Huntington Hospital Psychiatry Section Rules and Regulations June 2013 Psychiatry Section Page 1
HUNTINGTON MEMORIAL HOSPITAL PSYCHIATRY SECTION RULES AND REGULATIONS Table of Contents 1. MEMBERSHIP... 1 2. SCOPE OF PRACTICE... 1 3. RESPONSIBILITIES OF THE SECTION... 1 4. SECTION MEETINGS... 2 5. SECTION OFFICERS... 2 6. ELECTION PROCESS... 3 7. SECTION CHAIR... 3 7.1 Qualifications:... 3 7.2 Term of Office:... 3 7.3 Responsibilities:... 3 8. CLINICAL PRIVILEGES... 4 9. PROCTORING... 4 10. EMERGENCY ROOM ON-CALL REQUIREMENT... 4 11. GENERAL GUIDELINES... 4 11.1 Allied Health Professionals Clinical Psychologist... 4 11.2 Transfers from other facilities by HMH Medical Staff.. 5 11.3 DMC and HMH Organization Patient Care Policies... 5
HUNTINGTON MEMORIAL HOSPITAL PSYCHIATRY SECTION RULES AND REGULATIONS 1.0 MEMBERSHIP The Psychiatry Section shall be organized as a Section of the Department of Medicine. The membership shall consist of medical staff members who limit their practice to Psychiatry and are qualified by training and demonstrated clinical competence. Only practitioners who are either Board Certified or have completed an approved residency program in psychiatry shall be granted clinical privileges as defined by the American Board of Psychiatry and Neurology and the Medical Staff Bylaws, 3.2-1. 2.0 SCOPE OF PRACTICE The Psychiatry Section provides comprehensive inpatient and outpatient psychiatric services for adult and geriatric patients. Treatment modalities include: psychopharmacology; family, group and individual psychotherapy; milieu therapy; behavioral therapy, excluding aversion therapy; ECT (electroconvulsive therapy); management of dual diagnosis; chemical dependency and detoxification. These services are provided 24 hours per day, seven days per week. Members of the Psychiatric Section also provide consultation services to patients presenting to the Emergency Department and admitted to the general acute care hospital. Age groups served in this setting are adult, geriatric, adolescent and children. 2.1 Physicians designated as Board Certified by the American Board of Psychiatry and Neurology or who have completed an approved residency program in psychiatry render patient care. 2.2 Leadership responsibility resides with the Section Chair. 3.0 RESPONSIBILITIES OF THE SECTION The Psychiatry Section shall be organized within the Department of Medicine and report all business to the Medicine Committee. In addition the Section shall: 3.1 Recommend clinical privileges for each member of the section 3.2 Recommend criteria for granting clinical privileges within the psychiatry section 3.3 Provide support to section members in resolving difficult or unusual physician-related credentialing issues. Psychiatry Section Page 1
3.4 Ensure Medical staff compliance with Della Martin Center policies and procedures 3.5 Review and prioritize equipment and space requests related to patient care and recommend purchase or non-purchase to Administration 3.6 Continuous surveillance of the professional performance of all individuals in the section have delineated clinical privileges 3.7 Continuous assessment and improvement of the quality of care and services provided to psychiatric patients 3.8 Assure maintenance of quality control programs, as appropriate 3.9 Recommend to the Medicine Committee all changes to Section Rules and Regulations 3.10 It is the responsibility of the attending psychiatrist to obtain an internal medicine consultation. The consultant is expected to perform the history and physical as well as follow the patient for concomitant medical conditions throughout the hospital stay. Initial consultation will be performed within time frames appropriate to the condition of the patient and at least within 24 hours of admission. 3.11 The consultant selected must be qualified by training, experience, and demonstrated current competence to give an opinion. 3.12 It is the responsibility of the attending psychiatrist to perform daily assessment. 4.0 SECTION MEETINGS The Psychiatry Section shall meet as often as necessary at the call of the Chair, but at least quarterly. The Section Chair may, at his/her discretion, appoint any special or sub-committee necessary to properly fulfill the duties and responsibilities of the Section. A permanent record of the proceedings of Section meetings shall be maintained and reported to the Medicine Committee. Issues important to the Section members shall be submitted to a mail ballot, if there is doubt about a quorum. 5.0 SECTION OFFICERS The Section shall have a duly elected Chair and Chair Elect. Psychiatry Section Page 2
