ARTICLE X: RULES AND REGULATIONS The Medical Staff shall adopt such rules and regulations as necessary for the proper conduct of its work. Such rules and regulations may be a part of these bylaws except they may be amended without previous notice by a two-thirds vote of the total membership of the Active Medical Staff present at any regular meeting. Such amendments shall become effective when approved by the Governing Board. Review of the Rules and Regulations will be performed annually to reflect revisions and updated policies. All Medical Staff members shall adhere to the following policies and procedures, as well as those not included in this summary, and located in the Hospital Policy and Procedure Manual or online at: http://www.sh.lsumc.edu/policies/policy_manuals_via_ms_word/home.htm Quality Patient care is the first priority of the organization. The challenge to the physicians is to balance patient expectations, patient needs, and available resources to achieve patient satisfaction and quality care. (HP 1.1) The Medical Staff shall take a leadership role in organization Performance Improvement activities. (HP 1.1.1) Observation beds shall be used to provide facilities for patients requiring a period of observation or short term nursing care, but for whom an impatient admission is not indicated. If the patient s stay is longer than 23 hours, the record must reflect extenuating circumstances that caused the discharge delay. (HP 2.2) Only the standardized prescription pad approved by the Pharmacy and Therapeutics Committee and the Clinical Board may be used. All medication orders written by medical students must be countersigned. (HP 8.2) The introduction or possession of weapons on state property is prohibited. Weapons include but are not limited to firearms, explosives, knives with blades six or more inches in length, and straight razors. (HP 2.7) Admissions are permitted by faculty, house staff or fellows for an attending physician. Bed Control or the Physicians Referral Office shall be contacted prior to accepting non-emergency admissions/transfers. An Admission Approval Form shall be completed by the physician writing the admit orders. Requests for emergency/trauma transfers are referred to the ER/Trauma Team for disposition. When receiving a patient via helicopter, the physician receiving the patients is responsible for verifying bed availability, notifying admitting and the ECC and completing the Admission Approval Form. (HP 2.9, 2.9.1, 2.9.2) Emergency care only shall be provided to non-residents of the State of Louisiana without regard to their ability to pay for emergency care. Non-residents presenting for non-emergency care and unable to pay for their care shall be referred to a public health care provider in their state of residency. A non-resident pediatric patient 1
presenting for care will be seen without an advance deposit. The adult person accompanying the patient shall be informed at registration that they will receive a bill for all services rendered and they cannot be classified as free care. (HP 2.11, 2.1l.1, 2.11.3) Patients who are contracted managed care patients shall be accepted for transfer from an out of network hospital. The case manager of the managed health care provider should request the transfer. A LSUHSC-S staff physician must accept and approve the transfer and a bed must be available. (HP 2.11.2) Off-site clinics that are within 250 yards of the main campus shall have trained clinical personnel who can respond to patients with emergency medical conditions. If a medical emergency occurs in a non-clinical setting, including but not limited to parking areas within the 250-yard rule, personnel shall immediately notify Shreveport Emergency Services at 911. (HP 2.11.4) All approved safety/infection control policies in the Hospital Safety/Infection Control Manual(s) shall be followed. (HP 2.12) The hospital is a Smoke Free facility. Inpatients only may be permitted to smoke while hospitalized providing they meet the criteria for authorization of smoking and appropriate physician documentation is in the record. No medical staff may smoke in the institution. (HP 2.15) A variance is any event or circumstance not consistent with the standard routine operations of the hospital and its staff or the routine care of a patient/visitor. The person identifying the event shall be responsible for initiating the Variance/ Sentinel Event Report form prior to the end of their scheduled shift of duty. (HP 2.22) Physician related Patient Complaints shall be reviewed/investigated, tracked, and trended on an individual basis in a timely and efficient manner to improve the delivery of quality healthcare services and protect patient health and safety. (HP 2.23) A release form must be signed before photography, video, audio, or cinematography recording shall be done by anyone. (HP 2.28) When a medical accident or unanticipated outcome occurs, the patient and, when appropriate, their families are informed. The staff involved shall follow the procedure approved by the Clinical Board. (HP 2.35) To ensure the protection of patients, any physician suffering from an impairment that may interfere with optimal professional function may use the established mechanism for treatment and rehabilitation. (HP 3.10) Restraint use within the hospital is limited to those situations with adequate, appropriate clinical justification. A restraint is defined as use of any object or device that voluntarily restricts the patient s movement and access to his/her body. This is a
