Regulations shall be a part of the Bylaws except that they may be amended or repealed at any regular Staff meeting at which a quorum is present and without previous notice, or any special meeting on notice by a majority vote of those present and eligible to vote. 3. Such changes shall become effective when approved by the GSH Board. 4. Any Rules and Regulations promulgated hereunder, either by the Medical Staff, the Medical Executive Committee or by any department or section shall be consistent with and not contra to the Medical Staff Bylaws, and if applicable, the Hospital's Code of Regulations. B. RULES AND REGULATIONS ORIGINATED BY THE MEDICAL EXECUTIVE COMMITTEE (MEC) 1. The Medical Executive Committee (MEC), upon recommendation of the Bylaws and Review Committee or upon its own initiative, may originate or approve proposed changes, modifications or additions to the Rules and Regulations. 2. The Active and Consulting Staff (voting members) will be notified by mail of the proposed change which will be presented for approval at the next Staff meeting. C. RULES AND REGULATIONS ORIGINATED BY DEPARTMENTS 1. Departments may originate Rules and Regulations for the conduct of affairs of the Departments or Sections. If approved by the MEC, they will become effective immediately upon approval by the Board. 2. These departmental Rules and Regulations should be recorded in the minutes of the department's meeting and each department shall maintain its own book of approved Rules and Regulations. 3. Any change in Rules and Regulations involving practitioners from more than one department must be approved by the MEC as a change in the General Rules and Regulations. 1

4 A. ADMISSION REQUIREMENTS ARTICLE II. ADMITTING/OBSERVATION POLICY 1. The Hospital shall routinely admit patients suffering from all types of ailments except as limited by the MEC and the Board. The admitting practitioner is initially responsible for ordering the appropriate diagnostic tests necessary to make a determination of the patient's clinical status and treatment needs. 2. No person shall be admitted to the Hospital as an elective, urgent, or emergency admission without the consent of the Admitting Office. The provisional admitting diagnosis shall be given at the time of admission or as soon as possible after admission. 3. Practitioners admitting patients shall be held responsible for giving any known information as may be necessary to assure the protection of other patients from those who are a source of danger from any cause whatsoever. 4. On all staff admissions, the patient shall be seen by the attending practitioner or by a senior resident within twenty-four (24) hours of admission. Staff patients may be admitted by a resident under supervision of the attending practitioner or a senior resident. 5. There shall be adequate written documentation on each patient's medical record within the first twenty-four (24) hours of admission to substantiate the admission or the admitting diagnosis. 6. It is the practitioner's responsibility to secure any preadmission certification as required by a third-party payer (or insurance program) on elective and urgent admissions. 7. The hospital patient resource and/or Emergency Department staff will obtain certification of patients admitted from the Emergency Department with the assistance of the practitioner. B. EMERGENCY ADMISSIONS 1. The attending practitioner or his practitioner designee is required to enter the reason for admission or admitting diagnosis on the emergency record, at a minimum. 2. Emergency admission patients should be seen within a time consistent with good medical practice after admission by the attending practitioner or his practitioner designee. C. DENTAL ADMISSIONS 1. Patients admitted for any dental care shall have the name of the patient s responsible physician recorded on the medical record before or at the time of admission. 2. The dentist is responsible for the admission, management, and discharge of his patient with regards to the dental portion of the patient s care. All dental patients shall have a medical history and physical examination performed and recorded by a responsible staff physician upon admission. This restriction does not apply to those qualified oral surgeons who have been granted the privilege to perform the admission history and physical examination. An 2

5 oral surgeon who has been granted this privilege may perform this service only for his patients who are being admitted for dental and/or maxillofacial surgery. 3. Should an ambulatory patient require non-dental medical services, the Dentist is responsible for providing a practitioner who is a privileged member of the Medical Staff who can give immediate attention, accepting medical responsibility for the patient, including an H&P. D. PODIATRY ADMISSIONS 1. Patients admitted for podiatric care only may have their care, including admission and discharge, solely supervised by the podiatrist pursuant to their clinical privileges. For podiatry patients, the history and physical examination, as well as an update, may be completed by a podiatrist. Appropriate consultation for any condition of the patient is at the discretion of the podiatrist. E. ADMISSIONS FOR PSYCHOLOGICAL CARE 1. Psychologists shall not have admitting privileges. Patients may be admitted by an Active or Associate Staff Psychiatrist. The Psychologist is responsible for psychological assessment, management and discharge planning in collaboration with and under the direction of the attending Psychiatrist. F. OBSERVATION PATIENTS 1. Patients placed under this category must be seen within this observation period (23-hours or less), consistent with good medical practice. 3

