FAIRFIELD MEDICAL CENTER MEDICAL STAFF ORGANIZATION MANUAL

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1 FAIRFIELD MEDICAL CENTER MEDICAL STAFF ORGANIZATION MANUAL

2 ORGANIZATION MANUAL OF THE MEDICAL STAFF OF FAIRFIELD MEDICAL CENTER Lancaster, Ohio TABLE OF CONTENTS Page PART ONE DEFINITIONS DEFINITIONS...1 PART TWO OFFICERS QUALIFICATIONS OF OFFICERS DUTIES OF GENERAL OFFICERS RELATED POSITIONS NOT CONSIDERED OFFICERS OF THE MEDICAL STAFF...4 PART THREE COMMITTEES GENERAL FUNCTIONS MEMBERSHIP AND APPOINTMENTS TERM AND REMOVAL VACANCIES MEETINGS AND MINUTES COMMITTEE CHAIR TERMINATION OF COMMITTEES JJ ROCHE QUALITY & SAFETY INSTITUTE PHARMACY & THERAPEUTICS COMMITTEE CREDENTIALS COMMITTEE CONTINUING MEDICAL EDUCATION COMMITTEE BYLAWS COMMITTEE JOINT CONFERENCE COMMITTEE CANCER COMMITTEE PRACTITIONER EFFECTIVENESS COMMITTEE BIOETHICS COMMITTEE CRITICAL CARE COMMITTEE...18 i

3 3.19 PERIPHERAL VASCULAR COMMITTEE MEDICAL STAFF INFORMATION TECHNOLOGY COMMITTEE MEDICAL STAFF QUALITY COMMITTEE HOSPITAL COMMITTEES WITH MEDICAL STAFF REPRESENTATION PEER REVIEW COMMITTEES...23 PART FOUR DEPARTMENTS FUNCTIONS OF DEPARTMENTS MEETINGS REPORTS VICE CHIEFS SECRETARIES VACANCIES RESIGNATION AND REMOVAL FROM POSITION AS DEPARTMENT CHIEF OR DEPARTMENT VICE CHIEF SECTIONS AND SUBSECTIONS ADDITIONAL DEPARTMENTS INTEGRATION OF DEPARTMENTS 27 PART FIVE MEETINGS AGENDA PARLIAMENTARY PROCEDURE MINUTES...29 ii

4 PART ONE DEFINITIONS 1.1 DEFINITIONS INCORPORATION OF DEFINITIONS The Organization Manual adopts and incorporates by reference the definitions contained in the Medical Staff Bylaws of the Medical Center ADDITIONAL DEFINITIONS The following terms shall have these meanings when used in this Manual, unless otherwise specified: Manual means this Organization Manual of the Medical Center. 1

5 PART TWO OFFICERS 2.1 QUALIFICATIONS OF OFFICERS Medical Staff officers must demonstrate executive and administrative ability through experience and prior constructive participation in Medical Staff leadership activities at the Medical Center; be recognized as having a high level of clinical activity and competence at the Medical Center; show a high level of involvement with the Medical Center; and be board certified by an appropriate specialty board. Officers must have more than five (5) years experience in his or her specialty with at least five (5) years continuous Medical Staff appointment and Clinical Privileges maintained in Good Standing during his or her tenure at the Medical Center. The Medical Staff officers shall have had at least two (2) years of leadership experience in an administrative position defined as having held the position of Medical Staff Department Chief or Vice Chief, and/or chair or member of a Medical Staff or Hospital committee within the past five (5) years. Medical Staff Officers must be a doctor of medicine or a doctor of osteopathy. Medical Staff Officers may be compensated for performing administrative duties. 2.2 DUTIES OF GENERAL OFFICERS PRESIDENT OF MEDICAL STAFF The President of the Medical Staff shall serve as the chief administrative officer of the Medical Staff and have the following responsibilities and authority: (a) (b) (c) (d) Act in coordination and cooperation with the Medical Center President and Chief Medical Officer in all matters of mutual concern within the Medical Center; Call, preside at, and be responsible for the agenda of all general and special meetings of the Medical Staff and of the MEC; Serve as an ex officio member of all other Medical Staff committees, without vote unless otherwise provided; Unless otherwise provided in the Medical Staff Bylaws, appoint, subject to MEC approval, Medical Staff appointees to and committee chairs of all standing, special and multi-disciplinary Medical Staff committees and, if required, members-at-large to the MEC; 2

