Medical Staff. Organization and Functions Manual. Baptist Hospital of Miami, Inc.

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1 Medical Staff Organization and Functions Manual Baptist Hospital of Miami, Inc v1 REV:

2 Medical Staff: Organization and Functions Manual Table of Contents SECTION 1. ORGANIZATION AND FUNCTIONS OF THE STAFF Organization of the Medical Staff: Responsibilities For Medical Staff Functions: Description of Medical Staff functions: Responsibilities of Clinical Section Chiefs where a Section has been formed:...8 SECTION 2. MEDICAL STAFF COMMITTEES AND FUNCTIONS Committee Meetings: Medical Executive Committee: Credentials Committee: Creation of Standing Committees: Joint Conference Committee: Medical Staff Data Trends Council: Surgical/Invasive Case Review Committee: OB/GYN Review Committee: Pharmacy and Therapeutics Committee: Disruptive Practitioner Committee: CPR Committee: Infection Control Committee: Antibiotic Review Sub-Committee: Accreditation/Bylaws Committee: Medical Records Committee: Blood Utilization Committee: Operating Room Committee: Endoscopy Committee: Special Committees: Hospital Committees with Medical Staff liaisons: Cancer Committee Bylaws and Regulations Enforcement Committee Performance Improvement Steering Council...16 SECTION 3. MEDICAL STAFF DEPARTMENTS List of Departments: Functions and Responsibilities of Departments: Departmental Advisory Committees: Special Considerations for Interdisciplinary Departments: SECTION 4. CONFIDENTIALITY, IMMUNITY, AND RELEASES...18 SECTION 5. REVIEW, REVISION, ADOPTION, AND AMENDMENT v1 2

3 SECTION 1. ORGANIZATION AND FUNCTIONS OF THE STAFF 1.1 Organization of the Medical Staff: The Medical Staff of Baptist Hospital of Miami shall be organized as a departmentalized Medical Staff including Department Chiefs. A Department Chief shall head each clinical department with overall responsibility for the supervision and satisfactory discharge of assigned functions under the MEC. 1.2 Responsibilities for Medical Staff Functions: The MEC is responsible for the Medical Staff functions set forth in Section 1.3 of this Manual. The Medical Staff officers, Department Chiefs, Hospital and Medical Staff committee chairs, must work together collaboratively to carry out these functions and maintain effective mechanisms for communication through the creation of periodic reports to the appropriate department, committee, or MEC. Issues of concern should be reported to the MEC as needed to ensure adherence to regulatory requirements, accreditation standards, and appropriate standards of medical care. Medical Staff officers may appoint Designated Physician Leaders to help fulfill Medical Staff functions and identify other medical and administrative resources when needed to adequately fulfill Medical Staff functions. 1.3 Description of Medical Staff functions: The responsible party is listed in parentheses following each activity outlined below: Governance, direction, coordination, and action: a. Receive, coordinate and act upon, as necessary, the reports and recommendations from departments, committees, other groups, and officers concerning the functions assigned to them and the discharge of their delegated administrative responsibilities (MEC and appropriate Medical Staff departments and committees); b. Account to the Board and to the Medical Staff by written recommendations for the overall quality and efficiency of patient care at Baptist Hospital of Miami (President and MEC); c. Take reasonable steps to obtain professional and ethical conduct and initiate investigations, and pursue corrective action of Medical Staff members, when warranted (President and MEC); d. Make recommendations on medico-administrative and Hospital clinical and operational matters (President and MEC); e. Inform the Medical Staff of the accreditation requirements and the accreditation and state licensure status of the Hospital (President and MEC); f. Act on all matters of Medical Staff business, and fulfill any state and federal reporting requirements (MEC and appropriate Medical Staff committees); g. Oversee, develop, and plan Continuing Medical Education plans, programs, and activities that are designed to keep the Medical Staff informed of significant new 46309v1 3

