McLaren Greater Lansing Rules of the Department of Radiology ARTICLE I. PURPOSE AND ORGANIZATION ARTICLE II. DEPARTMENT MEMBERSHIP

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1 1.1 PURPOSE McLaren Greater Lansing Rules of the Department of Radiology ARTICLE I. PURPOSE AND ORGANIZATION The purpose of the Department of Radiology (Department) shall be to perform the organizational responsibilities incumbent upon Professional Staff Departments as prescribed in the Bylaws of the McLaren Greater Lansing (MGL) Professional Staff (Bylaws) and specifically to address issues related to the practice of Radiology. 1.2 ORGANIZATION The Department is established pursuant to the current Bylaws of the Professional Staff of MGL. 2.1 APPOINTMENT ARTICLE II. DEPARTMENT MEMBERSHIP The Department shall consist of Members of the Professional Staff who have been recommended to the Department of Radiology by the Credentials Committee and Professional Staff Executive Committee (PSEC) and appointed by the Board of Trustees Allied Health Professionals (AHPs) with specified service authority to provide dependent services shall be those as recommended by the Credentials Committee and PSEC and appointed by the Board of Trustees and as departmentally assigned per established policy of the institution and as consistent with the Special Policy for Allied Health Professionals of the Bylaws. 2.2 BASIC QUALIFICATIONS FOR MEMBERSHIP Where radiology services are provided by virtue of contract services with MGL, Active Professional Staff membership in the Department shall be limited to employees of, or independent contractors of the contracted group Members/Applicants must have completed a residency program in radiology accredited by the Accreditation Council of Graduate Medical Education (ACGME) or the American Osteopathic Association (AOA) 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 Last Approved: 8/15/94 Page 1

2 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 Application for membership will be considered under provisions outlined in the Bylaws. Radiology services are contracted by MGL and activity in the Department is defined by the terms of the contract as long as it is not in conflict with the Bylaws Members initially appointed to the Department must satisfactorily complete the observation requirements of the Department as defined in Article III of these Rules New applicants must appear for an interview by the Department. 2.3 RESPONSIBILITIES Responsibilities of the Department Members shall be as prescribed in the Bylaws; Article III. 2.4 ADDITIONAL RESPONSIBILITIES Participation in the observation system by Active Professional Staff Members and Other Members as assigned by the Department Chairman Participation in the emergency call rotation as assigned Responsible to provide timely, cost effective, high quality radiologic service to the Professional Staff Provide radiologic consultation with Members of the Professional Staff as to the most appropriate procedures to be used in the diagnosis and/or treatment of their patient Assist in educational programs of MGL through participation in their conferences, teaching residents and medical students, and assist in the instruction of radiologic technologists Responsible to work with MGL Management and Administration to assure that adequate staffing with qualified technologists is available to meet the requirements of the Professional Staff Responsible to maintain and upgrade professional skills through various means, including attendance at professional seminars and workshops, literature review, and quality assessment/improvement activities within the Department. Last Approved: 8/15/94 Page 2

3 2.4.8 Responsible to periodically survey the facilities and equipment, and to recommend replacements and/or upgrades of new equipment so as to maintain the highest quality service to the Professional Staff Responsible to supervise the use of radiologic equipment within the hospital to ensure it is utilized in a safe and efficient manner Responsible to supervise the recording of fluoroscopy and examination times on the patient s record Assure radiological reports and consultation forms are signed by the responsible radiologist. An electronic signature is acceptable. Reports shall be sent to the referring physician(s), original kept with the patient s medical record, and a duplicate in the radiology information system (RIS) Diagnostic procedures involving a combination of surgical or endoscopic and radiologic techniques shall be performed on a cooperative basis with the surgeon, endoscopist or other Professional Staff physician responsible for the surgical or endoscopic portions of the examination and the radiologist responsible for the radiological and film interpretation aspects of the procedure. The medical interests, safety and comfort of the patient shall be given prime consideration Each Member shall be responsible to the Chairman for carrying out the responsibilities of the Department. ARTICLE III. PRIVILEGES 3.1 DETERMINATION OF CLINICAL PRIVILEGES As consistent with the Bylaws, determination of clinical privileges shall be made based on documented evidence of training and experience, objective performance data, participation in Department and Professional Staff activities, ability to work cooperatively with Members of the Professional Staff and other professionals, and other indicators of the applicant s competence relative to the discipline of Radiology In developing credentialing policy, the Department shall take into account interdepartmental considerations and shall make every effort to establish consistent criteria, were appropriate Membership in the Department will not automatically infer clinical privileges. Members must submit in writing, on the appropriate clinical privilege request form, those areas of clinical privileges they wish to practice. Requests for clinical privileges shall be considered in accordance with the Bylaws and established credentialing criteria Prior to performing new techniques/procedures, the applicable credentialing must occur. Please refer to the Practitioner Apprenticeship in Established Techniques/Procedures Last Approved: 8/15/94 Page 3

