MEDICAL STAFF RULES AND REGULATIONS OF MEMORIAL HERMANN SOUTHEAST/PEARLAND HOSPITAL. Version (December 21, 2017)

Transcription

1 MEDICAL STAFF RULES AND REGULATIONS OF MEMORIAL HERMANN SOUTHEAST/PEARLAND HOSPITAL Version (December 21, 2017)

2 Medical Staff Rules and Regulations of Memorial Hermann Southeast/Pearland Hospital 1. PATIENT MANAGEMENT 1.1 Except in emergency, no patient shall be admitted to the Hospital until after a provisional diagnosis has been stated. In the case of emergency, the provisional diagnosis shall be stated as soon after admission as possible. 1.2 All patients admitted to or placed in observation status in the hospital shall have an Attending Physician who shall be in charge of coordinating the overall care of the patient while in the hospital. The Attending Physician or one of his/her consultants shall see the patient as soon as medically necessary but in all cases within 4 hours. If a patient is seen in the physician s office and is a Direct Admission to the hospital and the physician has performed a complete and up to date history and physical and written orders that are sent with the patient, then they have already met the 4 hour rule. The Attending Physician shall see the patient every day thereafter until the patient is discharged. The Attending Physician shall see the patient within 2 hours of admission to the ICU. The Attending Physician shall then see the patient every day thereafter until the patient is discharged. The Attending Physician or one of his/her consultants shall see newborn admissions in the Level One Nursery within 24 hours of birth. Documentation of admission examination, including the current status of the patient, shall be recorded in the medical record. The physician ultimately responsible for meeting these timelines and for the patient s care and well-being is the Attending physician. 1.3 The treatment of mentally incompetent persons or unemancipated minors without written consent or a court order is authorized upon written consultation between the attending physician and at least one physician on the Attending Staff who is a specialist in a related discipline, and it is determined from such consultation that serious permanent harm would result to the patient or that the life of the patient is in immediate danger and any delay in administering treatment would add to that danger. 1.4 When a Nurse Anesthetist is giving anesthesia, an anesthesiologist must be immediately available in the operating suite for consultation. 1.5 Except in emergency situations, the Attending Physician is responsible for ordering all consultation when indicated, and for calling in a qualified Consultant which should be noted in the doctor's orders. The Attending Physician will be responsible for communicating to the Consulting Physician the reason for the consultation either in the order, progress note or verbal communication. The following circumstances require the requesting physician to have an immediate verbal discussion with the Consultant: stat consults and consults for Intensivists. Regarding the requirement for response back to the Emergency Department for Attending Physicians and Consultants: Attending Physicians: 2

3 If no response within 30 minutes for STAT calls or within 60 minutes for ROUTINE calls, the Emergency Department shall contact the On-Call physician for the respective specialty. If the specialty does not have an On Call physician, the Emergency Room Physician shall have the discretion to admit or transfer the patient to any available physician of the appropriate specialty. Consulting Physicians: If no response within 30 minutes for STAT calls the Emergency Department shall contact the On-Call physician for the respective specialty. If the specialty does not have an On Call physician, the Emergency Room Physician shall have the discretion to admit or transfer the patient to any available physician of the appropriate specialty. For ROUTINE consults, while the Emergency Department may notify Consultants, it is ultimately the responsibility of the Attending Physician to coordinate and follow up with Consultants. 1.6 Indication for the administration of blood or blood products shall be documented by the physician ordering them in progress notes, or if given at time of operative procedure, it will be reflected in the dictated operation report. 1.7 Include in Newsletter Midlevel Providers may perform medical screening exams on non-urgent patients in the Emergency Department under the direct supervision and delegation of the Emergency Department physician. While Midlevel Providers may see inpatients as defined by their delineation of privileges, the Attending Physician is still required to see patients as defined in rule 1.2 and document such in the chart. If a Mid-level Provider working under the Attending Physician performs the History and Physical, Daily Progress Notes, and/or Discharge Summary, then the Attending Physician may refer to the note but must provide summary comments that confirm their finding and treatment plan prior to electronic signature of the History and Physical, Daily Progress Notes, and/or Discharge Summary. 1.8 Except for blood, blood products, and chemotherapy, orders for outpatient diagnostic tests/treatments and physical therapy may be accepted from a physician or doctor of chiropractic who is not a member of the Memorial Hermann Southeast Hospital Medical Staff but who has a valid license to practice in the United States. Orders for blood, blood products, and chemotherapy shall be ordered only by a member of the Active or Affiliate Staff. 1.9 Telemedicine. Telemedicine is the use of any medium, including electronic, by a licensed independent practitioner to provide interpretive services for the diagnosis or treatment of a patient at Memorial Hermann Southeast Hospital ("Hospital"). Episodic services, as defined by the Texas Medical Board, provided solely for the purpose of offering an expert opinion and/or to advise the treating practitioner, but not directing the patient's care, are not telemedicine services for the purposes of these Bylaws. 3