4 developments and new skills in medicine that are related to the findings of performance improvement activities (MEC, CME Committee); h. Provide education on current ethical issues, recommend ethics policies and procedures, develop criteria and guidelines for the consideration of cases having ethical implications, and arrange for consultation with concerned physicians when ethical conflicts occur in order to facilitate and provide a process for conflict resolution (MEC, Ethics Committee or Subject Matter Expert); i. Provide oversight concerning the quality of care provided by any residents, interns, students who rotate through the Hospital facility, and ensure that the same act within approved guidelines established by the Medical Staff and governing body (MEC); and j. Ensure effective, timely and adequately comprehensive communication between the members of the Medical Staff and Medical Staff leaders as well as between Medical Staff leaders and Hospital administration and the Board (President, MEC, VPMA) Medical Care Evaluation/Performance Improvement/Patient Safety Activities, (Departmental Advisory Committees (DACs), MEC, and Hospital Performance Improvement Steering Council and Patient Safety Committee) a. Set expectations, develop plans, educate members, and manage processes to measure, assess, and improve the quality of clinical activities; b. Understand the adopted approach to and methods of performance improvement; c. Ensure that important processes and activities are measured, assessed, and improved systematically across all disciplines throughout the Hospital; d. Communication of findings, conclusions, recommendations, and actions to improve performance to appropriate Medical Staff members and the governing body. and define in writing responsibility for acting on recommendations for improvement; e. Participate in ensuring that the processes are defined and implemented for identifying and managing sentinel events and events that warrant intensive analysis; f. Ensure implementation of an integrated patient safety program throughout the Hospital; g. Ensure that an ongoing, proactive program for identifying risks to patient safety and reducing medical care errors are defined and implemented; h. Provide for mechanisms to measure, analyze, and manage variation in the performance of defined processes that affect patient safety; and i. Measure and assess the effectiveness of contributions to improving performance and patient safety Monitoring activities should include but not be limited to the following as further defined by the hospital wide performance improvement plan: (MEC, DACs, the Data Trends Council, Performance Improvement Steering Council and additional committees listed below) a. Medical assessment and treatment of patients; b. Use of medications; (Pharmacy and Therapeutics Committee) 46309v1 4

5 c. Use of blood and blood components; (Blood Usage Review Committee) d. Use of operative and other procedures; (Surgical Case Review, OR Committee e. Education of patients and families; f. Coordination of care with other Practitioners and Hospital personnel; g. Accurate, timely, and legible completion of patients medical records; (Hospital Health Information Committee) h. Appropriateness of clinical practice patterns; i. Significant departures from established patterns of clinical practice; j. Use of developed criteria for autopsies; (Pathology DAC) k. Sentinel event data; (Patient Safety Committee, Hospital Physician Risk Management Committee,) l. Patient safety data; (Patient Safety Committee) m. Coordination of care, treatment, and services with other Practitioners and Hospital personnel, as relevant to the care, treatment, and services of an individual patient; n. Findings of the assessment process that are relevant to an individual's performance; and o. Use of clinical guidelines and evidence based order sets that promote evidence based medicine Credentials review (see Medical Staff Credentials Procedure Manual) Information Management (MEC and Health Information Management Committee) a. Review and evaluate medical records to determine that they: Properly describe the condition and progress of the patient, the therapy, the tests provided and the results thereof, and the identification of responsibility for all actions taken; and Are sufficiently complete at all times so as to facilitate continuity of care and communication between all those providing patient care services in the Hospital. b. Develop, review, enforce, and maintain surveillance at least quarterly over enforcement of Medical Staff and Hospital policies and rules relating to medical record including completion, preparation, forms, format, filing, indexing, storage, destruction, and availability; and recommend methods of enforcement thereof and changes therein. and c. Provide liaison with Hospital administration, nursing service, and medical records professionals in the employ of the Hospital on matters relating to medical records practices and information management planning v1 5

6 1.3.6 Emergency Preparedness: Assist the Hospital administration in developing, periodically reviewing, and implementing a crisis management manual that addresses disasters both external and internal to the Hospital. (MEC) Planning (President, MEC, Department Chiefs) a. Participate in evaluating existing programs, services, and facilities of the Hospital and Medical Staff; and recommend continuation, expansion, abridgment, or termination of each; b. Participate in evaluating the financial, personnel, and other resource needs for beginning a new program or service, for constructing new facilities, or for acquiring new or replacement capital equipment; and assess the relative priorities or services and needs and allocation of present and future resources; and c. Communicate strategic, operational, capital, human resources, information management, and corporate compliance plans to Medical Staff members Bylaws review (MEC & Bylaws Committee) a. Conduct periodic review of the Medical Staff Bylaws, Investigations, Corrective Action, Hearing and Appeal Plan, Organization and Functions Manual, Credentials Procedure Manual, and Medical Staff Rules and Regulations; b. Conduct periodic review of the clinical policies and rules; and c. Submit written recommendations to the MEC and to the Board for amendments to the Medical Staff Bylaws, Credentials Procedure Manual, Organization and Functions Manual, and Rules and Regulations Nominating (MEC & Nominating Committee) a. Identify nominees for election to the officer positions and to other elected positions in the Medical Staff organizational structure; and b. In identifying nominees, consult with members of the Medical Staff, the MEC, and administration concerning the qualifications and acceptability of prospective nominees Infection Control Oversight (MEC, DACs, Antibiotic Review Committee, Infection Control Committee and the Performance Improvement and Patient Safety Committee) a. The Medical Staff oversees the development and coordination of the Hospital-wide program for surveillance, prevention, implementation, and control of infection. b. Develop and approve policies describing the type and scope of surveillance activities including: Review of cumulative microbiology recurrence and sensitivity reports; Determination of definitions and criteria for nosocomial infections; Review of prevalence and incidence studies, as appropriate; and Collection of additional data as needed. c. Approve infection prevention and control actions based on evaluation of surveillance reports and other information; d. Evaluate and revise the type and scope of surveillance annually; 46309v1 6