4 and Privileging for New Techniques/Procedures located in the General Policies of the Bylaws. 3.2 SCOPE OF CLINICAL PRIVILEGES The scope of clinical practice with the Department shall include diagnostic and therapeutic management within the discipline of Radiology Requests for clinical privileges in the Department by Professional Staff, who do not meet all the basic requirements for Department membership, but who demonstrate evidence of special training and/or experience, shall be considered on an individual basis as consistent with the Bylaws The Professional Staff appointees who are not Members of the Department and are granted privileges in the Department shall participate in peer review functions of the Department as requested and shall adhere to the Rules of the Department as consistent with the Bylaws. 3.3 COMPLETION OF OBSERVATION The Chairman shall appoint three (3) Active and/or Emeritus Members of the Department to observe the provisional physician s activities during the first six (6) months Observation shall include not only the provisional Member s clinical abilities, but also his participation in Department educational and quality care activities, timely performance of duties, productivity and ability to interact with other Members of the Department, Professional Staff, and other health care professionals Members requesting privileges in interventional and angiographic procedures shall have a minimum of nine (9) cases observed and reviewed by appropriately designated Department Members Members requesting privileges in Nuclear Medicine, Ultrasound, Computed Tomography and/or Magnetic Resonance Imaging shall have at least fifty (50) cases in each discipline reviewed by an appropriate observer. Members requesting privileges in these areas will have the first nine (9) cases observed by three (3) Active and/or Emeritus Members of the Department, and the remainder of the fifty (50) cases in each discipline shall be reviewed as part of the ongoing quality assessment/improvement activities In the event a request for privilege is granted by the Board of Trustees in a new technology, the Chairman, in cooperation with Administration, may seek outside observation, if required Upon completion of observation requirements, the observer(s) shall review and evaluate the Member s performance and shall make a recommendation in writing to the Department Chairman for consideration. A provisional member may initiate Last Approved: 8/15/94 Page 4

5 consideration of advancement at such time as he believes he has completed the requirements and the observers have not timely submitted a recommendation Upon receipt of a recommendation, the Department shall consider the written recommendation and shall forward its written recommendation to the Credentials Committee to: Recommend approval without further observation; Extend the observation period; and/or Recommend approval of certain identified privileges as requested and revocation of certain identified privileges for stated cause; or 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 shall be explicitly defined. The reasons for denials/revocation of appointment and/or clinical privileges shall be explicitly stated. 3.4 FAILURE TO COMPLETE OBSERVATION REQUIREMENTS Failure of the candidate to complete the observation requirements within the designated period will result in re-evaluation of the application for appointment and/or privileges in the Department as set forth by the Bylaws 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 shall 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 IV. REAPPOINTMENT AND RENEWAL OF CLINICAL PRIVILEGES 4.1 REAPPOINTMENT Reappointment and renewal of clinical privileges is carried out as prescribed by the Professional Staff Bylaws. 4.2 CLINICAL PERFORMANCE ASSESSMENT In connection with reappointment/renewal of clinical privileges, observed clinical performance and results of quality improvement activities of the Professional Staff shall Last Approved: 8/15/94 Page 5