4 Practitioners providing telemedicine services need not be members of the Hospital Medical Staff; however they shall be credentialed and privileged for relevant services in accordance with the requirements of the Memorial Hermann Southeast Bylaws. Credentialing information from the site where the Practitioner providing the services is located ("Originating Site") may be used by the Hospital to establish privileges if the Originating Site is a TJC accredited organization. Practitioners providing telemedicine services who are physically located outside the State of Texas, shall be credentialed and privileged in accordance with the requirement of the Memorial Hermann Southeast Bylaws and shall be required to present a current Special Purpose License for Practice of Medicine Across State Lines ("SPL") as required by the laws of the State of Texas. All telemedicine services shall be provided pursuant to a contract in accordance with such terms and conditions as the Hospital from time to time may require Every ICU patient, with the exception of those patients that have a Cardiologist acting as their attending physician, shall have a mandatory Intensivist consult. The Attending physicians shall directly communicate with the Intensivist regarding the patient (see rule 1.5). The Intensivist shall see and assume care of the patient within 2 hours of admission to the ICU (see also rule 1.2). Trauma Patients admitted to ICU shall be admitted to the Trauma Surgeon and seen by the Trauma Surgeon within 1 hour All observation and admitted patients shall be assessed for Deep Vein Thrombosis prophylaxis by using the VTE Advisor Tool in Care4 (if appropriate for that subset of patient population). The VTE assessment is the responsibility of the Attending physician for all patients, the Attending and Critical Care physician for all ICU patients, and the Attending and Surgeon for all surgical patients All central venous line insertions shall be completed with the assistance of ultrasound guidance. Imaging guidance will be used at the time of the procedure for the performance of all thoracentesis procedures. Exceptions would be in emergent situations when waiting for the availability of ultrasound or trained personnel would be detrimental to patient care. Physicians and other individuals performing thoracentesis under imaging guidance will be required to have appropriate training in the use of imaging guidance for this purpose, if not already trained (i.e. radiologists or other specialists already familiar with using these modalities) The Time Out process is essential to patient safety. It is mandatory for all Practitioners to participate in the Time Out process 4

5 before all invasive and high risk procedures. Preferably, the practitioner who is performing the procedure will lead the Time Out process. Failure to participate in the Time Out process may result in corrective action Consultant Physicians shall not cancel the discharge order of an Attending Physician without first having a verbal discussion with the Attending Physician An autopsy may be performed only with a valid written consent, or as required by State law. All autopsies shall be performed by a Hospital Pathologist, or by a practitioner who is delegated this responsibility in accordance with State law. Every member of the Medical Staff is expected to be proactive in securing autopsies in all cases of unusual deaths and of medical legal and educational interest. Provisional anatomic diagnosis shall be recorded on the medical record within three days from the patient s death, and a complete protocol should be made a part of the record within 60 days from the patient s death unless exceptions for special studies are established by the Medical Staff. For further details refer to Autopsy Procedure Version 2, Publication date 02/12/2016 in SE/PL Hospital Policies. 2. EMERGENCY DEPARTMENT 2.1 In case of a major disaster as determined pursuant to the Hospitals Emergency Disaster Plan, the Emergency Medicine Section has the authority to move or discharge patients. 2.2 Physicians on the Emergency Department call list are obligated to respond. On Call Physicians must respond in person within a reasonable period of time if requested to do so by the Emergency Department Physician. The Emergency Department Physician will clearly articulate and document that the On Call Physician has been requested to come in to see the patient. Trauma Surgeons must respond in person within 30 minutes for Trauma 1 activations. Failure to do so may result in corrective action and/or dismissal from the Medical Staff. Any failure to comply will be reported immediately to the Hospital Administrator On Call, who will intervene as needed and notify the Chairman of the Section of Emergency Medicine. If an individual physician does not want to take call, he/she is responsible for reaching an agreement with his/her section regarding the ongoing duty to take Emergency Department call, or on an individual event basis, he/she is responsible for finding a substitute who shall have appropriate credentials (as determined by the Service/Section) to cover for the original on-call member. The physician who secures a substitute physician to take his/her call shall notify the Chief of Service/Section and Hospital Administration via Medical Staff Services in writing of this fact in advance of the date that the original physician was scheduled for Emergency Department call. Regarding to calls from the Emergency Department, refer to General Rule 1.5. The time that the call from the Emergency Department is placed shall determine which On Call Physician to contact. The time that patient arrived to the Emergency Department does not determine which On Call Physician will be contacted. 5