7 e. Develop a surveillance plan for all sampling of personnel and environments; f. Develop procedures and systems for identifying, reporting, and analyzing the incidence and causes of infections; g. Institute any surveillance, prevention, and control measures or studies when there is reason to believe any patient or personnel may be at risk; h. Report nosocomial infection findings on a day-to-day basis to the attending physician and appropriate clinical or administrative leader; and i. Review all policies and procedures on infection prevention, surveillance, and control at least biannually Pharmacy and Therapeutics functions (MEC, Pharmacy and Therapeutics Committee and the Performance Improvement and Patient Safety Committee) a. Maintain a formulary of drugs approved for use by the Hospital; b. Create treatment guidelines and protocols in cooperation with medical and nursing staff; c. Monitor and evaluate the efforts to minimize drug misadventures (adverse drug reactions, medication errors, drug/drug interactions, drug/food interactions, pharmacist interventions); d. Perform drug usage evaluation studies on selected topics; e. Perform medication usage evaluation studies as required by The Joint Commission; f. Perform blinded practitioner profile analysis related to medication use; g. Approve policies and procedures related to The Joint Commission Care of Patient Standards: to include the review of nutrition policies and practices, including guidelines/protocols on the use of special diets and total parenteral nutrition; pain management; procurement; storage; distribution; use; safety procedures; and other matters relating to medication use within the Hospital; h. Develop and measure indicators for the following elements of the patient treatment functions: Prescribing/ordering of medications; Preparing and dispensing of medications; Administrating medications; and Monitoring of the effects of medication. i. Analyze and profile data regarding the measurement of the patient treatment functions by service and practitioner, where appropriate; j. Provide routine summaries of the above analyses and recommend process improvement when opportunities are identified; k. Serve as an advisory group to the Hospital and Medical Staff pertaining to the choice of available medications; and l. Establish standards concerning the use and control of investigational medication and 46309v1 7

8 of research in the use of recognized medication All functions mentioned above shall be reported to the MEC with all minutes and records reviewed maintained as a permanent record and handled in compliance with the confidentiality policies of the Medical Staff and the Hospital. 1.4 Responsibilities of Clinical Section Chiefs where a Section has been formed: a. Formulate continuing education and encourage discussion of patient care issues pertinent to that clinical specialty; b. Conduct Grand rounds as desired by physicians in the clinical section; c. Discuss policies and procedures and recommend same to the appropriate Department Chief; d. Discuss equipment needs pertinent to that clinical section; e. Develop recommendations of a specific issue at the request of a Department Chief or the MEC; f. Encourage participation in the development of criteria for Clinical Privileges and give input on an application or reapplication, when requested by the Department Chief, Credentials Committee or MEC. g. Participate in departmental peer review SECTION 2. MEDICAL STAFF COMMITTEES AND FUNCTIONS 2.1 Committee Meetings: Schedule of Meetings a. All Medical Staff committees shall meet at least quarterly, unless otherwise specified in this manual, at a time set by the chairperson of the committee. The agenda for the meeting shall be set by the chairperson. b. All committee chairpersons shall have the authority to convene their committees for special meetings. The notice requirements set forth in Article VI-Section 2 of Part I of the Medical Staff Bylaws shall apply. A special meeting of a committee may also be called by or at the request of the President, or a petition signed by not less than onefourth (1/4) of all of the members of the committee Quorum for Committee Meetings A quorum shall be defined as the number of members who must be present in order to conduct a vote on a matter before the committee or department. A quorum shall not be required to conduct business. Quorum requirements shall be as follows: a. Medical Staff meetings: those present. b. Medical Executive Committee (MEC): The MEC may act upon Medical Staff Bylaws recommendations only when a quorum of two-thirds (2/3) of the members is present and voting. All other regular business items requiring MEC action will require a fifty-one percent (51%) quorum v1 8