6 A. DISCHARGE ORDERS ARTICLE III. DISCHARGE POLICY AND PROCEDURE 1. Patients will be discharged only upon the order of the attending practitioner or resident in consultation with the attending practitioner or a senior resident. 2. A patient wishing to leave the hospital against the advice of the attending practitioner or the hospital will be asked to sign his own release. Any patient not capable of signing his own release, legally or otherwise, will be released when a legally authorized individual, guardian, or responsible family member signs the release. 3. It is the responsibility of the attending practitioner to see that patients held for observation have their status changed during that observation period. If dismissal is not appropriate, the practitioner has the responsibility of notifying the admission office of the need for admission. B. REFUSAL OF TREATMENT BY PATIENTS In the event of disagreement over the medical care provided to a patient by a designated practitioner, or resident staff, such practitioner, or resident shall attempt to resolve such disagreement between the practitioner and the patient by referral to an appropriate practitioner. Should this effort fail, the matter shall be referred to the Chairman of the respective department or the Chief of the Section, the Chief of Staff, or the Vice President/Medical Affairs. 4

7 A. PHYSICIAN'S ORDERS ARTICLE IV. PHYSICIAN'S ORDERS AND STOP ORDERS 1. Physician Personal Order Sets a. Individual practitioners who formerly had pre-printed orders or physicians requesting the creation of personal order sets (POS) will submit the orders to the Admitting Orders Department to be forwarded to the Computer Order Entry RN for creation of, and/or changes in POS. A current copy of the computer generated print-out of POS will be reviewed, signed, and dated by the practitioner to maintain a current master file. b. Personal order sets must be reviewed annually by the responsible practitioner. c. Residents may use the attending physician's personal order sets by accessing the computer system. d. All other patient care orders shall be in writing and each order or group of orders shall be signed by a practitioner. 2. Verbal/Telephone Orders a. Only an appropriately licensed individual (i.e., a resident or licensed registered nurse) may accept telephone orders or verbal orders from a practitioner. Such orders shall be signed by the appropriate person with the name of the practitioner or resident and the name of the person who took the order. 1) One exception: a secretary in the Emergency Department or in a scheduling center may accept orders for diagnostic examinations, consultations or referrals. They cannot take orders for medications or treatments. b. At, or before the time of final record completion, the attending practitioner will be responsible for countersigning the appropriate verbal orders. c. Verbal or telephone order may be countersigned by the ordering practitioner or his designee. 3. Residents' Orders a. Residents may write patient care orders under the supervision of an attending practitioner or senior resident. Such orders are to be routinely reviewed by the attending practitioner or senior resident and may be amended as deemed appropriate indicating revision by countersignature. 4. Do Not Resuscitate Orders a. Do not resuscitate (no signal) orders may be given as a telephone order and must be countersigned within twenty-four (24) hours. Failure to sign the order will result in its cancellation. No signal orders are usually suspended when patients go to surgery unless otherwise indicated by written order by the physician. The attending physician and/or surgeon will discuss the matter with the patient or patient s representative. Post-operatively the order for No Signal must be rewritten to reinstate the order. B. AUTOMATIC STOP ORDERS 1. Drug Orders The Hospital "Automatic Stop Order Policy for Medications" is designed to insure the 5

8 proper administration of selected drug categories under reasonable Medical Staff control and to prevent the continuation of administration of dangerous drugs in lieu of specific practitioner authorization. The dispensing and administration of the selected categories of medications will be automatically discontinued after the indicated time period has elapsed following the original or renewal order of the practitioner unless: a. the order indicated an exact number of doses to be administered; b. an exact period of time for medication administration is specified; c. the order is renewed by a practitioner; d. implementation of the stop order may be delayed up to an additional twenty-four (24) hours, when the nurse is unable to contact the practitioner, but is aware of the practitioner's preference to continue medication. Efforts to contact the practitioner will continue. Medication Category Automatic Stop Narcotics 3 Days Hypnotics 7 Days Anticoagulants (Coumadin) 24 Hours Antibiotics 7 Days 2. Respiratory Therapy A six (6) day automatic stop order will be applied to inhalation therapy treatment order by practitioners or residents. Oxygen equipment "stand-by" orders are discontinued after three (3) days of nonuse. 6

