FY2018 TRACKING FORM SACRED HEART HOSPITAL MEDICAL STAFF BYLAWS AND POLICIES

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1 SACRED HEART HOSPITAL MEDICAL STAFF AND POLICIES 1 REVISION Change the number of ad hoc investigative committee members from up to three to at least three. RATIONALE A committee of this nature may need more than three (3) individuals involved in the investigation. ORIGIN OF RECOMMENDATION: Legal Counsel 2 REVISION Add additional health requirements including at least flu annually RATIONALE Current Joint Commission standards (IC ) require hospitals to establish an influenza vaccination program, set incremental goals for meeting 90% by 2020, and measure and improve vaccination rates for staff. Currently, only TB and Rubella are listed as health requirements. (b) If the concern does not state sufficient information to warrant a recommendation, the Medical Executive Committee shall either immediately investigate the matter itself, request that the Credentials Committee conduct the investigation, or appoint an individual or an ad hoc investigating committee consisting of up to at least three (3) persons, who may or may not hold appointments to the Medical Staff. This investigating committee shall not include partners, associates, relatives or any individual who is in direct economic competition with the individual being investigated. Whenever the questions raised concern the clinical competence of the individual under review, the investigating committee shall include a peer of the individual (e.g., physician, dentist, podiatrist). (s) to undergo a tuberculin test as a condition of initial appointment, and at reappointment as requested; (t) to provide documented evidence of influenza vaccination status or reason for declination annually, as requested; MS Bylaws: Page 96 Article VIII: Procedure For Questions Involving Medical Staff Appointees - Section 3. Investigative Procedure: (b) MS Bylaws: Page 53 ARTICLE VI: Appointment To The Medical Staff: Part C - Section 4. Basic Responsibilities and Requirements Red-lined language to be drafted for review/ ORIGIN OF RECOMMENDATION: IPC Panel, MSS. 3 REVISION Allow podiatrists and oral surgeons to complete a full H & P if they can provide evidence of traditional medical training and experience to perform such which is satisfactory to the Credentials Committee of the Medical Staff. Revisions to the privilege cards for each specialty would also be made. (c) The podiatrist shall be responsible for the podiatric care of the patient, including the podiatric history and the podiatric physical examination as well as all appropriate elements of the patient s record. Podiatrists who admit patients without underlying health problems, MS Bylaws: Page 62 ARTICLE VI: Appointment To The Medical Staff: Part E Section 2 and 3 Created: May 2, 2018; Updated May 7, 2018; Updated May 16, 2018; Updated May 30, 2018; Updated June 6, 2018 Page 1 of 6

2 SACRED HEART HOSPITAL MEDICAL STAFF AND POLICIES RATIONALE Currently, two of our podiatrists have shown evidence of such training and competence. ORIGIN OF RECOMMENDATION: Podiatry Section. defined as ASA class I or II, may perform a complete admission history and physical examination and assess the medical risks of the procedure on the patient if they are deemed qualified to do so by the Credentials Committee. Podiatrists may write orders which are within the scope of their license, consistent with the Hospital and Medical Staff bylaws and rules and regulations. (c) Oral surgeons who admit patients without underlying health problems may perform a complete admission history and physical examination and assess the medical risks of the procedure on the patient if they are deemed qualified to do so by the Credentials Committee. 4 REVISION Standardize the Rules & Regs between SHEC and SJCF as they relate to qualified medical personnel who can perform medical screening exams. RATIONALE For standardization between practices. ORIGIN OF RECOMMENDATION: Legal Counsel. (d) The dentist shall be responsible for the dental care of the patient, including the dental history and dental physical examination as well as all appropriate elements of the patient s record. Dentists may write orders within the scope of their license and consistent with Hospital and Medical Staff Bylaws and Rules and Regulations. Section 2. Medical Screening Examinations: (a) Medical screening examinations, within the capability of the hospital, will be performed on all individuals who come to the hospital requesting examination or treatment to determine the presence of an emergency medical condition. Qualified medical personnel who can perform medical screening Rules and Regulations: Pages 30 ARTICLE XI: Section 2 Red-lined language to be drafted for review/ Created: May 2, 2018; Updated May 7, 2018; Updated May 16, 2018; Updated May 30, 2018; Updated June 6, 2018 Page 2 of 6

3 SACRED HEART HOSPITAL MEDICAL STAFF AND POLICIES 5 REVISION Standardize medical record delinquency language between SHEC and SJCF. RATIONALE HIM departments and MSS for SHEC and SJCF are now divisional and requirements and practices should be standardized for ease of management. ORIGIN OF RECOMMENDATION: HIM and MSS. examinations within applicable hospital policies and procedures are defined as: (1) Emergency Department: (i) members of the Medical Staff with clinical privileges in Emergency Medicine; (ii) other Active Staff members; and (iii) appropriately credentialed allied health Professionals; and (iv) in the case of sexual assault, by a SANE forensic nurse under the written physician directed protocols. (2) Labor and Delivery: (i) members of the Medical Staff with OB/GYN privileges; (ii) certified nurse midwives with OB privileges; and (iii) registered nurses who have achieved competency in labor and delivery and who have validated skills to provide fetal monitoring and labor assessment. (b) The results of the medical screening examination must be dictated within 48 hours of the conclusion of an Emergency Department visit. Bylaws (a) The elective and emergency admitting privileges of a Medical Staff appointee, except with respect to those patients already in the Hospital, shall be automatically relinquished for failure to complete medical records after notification of delinquency by the Medical Records Department, unless the appointee is without fault in causing the delinquency. A medical record is considered to be delinquent thirty (30) days after discharge. Written notice MS Bylaws: Page ARTICLE VII: Part E. Section 1 Rules and Regulations: Pages ARTICLE IV: Section 12 Red-lined language to be drafted for review/ Created: May 2, 2018; Updated May 7, 2018; Updated May 16, 2018; Updated May 30, 2018; Updated June 6, 2018 Page 3 of 6