9 c. Credentials, Performance Improvement/Quality Assessment and Departmental Advisory Committees: Thirty-three (33%) percent of the voting member of the committee. d. Committee/Department meetings: The committee chair and at least three additional members of the committee who are members of the Medical Staff eligible to vote. 2.2 Medical Executive Committee: This committee is described in Section V of Part I of the Bylaws. 2.3 Credentials Committee: This committee is described in the Credentials Procedure Manual. 2.4 Creation of Standing Committees: The MEC may, by resolution and upon approval of the Board, without amendment of the Bylaws, establish additional committees to perform one or more Medical Staff functions. In the same manner, the MEC may, by resolution and upon approval of the Board, dissolve or rearrange committee structure, duties or composition as needed to better accomplish Medical Staff functions. The only exception will be the MEC which can only be altered through the process of bylaws amendment described in section VIII of the Medical Staff bylaws. Any function required to be performed by the Bylaws which is not assigned to a standing or special committee shall be performed by the MEC. The following standing committees are established upon adoption of this Medical Staff Organizational Manual: 2.5 Joint Conference Committee: Composition: The Joint Conference Committee shall be comprised of the officers of the Medical Staff; the members of the Executive Committee of the Board of Directors or such other Board members as are designated by the Board in accordance with the Hospital s Articles of Incorporation and Bylaws, and the Chief Executive Officer or designee Duties: The purpose of the Joint Conference Committee shall be to provide formal liaison among the Medical Staff, Board and Hospital CEO. The Committee shall meet for the following purposes: maintenance of effective communications to keep the Board, Medical Staff and CEO cognizant of any pertinent actions taken or contemplated; planning for growth and development of the Hospital and Medical Staff; recommendations to the Board in connection with peer review matters as provided in the bylaws and related manuals of the Medical Staff Meetings: The Joint Conference Committee shall meet at least quarterly and on an asneeded basis when a member of the committee feels there is a need to address an issue(s) of concern to or affecting the Medical Staff, Hospital management and the Board v1 9

10 2.6 Medical Staff Data Trends Council: Composition: The following positions will be represented on the Data Trends Council Vice President Medical Affairs Director of Performance Improvement or Designee Nursing PI Coordinator Infection Control Nurse Pharmacy Director or Designee Data Analyst Director of HIM or designee Representative of Hospital Information Systems Physicians appointed by Medical Staff President Duties: Initial analysis of trends for all aggregate or rate indicator data collected as ongoing indicators for either hospital performance improvement or physician performance improvement activities that are the responsibility of medical staff quality committees or the DACs. The Data Trends Council will not analyze the results of individual case reviews performed as peer review through the Medical Staff DACs. The following are some specific tasks this committee will undertake: Analyze data using either control charts or predetermined targets potential performance issues either from failure to achieve targets or changes in performance exceeding allowable limits either as an individual time period or as a trend over time. Obtain from the appropriate oversight committee the necessary indicator targets to perform the analysis. Report findings of potential performance issues to the appropriate oversight committee. Conduct additional analyses when necessary to determine potential sources of variation. Make recommendations to the appropriate oversight committee regarding the feasibility and validity of requests for new indicators or studies from hospital or medical staff committees or individuals. Create and maintain an indicator scorecard for continuous performance evaluation, exception reporting, re-credentialing, and feedback reporting when warranted Meetings and Reporting: The Council will meet monthly and will report potential performance trends at the regularly scheduled meetings of the responsible oversight committees. Data on all indicators not showing trends will be reported to the responsible oversight committee chair prior to each regular meeting but not discussed at the oversight committee meetings unless the chair has a concern. Data showing outstanding performance may be presented at the discretion of the chair v1 10

11 2.7 Surgical/Invasive Case Review Committee: The Surgical/Invasive Case Review Committee is an interdisciplinary subcommittee of the Department of Surgery which evaluates the quality and appropriateness of the performance of invasive procedures referred to it and reports its findings and recommendations to the Department of Surgery. 2.8 OB/GYN Review Committee: The OB/GYN Review Committee evaluates obstetrical care including Cesarean Sections and gynecological care referred to it and reports its findings to the Department of Obstetrics and Gynecology DAC. The minutes of OB/GYN Review Committee are forwarded to the Department of Obstetrics and Gynecology DAC. 2.9 Pharmacy and Therapeutics Committee: The Pharmacy and Therapeutics Committee is an interdisciplinary committee which evaluates the pharmacological agents for inclusion in or exclusion from the Hospital s formularies. The Pharmacy and Therapeutics Committee conducts drug usage evaluation studies as warranted by the practices of the Medical Staff. The Pharmacy and Therapeutics Committee reports to and makes recommendations to the MEC Disruptive Practitioner Committee: The Disruptive Practitioner Committee is a Committee which investigates reported incidents of behavior by Practitioners who are disruptive, unprofessional or otherwise violate the Bylaws, Manuals, Policies, Rules and Regulations or procedures of the Medical Staff. If there is an incident of disruptive behavior that appears to be significant, or a pattern of disruptive behavior is developing the President of the Medical Staff, Vice President of the Medical Staff, Department Chief, Chief Nursing Officer, Risk Manager and the administrative representative of the involved department shall meet to discuss the matter formally with the disruptive practitioner. When the disruptive behavior is exhibited by the President of the Medical Staff, the Hospital CEO and Chairman of the Board shall meet with and advise the practitioner that such behavior is not acceptable. When the disruptive behavior is exhibited by a Member of a contracted group such that the practitioner is employed by the contracted group, the Medical Director of the contracted group and the Risk Manager shall meet with and advise the practitioner that such behavior is not acceptable... The Disruptive Practitioner Committee reports its findings to the MEC and may make recommendations to the MEC regarding Practitioner counseling or discipline CPR Committee: Composition: CPR Committee member composition shall be interdisciplinary including, but not limited to, the following: Medical Staff representation as appointed by the President of the Medical Staff, a Nursing Administrative representative, a Critical Care Nursing representative, a representative of the Department of Organizational Learning, a representative of the Department of Respiratory Therapy, a Clinical Pharmacist, a member of the Pediatric CPR Committee and a representative of Hospital Quality management. A co-chair will be selected by the CPR Committee membership to assist the chair with leadership responsibilities Scope and Responsibilities: The CPR Committee exists as a sub-committee of the Critical Care Collaborative. The Chairman of the CPR Committee is appointed by the Medical Staff President. The Baptist Children s Hospital CPR Committee exists as a sub-committee of the Pediatric Collaborative (See Pediatric CPR Committee Policy # 46309v1 11