6 2.3 The respective Department/Section will determine criteria regarding call expectation subject to approval by the Medical Executive Committee. Please see also Rule 7.6 regarding the Department of Internal Medicine Emergency Call. 2.4 ED physicians will retain direct supervising responsibility for patients who are still within the ED regardless of the status of the patient's admission until an attending physician has personally appeared and assumed care. The ED staff will continue to provide stabilizing treatment within the capability of the ED physician and the Hospital, including periodic reassessments and interventions as appropriate, as long as a patient is physically in the ED. 3. PATIENT MEDICAL RECORD RECORD OF CARE, TREATMENT, AND SERVICES 3.1 Documentation General Content A. The practitioner in attendance and any consultants are responsible for the preparation of a timely, complete and legible medical record for each patient. The medical record shall contain sufficient information to identify the patient, support the diagnosis and treatment and document the results. B. Each medical record contains the following clinical information: 1. The reason(s) for admission for care, treatment, and services; 2. The patient s initial diagnosis, diagnostic impression(s), or condition(s); 3. Any findings of assessments and reassessments; 4. Any allergies to food; 5. Any allergies to medications; 6. Any conclusions or impressions drawn from the patient s medical history and physical examination; 7. Any diagnosis or conditions established during the patient s course of care, treatment, and services; 8. Any consultation reports; 9. Any observations relevant to care, treatment, and services; 10. The patient s response to care, treatment, and services; 11. Any emergency care, treatment, and services provided to the patient before his or her arrival; 12. Any progress notes; 13. Any medications ordered or prescribed; 14. Any medications administered, including the strength, dose and route; 15. Any access site for medication, administration devices used, and rate of administration; 16. Any adverse drug reactions; 17. Treatment goals, plan of care, and revisions to the plan of care; 6

7 18. Orders for diagnostic and therapeutic tests and procedures and their results; 19. Any medications dispensed or prescribed at discharge; 20. Any advanced directives; 21. Any informed consent, when required by hospital policy; 22. Any records of communication with the patient; 23. Any patient-generated information; C. All medical record entries are dated, timed and signed; D. Authentication can be verified through the use of, written signatures, or electronic signatures. 3.2 Documentation History & Physicals A. A medical history and physical examination shall be recorded no more than 30 days prior or within 24 hours after inpatient and/or observation admission by a practitioner who has been granted privileges by the hospital. If a history and physical has been completed within 30 days prior to admission, an update documenting any changes in the patient s condition is completed within 24 hours after inpatient admission or prior to surgery, whichever comes first. Patient records without a history and physical assessment recorded within 24 hours of admission shall be considered delinquent. See Rule 1.7. B. The medical history and physical assessment must contain, when pertinent, the items in Addendum A. The physical assessment/exam should be extensive enough to support the care provided. C. A legible photocopy/facsimile of a history and physical assessment can be utilized: 1. If performed within 30 days of admission/treatment and updated with current condition(s) within 24 hours of admission; for surgical patients the update must be documented prior to surgery. 2. If patient is being discharged and readmitted to another level of care. D. A medical history and physical examination is recorded before an operative or other high-risk procedure is performed. If the report is not present the procedure shall be canceled, unless the physician in attendance states in writing that such delay would constitute a hazard to the patient. E. A practitioner may co-sign and update a history and physical assessment that has been provided by another physician member of the medical staff if the report is within 30 days and the practitioner is agreeable to do so. 7

8 F. For obstetrical patients a legible copy of the practitioner s prenatal record which includes findings from the last visit may be used. An interval admission note must also be written within 24 hours after admission and includes pertinent additions to the history and subsequent changes in the physical findings. Any obstetrical patient who undergoes a C- Section or other post delivery procedure must have a complete history and physical other than the prenatal history, documented before the procedure. 3.3 Documentation Operative Reports All operative or other high-risk procedure reports shall be fully recorded in the patient's record within 24 hours following the procedure. The report includes the following information: the name(s) of the licensed independent practitioner(s) who performed the procedure and his or her assistant(s); the name of the procedure performed; a description of the procedure; findings of the procedure; estimated blood loss; any specimens removed and the postoperative diagnosis. Patient records without a written or dictated operative report within 24 hours following the procedure shall be considered delinquent. A progress note (post-op note) is entered in the medical record before the patient is transferred to the next level of care. 3.4 Documentation Other High-Risk Procedures For patients undergoing a high risk procedure, an assessment of the patient s general medical condition, pertinent history, pertinent physical examination, allergies, pertinent current medications, and reason for the procedure will be documented in the patient record. An assessment performed in the referring physician s office will suffice, if performed within 30 days of the procedure and updated at the time of the procedure. Examples of high risk procedures include, but may not be limited to, Cardiac Catheterization, Endoscopic procedures and any procedure in which the administration of moderate or deep sedation occurs. For Interventional Radiological Procedures (e.g. Angiograms) an assessment of the patient s general medical condition from the referring physician, who must be a credentialed member of the medical staff or a pre-procedure assessment approved by Radiology will suffice. This is not required for non-invasive radiographic procedures utilizing contrast material (e.g. IVP, CT), where a contrast media information sheet is completed prior to the procedure. 3.5 Documentation Progress Notes Progress notes shall give a clinically pertinent report of the patient's hospital course and reflect any change in condition and/or results of treatment. Progress notes shall be recorded at the time of observation, or as warranted by the patient's condition, at least daily. They shall be sufficient to permit continuity of care. 3.6 Documentation Consultations 8