9 A. OWNERSHIP AND AVAILABILITY ARTICLE V. MEDICAL RECORD RULES 1. All medical records including radiologic studies are the property of the Hospital. They shall not be removed from the Hospital without either the permission of the President or his designee or by subpoena, court order, or statute. Radiologic studies may be removed from the Hospital when specifically released by an authorized person in the Department of Radiological Sciences and Medical Imaging. 2. In the event of readmission, all of the patient's records from the most recent admission, unless otherwise specified, shall accompany the patient and be kept with the patient for a minimum of three days. The records shall be returned to Medical Records. B. RESPONSIBILITY OF ATTENDING PRACTITIONER 1. The attending practitioner admitting the patient or the practitioner to whom the patient is assigned, is responsible for the preparation and completion of the whole medical record except those portions having to do with consultation, surgery, etc., performed by others with Staff privileges. The attending practitioner for a private patient is responsible for the completion of the record, irrespective of a resident's involvement. C. THE MEDICAL RECORD 1. Contents of the record shall include: a. Identification data b. History c. Physical Examination d. Special reports such as consultations e. Clinical laboratory data f. Radiologic studies and others g. Nursing Notes h. Medical and surgical treatment records i. Pathological findings j. Progress notes k. Final diagnoses l. Discharge summary m. Condition at discharge n. Autopsy report, when available o. Preliminary cause of death, if applicable 2. History and Physical Examination (H&P) a. H&P requirements are determined by the Medical Staff and Administrative Policies, which must be consistent with CMS and JC conditions and standards. 3. Discharge Summaries a. The summary shall include: 1) Reason for hospitalization 2) Significant findings 3) Procedures performed and treatment rendered 7

10 4) Patient's condition on discharge 5) Specific instructions given to the patient and/or family b. This summary is required on all dismissals except normal newborns, and uncomplicated obstetric deliveries. A discharge summary is required on all deaths. c. This summary will be completed on all in-patient admissions and observations. d. Discharge summary to be completed within 72 hours of discharge. 4. Preliminary Cause of Death The Attending Physician will be responsible for recording the preliminary cause of death in the deceased patient s Epic record at or after the time of death. This activity will be completed by the physician using the Epic Deficiency Inbasket functionality. Once the physician opens the Inbasket for this deficiency, a hyperlink will take s/he to the Discharge Patient Navigator for them to enter the preliminary cause of death. If this preliminary cause of death is not recorded by the physician by 30 days post expiration, the hospital s suspension process will be activated. 5. Physician's Signature Stamp a. Use of a signature stamp on medical records is not permitted. b. The use of an electronic signature will be permitted as outlined in hospital policy. D. COMPLETION OF RECORD 1. The attending practitioner is responsible for the completion of the medical record on his patients. The resident is responsible for the completion of the records on service patients, under the supervision of the attending practitioner or senior resident. 2. History and physical examinations, the face sheet (if any documentation is present), operative reports and discharge summaries written or dictated by residents shall be reviewed, edited, and countersigned by the attending physician except as provided in the following: Upon the recommendation of a respective department and with the approval of the Department of Medical Education and the MEC, a licensed senior resident (third, fourth, or fifth year) may review, edit and countersign histories, physicals, and summaries in the specified service. 3. No medical record shall be filed until it is complete, except on order of the Medical Records Committee. Members of the Medical Staff are urged to complete the medical records upon discharge of patients. E. DEFINITION OF DELINQUENT MEDICAL RECORDS 1. Incomplete Medical Record An incomplete medical record shall be regarded as a record which on the thirtieth (30) day following the discharge of the patient is found by quantitative analysis to be deficient in any of the following respects: a. Face Sheet with Signature, which includes: (only if handwritten information by a physician appears) 1) Discharge diagnosis 2) Name of operation 3) Cause of death 8

11 b. History and Physical with Signature c. Operative Note with Signature d. Countersignature on all Phone and Verbal Orders e. Progress Notes with Signatures f. Physician Orders with Signature g. Anesthesia Record with Signature, if applicable h. Description of Delivery with Signature i. Indication for Cesarean Section j. OB Dismissal Form with Signature k. Consultation with Signature l. Discharge Summary with Signature m. Preliminary cause of death, if applicable All entries in the medical record shall be authenticated, timed and dated. 2. Delinquent Medical Record Any incomplete medical record, based upon the quantitative analysis which has not yet been completed thirty (30) days from the date of discharge of the patient, and has been available to the practitioner for thirty (30) days. F. PROCEDURE FOR SUSPENSION The Medical Record Administrator will report to both the President or his designee and to the Chairman of the Medical Records Committee all cases of delinquent medical records. 1. Post Discharge Delinquent Records a. Unless the Vice President Medical Affairs has been previously advised of extenuating circumstances (e.g., illness) to excuse those whose medical records remain delinquent, notices from the President will be sent to the Admitting Office and to the practitioner, in writing, that privileges of admitting, caring for, treating, or participating in the diagnostic treatment of new patients are automatically suspended upon the written notification until the delinquent medical records are completed. Privileges are suspended as of the date of suspension or termination notification. Thirty (30) days after the first letter of suspension for incomplete medical records is sent and the records remain delinquent, a second letter of suspension will be sent. If the records have still not been completed after thirty (30) additional days, the third letter will be sent notifying the practitioner that his medical staff privileges have been terminated. If undue hardship occurs, recourse may be had to the President, Chief of Staff, or Vice President/ Medical Affairs. b. Practitioners who have received two (2) suspension letters during one (1) calendar year and whose medical records become delinquent for a third time in a calendar year shall be notified by the President, by certified mail, that his privileges have been automatically terminated and the practitioner will have to reapply for Staff privileges after the completion of his medical records. (On a second suspension notice, the practitioner will be reminded that his privileges will be fully terminated if his medical records become delinquent again during the calendar year.) If a practitioner's privileges are terminated, he will be unable to admit, care for, treat, or participate in the diagnostic treatment of new patients in the Hospital until reapplication, in writing, has been approved in the usual manner. The practitioner's reapplication will not be considered until all incomplete medical records are completed. 9

