ZSFG Medical Staff ByLaws Table of Substantive Changes

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1 Preamble 1 Updated name throughout: The Priscilla Chan and Mark Zuckerberg San Francisco General Hospital and Trauma Center Definitions 2 Governing Body Revised to align with Governing Body Bylaws Added Hospital Hospital Administration and Joint Conference Committee to align with Governing Body Bylaws Article 1 Name and Purposes 4 None Article 2 Medical Staff Membership Professional Liability Insurance-minimum $1 million each occurrence/$3 million aggregate Increased to $2 million/$6million; allows an excess or umbrella policy to meet minimums 8 Complete new hospital orientation within thirty (30) days of receipt of temporary privileges or appointment to the Medical Staff. Complete new hospital orientation prior to exercising privileges. Article 3 Categories of the Medical Staff Article 4 Appointment and Reappointments Article 5 Clinical Privileges Article 6 Corrective Action 9 Active, Courtesy and Provisional Added Administrative and Inactive and revised definition of Courtesy Affiliated Professionals Added Genetic Counselors 19 Added 5.6. Physician Observers 25 Added C. The Director of Health, or her/his designee, may restrict a Member s access to key aspects of the ZSFG infrastructure in 1

2 instances involving serious, material violations of federal, state, local, or ZSFG rules, regulations, or policies that are not primarily related to quality of patient care, including any violation of patient confidentiality laws or policies. Access to patient health records kept or maintained by the City and/or to physical locations (ZSFG, clinics, or other buildings owned or operated by the City) may be restricted, suspended, or permanently revoked in this manner. The approval of the MEC is not required for such actions. Article 7 Hearings and Appellate Reviews 34 Added Actions taken by the Director of Health, or her/his designee, pursuant to Section C. are subject to hearing under these Bylaws only for the purpose of determining whether to revoke, suspend or restrict Privileges conferred by these Bylaws. Article 8 Structure of the Medical Staff Article 9 Clinical Services Article 10 Physician Leadership 43 None 45 None 51 Entire Article is new 2

3 Article 11 Committees of the Medical Staff Minutes and Reporting (former) Joint Conference Committee Added standard meeting minutes template, Appendix 2 Deleted Credentials Reports to MEC monthly D. Reports Monthly CIDP (1) Donor Council (1)D. Reports twice yearly Infection Control Revised composition Revised duties Meets monthly Medical Staff Well Being Meets bimonthly Reports to MEC quarterly Operating Room Revised composition Revised duties Pharamacy & Therapeutics Reports to MEC monthly C. Medication Use C. Revised duties E. Pain Management D. Revised duties Added: D. Medication Error Reduction Plan Added: s report monthly PIPS Revised composition Revised duties 3

4 Reports to JCC monthly B. Pediatric Emergency Medicine C. Risk Management B. Deleted B. Renamed Event Analysis & System Improvement (EASI) B.(2) Revised duties B.(4)Reports to PIPS twice yearly D. Transfusion E. Trauma Program Operational Process Performance F. Trauma Multidisciplinary Peer Review subcommittee G.Tissue H. Procedural Sedation Utilization Management D.(1) Revised composition D.(4) Reports to PIPS twice yearly D and F.(4) Trauma Program Operational Process Performance and Trauma Multidisciplinary Peer Review s combined Trauma report to PIPS twiceyearly G(2) Revised duties H.(1) Revised Composition H.(4) Reports to PIPS twice yearly Reports to MEC quarterly 4

5 Article 12 Meetings of the Whole Medical Staff Article 13 Confidentiality of Information; Immunity and Releases Article 14 Conflicts and Dispute Resolution Article 15 Rules and Regulations Article 16 Adoption and Amendment 80 None 81 None 83 None 84 None 85 None Any Other Comments/Changes SECTION 1 - Admission and Attendance Policies RULES AND REGULATIONS 2-17 Attending, provider, practitioner Member of Medical Staff (Member) or Affiliate Member of the Medical Staff Section 5 - Surgeries 6 Op. reports signed with 14 days Signed within 5 calendar days Section 6 Medical records Section 6 Medical records Section 6- Medical Records 8 Post anesthesia note within 24 hours Within 48 hours 8 Op reports completed within 14 days Within 5 calendar days 8 Verbal orders signed within 14 days Within 5 calendar days Section 6- Medical Records Section 6- Medical Records (Outpatient) 9 Medical records completed within 14 days 10 Medical records completed within 14 days Within 5 calendar days Within 5 calendar days 5

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