9 A. The attending practitioner is responsible for requesting consultation when indicated and for calling in a qualified consultant. The request for the consultation must include the specific reason for the consult and the name of the practitioner requesting the review. A consultation report will be recorded in the medical record. 3.7 Documentation Discharge Summaries A. A narrative discharge summary shall be recorded on each patient discharged from the hospital with the following exceptions: 1. Normal newborn infants; 2. Normal obstetrical patients; 3. Minor problems or interventions with a stay of less than 48 hours. B. The narrative summary shall include a concise review of the reason for hospitalization, the procedures performed; the care, treatment, and services provided; the patient s condition at discharge and information provided to the patient and family. C. A final progress note may be recorded in lieu of a narrative summary in the cases of normal newborns, normal obstetrical deliveries and minor cases staying less than 48 hours. This final progress note shall include the patient's condition on discharge and instructions to the patient and/or family. 3.8 A final diagnosis is required on all patients in which treatment is rendered or a procedure is performed, whether on an inpatient or outpatient basis. 3.9 The attending physician or any other supervising physician must countersign any Pre-op history and physical, routine history and physical, operative reports, consultations, and discharge note/summary that is recorded by the house staff (Medical Students) or any other non-independent practitioner Physician Orders A. The individual receiving the information writes down the complete order or test result or enters it into the EMR (electronic medical record). B. All Verbal orders shall include the date and names of the individuals, who gave, received, recorded, and implemented the orders. 9

10 C. The individual receiving the information reads back the complete order or test results, along with the name of the individual who gave the order and the MSO #. D. The individual who gave the order or test result confirms the information that was read back. E. All orders shall be dated, timed and signed. F. Verbal orders are authenticated within 48 hours. G. Verbal orders shall not be taken for chemotherapeutic agents, however, these orders may be accepted if written legibly and faxed to the hospital Emergency Department Documentation Patients who receive urgent or immediate care, treatment or services shall have the following information documented in the medical record: A. The time and means of arrival; B. Documentation that the patient left against medical advice, when applicable; C. The patient s final disposition, condition, and instructions given for follow-up care, treatment, and services Anesthesia Documentation A complete anesthesia record shall be maintained before, during and immediately following an operative or other high-risk procedure in which moderate or deep sedation or anesthesia is administered. The record should include documentation of the following information: A. A pre-sedation or pre-anesthesia patient assessment; B. The plan for sedation or anesthesia; C. Intra-operative continuous monitoring; 10

11 D. Discharge from the post-sedation or post anesthesia care area either by a licensed independent practitioner or according to discharge criteria; E. The discharge criteria that determine the patient s readiness for discharge; F. The name of the licensed independent practitioner responsible for discharge from the recovery area or the hospital Cancer Staging A cancer staging form will be required on all reportable cases and must be completed within 30 days of discharge. The staging form will be considered as a component of the complete record and the appropriate physicians will be subject to suspension for incomplete staging if 30 days or more post discharge Delinquent Status/Suspension of Privileges A. Records not completed within 30 days after discharge are considered delinquent and a physician may be subject to suspension of hospital privileges. The following are also considered delinquent in the time frame specified below and can also subject a physician to suspension of hospital privileges: 1. History and Physicals delinquent 24 hours after admission or not present prior to an outpatient procedure; 2. Operative Reports delinquent 24 hours after the completion of an operative or other high risk procedure; 3. Verbal or everbal orders delinquent if not signed within 48 hours. B. Written notification will be sent to the responsible practitioner s office with the due date for record completion. If the practitioner has not completed the records or specific items as noted above and they remain delinquent on the due date the physician will be suspended. C. When suspended the practitioner or his office staff will be notified that he/she is suspended for delinquent medical records or items. Suspension of privileges includes admitting, consulting and surgical privileges with the exception of those patients already admitted to the hospital, those cases already posted for surgery and any scheduled Emergency Department call. No additional surgical postings will be allowed until the practitioner has been removed from the suspension list. D. Any practitioner who has been suspended and remains so in excess of thirty days, will be notified of his/her pending termination from the medical staff and will be given ten (10) calendar days from the date of the letter to complete all delinquent records and/or items. If the practitioner fails to complete the records within the ten (10) day period, he/she 11