12 2. Nondischarged Delinquent Records Upon review, both current and retrospective, of these records, the following applies: a. History and Physical Delinquencies When a practitioner has been found to be delinquent three (3) times in one (1) calendar month in the timely completion of the history and physical reporting requirements, upon the third time, the practitioner shall have his admitting and surgical privileges automatically suspended until all known delinquencies are corrected. b. Operative (Surgery, Delivery, etc.) Note Delinquencies When a practitioner has been found to be delinquent three times in one calendar month in regard to the timely completion of operative notes, upon the third time, the practitioner shall have his admitting and surgical privileges automatically suspended until all known delinquencies are corrected. Subdivisions F.2.a. and F.2.b. are independent of one another and are not to be considered together in regard to the accumulation of delinquencies that may lead to a suspension of privileges. Practitioners who have received two (2) suspension letters during one (1) calendar year and whose medical records become delinquent for a third time in a calendar year shall be notified by the President, by certified mail, that his privileges have been automatically terminated and the practitioner will have to reapply for Staff privileges after the completion of his medical records. (On a second suspension notice, the practitioner will be reminded that his privileges will be fully terminated if his medical records become delinquent again during the calendar year.) If a practitioner's privileges are terminated, he will be unable to admit, care for, treat, or participate in the diagnostic treatment of new patients in the Hospital until reapplication, in writing, has been approved in the usual manner. G. USE OF MEDICAL RECORDS FOR STUDIES 1. All studies using hospital records must be approved by: a. the Medical Staff Committee originating the study, or b. a Medical Staff Department or QA Section, or c. the Human Investigation & Research Committee, especially in the case of studies requested by individual practitioners. 2. All studies using hospital records must be reviewed for comments and recommendations by: a. the originating Medical Staff Committee, b. the appropriate departmental QA sections, c. the Human Investigation & Research Committee, d. the Quality Improvement Committee, and e. the Medical Executive Committee 3. Studies using hospital records cannot be used for publication or policy enactment until they have been reviewed through the level of the Medical Executive Committee. 4. Studies may be initiated by a practitioner on his own cases without prior approval. He is encouraged to submit any interesting data to his Department. 10

13 ARTICLE VI. STANDARDS OF CONDUCT A. DISPUTES Personal attacks against the Hospital, practitioners, residents, administration, personnel, departments, services, committees, and members thereof may not be written on or dictated as part of the medical record including the discharge summary and discharge diagnosis. Any violation of these rules will be referred to the Vice President/Medical Affairs and to the Chief of Staff. If warranted, suspension, termination of privileges, or nonreappointment of the offender may be recommended and enforced. If the penalty is upheld by the MEC and the Board, the practitioner will be entitled to recourse to the Fair Hearing Plan. No reference to or ordering of any incident report or report of same, for any reason, may be recorded on any record by anyone. B. PROCEDURE TO RESOLVE DISPUTES Any and all disputes between two practitioners on the medical staff should be resolved by discussion between the involved practitioners. If such discussion does not satisfactorily resolve the dispute then the chairman of each practitioner's respective department should become involved in an attempt to mediate and resolve the conflict. If the practitioners are from the same department and the Chairman cannot resolve the dispute by himself, then the department Chairman should use the department members to review and resolve the dispute. If the department Chairman and members cannot resolve the dispute, then they should so advise the Chief of Staff, who will then assist in an effort to bring the matter to a satisfactory conclusion. In the event the department Chairman is one of the practitioners involved, or the dispute is between two department Chairmen, then the Chief of Staff will become immediately involved in an attempt to resolve the dispute. In the event that the Chief of Staff does not meet with success, then the practitioner who raised the complaint shall bring his concern to the MEC, which shall review all of the facts, allow each practitioner an opportunity to appear before it, and propose a resolution to the dispute. C. Complaints regarding sexual and/or other harassment against, concerning and/or involving a member of the Medical Staff shall be addressed and governed by the Medical Staff Policy Sexual and Other Harassment. Sexual and other harassment of or by employees, patients, medical staff and others shall not be tolerated in the hospital. 11