4 SACRED HEART HOSPITAL MEDICAL STAFF AND POLICIES of such automatic relinquishment shall be forwarded by mail from the appropriate clinical department chairperson through to the affected individual by mail from the appropriate clinical department chairperson through the Medical Staff Office with notification to the appropriate clinical department chairperson. Relinquishment shall continue until all the delinquent records are completed. Failure to complete the medical records that caused relinquishment of clinical privileges within sixty (60) days from the date of the first notification of relinquishment shall result in automatic resignation from the Medical Staff. (b) For the purpose of enforcing this Section, extensions may be granted for justified reasons for delay in completing medical records which shall include, but not be limited to, the following: (1) the staff member or other individual contributing to the medical record is ill, on vacation, or otherwise unavailable for a period of time; (2) the staff member is waiting for the results of a late report and the medical record is otherwise complete except for the discharge summary and the final diagnosis; and/or (3) the staff member has dictated reports, including but not limited to, discharge summaries, and is waiting for transcription to be complete Hospital personnel to transcribe them. Rules and Regs (a) The elective and emergency admitting Created: May 2, 2018; Updated May 7, 2018; Updated May 16, 2018; Updated May 30, 2018; Updated June 6, 2018 Page 4 of 6

5 SACRED HEART HOSPITAL MEDICAL STAFF AND POLICIES 6 REVISION Review Department Structure and consider service lines. RATIONALE Ensure current structure is working for the Medical Staff to facilitate meeting key functions. ORIGIN OF RECOMMENDATION: Medical Staff. privileges of a Medical Staff appointee, except with respect to those patients already in the hospital, shall be automatically relinquished for failure to complete medical records in accordance with applicable Bylaws, regulations governing same, and other relevant hospital policies, after notification of delinquency by the Health Information Management Department Medical Staff Office, unless the appointee is without fault in causing the delinquency. (b) Each medical record shall be completed within thirty (30) days following discharge. An appointee who has not completed his or her medical records within thirty (30) days after discharge shall be considered delinquent and written notice of such automatic relinquishment shall be forwarded to the affected appointee by mail from the Department Chair through the Medical Staff Office with notification to the appropriate clinical department chairperson. Such relinquishment shall continue until all the delinquent records are completed. Section 3. Functions of Clinical Departments: The departments are organized for the purpose of implementing processes (i) to monitor and evaluate the quality and appropriateness of the care of patients served by the department; (ii) to monitor the practice of individuals with clinical privileges in a given department; and (iii) to provide appropriate specialty coverage in the Emergency Department, consistent with the provisions of these Bylaws and related documents. Departments may utilize sections, committees or service lines to facilitate compliance with department functions. MS Bylaws: Page 31. ARTICLE IV: B. Section 3. Created: May 2, 2018; Updated May 7, 2018; Updated May 16, 2018; Updated May 30, 2018; Updated June 6, 2018 Page 5 of 6

6 SACRED HEART HOSPITAL MEDICAL STAFF AND POLICIES 7 REVISION Consider changing Officer terms to two years. RATIONALE Reduce number of elections, standardize with SJCF. (SJCF currently has one year terms for both, SHEC one year for Officers and two years for Dept Chairs). ORIGIN OF RECOMMENDATION: MSS. Section 3. Officers: The officers of the Medical Staff shall be the President, Vice President and Secretary- Treasurer. Each officer shall serve a term of two (2) years for one (1) year, and may serve a maximum of one two (21) consecutive terms (2 years). Any officer who has served the maximum term of two (2) years in that office shall not be eligible again for election to that same office for a period of three (3) years. In special circumstances, the maximum term limit for an officer may be waived by the Nominating Committee with the approval of the Medical Executive Committee. MS Bylaws: Page 25 & 32 ARTICLE IV: Part A. Section 3 ARTICLE IV: Part A. Section 6 8 REVISION Clarify that AHPs can consult on patients in addition to physicians. RATIONALE Harmonize Rules and Regulations with current practice and standardize consultation language between SHEC and SJCF. ORIGIN OF RECOMMENDATION: MSS. Section 6. Selection and Term of Chairs and Vice Chairs: (a) Each chair and vice chair will be elected for a term of two (2) years by a majority vote of those department members eligible to vote in each department respectively. (b) These recommendations will be reviewed by the Medical Executive Committee and will be forwarded to the Board for final action. Section 2. Who May Give Consultations: Any Medical Staff appointee individual with clinical privileges at this hospital can be asked for consultation within his or her area of expertise. MS Rules and Regulations: Page 20 ARTICLE V: Section 2 Created: May 2, 2018; Updated May 7, 2018; Updated May 16, 2018; Updated May 30, 2018; Updated June 6, 2018 Page 6 of 6