6 (e) (f) (g) (h) In conjunction with the Chief Medical Officer, be responsible for the review and enforcement of Medical Staff Bylaws and Related Manuals, and other policies, for implementation of sanctions where these are indicated, and for obtaining the Medical Staff s compliance with procedural safeguards in all instances where corrective action has been requested against a Practitioner; In the absence of a Chief Medical Officer, the President of the Medical Staff in conjunction with the MEC shall fulfill these duties by working jointly with the Medical Center President in coordinating the Medical Center s clinical services, by coordinating the overseeing of the Medical Center s quality review, risk management and utilization management activities, by supervising the clinical organization of the Medical Staff and by advising the Medical Center President and Board on these matters; Transmit to the Board or to the appropriate committee of the Board and to the Medical Center President and Chief Medical Officer, the views and recommendations of the Medical Staff and MEC on matters of Medical Center policy, planning, operations, governance, grievances, quality review findings and relationships with external agencies, and transmitting the view and decisions of the Board and Medical Center President to the MEC and the Medical Staff; and Advise the Board, Chief Medical Officer and Medical Center President on matters impacting on patient care and clinical services, including the need for new or modified programs and services, for recruitment and training of professional and support staff personnel and for staffing patterns PRESIDENT-ELECT OR IMMEDIATE PAST PRESIDENT OF THE MEDICAL STAFF The President-elect or Immediate Past President of the Medical Staff shall alternate the following responsibilities and authority during their tenure while in office: a) Assume all of the duties and responsibilities and exercise all of the authority of the President of the Medical Staff when the latter is temporarily or permanently unable to accomplish the same; b) Serve as a member of the MEC and of the Joint Conference Committee; c) Perform such additional duties and to exercise such authority as is set forth in the Medical Staff Bylaws and Related Manuals or as is delegated by the President of the Medical Staff, the MEC or the Board of Directors; 3

7 (d) (e) (f) (g) (h) (i) Report and assure that accurate and complete minutes of all meetings of the Medical Staff and of the MEC are kept; Give proper notice of all Medical Staff and MEC meetings on order of the appropriate authority; Attend to all correspondence; Supervise the collection and accounting of any funds that may be collected in the form of dues, assessments, or otherwise and disburse funds as directed by the MEC or Medical Staff; Account for all funds of the Medical Staff at the monthly MEC and Medical Staff meetings; Prepare an annual financial report for transmittal to the Medical Staff and Medical Center President and any other interim reports that may be requested by the Medical Staff President or the MEC. 2.3 RELATED POSITIONS NOT CONSIDERED OFFICERS OF THE MEDICAL STAFF The following positions perform administrative functions for the Medical Center and the Medical Staff but shall not be considered officers of the Medical Staff. These positions are described in this Section for convenience OSMA HOSPITAL MEDICAL STAFF SECTION REPRESENTATIVE AND ALTERNATE Appointees of the Active Medical Staff shall be elected annually at the fourth quarterly meeting of the Medical Staff to serve as the representative and alternate to the Hospital Medical Staff Section of the Ohio State Medical Association, under the same election procedures as set forth in this Article for the election of general Medical Staff officers CHIEF MEDICAL OFFICER The position of Chief Medical Officer (CMO) shall be a Physician hired by the Medical Center and answering directly to the Medical Center President. The appointment of the CMO must have the endorsement of the Medical Staff by a two-thirds majority vote of the Medical Executive Committee. Termination of employment is the prerogative of the Medical Center President but would require consultation with the Medical Executive Committee prior to final action. If the CMO holds an appointment to the Medical Staff, termination of the CMO s Medical Staff status would exclude him or her from continuing as CMO, but termination of the Physician as CMO would have no bearing per se on the Physician s Medical Staff status. 4

8 The CMO is available for coordinating and enhancing the activities of the Medical Staff and representing the administration and Board of Directors to the Medical Staff. Duties shall include, but not be limited to: (a) (b) (c) (d) Serves as chief medical advisor to the Medical Center President and the administration while providing advice and counsel to the Medical Center management, Medical Staff and Board of Directors; Serves as non-voting advisor to and attends meetings of the Medical Executive Committee and Board of Directors and serves on the Administrative Council of the Medical Center; Facilitates communication and cooperation by attending Medical Staff department and section meetings; Facilitates communication and cooperation as non-voting ex officio member of the following committees: (i) (ii) (iii) (iv) (v) (vi) (vii) Credentials Committee; Bylaws Committee; Practitioner Effectiveness Committee; Medical Staff Quality Committee; Pharmacy & Therapeutics Committee; Practitioner Recruitment Committee; and Safety and Health Committee. (e) (f) Is actively involved in the Medical Center Quality Improvement program, coordinating the reporting of quality improvement data from the level of patient care through channels, ultimately to the Board of Directors; and If the CMO is an Appointee of the Medical Staff, he or she may have voting privileges on any Medical Staff committee only with appointment to that committee by the Medical Staff President. However, the CMO may not be appointed to the Medical Executive Committee or the Joint Conference Committee as a voting member DIRECTOR OF MEDICAL EDUCATION The position of Director of Medical Education shall be a Practitioner hired by the Medical Center and answering directly to the CMO and through the CMO to the President of the Medical Center. The Director of Medical Education is available 5

9 for coordinating and enhancing the Medical Education of the Medical Staff (primarily) and Medical Center personnel (secondarily). Duties shall include, but not be limited to: (a) (b) (c) (d) (e) (f) (g) (h) Attends and supports the meeting of the Continuing Medical Education (CME) Committee of the Medical Staff; Supervises the implementation of the CME Committee s activities including symposiums, third Tuesday educational presentations, and OMEN; Supports and explores the acquisition of CME credits for Medical Center sponsored programs; Available to instruct or arrange for instruction of individuals or groups of Practitioners at their request or at the request of peer review committees of the Medical Staff; Available to assist the CMO in the education of the Medical Staff regarding the medically related aspects of healthcare changes such as, Continuous Quality Improvement (CQI), National Practice Guidelines, and Healthcare Reform; Oversees the development and maintenance of the Medical Staff library; Serves as an advisor to the Chief Medical Officer and administration in areas of Medical Education and related fields as requested; and May attend, as a non-voting member, the Medical Staff Quality Committee meetings, or any other departmental meetings. 6