12 will then be automatically dropped from the staff. He/she must then complete all unfinished records and reapply for membership to the staff through the regular process. This reapplication will include the payment of application fees. This must be completed before he/she can admit patients to the Hospital or enjoy Hospital privileges. E. Any practitioner who is suspended four (4) times within a consecutive twelve month period shall be notified of his/her removal from the medical staff. He/she must then complete all unfinished records and reapply for membership to the staff through the regular process. This reapplication will include the payment of application fees. This must be completed before he/she can admit patients to the Hospital or enjoy Hospital privileges Ownership All records are the property of Memorial Hermann Hospital System and cannot be removed from the premises except on court order, subpoena from a court of law, or statutory authority. In case of readmission of a patient, all previous records shall be available for use by the practitioner(s) in attendance Administrative Closure of Incomplete Medical Records A list of any medical records which have remained delinquent for a period specified by HIM policy will be submitted to the facility Medical Executive Committee on a quarterly basis for approved closure. An Administrative Chart Closure form will be placed in the record to identify what components of the chart remain incomplete and to identify that the chart has been deemed closed In order to assure the safe and effective care of patients, the Practitioner may not use unapproved abbreviations for any and all medical record entries (Refer to the current Joint Commission list of unapproved abbreviations.) 4. Electronic Medical Record 4.1 Every physician must enter orders electronically at least 65% of the time. 4.2 The Attending Physician is responsible for completing the Transfer Medical Power Plan (MPP), which is required anytime that a patient transfers to a different level of care within the hospital. 4.3 The Discharging Physician shall enter discharge orders electronically. The Attending Physician remains ultimately responsible for the discharge order. 4.4 Effective January 1 st, 2014, where possible, physician documentation (i.e. progress notes, H&P) will be entered electronically. 12

13 4.5 Copying and pasting in a patient medical record without editing that results in inaccurate patient care documentation is unacceptable; therefore, progress notes shall accurately reflect the current care and status of the patient, at that time, as provided by the practitioner. 5. IMPAIRED PRACTITIONERS 5.1 Regarding impaired practitioners, it is the policy of this Medical Staff to: A. Ensure quality of care for all patients. B. Maintain a safe environment for patients, employees, and other Medical Staff members. C. Provide a positive, non-punitive process to assist in the identification and resolution of Practitioner health problems. 5.2 Definition and Policy A. An Impaired Practitioner is defined as one who is unable to practice medicine with reasonable skill and safety on their patients because of impaired judgment due to physical or mental illness, including deterioration through the aging process, or loss of motor skill, psychological dysfunction, or use or abuse of drugs or chemicals, including alcohol. B. Recognizing that the Medical Staff is accountable to the Board of Directors for the overall quality of patient care, this policy has been established to identify, review and resolve in a non-punitive manner, conduct, conditions, or actions by Practitioners which could compromise the quality of patient care. This process shall be conducted in a manner to assure that the information obtained thereby is confidential and privileged as the product of a peer review process, conducted in accordance with the rules, regulations and bylaws of the medical staff. C. It shall be the policy of the Medical Staff of Memorial Hermann Southeast ( Hospital ) to provide education to the medical staff regarding the process of managing issues of Practitioner impairment and to provide education to Practitioners and other staff about illness and impairment recognition issues. Such education will include the procedure for the identification, intervention, and referral (and self-referral) for treatment of a Practitioner who may be impaired and to protect the confidentiality of that information. 5.3 Report and Investigation. If a Medical Staff member and/or an individual working in the Hospital has a reasonable belief that a Practitioner may be impaired, or if a Practitioner desires to self-report, the following steps shall be taken: 13

14 A. If other than a self-referral, a written report shall be delivered to the Chief of Staff. The report should include a description of any incident(s) which led to the belief that the practitioner may be impaired. The report must be factual and objective and avoid the expression of opinion(s). After receiving the report the Chief of Staff shall promptly inform the Hospital CEO. B. The Chief of Staff shall discuss the report with the individual who filed the report. If the Chief of Staff determines that there is reason to believe that a Practitioner may be impaired, then the Chief of Staff shall meet with the Practitioner to determine an appropriate course of action. If the Chief of Staff determines that the Practitioner is an imminent threat to the health and safety of others or to the Practitioner s patients, the Practitioner shall be summarily suspended and the Summary Suspension provisions of the Bylaws shall control the conduct of the investigation and define the rights of the Practitioner to notice and due process. C. If the Chief of Staff determines that the Practitioner likely is impaired but is not an imminent threat to the health and safety of others or the Practitioner s patients, and, if the Practitioner agrees voluntarily to limit their practice and to participate in a rehabilitation program, no further formal action is required. Additional follow-up to be determined on a case-by-case basis by the Chief Of Staff and Chief Executive Officer (or representative). D. If the Practitioner is uncooperative or resistive, or if the information provided to the Chief of Staff by the reporting individual and the affected Practitioner conflict and the Chief of Staff believes further investigation is warranted, the Chief of Staff may convene a peer review committee for the sole purpose of determining whether an impairment exists. If that peer review process concludes that impairment exists and that the Practitioner is a risk or potential risk to the health and safety of others or to the Practitioner s patients, the Chief of Staff shall meet with the affected Practitioner to discuss the findings. If the Practitioner is still uncooperative or resistive, the Chief of Staff will initiate either a summary suspension or corrective action in accordance with the provisions of the medical staff bylaws, depending upon the seriousness of the impairment or the imminence of the threat to the health and safety of others. If the practitioner self-refers, such self-referral need not be in writing and may be either to the Chief of Staff or the Hospital CEO. The necessity for any further action shall be determined by the Chief of Staff or Hospital CEO and may result in referral to a rehabilitation program or any such other remediation as they and the Practitioner may agree is indicated. If at any time the Chief of Staff or the CEO are unable to come to an appropriate resolution of their concerns with the Practitioner, the matter shall proceed in accordance with this policy. 5.4 Rehabilitation A fundamental goal of the Impaired Practitioner policy is the removal of any limitation on practice or privileges as soon as such action is consistent with patient safety. Hospital and medical staff leadership shall assist the Practitioner in locating a suitable rehabilitation program. 14