14 A. ADMITTED PATIENTS ARTICLE VII. STANDARDS OF CLINICAL CARE 1. All patients should be seen daily and documentation noted in the medical record by the practitioner or the practitioner's designee. B. OPERATING AND DELIVERY ROOM HOSPITAL CODES 1. Dress Code a. All personnel using the Operating or Delivery Rooms must conform to the dress and scrub codes as determined by the Surgical and Obstetrical Departments and included in the hospital policy manual. 2. History & Physical a. Inpatient surgical cases must have a recorded or dictated history and physical examination and written admitting note prior to surgery. If dictated, this fact must be substantiated by signed documentation by the surgeon on the progress notes and a written admitting note including: 1) Diagnosis 2) Nature of procedure 3) Allergies 4) Medications 5) Significant medical problems b. The dictated or written history and physical examination may be done by the attending practitioner, or his practitioner designee, or the resident. If dictated, the documentation of this fact is the responsibility of the attending practitioner. c. Each patient undergoing surgery or other invasive procedures must have a written history and physical examination or the signed documentation of a dictated history and physical examination in the patient's medical record before surgery or anesthesia induction with laboratory/x-ray/ekg studies as medically indicated. 3. Scheduling Procedures a. All regularly scheduled operations or procedures will be scheduled with the specific name of the patient, the surgeon, the resident and with the specific procedure, operating time required, and starting time. 4. Operative Reports a. All operative reports must be dictated, or written within the immediate postoperative period. A brief written operative note, including diagnosis, procedure, findings at surgery, adverse reactions, etc. must be entered in the chart immediately following a procedure. b. At the time of discharge, any record with an incomplete operative report shall be 12

15 delinquent (excluding signature). 5. Informed Consent a. The operating surgeon is responsible for making certain that a signed informed consent for each patient has been obtained. b. The consent must contain all preoperatively intended procedures. This is also the responsibility of the operating surgeon. c. This signed consent must be on the record prior to surgery or special procedures. 6. Surgical Assistants a. It is the responsibility of the practitioner to ensure, in advance, the presence of a qualified credentialed surgical assistant in the operating room who will enable the surgeon to best fulfill the needs of the patient. The day to day enforcement of this rule is the responsibility of the Chairman of the department or the Vice President/Medical Affairs. b. In all major procedures that require general anesthesia, the surgeon or resident must be in the surgical suite, or in the surgical area (O.R. Lounge, Locker Room, etc.) before the anesthesia is started and one of them must remain in one of these areas until the patient leaves the operating room. C. EMERGENCY SERVICES 1. Any person who presents himself to the Emergency Department (ED) for medical care must be personally seen by a practitioner. 2. Practitioner Privileges a. Emergency Department practitioners shall have no admitting privileges through the Department of Emergency Services. 3. Practitioner Responsibilities a. All patients presenting in the ETC shall be medically screened in a timely manner in the ETC, primarily by emergency physicians, or by the ETC Advanced Practice Nurse Practitioners operating within their scope of practice in the ETC (herinafter referred to as Emergency Department Practitioners or EDP ), or by the attending practitioner or his practitioner designee (hereinafter referred to as practitioner ). Any urgent emergency cases will be treated promptly by the Emergency Department Practitioner and the EDP, or practitioner may call for assistance and/or consultation with any available practitioner in the Hospital, including residents. If such a patient is under the care of a private practitioner, all efforts will be made to contact the attending practitioner in accordance with Section C.2 as soon as possible. However, the medical screening examination will not be delayed by the call to the attending practitioner. b. The EDP will give a tentative radiological interpretation when Radiologists are not available only when the patient has been examined by the EDP. Unless permitted under the license of any nonphysician personnel and only to the extent of that permission, nonphysician personnel in the ED are not permitted to give tentative interpretation of any diagnostic tests/procedures (i.e., lab studies, x-rays, EKGs, etc.). However, they may report to physicians the official results of diagnostic tests/procedures. c. It is policy in handling Emergency Department patients that the registration/triage personnel will check the ED physician preference file for specific instructions 13

