PROVIDENCE Holy Cross Medical Center Department ofobstetrics & Gynecology Rules and Regulations I. NAME AND PURPOSE: The Name of this Department shall be the Department of Obstetrics and Gynecology of the Medical Staff of Providence Holy Cross Medical Center. The Department's purpose shall be to concern itself with the medical care performed within the Hospital by members of the Department. This shall include the establishment of methods to ensure professional competence of members basing delineation of privileges on training, experience, demonstrated ability and integrity; the establishment of specific policies to facilitate and regulate the work of the Department; promote the continuing education of all Department members; and provide ongoing review and analysis of the clinical work performed in the Department. These Rules and Regulations have been developed pursuant to the Bylaws of the Medical Staff and provide a formalized guide for members of the Department of OB/GYN, thus eliminating the possibility of any confusion and/or misunderstanding as to their responsibilities as Department members. II. MEMBERSHIP: Membership in the Department shall consist of Obstetricians, Gynecologists, Gynecologic Oncologists, and Perinatologists who are members of the Medical Staff, and who meet the general qualifications for Medical Staff membership, as provided for in the Medical Staff Bylaws, and as documented on the privilege control card. III. ORGANIZATION/DU1"IES A. The Department of OB/GYN is organized under the provisions of the Bylaws of the Medical Staff of Providence Holy Cross Medical Center. The primary responsibility delegated to the Department shall be the implementation of specific review and evaluation activities which contribute to the preservation and to the improvement of the quality and efficiency of patient care provided within the Department. To carry out this responsibility, the Department's duties shall include: 1. The formulation, regular review and revision of these Rules and Regulations as deemed appropriate; 2. Conducting patient care review activities for the purposes of analyzing and evaluating the quality of care rendered and the appropriateness of treatment and appropriate utilization of services provided to patients served by the Department. 3. Holding meetings at the frequency described in the Bylaws of the Medical Staff, for the purpose of receiving, assessing, and when necessary, acting upon reports regarding the findings of the Department's patient care/clinical performance review activities and reports regarding the other activities of the Department. 4. Submitting regular reports to the Medical Executive Committee detailing the activities of the Department. S. Establishing guidelines for the granting of clinical and practice privileges within the Department. 6. Coordinating the patient care provided by those exercising privileges within the Department with Nursing Services, ancillary patient care and administrative support. 7. Monitoring on a continuing basis, Departmental adherence to: Medical Staff and Hospital rules and regulations/policies and procedures; Requirements for alternate coverage and consultations; Sound principles of clinical practice 8. Conducting. participating and making recommendations regarding Continuing Medical Education programs relevant to the Department.
Rules & Regulations, page 2 9. Delineating privileges to members of the Department consistent with the best interest of the patient and based upon the recommendation of those best qualified to evaluate ability. 10. Proctoring all provisional appointees, current members requesting additional privileges and those members with quality of care issues. IV. SUPERVISION: A. The Department of OB/GYN will be organized to meet the requirements of the Bylaws of the Medical Staff, under the supervision of the Department Chairperson and Vice Chairperson. 1. The Chairperson and Vice-Chairperson of the Department shall be members of the Active Staff who are best qualified by training. experience. and demonstrated ability for these positions. 2. The Officers of the Department shall be elected every two (2) years in accordance with the Bylaws of the Medical Staff, and may not serve more than three (3) consecutive terms. 3. The incoming officers shall begin their tenure at the beginning of the respective medical staff year as defined in the Bylaws of the Medical Staff. B. The Vice Chairperson shall act in the Chairperson's absence. C. The Chief of a Clinical Division must be an Active member of the Department. who is qualified by training. experience. and demonstrated current ability in the specialty area covered by the Division. V. DUTIES OF THE OFFICERS: A. The duties of the Chairperson of the Department of OB/GYN shall include those required by the Joint Commission on Accreditation of Healthcare Organization. and shall include at least the following: Presiding over the meetings of the Department of OB/GYN; Assuring the ongoing review of the quality and appropriateness of patient care provided within the Department through monitoring. evaluation. and evidence of resolution; Accountability for all professional and administrative activities within the Department; Surveillance of the professional performance of all practitioners holding clinical privileges in the Department. taking appropriate action as indicated; Recommending the appointment and reappointment of physicians to the Department. and clinical privileges granted based on qualifications and demonstrated competence; Serving as a member of the Executive Committee of the Medical Staff; Initiation of disciplinary action. as warranted. expeditiously and in accordance with the Bylaws of the Medical Staff; Appointment of task force groups. as are necessary to carry out specific tasks within the Department;