12 UPP 512) Policies: The CPR Committee shall be divided into 4 subcommittees which will address specific aspects of committee function: Policy and Procedures, Education, Equipment, and Risk Management/Quality Management. Each subcommittee will monitor and report findings and recommendations to the CPR Committee. (a) Review/revise all existing Code Blue and Code Rescue policies and develop new policies when appropriate. (b) Review/revise and monitor hospital wide personnel roles, procedures, and practices for Code Blue and Code Rescue responses. (c) Education: Review and coordinate hospital-wide basic and advanced life support teaching and testing with appropriate revisions as necessary. Department specific policies will stipulate which Medical Staff members are expected to demonstrate competence in cardiopulmonary resuscitation and other designated life safety interventions. (d) Equipment: Review, revise, and standardize hospital-wide equipment and medications involved in Code Blue and Code Rescue responses. (e) Risk Management/Quality Management: Establish minimal acceptance standards for Code Blue and Code Rescue responses with a mechanism for systematic, ongoing monitoring for the purpose of performance improvement in order to provide improved patient care to cardiac arrest victims. Develop methodology for the collection, collation, and analysis of performance and outcomes data (both short term and long term) of CPR in Baptist Hospital. This will be done in a manner which permits benchmarking of performance and comparisons with national standards, as well as inter-institutional comparisons within Baptist Health South Florida Hospitals and other comparable hospitals. Process and outcomes data analysis will be an ongoing work in progress, using skew chart methodology Procedure: (a) The frequency of committee meetings will be determined by the Chairman, but shall not be less than quarterly. (b) All new/revised policies and procedures will be reviewed/approved by the majority of committee members. (c) Policy/procedures additions/revisions approved by the committee will be presented to the critical care collaborative at its next meeting for approval. (d) No policy/procedure addition/revision will be put into effect without the approval of the Critical Care Committee and subsequent review/approval of other hospital committees/personnel when appropriate. (e) Policy/procedure additions and revisions will be communicated to all system entities for implementation as applicable Policy Statement: it is the responsibility of the CPR Committee to develop, implement, and monitor all standards (policies, procedures, and performance improvement initiatives) relating to cardiopulmonary resuscitation, and to distribute information and recommendations for standardization across all system entities Infection Control Committee: Composition: The Infection Control Committee shall consist of at least four (4) multidisciplinary members of the Medical Staff, one of whom is a pathologist. The Infection Control Coordinator shall serve as an ex-officio member. Consulting members, who shall attend at the invitation of the Chair, shall include representatives from dietary, environmental services, central supply, operating room, and nursing 46309v1 12

13 services Responsibilities: The committee shall be responsible for the development and maintenance of a protocol that will insure constant surveillance of all potential sources of Hospital infections. The committee will review and analyze infections occurring in the Hospital. A report of infections, their outcomes and recommendations shall be made to the MEC Antibiotic Review Sub-Committee: Composition: The sub-committee is chaired by an infectious disease specialist who also serves on the P&T Committee. The membership of the sub-committee consists of all infectious disease Practitioners who are members of the Active Medical Staff at Baptist Hospital, the Chief Microbiologist, the Director of Pharmacy Services, Clinical Coordinator of Pharmacy department, RN director of the Infection Control Department, and any other physicians and/or staff members of the Hospital as deemed necessary Responsibilities: The Antibiotic Review Committee is a sub-committee of the Pharmacy & Therapeutics Committee. The sub-committee assists the P&T Committee in the formulation of criteria and drug use review of antibacterial drugs and in the review of drugs for acceptance and/or deletion to the antimicrobial formulary. The sub-committee develops and implements effective policies for selected antimicrobial agents in the effort to prevent the development of resistant nosocomial pathogens and minimize inappropriate antimicrobial use. Meetings of the sub-committee are held every other month or more often if deemed necessary. All findings and/or recommendations of the sub-committee are presented to the Pharmacy & Therapeutics Committee for review and approval Accreditation/Bylaws Committee: Composition: The Accreditation/Bylaws Committee shall consist of at least five (5) members of the Medical Staff, two of whom shall be the past president and Vice President Responsibilities: The committee shall be responsible for ascertaining that all services in the Hospital meet the standards set by the TJC, including incorporating these standards into the Medical Staff Bylaws. The committee further shall be responsible for effecting changes recommended by the TJC. The committee is charged with biannual review of the Medical Staff Bylaws for any needed amendments, revisions, and rewriting Medical Records Committee: Composition: The Medical Records Committee shall consist of at least three (3) representatives from the Medical Staff and one each from the nursing services and from Hospital management. The medical record director shall be a member of this committee and may be delegated to act as its secretary Responsibilities: The committee shall be responsible for assuring that all medical records reflect realistic documentation of medical events. The committee shall conduct a monthly review of currently maintained medical records to assure that they properly 46309v1 13