15 5.5. Reinstatement A. It shall be the policy of Memorial Hermann Southeast Hospital to promote the timely reinstatement of recovering Practitioners as soon as such action is consistent with patient safety and the health and safety of others. B. The goal of the Medical Staff is to promote the safety and quality of care of all patients admitted to or treated at the Hospital and assist the Practitioner in their efforts to recover from the problems associated with impairment through a non-punitive, cooperative process. C. Upon sufficient medical evidence that a suspended practitioner is (1) recovering and (2) is functioning consistently at a level that no longer poses a threat to patient safety or to the health and safety of others, the Practitioner may apply to the Credentials and Medical Executive Committee for reinstatement. Sufficient medical evidence shall consist of: 1. A letter from the treating mental health or chemical dependency professional or treatment center qualified by education, training and experience to care for an individual with the condition for which the Practitioner was treated and who has been chosen by or is acceptable to the Hospital which covers the following: a. Description of the impairment; b. Current status of the impairment; c. Description of the treatment; and d. Statement of the short-term and long-term prognosis. 2. A letter from the Practitioner s physician covering the four points listed in (a) above and: a. Personal physician s opinion of the effect of impairment on the Practitioner s professional performance; b. Personal physician s statement that the Practitioner is recovering; and c. Any additional pertinent information as may be reasonably requested by the CEO or committee. 3. A letter from the Practitioner, which covers the following: a. Practitioner s description of the impairment; b. The Practitioner s opinion as to whether they are recovering and how their professional performance has been affected; and c. Agreement to accept periodic medical evaluations as may be requested by the Chief of Staff, Credentials and Medical Executive Committee, Executive Committee and/or the appropriate Chairman of Section/Service. The evaluation is to be performed by a Physician qualified by education, training and 15

16 experience to care for an individual with the condition for which the Practitioner was treated, and who has been chosen by or is acceptable to the Hospital Texas Medical Board. Any formal corrective action adversely affecting the clinical privileges of the practitioner for a period longer than thirty (30) days will be reported to the Texas Medical Board pursuant to the Texas Medical Practice Act and Health Care Quality Improvement Act of Failure to Complete Program. If a practitioner does not comply with the agreed program or required evaluation, the issue will be forwarded to the Medical Executive Committee for further disposition. 5.8 Confidentiality and Privilege. Every reasonable effort shall be made at all stages of the process to preserve the confidentiality and privilege of any and all information related to the identity of reporting individuals, the identity of self-referring Practitioners, the nature of the concerns and/or impairment, actions taken and outcome. 6. Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) 6.1 Regarding the Process of Ongoing Professional Practice and Focused Professional Practice Evaluation, it is the policy of the Medical Staff to ensure that the hospital, through the activities of the medical staff, assesses the performance of individuals granted clinical privileges and uses the results of such assessments to improve care. Ongoing professional practice evaluation information is factored into the decision to maintain existing privilege(s), to revise existing privilege(s), or to revoke an existing privilege prior to or at the time of renewal. The focused review process will involve monitoring, analyzing and understanding the special circumstances of practitioner performance which require further evaluation. Focused Professional Practice Evaluations will be initiated for all initially requested privileges Process for OPPE and FPPE A. OPPE reports for individual practitioners will be generated according to Service/Section. Reports will be generated for each practitioner twice per 12-month period. When generated, the reports will include data from the most recent 6-month period for which data abstraction is complete. The reports will be presented to the Credentials Committee, Medical Executive Committee, and the Board. B. All practitioners who were referred to FPPE will then have a minimum of 3 charts reviewed during the next 6 month period. Resulting review scores of 3 or above will be referred to PI/QR for a full peer review. A summary report will be sent to Credentials. 16