functional definition and is not based on the device used. A drug used as a restraint is a medication used to control behavior or to restrict the patient s freedom of movement and is not a standard treatment for the patient s medical or psychiatric condition is reported via the Variance Reporting Process. (HP 5.15, 5.15.1, 5.15.2) Non-Point-of-Care Testing physician practice guidelines identify tests performed by physicians to confirm a diagnosis and to monitor treatment. Nursing personnel can assist with sample collection but cannot perform testing without approval from the Point-of-Care area of the Clinic Laboratory. (HP 5.2.5) Sample medications are stored, controlled and distributed in accordance with federal and state guidelines and university hospital policies and procedures. If medications are dispensed to a patient in an outpatient care area, the physician must adhere to the policy. (HP 8.5) University Hospital operates under a closed formulary system. Any medical staff member may initiate a request for addition of a drug to the formulary. If drugs available on formulary would not meet the needs of the patient, the attending may complete the NonFormulary Drug Request form. (HP 8.7, 8.7.1, 8.7.2) To provide appropriate and safe use of investigational drugs, the policy Investigation Drug Use shall be followed. Informed consent for the use of investigational drugs shall be obtained and placed in the patient s medical record. (HP 8.8) When providing care a physician will follow patients wishes for withholding or withdrawing life sustaining treatment. (HP 5.21) Medical staff notified of critical lab results or lab results outside the normal range shall take appropriate action to assure the patient receives appropriate intervention. (HP 5.30) Physicians performing surgical or operative procedures shall verify the site preoperatively to minimize the risk of surgery on the unaffected site and on the wrong patient. (HP 5.32) Medical staff shall notify the appropriate authorities immediately of all cases of suspected abuse/neglect. (HP 5.5) 26. Louisiana statues specifically and expressly forbid the performance of an abortion in a state health care facility other than to prevent the death of the mother or in cases of rape or incest. (HP 5.6) To obtain organs for transplantation and maintain confidentiality for donor/recipient information, the Louisiana Organ Procurement Agency Organ Donation policy shall be followed. (HP 5.7)
To assure care provided to each patient is based on a determination of the patient s needs, a duly licensed and credentialed staff physician will either perform or supervise the performance of a Patient Assessment as outlined in the Medical Staff Bylaws, Rules and Regulations Section on Health Information Management. (HP. 5.9, 5.23) Physicians or other designated staff are responsible for determining the need to recall patients for further examination or treatment as a result of missed appointments for high-risk diagnosis and/or abnormal test results. (HP 5.11) Informed consent shall be obtained and placed in the patient s medical record for surgical procedures, use of investigational drugs, emergency services treatment, administration of blood and/or blood components, ambulatory care treatment and other services, including treatment of minors and the mentally disable, sterilization procedures, and anesthesia. (HP 5.16.1) The patient has the right to considerate, respectful care at all times and under all circumstances, with recognition of his personal dignity and worth. (HP 5.17) The attending faculty physician shall be responsible for documenting justification for continuous morphine therapy to manage the pain the terminally ill patient. (HP 5.18) The physician primarily responsible for a patient s care is responsible for determining when CPR is no longer an appropriate medical response. A faculty member must review evidence of irreversible illness, which is reasonably expected to result in the patient s death. (HP 5.19) Physicians shall assist patients in making decisions about advance directives by providing information to make an informed decision, review advance directives and record review in the medical