6.0 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. 7.0 SECTION CHAIR 7.1 Qualifications: The Chair and Chair Elect shall be members of the active staff and shall be Board Certified by the American Board of Psychiatry and Neurology or will have completed an acceptable residency program in psychiatry. 7.2 Term of Office: The Chair shall be elected for a two (2) year term, by the Active Staff members of the Section, as provided for in Chapter 11.5 of the Medical Staff Bylaws. Upon completion of the 2-year term, the Chair Elect will then become the Chair for 2 years at which time a new Chair Elect will need to be elected. 7.3 Responsibilities: 7.3.1 The Section Chair shall arrange for, preside at, and conduct the meetings of the Section and ensure that the policies and functions of the Della Martin Center are followed. The Chair shall be accountable to the Medicine Committee for all professional and Medical Staff administrative activities within the Section 7.3.2 The Section Chair shall be responsible for surveillance of the professional performance of the Medical Staff members who exercise privileges in the Section and shall participate in the privileges and reappointment deliberations. The Chair shall be responsible for recommending privileges for those practitioners applying to the Psychiatry Section. These privileges shall be based upon the applicant s documented training, experience, and demonstrated ability. 7.3.3 The Chair shall advise the hospital of outside service needs. 7.3.4 The Chair shall be responsible for quality improvement and peer review activities within the section. Psychiatry Section Page 3
7.3.5 The Chair shall appoint committees as needed to conduct Section functions. 7.3.6 In the absence of the Section Chair, the Section Chair Elect shall preside over the above mentioned Section matters. 8.0 CLINICAL PRIVILEGES Clinical privileges shall be divided into Core Privileges (usual and customary privileges) and Supplemental Privileges (more advanced privileges requiring additional training and/or experience). Details of privilege delineation are explained on the individual clinical privilege delineation for this Section. 9.0 PROCTORING Proctoring will be conducted in accordance with the Huntington Hospital Medical Staff Proctoring Protocol. 10. EMERGENCY ROOM ON-CALL REQUIREMENT 10.1 Participation on the emergency room call panel for emergency services and consultation call shall be voluntary for Psychiatry section members who have completed proctoring requirements. 10.2 It is the responsibility of the physician on call to obtain substitute coverage if he/she is unable to provide coverage for his/her assigned time. 10.3 If emergency services is unable to contact the physician on-call, please refer to Administrative Policy & Procedure Manual, Policy #020 (Failure to Respond to On-Call) and the Medical Staff Rules and Regulations. 10.4 If a practitioner voluntarily relinquishes privileges he/she must give the Section at least thirty (30) days notice in order to obtain coverage for the resigning practitioner s call assignment. 11.0 GENERAL GUIDELINES 11.1 Allied Health Professionals Clinical Psychologist Proctoring for Allied Health Professionals is as outlined in the Huntington Hospital Medical Staff Proctoring Protocol. Psychiatry Section Page 4
11.2 Transfers from other facilities by HMH Medical Staff members In the event a physician holds privileges at both the transferring facility and Huntington Memorial Hospital, and transfers a patient to Huntington Memorial Hospital Della Martin Center, the transferring physician shall be responsible for following the patient at Huntington Memorial Hospital. 11.3 Della Martin Center and HMH Organization and Patient Care Policies Members of the Psychiatry Section are expected to abide by the Della Martin Center and Huntington Memorial Hospital organizational and patient care policies and procedures, which are available on the hospital intranet. Approval dates: Psychiatry Section: 1/26/09; 01/28/2013 Medicine Committee: 3/5/09; 05/02/2013 Medical Executive Committee: 4/6/09; 07/01/2013 Board of Directors: 4/23/09; 07/25/13 Psychiatry Section Page 5