6 be considered. Evaluation of practice experience of Members shall be specifically evaluated against professionally recognized standards and comparative practice pattern analysis as established by the Department. 4.3 PRIVILEGE RENEWAL/RECREDENTIALING Privileges renewal/recredentialing criteria includes activity benchmarks in conjunction with clinical performance as demonstrated through quality assessment/improvement activities in the Department. ARTICLE V. QUALITY IMPROVEMENT AND PEER REVIEW QUALITY IMPROVEMENT PLAN Under the direction of the Department Chairman, the Department shall 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 shall be evaluated on an annual basis to assess the results of activities and recommendations and to consider modifications and/or revisions. ARTICLE V. CHAIRMAN 5.1 The Chairman shall be a Member of the Active and/or Emeritus Staff for at least two (2) years and shall be elected in accordance with the Bylaws and shall be Board Certified or documented equivalent professional status as determined by the Department of Radiology. 5.2 The Chairman shall be responsible for carrying out all responsibilities and functions as designated in the Bylaws and shall serve as the representative of the Department of Radiology on the PSEC. (Bylaws Article XII) 5.3 The Chairman shall appoint all special committees. 5.4 The Chairman shall be responsible for supervising the emergency call rotation schedule. 5.5 The Chairman shall be an Ex-Officio Member of all committees of the Department unless otherwise designated. 5.6 The Members of the Department shall elect a Chairman at the October meeting of the Department biennially, consistent with the Bylaws. Last Approved: 8/15/94 Page 6

7 ARTICLE VI. VICE CHAIRMAN 6.1 A Vice Chairman shall be appointed to act on behalf of the Chairman in his absence or to assist in carrying out specific duties on behalf of the Department, as may be designated by the Chairman. 6.2 The Vice Chairman is appointed by the Chairman of the Department for the term concurrent with that of the Chairman. ARTICLE VII. MEETINGS/ATTENDANCE 7.1 DEPARTMENT MEETINGS The Department shall meet on a schedule established by the Chairman in consultation with Department Members, but at least quarterly. 7.2 MINUTES A record of each meeting shall be prepared in accordance with the Bylaws and administrative policy. Records shall be handled in a confidential manner. 7.3 NOTICE Routine notice of regularly scheduled meetings shall be provided fourteen (14) business days in advance. 7.4 QUORUM Members eligible to vote and present, but at least three (3), shall constitute a quorum as prescribed by the Bylaws. 7.5 SPECIAL MEETINGS Special meetings may be called by the Chairman or upon written request by one-third (1/3) of the Active Members of the Department. Notice of special meetings shall state the purpose of the meeting and be sent fourteen (14) business days prior to the meeting. 7.6 ATTENDANCE Each Member of the Active Category shall be encouraged to attend at least fifty percent (50%) of all Department meetings. (Bylaws Article IX) Last Approved: 8/15/94 Page 7

8 8.1 AD-HOC COMMITTEES ARTICLE VIII. COMMITTEES Ad-Hoc Committees may be established at the discretion of the Chairman in accordance with the Bylaws and shall meet as needed. ARTICLE IX. ADOPTION AND AMENDMENT 9.1 DEPARTMENT RESPONSIBILITY AND AUTHORITY The Department shall have the responsibility and delegated authority to formulate, adopt and recommend Rules and Amendments for the Department of Radiology after recommendation to the PSEC and subject to the approval of the Board of Trustees Rules for the Department shall be reviewed biennially by the Department 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. 9.2 ADHERENCE Each new applicant to the Department shall be supplied with a copy of these Rules and regulations in conjunction with the Bylaws of the Professional Staff. An affidavit attesting that the applicant has read and understands the Rules of the Department of Radiology shall be obtained Each Member of the Department agrees to abide by the Rules of the Department, and these Rules serve in no event to be inconsistent with the Professional Staff Bylaws or Professional Staff Rules of the Bylaws of MGL. The former shall yield to the provisions of the later document. 9.3 GLOSSARY All terms utilized in the context of these Rules shall be consistent with terms defined in Article II of the Bylaws. 9.4 ADOPTION The foregoing Rules were adopted and recommended to the PSEC and the Board of Trustees in accordance with and subject to, the Bylaws of the Professional Staff. Last Approved: 8/15/94 Page 8

9 ADOPTED AND APPROVED: Chairman, Department of Radiology Professional Staff Executive Committee Board of Trustees Date Date Date Last Approved: 8/15/94 Page 9