10 PART THREE COMMITTEES 3.1 GENERAL Committees of the Medical Staff shall be designated as standing or special STANDING COMMITTEES Standing committees shall be those committees established as standing committees in the Bylaws and the following additional committees: (a) (b) (c) (d) (e) (f) (g) (h) (i) (j) (k) (l) (m) JJ Roche Quality & Safety Institute; Pharmacy & Therapeutics Committee; Credentials Committee; Continuing Medical Education Committee; Bylaws Committee; Joint Conference Committee; Cancer Committee; Practitioner Effectiveness Committee; Bioethics Committee; Critical Care Committee; Peripheral Vascular Committee; and Medical Staff Information Technology Committee Medical Staff Quality Committee SPECIAL COMMITTEES 3.2 FUNCTIONS Special Committees shall be those committees that the MEC shall from time to time determine to be necessary with those functions and responsibilities as directed by the MEC. All committees of the Medical Staff, except the MEC, are subject to the authority of, and shall report to, the MEC. 7

11 Committees are authorized to perform such functions as are specified in the Bylaws or as may be directed by the MEC. The MEC or the Medical Staff President may also assign new functions to existing committees or make certain committees functions the responsibility of the Medical Staff as a whole. A committee may elect to perform any of its specifically designated functions by constituting a subcommittee for that purpose and reporting such action to the MEC in writing. Any such subcommittee may include individuals in addition to or other than members of the committee. 3.3 MEMBERSHIP AND APPOINTMENTS Unless otherwise specified, the chair and Medical Staff Appointees of all standing and special Medical Staff committees shall be appointed by the President of the Medical Staff, subject to consultation with and approval by the MEC. The Medical Center President shall serve as an ex officio member of all committees of the Medical Staff. 3.4 TERM AND REMOVAL Unless otherwise specifically provided, a Medical Staff committee member (other than one serving ex officio) shall continue until his or her successor is appointed, unless he or she shall sooner resign or be removed from the committee. A Medical Staff committee member (other than one serving ex officio) may be removed from the committee by a majority vote of the MEC, or by the Medical Staff President, subject to consultation with and approval by the MEC. 3.5 VACANCIES Unless otherwise specifically provided, vacancies on any Medical Staff committee shall be filled in the same manner in which the original appointment to such committee was made. 3.6 MEETINGS AND MINUTES A standing or special Medical Staff committee established to perform one or more of the Medical Staff functions required by these Bylaws shall meet as often as necessary to discharge its assigned duties; such shall require each standing Medical Staff Committee to meet in a regular schedule, not less than once each Medical Staff Year. Minutes shall be taken and kept at all standing or special Medical Staff Committees. All minutes and records of any committee relating to individual Practitioner quality improvement and peer review activities shall be maintained separately. All such minutes 8

12 and records of these committees shall be treated as confidential to the full extent permitted by law. 3.7 COMMITTEE CHAIR Unless otherwise specified herein, the chair of each committee shall be appointed by the President of the Medical Staff. Except as otherwise expressly provided, each chair of a committee shall have served for at least one (1) year on the committee or otherwise have experience in the functions assigned to the committee. 3.8 TERMINATION OF COMMITTEES A standing committee of the Medical Staff, except the MEC, may be abolished by amendment to this Manual in accordance with the provisions as set forth in the Medical Staff Bylaws. A special committee of the Medical Staff may be abolished by the imposition of a specific limitation upon its duration in accordance with the Bylaws or at any time by a resolution adopted by the MEC. 3.9 JJ ROCHE QUALITY & SAFETY INSTITUTE COMPOSITION The JJ Roche Quality and Safety Institute will be co-chaired by the Vice- President of the Medical Staff and the Chief Medical Officer. Medical Staff membership will consist of the Infection Control Medical Director and five (5) medical staff members appointed by the President of the Medical Staff. At least one of these five medical staff members will be a primary care provider with a predominantly outpatient practice in our service area. Medical Center representatives will include: Chief Nursing Officer, Chief Operating Officer, Chief Medical Information Officer, the Director of Quality, Safety and Six Sigma, a Six Sigma representative, the Director of Inpatient Services and the Director of Outpatient Services. Other members of the Medical Staff and Administration may be asked to attend on an ad hoc basis FUNCTIONS The functions of the Institute shall include, but are not limited to, the following: a) To be responsible for the integration and coordination of results of process and systems issues identified through the Medical Staff Quality Committee, ancillary service, standing committee of the Medical Staff, and risk management activities. b) To assure communication and reporting of quality activities among the Hospital Administration, the Medical Staff and the Board. 9

