Gastroenterology Section

Transcription

1 Huntington Hospital Gastroenterology Section Rules and Regulations May 2013

2 HUNTINGTON HOSPITAL GASTROENTEROLOGY SECTION RULES AND REGULATIONS TABLE OF CONTENTS I. MEMBERSHIP... 1 II. RESPONSIBILITIES OF THE SECTION... 1 III. SECTION MEETINGS... 1 IV. SECTION OFFICERS... 1 V. ELECTION PROCESS... 2 VI. SECTION CHAIR... 2 A. TERM OF OFFICE... 2 B. QUALIFICATIONS... 2 C. RESPONSIBILITIES... 2 VII. PRIVILEGES ) Fluoroscopy Certificates... 3 VIII. PROCTORING... 3 IX. GENERAL GUIDELINES ) ED Call Panel ) Failure to Respond to On-Call Policy... 3

3 HUNTINGTON HOSPITAL GASTROENTEROLOGY SECTION RULES AND REGULATIONS I. MEMBERSHIP The Gastroenterology Section of the Department of Medicine is comprised of those members of the Medical Staff whose primary practice includes the field of adult Gastroenterology. II. RESPONSIBILITIES OF THE SECTION A. Participation in the provision of education support to the Medicine training program and participation in staff development activities through provision of inservice education to the nursing staff. B. Specialty-specific ER coverage and coverage for the GI Clinic. C. Develop and oversee policies related to the Endoscopy Unit and regarding medical appropriateness and expected outcomes of GI services and procedures. D. Participation in quality management and performance improvement activities from the Gastroenterology specialty perspective. E. Assuring the same level of care is provided to all patients undergoing endoscopic procedures in the hospital. III. SECTION MEETINGS Regularly scheduled meetings of the Gastroenterology Section are held as often as necessary, but at least quarterly. IV. SECTION OFFICERS The Gastroenterology Section officers shall consist of the Chair and does not include a Chair Elect position. If the Section Chair is absent temporarily, the designee of the Chair shall function as temporary Chair. If the Chair position becomes vacant permanently, new elections are held immediately. Gastroenterology Section Page # 1

4 V. ELECTION PROCESS The election process outlined in Section 11.5, 11.6 and 11.7 of the Medical Staff Bylaws for Department Chairs shall be utilized for the election of Section Chairs. VI. SECTION CHAIR A. TERM OF OFFICE Length of term for Section Chair shall be two (2) years, eligible for further terms if non-consecutive. B. QUALIFICATIONS The Chair shall be an Active Staff member of the Section, and shall be certified by the appropriate specialty board or shall affirmatively establish through the privilege delineation process the possession of comparable competence. C. RESPONSIBILITIES 1. The ongoing effective operation of the Section/service and for the assessment and improvement of its activities. 2. All clinically related activities of the Section 3. All administratively related activities of the Section 4. Continuing surveillance of the professional performance of all individuals who have delineated clinical privileges in the Section 5. Recommending to the medical staff the criteria for clinical privileges in the Section 6. Recommending clinical privileges for each member of the Section 7. Conducting meetings of the Section, developing meeting agendas, and reviewing and approving meeting minutes 8. Spokesperson representing the Section to the Department of Medicine 9. Establishing, together with medical staff and administration, the type and scope of services required to meet the needs of patients and hospital Gastroenterology Section Page # 2

5 10. Developing and implementing policies and procedures that guide and support the provision of services by the Section. 11. Coordinating CME activity for Section members and for the Medical Staff related to Gastroenterology programs with the CME Committee. VII. PRIVILEGES Clinical privileges shall be divided into Core Privileges (usual and customary privileges) and Supplemental Privileges (for more advanced privileges requiring increased training and/or expertise). Details of privilege delineation are explained in the individual clinical privilege delineation for this Section. 1) Fluoroscopy Certificates Members of the GI Section shall be required to keep a current Fluoroscopy Certificate on file in the medical staff office when performing ERCP procedures. Physicians who do not comply with this requirement or have an expired certificate on file shall not be allowed to schedule or perform ERCP procedures that require the use of fluoroscopy equipment until a permit is acquired. VIII. PROCTORING Proctoring will be conducted in accordance with the Huntington Hospital Medical Staff Proctoring Protocol. IX. GENERAL GUIDELINES 1) ED Call Panel Only those Section members who have completed the proctoring requirement are eligible to participate in the provision of ER back up coverage for patients in the Emergency Department or to participate in referral coverage for post-er follow up care, or to participate in any Section-wide hospital program that involves referral for professional services. 2) Failure to Respond to On-Call Policy Please refer to the Medical Staff Rules and Regulations and the Administrative Policy and Procedure Manual, Policy #020. Gastroenterology Section Page # 3

6 Approved by: Gastroenterology Section: 1/29/09; 01/17/13 Medicine Committee: 2/5/09; 05/02/2013 Executive Committee: 3/2/09; 05/06/2013 Board of Directors: 4/23/09; 05/23/2013 Gastroenterology Section Page # 4