14 describe the condition and progress of the patient, the therapy provided, the results thereof, and the identification of responsibility for all actions taken, and that they sufficiently complete at all times so as to meet the criteria of medical comprehension of the case in the event of transfer of physician responsibility for patient care. It shall also conduct a review of records of discharged patients to determine the promptness, pertinence, adequacy and completeness thereof Blood Utilization Committee: Composition: The Blood Utilization Committee is an interdisciplinary committee that meets at least quarterly and is composed of the following members: (a) Transfusion Service Department representatives; (b) at least one (1) member from the departments of Pathology, Surgery, Internal Medicine-Hematology, Critical Care, Obstetrics, and Orthopedics; (c) Nursing Department Membership; (d) IV Therapy Coordinator; (e) Quality Management; (f) Administrative Director, Laboratory Services or their assigned; and (g) Laboratory Quality Manager The Chairman of the Blood Usage Review Committee is responsible for the overall direction and supervision of the committee s activities and has authority to take necessary action to complete monitoring activities and to reduce or eliminate identified problems. The screening for peer review will be performed by the Quality Management staff Scope and Responsibilities: The Blood Utilization Committee at Baptist Hospital serves to enhance the quality of patient care through ongoing objective assessment of blood transfusion and component therapy. Recognizing both the therapeutic potential and risk of blood and blood components an interdisciplinary committee has been designated to conduct measurement activities of the four blood use processes: (1) Ordering; (2) Distributing, handling and dispensing (3) Administering (4) Monitoring the effects (a) To identify opportunities for improvement (b) To target processes in need of redesign (c) To assess if redesigned processes have met the desired objectives Objectives: (1) To improve quality of patient care through the assessment of the appropriateness of administration. (2) To improve the efficiency of services through the ongoing monitoring of timeliness, availability, and effectiveness of processes. (3) To identify and evaluate all sentinel events in a timely manner and make recommendations to improve desired outcomes. (4) To assess the involvement of patients in their own care decisions through the consent process. (5) To improve communication and reporting of findings (6) To improve identification and correction of problems by sharing information. (7) To recognize areas for continuing medical and personnel education v1 14

15 2.17 Operating Room Committee: Composition: The Operating Room Committee shall consisting of at least eight (8) members, including the Chief and the coordinator, of Anesthesia, all surgical subsection chiefs, a representative of the quality management department, the Director and Assistant Directors of surgery, and a Hospital Vice President responsible for surgical services Responsibilities: The committee has the responsibility of reviewing operating room procedures; updating operating room policies; and considering issues that pertain to the operating room. The committee will report directly to the MEC and will make recommendations from time to time on matters concerning the operating room policies and procedures Endoscopy Committee: Composition: The Endoscopy Committee shall consist of at least five (5) members, including at least one gastroenterologist, one pulmonologist and one colorectal surgeon, as well as a Hospital Vice President responsible for endoscopy services or their designee Responsibilities: The committee has the responsibility of reviewing endoscopy procedures; updating endoscopy policies; making recommendations for gastrointestinal and endoscopic privileges to the Credentials Committee and considering issues that pertain to endoscopy services provided at the Hospital. The committee will report directly to the MEC and will make recommendations from time to time on matters concerning endoscopy policies and procedures Special Committees: Special committees shall be created, and their members and chairpersons shall be appointed by the President with the approval of the Board as required. Such committees shall confine their activities to the purpose for which they were appointed, and shall report to the MEC Hospital Committees with Medical Staff liaisons: The Medical Staff President may appoint one or more Medical Staff liaisons to represent the Medical Staff on Hospital committees. These liaisons will bring appropriate expertise to these committees; promote communication between the committee and the Medical Staff; and issues periodic reports to appropriate Medical Staff committees. Upon making liaison appointments the President will indicate the appropriate Medical Staff committee to which the liaison should report The following Hospital committees will have Medical Staff liaisons appointed by the President: Physician risk management committee; health information management committee, cancer committee, continuing medical education committee, performance improvement steering council, ethics committee, and the Institutional Review Board. This list can be modified at any time through additional appointments by the President or removal of a committee from this list by action of the MEC v1 15