13 c) Develop innovative programs and provide expertise for quality improvement projects. d) Establish priorities and recommend resource allocation for performance improvement and safety projects throughout the organization, based on Fairfield Medical Center s strategic goals. e) To receive and review recommendations from relevant private and governmental agencies and devise program developments to meet regulatory standards. f) Review Scorecard Metrics and external data on a regular basis. g) Submit reports to the Medical Executive Committee and the Board of Directors on the overall quality and efficiency of medical care provided at Fairfield Medical Center. h) Analyze reports of utilization data compiled by Case Management. i) Develop processes to help guide physicians in patient care decisions using evidence-based medicine. j) Review findings from all Root Cause Analysis meetings MEETINGS The JJ Roche Quality & Safety Institute will meet on a regular basis and report to the Medical Executive Committee and the Board of Directors PHARMACY & THERAPEUTICS COMMITTEE COMPOSITION The Pharmacy & Therapeutics Committee shall consist of at least three (3) Medical Staff Appointees, the Pharmacy manager, a nurse and an administrator FUNCTIONS The Pharmacy & Therapeutics Committee shall perform the following functions: (a) (b) To serve in an advisory capacity to the Medical Staff and Medical Center Administration in all matters pertaining to the use of drugs; To develop a formulary of drugs accepted for use within the institution and provide for its constant revision; 10

14 (c) (d) (e) (f) (g) (h) (i) (j) (k) (l) To establish programs and procedures that help ensure cost effective drug therapy; To assist in establishing or planning suitable educational programs on matters related to drug use for the institution's professional staff; To participate in quality improvement activities related to the distribution, administration, and use of medications; To review adverse drug reactions within the institution; To initiate and/or direct Drug Use Evaluations (DUE) and review the results of such activities; To advise the pharmacy in the implementation of effective drug distribution and control procedures; To make recommendations concerning drugs to be stocked in patient care areas. Review all non-cpoe pre-printed order sheets to ensure that they are clear, complete and consistent with the pharmacy formulary; and Serve as a reference for the CPOE Oversight Committee in the development of order sets; and To reduce medical errors MEETINGS The Pharmacy & Therapeutics Committee shall meet on a regular basis CREDENTIALS COMMITTEE COMPOSITION The Credentials Committee shall consist of a representative from the departments of Anesthesiology, Emergency Medicine, Medicine, OB/GYN, Pediatrics, Pathology, Surgery and Radiology. Additional members from the departments may be appointed at the discretion of the Medical Staff President. The Medical Staff President, the CMO, and a representative from, and designated by, the Board of Directors shall serve as ex officio members without vote FUNCTIONS 11

15 The Credentials Committee is responsible for ensuring that Appointees of Medical Staff and AHPs are qualified in the performance of Clinical Privileges granted to them. The Credentials Committee shall review the credentials of all Applicants for all classifications of Clinical Privileges within the Medical Center and make recommendations for Medical Staff appointment, assignment to departments and delineation of Clinical Privileges in order to assist the Medical Executive Committee in its responsibilities of credentialing, appointment and reappointment and delineation of Clinical Privileges. It shall review periodically all information available regarding the performance and clinical competence of Medical Staff Appointees and AHPs with Clinical Privileges and make recommendations for reappointment and renewal or changes in Clinical Privileges. The Credentials Committee shall have the authority to require the submission of adequate information for proper evaluation of competence, character, ethics, ability to perform and other qualifications. The Credentials Committee has the responsibility for monitoring the proctoring process as provided in the Credentials Manual. Whenever the Credentials Committee is considering a possible action that could result in reduction of a Practitioner's current Clinical Privileges, the Practitioner shall be notified and given the opportunity to present information to the Credentials Committee prior to the Credentials Committee rendering a decision or recommendation MEETINGS The Credentials Committee shall meet on a regular basis, shall maintain a permanent record of its findings, proceedings and actions and shall make a report thereof to the Medical Executive Committee. The chair of the Credentials Committee shall be responsible to the Medical Executive Committee and will attend meetings as necessary CONTINUING MEDICAL EDUCATION COMMITTEE COMPOSITION The President of the Medical Staff shall appoint an Appointee of the Medical Staff to serve as chair of the Continuing Medical Education Committee. Additional members shall be appointed by the Medical Staff President as deemed necessary FUNCTIONS The Continuing Medical Education Committee shall be responsible for a program of continuing education for all Medical Staff Appointees and other Practitioners with Clinical Privileges, designed to keep them informed of pertinent new developments in the diagnostic and therapeutic aspects of patient care and to refresh them in various aspects of their basic medical education. The program 12

16 should include Medical Center sponsored elements on a regular recurring basis and may be presented on a Medical Staff or departmental level as appropriate. The program shall be relevant to the type of patient care delivered in the Medical Center and shall, in part, be related to the findings of concurrent and retrospective quality assessment and patient care evaluation studies. The degree of participation of each Medical Staff Appointee shall be documented. Participation in continuing education programs outside the Medical Center should also be documented to demonstrate its relevance and the effort made by individual Medical Staff Appointees to stay current in their field. This information should be incorporated into each Medical Staff Appointee s credentials file for evaluation at the time of reappointment. The Continuing Medical Education Committee shall be responsible for the changing needs and adequacy of the professional library services, including audiovisual aids, to meet the needs of the Medical Center and Medical Staff. This shall include deletion of outmoded materials as well as the acquisition of new materials. The Continuing Medical Education Committee shall maintain the Medical Center s OSMA accreditation as a Category I CME provider MEETINGS The Continuing Medical Education Committee shall meet on a regular basis, shall maintain a permanent record of its findings, proceedings and actions. The chair of the Continuing Medical Education Committee shall be responsible to the Medical Executive Committee BYLAWS COMMITTEE COMPOSITION The President-elect and Immediate Past President shall alternate serving as chair of the Bylaws Committee. Additional committee members shall be selected in accordance with the procedure set forth in Section of the Medical Staff Bylaws FUNCTIONS The Bylaws Committee shall meet on a regular basis and be responsible for periodic review of the Medical Staff Bylaws and Related Manuals at least biennially and shall make recommendations relating to revisions and updating to conform with current requirements. The Bylaws Committee shall review proposed changes in the Medical Staff Bylaws and Related Manuals and prepare amendments for presentation to the Medical Executive Committee. It shall also 13