16 regarding each attending physician's personal preference in regards to notification. The notification choices will be: 1) to be notified of all patients that present to the ED; or 2) to be notified only of those patients that require admission or referral after a professional appraisal of the patient by the EDP. This choice must apply to the entire time that the individual physician, physician group, or practitioner designee is providing coverage. In either case, the patient must be medically screened in a timely manner, either by the practitioner or the EDP. The medical screening of the patient will not be delayed by this call procedure. Except where immediate attention is warranted by the circumstances, the practitioner may request lab or other procedures/tests and may see the patient himself as long as the patient is seen within sixty (60) minutes of notification. If the practitioner or patient chooses, the care of the patient, after medical screening shall be the sole responsibility of the EDP until the practitioner assumes care, or the patient is discharged or admitted. The practitioner will be contacted for admission and/or referrals. (Private referral preferences may also be kept in the physician preference file at each practitioner's discretion.) If there is a discrepancy in management/disposition between the practitioner accepting the patient and the EDP, then the EDP's orders prevail until the patient is seen by the attending practitioner or the practitioner designee. d. When specific instructions cannot be obtained from the attending practitioner or his alternate within thirty (30) minutes, the EDP shall proceed with the examination and treatment of the patient as indicated. e. In the event the attending practitioner or his practitioner designee calls in orders or provides written orders on a patient in the Emergency Department and states that he is coming, and if the nurse feels that the patient's condition warrants more immediate treatment, the EDP will evaluate and/or treat this patient immediately. f. Responsibility for continuing care by the EDP will cease after the patient leaves the Emergency Department. If the patient is dismissed from the Emergency Department, he will be referred to his attending practitioner or practitioner designee, to the Hospital Clinic, or to practitioners accepting new patients, according to the instruction of the attending practitioner. g. If the attending practitioner or his practitioner designee is not available and the patient needs admission to the Hospital, the attending practitioner on the appropriate service will be notified. The EDP may write admission orders. Such orders shall include a request for notification of the attending practitioner. The history and physical examination are the responsibility of the admitting practitioner or his practitioner designee. 4. Other Patient Categories a. Attached Patients 1) Attached patients, i.e., those having their own attending practitioner shall be cared for by such practitioner, or the practitioner's designee. b. Unattached Patients 1) If the unattached patient does not require admission to the Hospital, he may be treated by the EDP and released. This patient is then referred to a practitioner whom he may choose from the current list of participating practitioners or referral to the appropriate Hospital Clinic. 2) All nonprivate patients shall be attended by members of the appropriate 14

17 staff on service and will be assigned to the service concerned with the treatment of the illness which necessitates admission. 3) Patients requiring admission or medical care, who have no attending practitioner, i.e., unattached, who do not elect or are unable to choose a practitioner shall be assigned to a practitioner of the appropriate Active or Consulting Staff on service at the time of the patient's admission or need of medical care. 4) In the event an unattached patient requires care by another practitioner because of third party payer requirements, the assigned practitioner shall aid and facilitate the transfer of care of such patient. 5) No practitioner shall receive any compensation for the attendance of any patient whose admission is authorized as a nonprivate patient except where public funds are legally provided for that professional medical or surgical care. 6) The provision of care by a practitioner or his designee hereunder shall not be refused nor impacted by the patient's sex, race, creed, color, national origin, handicap, or ability to pay. c. Clinic Patients 1) Patients enrolled in the Hospital Clinics who present themselves to the Emergency Department for treatment shall be seen and treated by the EDP. Emergency Department records of such patients shall be forwarded to the appropriate Clinic. 2) Patients referred to the Clinics from the Emergency Department will be instructed to call the Clinic for an appointment. 15

18 ARTICLE VIII. REQUIREMENTS AND GUIDELINES FOR CONSULTATIONS A. GENERAL CONSULTATIONS 1. Consultation at GSH: a. May be performed by any practitioner subject to the practitioner s clinical privileges. b. Is required when: i) The diagnosis is obscure after ordinary diagnostic procedure have been completed; or, ii) There is doubt as to the choice of therapeutic measures to be utilized; or, iii) At the request of the patient or family c. Shall show; i) Evidence of a review of the patient s record by the consultant; ii) Pertinent findings on examination of the patient; and iii) The consultant s opinion and recommendations. d. Shall be made a part of the patient s record; e. Shall be recorded prior to any surgery; and f. Shall not consist solely of a statement such as I concur. 2. Restrictions a. Consultation by practitioners associated in the same office, for the above required consultations, should be avoided. b. In circumstances of grave urgency, or where consultation is required by the rules of the Hospital, the President shall at all times have the right to call in a consultant or consultants after conference with the Chief of Staff or available members of the Active Staff. This standard is applicable to all members of the Medical Staff. B. PSYCHIATRIC CONSULTATIONS 1. Any practitioner having admitting privileges at the Hospital may admit to the Mental Health Inpatient Unit, but must request a psychiatric consultation within twenty-four (24) hours. The practitioner will abide by the rules of that department. 16