16 2.21 Cancer Committee The Cancer Committee is an interdisciplinary committee, which assists the Hospital in the continued improvement of their oncology programs. It is responsible for the development and evaluation of the annual goals and objectives for clinical, community outreach, quality improvement, and programmatic endeavors related to cancer care. The Cancer Committee will follow the requirements outlined in the most current Commission on Cancer American College of Surgeons Cancer Program Standards for other committee responsibilities, composition, and duties of the Baptist-South Miami Regional Cancer Program. The Cancer Committee reports to the MEC Bylaws and Regulations Enforcement Committee: Composition. The BREC shall consist of no less than six (6) Medical Staff Members appointed by the Medical Staff President, the Vice President of Medical Affairs, a representative of Risk Management and the Director of Performance Improvement or his/her designee. It shall be supported by a QM nurse familiar with Emergency Department on call, EMTALA and the Medical Staff Bylaws and Rules and Regulations. The chair of the BREC shall be appointed by the Medical Staff President Responsibilities. The committee will investigate and address alleged violations of Emergency Department on call responsibility, Medical Staff Bylaws, Rules and Regulations, policies and the Medicare Conditions of Participation. Issues of clinical and technical quality as they pertain to credentialing or peer review are reserved for the Department Advisory Committees, other specialty specific peer review committees and the Credentials Committee. The committee will develop standardized methods for dealing with rule violations and reporting to the Medical Executive Committee and department chairpersons. The committee will meet monthly Performance Improvement Steering Council (Note: Refer to the Performance Improvement Steering Council Plan) Composition: The Performance Improvement Steering Council shall consist of the chairpersons and representatives from the Performance Improvement Collaboratives, as well as the Hospital Vice President responsible for performance improvement and those Hospital representatives that he/she invites Responsibilities: The Performance Improvement Steering Council shall be responsible for the performance improvement activities at the Hospital v1 16

17 SECTION 3. MEDICAL STAFF DEPARTMENTS 3.1 List of Departments: Anesthesiology Emergency Services Family Medicine Internal Medicine (includes: General Internal Medicine, Medical subspecialties except Neurology, Allergy and Immunology, Psychology and Psychiatry.) Neurosciences (includes: Neurology, Neurosurgery, Neuroradiology(joint membership with Radiology), and Neuro Critical Care (joint membership with primary department)) Obstetrics and Gynecology Orthopedic Surgery (includes: Podiatry, Hand Surgery and Rehabilitation.) Pathology Pediatrics (includes Neonatology) Radiology Surgery (Surgical Specialties except those in Orthopedic Surgery and the Department of Neuroscience) 3.2 Functions and Responsibilities of Departments: Each Department shall serve to address the concerns and promote communication among those members of the Medical Staff members assigned to it. The Department Chief will carry out those functions and responsibilities articulated in Section 1 of this manual. 3.3 Departmental Advisory Committees: Each Department Chief shall annually appoint a Departmental Advisory Committee ( DAC ) consisting of at least seven (7) members who will be appointed after seeking recommendations from members of the Department and obtaining approval by the Board. Each DAC shall have at least 2 members who are not from the specialties represented by that Department and the remaining membership shall be drawn from members of the Department who are on the Active or Senior Active staff. The Department Chief or assistant chief shall chair the DAC. The members of the DAC shall generally represent the range of specialties included within the Department. Each DAC shall assist the Department Chief in carrying out the functions of the Department Chief and the Department as required by the Bylaws, including, but not limited to, development and refinement of indicators for screening cases for review; evaluation of patient care, development and assessment of criteria for Clinical Privileges; assessment of individual applications for appointment and reappointment; and education. Policies developed by the Departments related to patient care shall be developed using an interdisciplinary approach involving nursing and other relevant non-physician health care providers. Each DAC shall oversee the review of care in accordance with protocols approved by the MEC. The Department Chief may delegate patient care evaluations to members of the DAC or to other members of the Department. The DAC will review ongoing monitoring data of the clinical and professional performance of all members of the Department and of those non-physician Practitioners who perform clinical functions related to the Department. The results of this monitoring will be reported to the Credentials Committee for use in the appraisal of requests for Privileges. The DAC will also provide input to the Credentials Committee on all job descriptions and scope of practice documents relating to non-physician Practitioners who deliver services appropriate to the Department v1 17

