SUTTER MEDICAL CENTER, SACRAMENTO DEPARTMENT OF LABORATORY MEDICINE. Rules and Regulations

Transcription

1 SUTTER MEDICAL CENTER, SACRAMENTO DEPARTMENT OF LABORATORY MEDICINE Rules and Regulations I Goals and Objectives The goals and objectives of the members of the Department shall be to provide the best possible care of patients through high quality and cost-effective laboratory medicine. The major obligation must include proper development and implementation of all laboratory procedures, with assurance of their medical reliability through an adequate quality control system and an associated interpretation and correlation with patient status. There must be specific and regular application of the recommended Standards for Accreditation of Medical Laboratories as developed by the Commission on Laboratory Inspection and Accreditation and the College of American Pathologists. A few specific areas of action are emphasized. These areas may overlap to a variable extent with other hospital disciplines (such as bone marrow aspiration, interpretation by hematologists). As a modern laboratory, new procedures are expected to be introduced periodically for the best patient care. II Organization The Department will be organized into two informal sections as shown below. (In addition, there will be such committees as are described in Section V). A. Anatomic Pathology 1. This Section includes surgical and autopsy pathology. 2. General responsibilities of the anatomic pathology section include: a. The adequate examination of all tissues obtained from surgical procedures and autopsy specimens. This must include an adequate gross evaluation of each tissue specimen obtained as a part of a surgical procedure, and at the discretion of the pathologist may include histopathologic analysis with special studies or special stains done dependent upon initial histologic findings and available clinical data. b. The performance of autopsy examinations with correlation of clinical data, laboratory and radiologic and special studies with autopsy findings for the improvement of medical knowledge. c. The correlation of cytopathology with tissue biopsies and surgical specimens.

2 d. The performance of special techniques such as cytogenetics, immunopathology, electron microscopy and flow cytometry. e. Other special functions as described in Section VI. 3. Activities in Anatomic Pathology will be directed along the guidelines developed by the College of American Pathologists. B. Clinical Pathology 1. This section consists of five subsections: Chemistry, Transfusion Services, Hematology/Coagulation, Immunology and Microbiology. Each of these units is directed by a qualified medical technologist supervisor responsible to a member of the department. 2. General responsibilities of the section include: a. The introduction, evaluation, and interpretation of the quantitative and qualitative test procedures within the five major areas of clinical chemistry, hematology, immunology, microbiology, and Transfusion Services. Special areas of interest also include blood coagulation, hematopathology, virology, antibiotic test interpretation, computer application and the research and development of new procedures involving all areas of medical patient care. b. Consultation in the above areas to hospital physicians, as further described in Section III D. 3. Activities in Clinical Pathology will be directed along the guidelines developed by the College of American Pathologists. III Membership in the Department A. Criteria The Department will require that its members either be board certified or board qualified, (board qualified indicates that an individual has had proper training and qualifications, but has not taken and passed the certification examination). Additionally, members of the department shall be subject to all the Bylaws of the Medical Staff. Page 2 of 5

3 B. Privileges Privileges will be granted in the Department of Laboratory Medicine consistent with each staff member's training, experience, interest, competency and proficiency. It is understood that board eligibility or certification will usually satisfy the requirements of training, experience, and interests. Additional requirements for granting of privileges may be established by the Department Administrative Committee, subject to approval in accordance with the Medical Staff Bylaws. The Department of Laboratory Medicine shall establish and monitor the proctoring program. Consulting Staff members will be required to submit five (5) proctored reports from their primary hospital provided proctoring is not older than five years at the time of appointment to the Sutter Medical Center Medical Staff. If proctored reports are older than five years, the proctor could be the attending physician who should comment on the outcome of the case. C. Procedure Interview of a prospective member will be made by the Department Administrative Committee and a recommendation will be sent to the Credentials Committee within 30 days. D. General Responsibilities 1. The pathologists, as Directors of the Laboratory, are professionally responsible for all of the activities that are performed by qualified technical and clerical personnel, who shall be responsible to the Pathologists. 2. Pathologists are to have specific areas of responsibility in Anatomic Pathology and Clinical Pathology dependent upon qualifications and interests. The pathologist's general obligation is to provide a service within the hospital, and also his or her obligation involves a consultative role to hospital physicians. The consultant role of the pathologist is an important one which often is critical for ideal patient care. It is the obligation of the pathologist to promote his role as a consultant in all areas of laboratory medicine, recognizing that special areas of expertise will be developed by some pathologists. Physician education may be considered as an extension of the pathologist's role as a consultant in laboratory medicine. Such education may include the generation of notices, bulletins and information on new laboratory procedures, all directed at improving patient care. Page 3 of 5