19 ARTICLE IX. SPECIAL RULES AND PROCEDURES A. AUTOPSIES B. SPECIMENS The content of Section of the Ohio Revised Code relative to autopsy or post-mortem examinations will be followed along with existing Hospital policy. 1. An autopsy or post mortem examination may be performed upon the body of a deceased person by a licensed hospital pathologist or by another licensed physician or surgeon delegated this responsibility, if consent has been given in the order named by one of the following persons, who must be of sound mind and eighteen (18) years of age or older, in a written instrument executed by him or on his behalf at his express direction: a. The deceased person during his lifetime, and, if possible, one of the following individuals listed in "b" through "e" b. The decedent's spouse c. If there is no surviving spouse, if the address of the surviving spouse is unknown or outside the United States, if the surviving spouse is physically or mentally unable or incapable of giving consent, or if the deceased person was separated and living apart from such surviving spouse, then a person having the first named degree of relationship in the following list in which a relative of the deceased survives and is physically and mentally able and capable of giving consent may execute consent: 1) Children 2) Parents 3) Brothers or sisters d. If there are no surviving persons of any degree of relationship listed in division "c" of this Section, any other relative or person who assumes custody of the body for burial e. A person authorized by written instrument executed by the deceased person to make arrangements for burial 2. Consent may be revoked only by the person executing the consent and in the same manner as required for execution of consent under this Section. (As used in this Section, "written instrument" includes a telegram or cablegram. Telephone consent is not acceptable.) 3. Non-forensic autopsies should be sought in the following instances: a. Deaths in which the cause is not known with certainty on clinical grounds. b. Deaths occurring in patients who have participated in clinical trials (protocols) approved by institutional review boards. c. All obstetrical deaths. d. All neonatal (signs of life after delivery) and pediatric deaths. e. Sudden, unexpected or unexplained deaths in the hospital which are apparently natural and not subject to a forensic medical jurisdiction. All materials and tissues removed in any surgical procedure or recovered from a body cavity by 17

20 anyone at any time shall become the property of the Hospital. Exceptions may be made by the MEC. Organs and tissue removed for transplantation are excepted. The origin of the specimen with specific patient identification will be carefully transported to the Department of Pathology in the manner described in the Operating Room Procedural Manual where the pathologist will determine the degree of examination necessary. Upon the request of the attending practitioner, tissue specimens will be prepared by the pathologists and sent to any recognized pathologist for consultation. C. ACUPUNCTURE 1. Accepted current medical practice and theory indicates that acupuncture has been of demonstrated value only as a treatment modality for chronic pain disorders. The use of acupuncture should be limited to such applications. 2. Acupuncture should only be administered by a practitioner within the scope of the Medical Practice Act and only after he or she has demonstrated to the satisfaction of the Credentials Committee the completion of adequate training or experience. D. PATIENT RIGHTS 1. All members of the Medical Staff will abide by the established hospital policy regarding Patient Rights. E. PATIENT RESTRAINT POLICY 1. All members of the Medical Staff will follow the established hospital policy regarding the use of patient restraints. 18

21 A. MAINTENANCE AND ACCESS ARTICLE X. PERSONAL FILES 1. A personal, confidential, private file shall be originated on each Staff member and on all residents regardless of any special classifications 2. The file will be maintained by the Medical Staff office, under lock, and supervised by the Medical Staff secretaries. Files will be maintained in the Medical Education Office, under lock, for the residents. 3. Access to the files will only be available to the President, the Vice President/Medical Affairs, the Chief of Staff, the Credentials Committee (as a committee), and the MEC (as a committee), on proper occasions. Staff practitioners or residents may have access to their individual file under supervision by the Staff secretaries or Medical Education secretaries with permission from the President and/or the Chief of Staff. 4. When any person is given permission to inspect his own file, he may do so in presence of the President, the Chief of Staff the Staff secretaries, or Medical Education secretaries. At no time may any individual, himself, add to or delete any material from his own file. Individuals will be notified regarding any items added to their file. B. CONTENTS OF THE FILES 1. Automatic Inclusions a. All material required on the original application for Staff membership, including letters of endorsement or recommendations and a detailed list of privileges desired along with specific documentation of established capabilities for any special or unusual privileges required or desired. b. Periodic updating of curriculum vitae and a statement of current physical and mental health status every two (2) years before reappointment. c. Any significant professional recognition, position, or achievement in Good Samaritan Hospital or other medical units or organizations, nationally or locally. (This feature should be continuously updated.) d. Any significant civic, religious, or other nonprofessional recognition or achievement with continual updating of material by addition to, but not deletion. e. Record of medical malpractice judgments and malpractice statements. 2. Automatic Exclusions a. Hearsay comments b. Unrelated isolated incident reports c. Unsubstantiated or crank complaints d. Critical or unfavorable newspaper reports 19