17 review any matters concerning provisions of the Medical Staff Bylaws and Related Manuals as requested. The chair of the Bylaws Committee shall be responsible to the Medical Executive Committee JOINT CONFERENCE COMMITTEE COMPOSITION The Joint Conference Committee shall be composed of an equal number of at least three (3) members of the Medical Executive Committee and of an equal number of at least three (3) members of the Board of Directors. The representatives from the Medical Staff shall include the President, Vice President, and Immediate Past President. The chair shall be alternated between the Board of Directors and Medical Staff every two (2) years. The Medical Center President and the Medical Staff Secretary-Treasurer shall be ex officio members without voting privileges FUNCTIONS The Joint Conference Committee shall conduct itself as a forum for the discussion of matters of Medical Center policy and practice, especially those pertaining to efficient and effective patient care, and shall provide medico-administrative liaison with the Board of Directors and the Medical Center President. The Joint Conference Committee shall also review the strategic needs of the Medical Center and reassess the Medical Center s institutional need. The Joint Conference Committee shall recommend amendments to the Medical Center s recruitment plan as necessary and review any issues which may arise as to institutional need among the reviewing departments, sections, committees and the Board MEETINGS The Joint Conference Committee shall meet on a regular basis and upon call of either the President of the Medical Staff, the chair of the Board of Directors or the Medical Center President and shall submit written reports to the Medical Executive Committee and to the Board of Directors CANCER COMMITTEE COMPOSITION The President of the Medical Staff shall appoint an Appointee of the Medical Staff to serve as chair of the Cancer Committee and shall appoint additional members as deemed necessary. The appointments shall include at least one (1) member of the following clinical specialties: Internal Medicine, Medical Oncology, Family Practice, Surgery, Maternal Child Health, Diagnostic Radiology, Pathology, and Radiation 14

18 Oncology. The Cancer Committee shall also include the Cancer Liaison Physician who is a fellow of the American College of Surgeons. Medical Center representatives, appointed by the Medical Center President, shall attend meetings including a representative of administration, social services, quality assurance, nursing services, and the Oncology Data Analyst. Medical Center representatives shall not be considered in establishing a quorum and shall not have a vote FUNCTIONS The functions of the Cancer Committee shall be to: (a) (b) (c) (d) (e) (f) (g) (h) (i) (j) (k) (l) Organize, publicize, conduct and evaluate regular educational and consultative cancer conferences that are multi-disciplinary, Medical Center-wide and patient oriented; Assure that consultative services from all major disciplines and cancer rehabilitative services are available to patients; Encourage a supportive care system and lifelong surveillance for all patients with cancer; To determine which cancer prevention programs are needed; Encourage studies by clinicians, administrators, and other health care professionals and plan and complete a minimum of two (2) patient care evaluation studies annually, one to include survival data and, if available, comparison data; Analyze various aspects of cancer treatment in relation to regional or national data, including: (1) pre-treatment work-up and staging; (2) patient survival by stage of disease and treatment; (3) the need for public and professional educational programs about early diagnosis of specific malignancies; Document patterns of recurrence of specific malignancies and the occurrence of multiple primary malignancies; Evaluate the quality of care of patients with cancer; Reevaluate effectiveness of the patient care evaluation program; Supervise the cancer registry; Publish and distribute the annual report; Serve as registry physician-advisor(s); and 15

19 (m) Ascertain that educational programs, conferences, and other clinical activities include all major sites of cancer seen at the Medical Center MEETINGS The Cancer Committee shall meet on a regular basis. A permanent record of its policy-advisory functions, findings, proceedings and activities shall be maintained and reported to the Medical Executive Committee. The chair shall be responsible to the Medical Executive Committee and will attend Medical Executive Committee meetings as necessary PRACTITIONER EFFECTIVENESS COMMITTEE COMPOSITION In order to improve the quality of care and promote the competence of the Medical Staff, the President of the Medical Staff shall appoint a Practitioner Effectiveness Committee comprised of no less than five (5) Appointees of the Medical Staff, a majority of whom, including the chair, shall be Physicians FUNCTIONS The functions of the Practitioner Effectiveness Committee shall be to act in accordance with the Practitioner Effectiveness Policy in the Credentials Manual, including but not limited to, engaging in the following activities: (a) (b) (c) (d) (e) To review and investigate reports and other writings referred to it related to the health, well-being, or impairment of, or related to the suspected disruptive behavior of, any and all Medical Staff Appointees and to take such actions as are authorized pursuant to the Practitioner Effectiveness Policy. To consider general matters related to the health and well-being of the Medical Staff Appointees and, with the approval of the MEC, to develop education programs or related activities for the Medical Staff and Medical Center personnel concerning illness and impairment recognition issues specific to Practitioners. Such educational programs and materials will include information to assist Practitioners in self-referring for treatment; To provide advice, counseling, referrals to an approved treatment provider, or other referrals as may seem appropriate. To recommend procedures for the management of impaired Practitioners; To make recommendations regarding the restrictions on the Clinical Privileges of impaired practitioners; 16