17 C. Initial applicants all fall under the FPPE review following the requirements of their delineation of privileges. If no FPPE review is specified in the delineation of privileges, then FPPE will be conducted in the manner described in B above. Once the practitioner has met the FPPE requirements, they will go into the normal cycle for OPPE as described above. 7. MISCELLANEOUS 7.1 Officers. In addition to the officer positions described in Section 9.1 of the Medical Staff Bylaws, the Medical Staff shall elect a Secretary/Treasurer. 7.2 Each member of the Medical Staff shall pay a credentialing fee at the time of appointment or reappointment. Failure to render payment at that point shall, unless excused by the Medical Executive Committee for good cause, result in summary suspension of Staff appointment and clinical privileges until the delinquency is remedied. Credentialing Fees for Active staff category is $ for initial appointment and reappointments. Credentialing Fees for Affiliated staff categories is $ for initial appointment and reappointments. There is no Credential Fee requirement for Honorary staff category. Effective healthcare requires close collaboration and active participation in governance bodies of both the hospital and medical staff. While not a requirement to obtain or maintain staff privileges practitioners are encouraged to attend at least 50% of his/her assigned Department/Section meetings and General Medical Staff meetings. 7.3 An electronic copy of the most recent, approved version of the Medical Staff Bylaws shall be made available to the Medical Staff on PhysicianLink. 7.4 All specimens removed during the operation shall be sent to the Hospital Pathologist, who shall make such examination, as considered necessary to arrive at a pathological diagnosis. 7.5 When a Texas Healthspring/Texas Plus inpatient has a STEMI, the Texas Healthspring/Texas Plus Cardiologist will be called to assess the patient and then he/she will call the Interventional Cardiologist of their choice or whoever is on call if their services are needed. 7.6 Family Practitioners who are in good standing and wish to cover patients admitted to or placed under observation by Internal Medicine physicians, take Department of Internal Medicine Emergency Call, or act as Hospitalists may do so after obtaining Recognition of Focused Practice in Hospital Medicine (RFPHM) by the American Board of Family Medicine ( 7.7 Members of the MEC, PIQR, and Credentials Committee are required to keep the confidentiality of these meetings. Any suspected breach of confidentiality will be investigated and may result in the practitioner being referred for Corrective Actions. 17

18 See Article 7 of the Bylaws of the Medical Staff. 7.8 Relinquishment of Privileges due to Peer Review When privileges are relinquished or substantially modified or not renewed at one Memorial Hermann hospital due to peer review recommendation, those privileges or modification of privileges shall be relinquished or modified at all Memorial Hermann Hospitals. 7.9 Appointment to the Refer/Follow Staff category may be requested by practitioners who wish to have an affiliation with the Hospital for purposes of referring patients, following patients through access to the electronic record, visiting their patients while hospitalized, consultation with the attending practitioner, and obtaining the results of tests and therapy. Refer/Follow Staff appointees are not required to attend medical staff meetings, may not vote or hold elective office, and may not make entries in the in-patient medical record. Refer/Follow appointees do not have clinical privileges and may not admit or attend patients in the Hospital. 8. MEDICAL STAFF MEETINGS 8.1 At the regular meetings of the Medical Staff, the CEO or designee shall submit a report of the quality and operational performance of the Hospital for the previous period. 8.2 Meeting attendance will continue to be monitored but not required, except under the following circumstances: A. To be considered for a leadership position as a member of the MEC, Chairperson of a Department or Section; the practitioner will be expected to have attended at least 50% of his/her and Department/Section meetings in the previous twelve months from the closure of the nomination period and, also expected to attend a minimum of two thirds of meetings during the time of the practitioner s leadership appointment. Excused absences will not be accepted. B. To be considered for a Chairperson of a Medical Staff committee; the practitioner will be expected to have attended at least 50% of the respective committee meetings in the previous twelve months from the closure of the nomination period and, also expected to attend a minimum of two thirds of meetings during the time of the practitioner s leadership appointment. Excused absences will not be accepted. 8.3 The presence at a Committee, Section, or Department meeting of the Medical Staff of at least the Chairperson (or her/his designee who is already a member of said committee) and two voting members shall constitute a quorum for the transaction of business, unless required otherwise by other regulatory requirements, the Medical Staff Bylaws or these Rules and Regulations. 18

19 8.4 Departments / Sections A. The following are the current Departments/Services of the Medical Staff and the specialties represented in those Departments/Services: Family Practice/General Practice Service Emergency Medicine (Section) Family Practice General Practice General Medicine Industrial Medicine Occupational Medicine Medicine Service Allergy and Immunology Cardiology (Section) Critical Care Dermatology Endocrinology Gastroenterology Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Physical Medicine and Rehabilitation Psychiatry Pulmonology Radiation Oncology Rheumatology Obstetrics and Gynecology Service Gynecology Gynecologic Oncology Obstetrics 19

20 Reproductive Endocrinology Pathology Service Pediatric Service Pediatrics Neonatology Radiology Service Surgery Service Anesthesiology (Section) Bariatrics (MBSAQIP) Section Cardiovascular and Thoracic Surgery Colon and Rectal Surgery General Dentistry General Surgery Neurological Surgery Ophthalmology Oral and Maxillofacial Surgery Orthopedic Surgery (Section) Otorhinolaryngology and Head and Neck Surgery Pain Management Podiatry (Section) Pediatric Surgery Plastic Surgery Urology Vascular Surgery B. The following are the current Sections/Divisions of the Medical Staff: Anesthesiology Cardiology Emergency Medicine Orthopedic Surgery Podiatry 20