22 3. Inclusions Items to be included after particular or special action by the MEC, Chief of Staff, the Board, or the President shall include any instance of reprimand, criticism, or change of privileges, or any other adverse action supported by documented evidence and formally approved by the MEC. 4. Recognition by the Practitioner Within thirty (30) days when the record of any corrective or adverse action and its documentation is to be placed in an individual's file, the individual must note that he recognizes this fact by initialing the pertinent data before it is placed in the file. If an individual refuses to initial a record or disagrees with the action designated to be placed in his file, he has the right to request a hearing as outlined in the Medical Staff Bylaws, Article IX, Fair Hearing Plan. The record of corrective or adverse action shall be placed in the individual file pending the outcome of the Fair Hearing. 5. Periodic File Inventory At periodic intervals, particularly at times of evaluation for reappointment, the Credentials Committee may deem it advisable to delete or summarize or condense some or all of certain categories of material. They may not do so, however, without the mutual approval of the Chief of Staff and the President. 6. Removal of Information No items placed in the file by decision of the MEC may ever be deleted from the file except on direct order from the MEC and the Board. 20

23 ARTICLE XI. NATIONAL PRACTITIONER DATA BANK (NPDB) The Medical Staff's designated representative to be responsible for Hospital response to the requirements of the Health Care Quality Improvement Act of 1986 shall be the Vice President of Medical Affairs. His duties shall include but are not limited to reporting to The State Medical Board of Ohio or Ohio State Dental Board within fifteen days of: final Board decision of a professional review action that adversely affects the clinical privileges of a practitioner for a period longer than 30 days; voluntary surrender of medical staff membership or clinical privileges by a practitioner while under investigation for a possible incompetence or improper professional conduct; the voluntary surrender of clinical privileges or medical staff membership in lieu of conducting an investigation; or revisions to professional review actions, previously conducted and reported to the National Practitioner Data Bank. 21

24 A. APPLICATION FEE ARTICLE XII. MEDICAL STAFF APPLICATION/REAPPOINTMENT FEES Each applicant to the Medical Staff, regardless of Medical Staff category, shall submit along with those materials required in Article III, an application fee in the amount of Two Hundred Dollars ($200.00). B. REAPPOINTMENT FEE Each application for reappointment to the Medical Staff, regardless of Medical Staff category, shall submit along with those materials required in Article III, F., a reappointment fee of One Hundred Fifty Dollars ($150.00). However, each practitioner requesting reappointment in calendar year 1997 shall be required to only pay a Fifty Dollar ($50.00) reappointment fee; thereafter, such amount shall be One Hundred Dollars ($150.00) as provided for above. C. FAILURE TO PAY APPLICATION/REAPPOINTMENT FEE Any application, be it for initial application or reappointment to the Medical Staff, if not submitted with the required application/reappointment fee as delineated herein, shall not be processed as being clearly deficient on its face. Upon notification thereof, pursuant to Article III, 1, the prospective applicant shall not be entitled to any hearing or review rights hereunder. 22

25 A. AMOUNT ARTICLE XIII. COMPENSATION OF CHIEF OF STAFF AND CHIEF OF STAFF-ELECT The duly elected Chief of Staff and Chief of Staff-Elect of the Medical Staff of this Hospital, shall receive an annual stipend. The cost of such stipend shall be shared equally by the Staff and the Hospital. Such Staff portion shall be taken from funds received as a result of collection and receipt of application and reapplication fees. Such stipend to the Chief of Staff in the amount of forty thousand dollars ($40,000), and to the Chief of Staff-Elect in the amount of $20,000, shall be paid in quarterly increments on or about the beginning of each calendar quarter during such annual period. 23

26 A. INTRODUCTION ARTICLE XIV QUALITY IMPROVEMENT PROGRAM The total program encompasses multiple areas that need to be evaluated. Realizing that not all areas are pertinent to every clinical department or committee, it will be the responsibility of each department's Vice Chairman or Committee Chairman to review those areas that are applicable. These reviews should stress areas of high volume, high risk, and/or that are problem-prone. The following areas are to be included in the quality improvement review, but the various committees and departments are not restricted to only these areas: 1. Operative and Invasive Procedures In conjunction with Nursing Service, factors to be included are: a) appropriateness of the selected procedure, b) proper preparation of the patient, c) performance of the procedure and monitoring of the patient, d) provision of post-procedure care. 2. Medications In collaboration with pharmacy and nursing service, review the proper: a) prescribing of medication b) preparation and dispensing c) administration d) monitoring of effects on patient. 3. Blood and Blood Components In conjunction with the Blood Bank and Nursing Service, review the proper: a) ordering b) distribution and handling c) administration d) monitoring of effects on the patient. 4. Utilization In collaboration with the Q.I. analysts, the following will be reviewed: a) appropriateness of admissions b) appropriateness of continued hospitalization. 5. Autopsy Results In collaboration with the attending practitioner, the following will be reviewed: 24