20 (f) (g) (h) To monitor the progress of impaired Practitioners during treatment and aftercare, as described in an individualized reentry contract agreement; To make recommendations regarding the phased return to full Clinical Privileges after treatment; and To prepare, execute, supervise and direct reentry contract agreements. Such activities shall be confidential; however, in the event information received by the Practitioner Effectiveness Committee clearly demonstrates that the health or known impairment of a Medical Staff Appointee poses any risk of harm to patients, that Practitioner should be referred for corrective action or to an approved treatment provider. (See Ohio Revised Code Section (B)). The Practitioner Effectiveness Committee will coordinate its activities with the department chief, the Medical Staff President or Chief Medical Officer as the Practitioner Effectiveness Committee deems appropriate and necessary. The Practitioner Effectiveness Committee shall also consider general matters related to the health and well being of the Medical Staff and, with the approval of the Medical Executive Committee, develop educational programs or related activities, in conjunction with the Ohio State Medical Association. The Practitioner Effectiveness Committee may elect to refer a Practitioner to the Ohio Practitioner Effectiveness Committee, to have the Ohio Practitioner Effectiveness Committee perform these or similar functions MEETINGS The Practitioner Effectiveness Committee shall meet as often as necessary at the call of its chair. It shall maintain only such record of its proceedings, as it deems advisable but shall report on its activities to the President of the Medical Staff BIOETHICS COMMITTEE COMPOSITION The Bioethics Committee is advisory in nature. The chair shall be appointed by the President of the Medical Staff, and the Bioethics Committee shall consist of Practitioners, and may also include two (2) nursing representatives, one (1) case management representative, one (1) patient advocate and one (1) representative of the center chaplaincy. The Bioethics Committee may invite knowledgeable members of the community to become Bioethics Committee members, as they deem appropriate FUNCTIONS 17

21 The functions of the Bioethics Committee shall be: (a) (b) (c) (d) (e) To assist in the formulation of Medical Center policy as it pertains to medical ethics; To provide a non-judgmental atmosphere in which to explore ethical dilemmas both prospectively and retrospectively by clarification of values and development of a rational decision making process; To serve as a forum and source of ideas for resolution of ethical conflict in actual Medical Center cases; To assist and support the Medical Center and Medical Staff in clarifying treatment goals and care plans in ethical issues; and To educate Medical Center staff, Medical Staff and the community regarding ethical issues as they apply to healthcare MEETINGS The Bioethics Committee shall meet on a regular basis and at the call of its chair. It shall maintain a record of its activities and report to the Medical Executive Committee CRITICAL CARE COMMITTEE COMPOSITION The Critical Care Committee is a Medical Staff committee consisting of a minimum of four (4) Practitioners from the Department of Medicine, to include at least one (1) critical care specialist, one (1) cardiologist, one (1) internist and one (1) family practitioner; and at least one (1) Practitioner from the Department of Emergency Medicine. Practitioners from the Departments of Surgery, Anesthesiology, and OB/GYN are encouraged to attend, but not required. Nonvoting, ex officio members will be the nurse managers of the intensive care unit and step down unit, vice president of clinical services and the Medical Center Chief Medical Officer, and other Medical Center support staff as required. The Critical Care Committee chair and members will be appointed by the Medical Staff President annually. The chair will provide the meeting agenda and conduct the meetings. He or she will also serve as a liaison between Medical Staff, the Critical Care Committee, the unit manager and Medical Center administration on critical care issues FUNCTIONS The functions of the Critical Care Committee shall be: 18

22 (a) (b) (c) (d) (e) Review patient care processes unique to the critical care and step down units and recommend changes that would improve the outcomes, safety, and efficacy of these processes. This includes the adoption of clinical guidelines/standardized orders for high frequency, high risk and high cost processes; Adopt protocols for invasive procedures and monitor compliance and complications. All complications of invasive procedures will be peer reviewed; Review and make recommendations on policies to promote the most efficient utilization of our critical care resources; Provide recommendations to the Medical Staff and Medical Center administration regarding the organization of critical care services, credentialing and privileging, capital equipment needs and other critical care issues that may arise; and Promote compliance with guidelines, policies and procedures MEETINGS Meetings will be on a regular basis or at the call of the Chair and will include an executive session for all peer review matters PERIPHERAL VASCULAR COMMITTEE COMPOSITION The Chairperson of the Peripheral Vascular Committee will be appointed by the Medical Staff President and will be an appointee of the Active medical Staff. The members will consist of vascular surgeons, cardiologists, and invasive radiologists that are involved in peripheral vascular procedures and other appropriate members of the medial staff FUNCTIONS The Peripheral Vascular Committee shall perform the following functions: (a) Organization of quality improvement activities regarding peripheral vascular procedures and to make reports to the Medical Staff Quality Committee indicating recommendations, actions taken and the results thereof. (b) When important problems in patient care and clinical performance or opportunities to improve care are identified, actions are taken and the effectiveness of the action taken is evaluated. 19