4 3. The Department will provide pathologist services 24 hours a day, 7 days a week. 4. Pathologists shall serve on various Hospital and Department committees as appropriately designated or appointed. 5. Administrative responsibility E. Accountability Because of the multiple department activities involved in addition to the practice of pathology, a program indicating assignments of various members of the Department of Pathology has been developed and will be altered as necessary. This includes primary and secondary responsibility for business administration and administration of areas of clinical pathology and anatomical pathology. Members of the department are accountable to the Department Chief for the quality of care delivered in the department and for the performance of responsibilities assigned by these Rules and Regulation, the Department Chief, or the Medical Staff Bylaws, Rules and Regulations. IV. Officers Officers shall consist of the Chief of the Department, Vice-Chief and Secretary. The Officers shall be selected in a manner and for a term as specified by the Medical Staff Bylaws. The officers shall have the qualifications as outlined in the Medical Staff Bylaws and must be actively involved in staff and professional activities. The officers shall perform the duties and have the authority as outlined in the Medical Staff Bylaws. The Department Chief and Vice-Chief shall be accountable to the Chief of Staff and the Medical Executive Committee as outlined in the Medical Staff Bylaws. In addition, they shall oversee the Department's compliance with the requirements of Title XXII, California Code of Regulations, and of The Joint Commission insofar as they relate to the medical staff and the Department of Laboratory Medicine. V. Department and Committee Meetings A. Administrative/Department Meetings 1. Bimonthly meetings are held in combination with the Department Quality Improvement Committee. Other meetings may be held as needed. The agenda shall include, but not be limited to, the following: Page 4 of 5 Laboratory Medicine Department Rules and Regulations

5 a. Credentials/privileging review. b. A review of the previous Medical Executive Committee meeting. c. Discussion of new procedures, instruments, laboratory budget and related data. d. Status of technical and nontechnical personnel. e. Reports from committees. f. Other matters not covered above. B. Quality Improvement Committee 1. Committee Function: To meet the requirement to monitor and evaluate the appropriateness of Pathology and Laboratory Medicine services at Sutter Medical Center. 2. The Laboratory Medicine Quality Improvement Committee will meet and be chaired by the Vice-Chief of Laboratory Medicine Department. The meeting will be held in combination with the Administrative/Department meeting. Committee membership shall be composed of physicians from Laboratory Medicine Department. Additional support will be provided from the Laboratory Department, Quality Review Services, Health Information Services and Medical Staff Services. VI. Research Activity Projects are conducted on an individual basis. Any such research involving hospital patients will be reviewed, approved and monitored by the hospital's Institutional Review Committee. APPROVALS: LABORATORY MEDICINE ADMINISTRATIVE COMMITTEE 09/19/12 MEDICAL EXECUTIVE COMMITTEE 10/23/12 LABORATORY MEDICINE DEPARTMENT (Ballot Results) 12/03/12 MEDICAL POLICY COMMITTEE 01/03/13 BOARD OF DIRECTORS 01/03/13 Developed: Reviewed: 1/87; 10/89, 9/12 Revised: 2/92; 11/94; 9/99; 7/03; 5/06 J:\MedStaff Docs\Department Lab Medicine\Rules & Regulations\Lab Med Rules and Regs.2006.doc Page 5 of 5