record. (HP 5.22) To discharge patients effectively and efficiently and to allow for optimal utilization of resources, patient discharges shall occur by twelve noon. (HP 5.24) The policy outlining management of patients receiving minimum and moderate Conscious Sedation shall be followed. (HP 5.26) An interdisciplinary approach shall be utilized to manage, eliminate, or minimize the pain. (HP 5.34) Physicians are responsible for security, confidentiality, and integrity of patient information. Medical records shall not be removed from the hospital s jurisdiction except under receipt of subpoena duces tecum, court order or statute. (HP 6.2, 6.3) Verbal and telephone orders shall only be accepted by healthcare professionals within their scope of practice and when orders are appropriate. These orders shall be
countersigned by the physician as soon as possible or within five (5) days. (HP 6.13) The physician is responsible for documenting in the patients medical record pertinent information concerning the treatment of the patient accurately and in a timely fashion. (HP 6.5, 6.5.1, 6.5.2) Every member of the Professional staff is expected to be actively interested in securing autopsies. No autopsy shall be performed without proper written consent. All autopsies shall be performed by the department of Pathology. (HP 7.6) All deaths mandated to be reported shall be reported to the Coroner s Office. (HP 7.6.1) The evacuation of patients from any area, floor or the premises shall be initiated only on order of the Hospital Administrator or his designee. In the event of immediate threat to life, the most senior employee on the scene has the authority to order evacuation. (Safety Manual) Every clinical department is responsible for developing a plan for Disaster Response/Inclement Weather and recall of departmental personnel. Refer to the Clinical Departmental Disaster Plan for Proper response. (HP 2.8) The Infection Control Bloodborne Pathogen Control Plan, Isolation Guidelines, and TB control Plan shall be followed. Observed infractions shall be called the attention of the offender. (Infection Control Manual) Pages can be extremely important; therefore, pages shall be answered within ten (10) minutes of receipt. (HP 7.5) Consultations for services provided by a Medical Staff department shall be completed timely to ensure quality patient care is rendered (HP 2.37) The Medical Center shall carry out its operations in an ethically responsible manner. In conformance with the mission statement of the Health Sciences Center, all dealings with patients and community served through patient care, education, and research shall be conducted in accordance with specific organizational ethics. (HP 2.19) A rotation system is in place for licensed healthcare providers who supply post discharge services/care to patients not provided by the hospital. (HP 2.25) All laboratory testing performed outside the main Clinical Laboratory or designated Special Function Laboratory shall be performed utilizing methodologies to insure valid, reliable test results and that all such testing shall be done in compliance with all state and federal regulations. (HP 5.2.1) The patient identification system is in place to ensure that all hospital patients are properly identified prior to any care, treatment, or services provided. (HP 5.10.1)
The Code Blue Resuscitation Team is in place to administer Advanced Cardiac Life Support (ACLS)/Pediatric Advanced Life Support (PALS) to individuals who have experienced a cardiopulmonary arrest. (HP 5.12, 5.12.1, 5.12.2) A listing of unacceptable abbreviations and symbols, according to the Joint Commission on Accreditation of Healthcare Organization, to be used in all medical records is maintained (HP 6.5.2) Licensed practitioners (both Medical Staff and house staff) are authorized to prescribe medications in accordance with hospital policy. (HP 8.9) Patients are encouraged to bring medications and alternative/herbal remedies they are currently taking to the hospital at the time of admittance to assist the physician during the history procedure. Such medications should preferably be removed and stored with the patient s other belongings at the conclusion of the admitting history until such time that the patient is discharged from the hospital (HP 8.12) All medications stocked in a patient care area are secured in a locked Automated Drug Distribution System (ADS) and can only be removed by authorized users per order of a licensed prescriber and are administered to registered patients of the Medical Center. (HP 8.13) Medication Reconciliation is in place to ensure timely and accurate capture and documentation of a comprehensive list of a patient s medications in order to communicate this information across the continuum of care, reduce medicationrelated errors, and improve patient safety and outcomes. (HP 8.21)