23 (c) Make recommendations to the Medical Staff and Credentials Committee regarding peripheral vascular credentialing and privileging MEETINGS The Peripheral Vascular Committee shall meet on a regular basis and shall maintain a permanent record of its findings, proceedings, and actions MEDICAL STAFF INFORMATION TECHNOLOGY COMMITTEE COMPOSITION The Chairperson of the Medical Staff Information Technology Committee will be appointed by the Medical Staff President and will be an appointee of the Active medical staff. The members will consist of Practitioners and may also include representatives from Hospital IT, Administration, Board of Directors, and Patient Care Services FUNCTIONS The purpose of the Medical Staff Information Technology Committee is to provide physician-based oversight to the acquisition, implementation, and use of Information Technology, especially in regards to improving the overall quality of patient care, treatment, and services at Fairfield Medical Center. The Medical Staff IT Committee is accountable to the Medical Executive Committee. The Committee serves as a forum to identify important health information management and technology issues, and then develop plans and actions to address these concerns, with an emphasis on user-friendly functionality. The Committee shall operate by authorizing a set of working sub-committees that will focus on specific areas of concern. These sub-committees will report to the Medical Staff IT Committee on a regular basis MEETINGS Meetings shall be held on a regular basis or at the call of its chair. It shall maintain a record of its activities and report to the Medical Executive Committee COMPUTERIZED PATIENT ORDER ENTRY (CPOE) COMMITTEE The Computerized Patient Order Entry (CPOE) Oversight Committee is a subcommittee of the Medical Staff IT Committee responsible for the development of physician order sets at Fairfield Medical Center. The CPOE Oversight Committee will appoint various ad hoc subcommittees of physician specialists to create disease-specific and specialty-specific order sets. The Committee will 20

24 confer with the Pharmacy and Therapeutics Committee as needed to ensure the order sets are consistent with the pharmacy formulary. Preliminary order sets will then be reviewed by the appropriate department chairs and submitted to the Medical Executive Committee for final approval. The Committee will be responsible for the systematic review and maintenance of order sets, providing progress reports to the Medical Staff IT Committee on a regular basis MEDICAL STAFF QUALITY COMMITTEE COMPOSITION The Medical Staff Quality Committee shall consist of a chairperson and up to ten Appointees of the Medical Staff from a variety of specialties as appointed by the President of the Medical Staff. Members will be appointed for three year alternating terms. The Chairperson will be an ex-officio member of the MEC without vote FUNCTIONS The primary purpose of the Medical Staff Quality Committee is to improve the quality and safety of care at Fairfield Medical Center.The committee will examine the performance of individual practitioners and determine whether the physician under review has met accepted standards of care in rendering medical services. Peer review is conducted using multiple sources of information including: 1) the review of individual cases, 2) the review of aggregate data for compliance with general rules of the medical staff and clinical standards, and 3) the use of rate measures in comparison with established benchmarks or norms. This Committee will also review findings from the Root Cause Analysis meetings. All peer review information is privileged and confidential in accordance with medical staff and hospital bylaws, state and federal laws, and regulations pertaining to confidentiality and non-discoverability. Recommendations for performance improvement activities or corrective action for individual physicians will be reported to the Medical Executive Committee MEETINGS The Medical Staff Quality Committee will meet regularly and report to the Medical Executive Committee. 21

25 3.22 HOSPITAL COMMITTEES WITH MEDICAL STAFF REPRESENTATION The Hospital has the following standing Committees with Medical Staff representatives appointed by the Medical Staff President: Clinician & Physician Liaison Committee Graduate Medical Education Infection Control Nursing Executive Council Operating Room Committee Practitioner Recruitment & Retention Committee Value Analysis All Committees are subject to the authority of and shall report to the Medical Center President. Committees are authorized to perform such functions as are specified by the Hospital or directed by the Medical Center President. The Medical Center President may assign new functions to existing Committees. A Committee may elect to perform any of its specifically designated functions by constituting a subcommittee for that purpose and reporting such action to the Medical Center President in writing. Any such subcommittee may include individuals in addition to or other than members of the Committee. The Medical Center President may serve as ex officio member of any Hospital Committee. A Medical Staff Committee member shall continue serving on the Committee until his or her successor is appointed, unless he or she shall sooner resign or be removed from the Committee by the Medical Staff President. Meetings shall be held as often as necessary to discharge its assigned duties. Minutes shall be taken and kept for all Hospital Committee meetings. A Hospital Committee may be abolished at the discretion of the Medical Center President. Each Hospital Committee is responsible for delineating their Committee functions and goals PEER REVIEW COMMITTEES The Medical Staff as a whole and each committee provided for by these Bylaws is hereby designated as a peer review committee as that term is defined in Ohio Revised Code et seq. The Medical Staff, through its committees, shall be responsible for evaluating, maintaining, and/or monitoring the quality and utilization of the Medical Center s health care services. In carrying out his/her duties under these Bylaws, whether as a committee member, Department Chief, Medical Staff officer or otherwise, each Medical Staff Appointee shall be acting in his/her capacity as a peer review committee member and designated agent of the Medical Staff. Such peer review committees and their designated agents may, from time to time and/or as specifically provided herein, appoint Medical Center administrative personnel as their agent in carrying out such peer review duties. 22