18 3.4 Special Considerations for Interdisciplinary Departments Neuroscience Department The Neuroscience Department will include the Neurology and Neurosurgery Subspecialties, and Orthopedic Spine Surgery, Neuro-radiology, and Neuro Critical Care Medicine as Dual Department Subspecialties with their primary specialty Department. A Member must separately meet the requirements for each Department in which they are a member. Credentialing and Peer Review for the Subspecialty Departments of Neurology and Neurosurgery will performed by the Neurosciences Department. Credentialing for the Dual Department Subspecialties will be through their primary Departments: Orthopedic Spine Surgery Department of Orthopedics Neuro-radiology Department of Radiology Neuro-Critical Care Medicine Department of Medicine. Peer Review for the Dual Department Subspecialties will be through the Neuroscience Department for the Neuroscience subspecialty, and through their primary Department for all other aspects of their specialty: Orthopedic Spine Surgery Department of Neurosciences, and the Department of Orthopedics for all other orthopedic surgery Neuro-radiology Department of Neuroscience, and the Department of Radiology for all other radiology Neuro-Critical Care Medicine Neuroscience Department, and the Department of Internal Medicine for other critical care. SECTION 4. CONFIDENTIALITY, IMMUNITY, AND RELEASES 4.1 Confidentiality of Information: Information submitted, collected, or prepared by any representative of this or any other health care facility or organization or Medical Staff for the purpose of: assessing, reviewing, evaluating, monitoring, or improving the quality and efficiency of health care provided; evaluating current clinical competence and qualifications for staff appointment/affiliation, or Clinical Privileges or specified services; contributing to teaching or clinical research; or determining that health care services were indicated or were performed in compliance with an applicable standard of care shall, to the fullest extent permitted by law, confidential. This information will not be disseminated to anyone other than a representative of the Hospital or to other health care facilities or organizations of health professionals engaged in an official, authorized activity for which the information is needed. Such confidentiality shall also extend to information that may be provided by third parties. Each practitioner expressly acknowledges that violations of the confidentiality provided here are grounds for immediate and permanent revocation of staff appointment and/or 46309v1 18

19 Clinical Privileges or specified services. 4.2 Immunity From Liability: No representative shall be liable to a practitioner for damages or other relief for any decision, opinion, action, statement, or recommendation made within the scope of his or her duties as an official representative of the Medical Staff or Hospital or for providing information, opinion, counsel, or services to a representative or to any health care facility or organization of health professionals concerning said practitioner. Immunity protections afforded in the Bylaws are in addition to those prescribed by applicable state and federal law. 4.3 Activities: The confidentiality and immunity provided by this article applies to all information or disclosures performed or made in connection with this or any other health care facility s or organization s activities concerning, but not limited to: applications for appointment/affiliation, Clinical Privileges, or specified services; a. Applications for appointment/affiliation, Clinical Privileges, or specified services; b. Periodic reappraisals for renewed appointments/affiliations, Clinical Privileges, or specified services; c. Corrective or disciplinary actions; d. Hearings and appellate reviews; e. Quality assessment and performance improvement activities; f. Utilization review and improvement activities; g. Claims reviews; h. Risk management and liability prevention activities; and i. Other Hospital, committee, department/division, or staff activities related to monitoring and maintaining quality and efficient patient care and appropriate professional conduct. SECTION 5. REVIEW, REVISION, ADOPTION, AND AMENDMENT 5.1 Each year, the MEC shall review the structure and functions of the Medical Staff as set forth in this manual with reference to appropriate legal guidelines and accrediting agency standards. An ad hoc committee may be created by the MEC from time to time to assist with the development or revision of the organizational plan. 5.2 This Medical Staff Organization and Functions Manual may be amended or repealed by a resolution of the MEC, recommended to and adopted by the Board, in whole or in part by one of the following mechanisms consistent with Article VIII, Section 3 of Part I of the Bylaws: 5.3 Amendments This manual may be amended by the affirmative vote of a simple majority of the members of the MEC. Prior to voting on any amendments to this Manual, the MEC shall consider any written recommendations of Departmental Advisory Committees or 46309v1 19

20 appropriate peer review committees concerning the proposed amendments. No amendment to this manual shall be effective unless and until it has been approved by the Board The Board may amend this manual on their own motion(s) under the following circumstances: a. to comply with changes in federal and state laws that affect the Hospital and the Hospital s corporations, including any of its entities; b. to comply with requirements imposed by the Hospital s general and professional liability or Director s and Officer s insurance carrier; and c. action to comply with state licensure requirements, TJC accreditation standards, other applicable accreditation or certifying agencies and/or the Medicare/Medicaid Conditions of Participation. Any such amendment must first be submitted to the appropriate Departmental Advisory Committee(s) or peer review committees and the MEC for review and comment at least thirty (30) calendar days prior to any final action by the Board. Adopted by the Medical Executive Committee on: Date Signature of Medical Staff President Approved by the Board of Baptist Hospital Date Signature of Board Chairman Adopted by the Medical Executive Committee on October 18, 2010 Adopted by the Board of Baptist Hospital on November 16, v1 20

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