SUTTER MEDICAL CENTER, SACRAMENTO DEPARTMENT OF MEDICINE PULMONARY SECTION RULES AND REGULATIONS. 1. Must be a member of the Department of Medicine

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1 SUTTER MEDICAL CENTER, SACRAMENTO MEDICAL STAFF REVIEW DATE: 10/2014 SUTTER MEDICAL CENTER, SACRAMENTO DEPARTMENT OF MEDICINE PULMONARY SECTION RULES AND REGULATIONS I. PURPOSE The Pulmonary Section is an organized component of the Department of Medicine providing an opportunity for physicians in Pulmonary Medicine to confer for the purpose of education, quality improvement and to address administrative problems of their medical practice in the hospital setting. II. ORGANIZATION A. Membership criteria for the Pulmonary Section: 1. Must be a member of the Department of Medicine 2. Must be Board Certified or Admissible in the Subspecialty of Pulmonary Medicine 3. If unable to meet criteria (2), and if his/her practice includes a substantial amount of time in the Subspecialty of Pulmonary Medicine, the physician may be admitted to the section by majority vote of the Section 4. Member may not currently be a member of another specialty section of the Department of Medicine at Sutter Medical Center, Sacramento. 5. The Pulmonary Section will recommend the training and experience criteria for membership in the Pulmonary Section to the Administrative Committee of the Department of Medicine. B. Privileges 1. Pulmonary privileges may be granted to Section Members and other physicians who: a. Are Board Certified or Board Admissible in Pulmonary Medicine; or

2 Page Two b. Have completed one year of full-time clinical Pulmonary Fellowship; or c. Can document satisfactory completion of previous two years of practice in a JCAHO-accredited hospital where he/she exercised pulmonary privileges comparable to those being requested at this facility. Can document current clinical competence as set out in the current Pulmonary Section guidelines for privileges. C. Criteria for Continued Section Membership and Privileges 1. Continued membership in the Section requires: a. Continued authority to exercise clinical privileges in the Pulmonary Section. b. Continued satisfactory performance of Medical Staff responsibilities, compliance with hospital unit policies, Section policies and continued good standing on the Medical Staff. 2. Continued exercise of clinical privileges in the Pulmonary Section requires satisfactory results in any proctoring, audit or review conducted by any Section, Department or Medical Staff Committee concerned with quality of care or satisfactory correction of any problems noted in any such review. D. Meetings 1. The Pulmonary Section will meet as needed for discussion of Section business. 2. Additional meeting may be called by the Chairman of the Section. 3. Meetings of the Section will have a meeting notice sent to members ten (10) days before scheduled meeting.

3 Page Three E. Voting 1. Elections of Section Officers shall be by mail, secret ballot. 2. Other matters may be decided by the majority vote of those present at any properly called meeting of the Section. 3. Proxy voting at meetings is permissible with written proxy given to the Section Chairperson in advance of, or at the time of the meeting, signed by the absent member designating who shall cast the member's vote. 4. Senior staff members are eligible to vote. F. Officers 1. Chairperson of the Pulmonary Section a. Section head shall be known as Section Chairperson. b. Section Chairperson shall have been a member of the Department of Medicine in good standing for two years. c. The chairperson is elected by majority of votes cast. d. Term of office is for two years. e. There is no limit to the number of terms except the individual may not serve more than two terms consecutively. f. The Chairperson of the Pulmonary Section shall be elected in odd-numbered years for a term beginning January 1 of the even-numbered year. 2. Duties of the Chairperson Duties of the Chairperson shall be in accordance with Department of Medicine Rules and Regulations, Section III-K. 3. Vice-Chairperson The Pulmonary Section may elect a Vice-Chairperson to perform in the absence of the Chairperson, if the Section feels its size and volume of business so requires.

4 Page Four III. SECTION RESPONSIBILITY AND AUTHORITY A. The Section derives authority from the Department of Medicine. B. Section policy requires the approval of the Department of Medicine Administrative Committee as well as the Medical Executive Committee and the Board of Trustees. C. Section rules are subservient to the Department of Medicine Rules and Regulations, which are, in turn, subservient to the Medical Staff Bylaws. D. Section rules are intended to be read in concert with the Department of Medicine Rules and Regulations. E. Assisting in quality improvement is a responsibility of the Section, under the direction of the Department of Medicine Quality Improvement Committee. IV. AMENDMENTS TO RULES A. Rules of the Pulmonary Section may be changed by majority vote taken by written ballot or at any regular meeting of the Section. Proposed changes shall be submitted to members, allowing at least two weeks for consideration prior to voting. Any additional amendments to the proposed changes raised during this two week period or at the meeting may be incorporated into the proposed changes prior to voting. B. Amendments to Rules are subject to approval of the Department of Medicine Administrative Committee, the Medical Executive Committee and the Board of Trustees.

5 Page Five APPROVAL PAGE Pulmonary Section October 7, 2011 Medicine Administrative Committee October 11, 2011 Medical Executive Committee October 25, 2011 Medical Policy Committee November 3, 2011 Board of Directors November 14, 2011 Developed: Reviewed (no changes): 5/89; 5/05, 10/2011 Revised: 7/91; 1/95; 3/01 aef; 9/28/11J:\MedStaff Docs\Department Medicine\Rules & Regulations\Pulmonary Section Rules & Regs.doc