26 PART FOUR DEPARTMENTS 4.1 FUNCTIONS OF DEPARTMENTS GOVERNANCE Each department will function as a component of the Medical Staff under the authority of the Medical Executive Committee. Each department will have a chief as provided in the Bylaws. Each clinical department shall establish policies regarding its own criteria, consistent with the policies of the Medical Staff and of the Board of Directors, for the granting of Clinical Privileges in the department. Each department may establish other department policies as deemed necessary. All department policies will be contained in the Rules, Regulations and Policies Manual QUALITY 4.2 MEETINGS Each department shall be responsible for developing objective criteria that reflect current knowledge and clinical experience. Each department shall meet at least on a quarterly basis to conduct general business. A record of conclusions, recommendations, and action taken on these matters shall be maintained. 4.3 REPORTS Each department shall submit a report to the Medical Executive Committee at least quarterly detailing the department s activities, including meeting minutes. Minutes relating to peer review will be specifically delineated as such. 4.4 VICE CHIEFS Departments may elect vice chiefs as deemed necessary. A department must elect a vice chief if it is determined by the Medical Staff President or MEC such an officer is necessary for the department. A department vice chief must meet all of the same qualifications as the department chief. A vice chief shall be elected to the office, serve a term in the office and be removed from office in the same manner as provided for department chiefs in Section 10.4 of the Bylaws. 23

27 A department vice chief, if any, has the following responsibilities: (a) (b) (c) Conduct department meetings in the absence of the department chief; Assist the department chief with his or her specific duties and obligations; and Assume all of the duties and responsibilities and exercise all of the authority of the department chief, including attendance at the MEC as the department representative, when the department chief is temporarily or permanently unable to accomplish the same. 4.5 SECRETARIES Departments may elect a secretary as deemed necessary. A department must elect a secretary if it is determined by the Medical Staff President or the MEC that such an officer is necessary for the department. A department secretary must meet all of the same qualifications as the department chief. A secretary shall be elected to the office, serve a term in the office and be removed from office in the same manner as provided for department chiefs in Section 10.4 of the Bylaws. A department secretary, if any, shall have those responsibilities assigned to him or her by the department chief. 4.6 VACANCIES A vacancy in the office of department chief shall be filled by the department vice chief, if such a vice chief exists. If the department does not have a vice chief at the time of the vacancy of chief, the office of chief shall be filled temporarily by an Appointee of the Active Medical Staff appointed by the Medical Staff President. Subsequently, the office of chief shall be filled by an election of the department, in accordance with Section 10.4 of the Bylaws, to be held at the department s next regularly scheduled meeting. In such situation, the acting chief shall serve only until the election results are final, and the individual then elected shall assume office immediately. If the office of vice chief is vacant due to the accession of the vice chief to the office of chief, or for any other reason, the office of vice chief shall be filled by an election of the department, in accordance with Section 10.4 of the Bylaws, to be held at the department s next regularly scheduled meeting. The foregoing shall not require those departments that have decided not to maintain the office of vice chief, in accordance with Section 4.6 of this Manual, to elect a vice chief. 24

28 4.7 RESIGNATION AND REMOVAL FROM POSITION AS DEPARTMENT CHIEF OR DEPARTMENT VICE CHIEF RESIGNATION A department chief or vice chief may resign at any time by giving written notice to the MEC. Such resignation, which may or may not be made contingent on formal acceptance, shall take effect on the date of receipt or at any later time specified in it REMOVAL Removal of a department chief or vice chief may be effected either: (a) (b) by the Board acting upon its own initiative; or by a two-thirds (2/3) majority vote of the active Medical Staff Appointees in good standing of the department if such vote is ratified by the MEC and the Board. The chief or vice chief who is the subject of the removal action shall be given ten (10) days prior written notice of the meeting of the MEC or Board, as applicable, at which time the vote is to be taken and shall be afforded the opportunity to speak on his or her own behalf at said meeting. When the Board is contemplating action to remove a department chief or vice chief, it will refer the matter to a special combined committee composed of three (3) representatives each from the Board and the active Medical Staff, appointed respectively by the chair of the Board and the Medical Staff President. The Medical Center President shall also sit with this special committee as an ex officio member, without vote. Board action after receiving the special committee s report shall be the final decision. Permissible bases of removal of a department chief or vice chief include those specified in the Bylaws Section 9.6 for removal of a general Medical Staff officer. 4.8 SECTIONS AND SUBSECTIONS GENERAL The chief of a department, acting with the approval of a majority of the voting members of the department and the MEC, may create sections of a department. The chief of the department shall appoint a Practitioner who has or will have Clinical Privileges in the section or subsection to serve as the chair of the section. Such chair of a section shall serve at the pleasure of and shall report to the department chief. 25

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