21 C. Term of Office Department/Section Chairs/Chiefs. Department/Section Chair/Chiefs serve for a term of one (1) year. D. The Chairperson/Chief of the Anesthesia Section, Emergency Medicine Section, Pathology Service and Radiology Service shall be the Medical Director of that respective Service/Section. 8.5 Composition of the Medical Executive Committee. A. Section of the Medical Staff Bylaws provides that the Medical Executive Committee shall consist of the following voting members: the Chief of Staff, Vice Chief of Staff, Immediate Past Chief of Staff, and not less than eight (8) Active Staff Members who, as determined by the Medical Executive Committee, may be appointed committee members, ex officio committee members or elected members; provided, however, that a majority of the Medical Executive Committee shall hold committee membership by virtue of being elected to an office either by a Department/Service or the Medical Staff as a whole. B. In addition to the Chief of Staff, Vice Chief of Staff, Immediate Past Chief of Staff, the following Active Staff Members shall serve as voting members of the Medical Executive Committee: 1. The Chairpersons of the following committees: Credentials, Bylaws, Bioethics, Critical Care, Endoscopy, Pharmacy and Therapeutics; 2. The Chairs of each of the Services; 3. The Chiefs of each of the Sections; 4. A representative from Radiology (to serve a two-year term); 5. A representative from Pathology (to serve a two-year term); and 6. The Secretary/Treasurer of the Medical Staff. C. Meeting attendance requirement for MEC members is two thirds. An alternate who is designated at the beginning of the year may attend in their absence. The Chief of Staff will meet with MEC members individually to discuss attendance non-compliance, specifically in the event of two consecutive absences. If the member misses three consecutive meetings, the department/section/committee will be required to elect a new Chairperson. 21

22 D. Members of the Medical Executive Committee may be removed from an elected position for any valid cause, including, but not limited to, failure to carry out the duties of his/her elected position or gross neglect or malfeasance in office, or serious acts of moral turpitude. Members of the Medical Executive Committee may be removed for any of the following: 8.6 Other Committees 1. Failing to meet attendance requirements as described in 7.5.C 2. Two-thirds (2/3) of the eligible members of the Medical Executive Committee responding to a formal request for a vote, vote for a member s removal. A. Bioethics Committee 1. Purpose. The purpose of the Bioethics Committee is to provide an interdisciplinary forum for discussion, analysis, and consultation dealing with bioethical issues at the Hospital. 2. Composition. a. Voting Members. The Bioethics Committee shall consist of the following voting members: Seven (7) physician members of the Medical Staff, one of whom shall be elected as Chairperson. It is recommended that a core group of physicians maintain membership on the Committee from year to year to maintain consistency in leadership and education. b. Non-voting Members. The CEO, following consultation with the Chief of Staff, may appoint to the Bioethics Committee as non-voting ex officio members individuals who hold positions within the Hospital, including at least one representative from each of the following disciplines: clinical ethicist, nursing, chaplaincy, social work, clinical nutrition services, and administration. Community representatives and retired physicians may also be appointed to the Committee. 3. Authority. The Bioethics Committee shall have the authority to recommend a change in the healthcare plan for a patient. As with other consulting services, the Bioethics Committee's opinion is advisory. 4. Duties. The duties of the Bioethics Committee shall be to: a. Serve as a sounding board, advisor, and facilitator to clinical and non-clinical staff dealing with the ethical care of patients by providing consulting services regarding individual patients; 22

23 b. Be available to patients individually or together with their families, nurses, physicians, and other care givers to assist them in sorting out, clarifying, and making ethical decisions in the best interest of the patient within the context and the constraints of the patient's family, the institution, the community, and society; c. Serve as an educational resource for the entire Hospital staff, including the Medical Staff, and members of the local community; d. Serve as a resource for administration and the clinical services for developing institutional policies relating to bioethical issues. 5. Meetings. The Bioethics Committee shall meet as often as necessary at the call of its chair and shall maintain a written record of its proceedings and actions and shall report, through the Chief of Staff, to the Medical Executive Committee. B. Bylaws Committee 1. Purpose. The purpose of the Bylaws Committee is to conduct an ongoing review of the Bylaws, Rules and Regulations, Policies, and other organizational documents pertaining to the Staff, to review any proposed changes to the Bylaws, and to recommend changes to the Bylaws to the Medical Executive Committee and the Physician Leadership Council. 2. Composition. a. Voting Members. The Bylaws Committee shall consist of the following voting members: Five (5) members of the Medical Staff, one of whom shall serve as Chairperson. The Chairperson shall have been a member of the Bylaws Committee for at least one year immediately prior to being elected as Chairperson. Any vacancy in a voting member position occurring other than by expiration of term shall be filled by the Medical Executive Committee. b. Non-voting Members. The CEO or designee and a representative from Medical Staff Services shall serve as a non-voting ex officio member. The Chief of Staff may appoint any at-large members to the committee as warranted. 3. Authority. The Bylaws Committee shall have authority to review copies of the organizational documents of the Hospital and the Staff, to request and receive recommendations and reports from Services, Sections, and other committees of the Staff concerning the organization and operation of those Services, Sections, and other committees, and to make recommendations concerning the revisions thereof to the Medical Executive Committee. 23