Rules & Regulations, page 3 Appointment of Department members to serve as liaison members of other Medical Staff Department and/or Committee meetings for the purposes of representing the Department of OB/GYN. B. The duties of the Vice-Chairperson of the Department of OB/GYN shall include: Performance of the duties as may be assigned to him/her by the Chairperson; Automatic succession as the Chairperson of the Department when the latter fails to serve for any reason, and assuming all duties of the Chairperson in his/her absence. VI. DEPARTMENT MEETINGS: A. The Department of OB/GYN shall meet in accordance with the Bylaws of the Medical Staff. B. The presence of at least three (3) Department members shall constitute a quorum at Department meetings. VII. CLINICAL PRIVILEGES: A. Privileges available to members of the Department of OB/GYN and criteria for consideration are delineated on Department-specific privilege delineation forms. B. Any licensed practitioner (Le. MD. DO, DPM, Oralmaxillofacial Surgeon), who is a member of the Medical Staff with clinical privileges may assist in surgery without applying for surgical assisting privileges. A surgical first assistant provides assistance to the primary surgeon, under the direct supervision of the primary surgeon. The primary surgeon's judgement and prerogative shall determine the number and qualifications of surgical assistants necessary to optimize safe surgical care. C. A member may request modification of clinical privileges at any time. Such requests must include documentation of training and/or experience supportive of the request. D. If a practitioner desires privileges which are not available within the Department of OB/GYN, the privileges must be requested of. and considered by, the specific Department in which privileges are sought. The practitioner will then be subject to the rules and regulations of that Department. E. Current Competency: Department members shall be continually evaluated for determination of current competency performing the privileges granted. Evaluation shall be based on quality monitoring activities. as well as the exercise of clinical privileges within the Hospital. At the time of reappointment review, each Department member's privileges will be assessed to ensure that their activity and performance justifies maintenance/continuation of privileges through the next term of reappointment. If current competency is demonstrated, privileges will continue. However, if current competency cannot be demonstrated due to lack of clinical activity at this Hospital, the physician must prove he/she is maintaining his/her skills and competency by submitting for Department review. documentation which supports the privileges requested. Documentation may be submitted in the form of operative reports. summaries of activity at another local facility, or similar evidence. It shall be generally accepted that the satisfactory performance of at least three (3) procedures within the scope of the privileges requested shall substantiate competency.
Rules & Regulations, page 4 VIII. PROCTORING POLICY: A. Except as otherwise determined by the Medical Executive Committee, practitioners to be proctored include the following: 1. New Provisional Staff members appointed to the Department of OB/GYN; 2. Department members requesting an increase in clinical privileges, including new technology or procedures; 3. Medical staff members with quality of care issues. B. In general, a qualified proctor shall be defined as a Member of the Medical Staff of this Hospital, who has been granted full non-proctored status for the privilege/procedure being proctored/observed. However, the associate of a physician under proctoring requirements may not act as a proctor. C. At least two (2) different proctors must be utilized to meet proctoring requirements. D. Proctoring forms from another local facility may be submitted for consideration of meeting proctoring requirements at this facility. However, the cases must be those which were proctored/observed by a Staff physician at this facility who is eligible to serve as a proctor. Copies of such forms shall be maintained in the physician's credentials file. IX. PROCTORING REQUIREMENTS: 1. Types and numbers of cases indicated in (A) and (B) below must be proctored before the department will consider successful completion of the provisional period: A. Obstetrics: At least 3 vaginal deliveries must be proctored by either concurrent or retrospective review. Evaluation must include prenatal and post-partum care. B. Surgical Procedures: At least 6 cases must be concurrently proctored. These cases must be representative of the privileges granted. At least 1 case must be a C-Section. 2. Proctoring of certain procedures may continue after completion of the provisional period, to be determined by the department, and including the following: C. Laparoscopic Procedures: At least 1 complex case must be concurrently proctored. D. Laser Procedures: At least 1 case must be concurrently proctored. X. PROCTORING PROCESS: A. At a minimum, proctoring/observation requirements shall be observed. Fulfillment of the minimum requirements for proctoring/observation shall not necessarily constitute discontinuation of evaluation. The Department Chairperson may find it necessary to recommend that the practitioner be further proctored/ observed. This may be applicable to all, or part of the privileges/procedures granted. B. It is the responsibility of the practitioner under proctoring requirements to obtain an appropriate proctor. C. At the time a procedure is scheduled, it is the responsibility of the physician under proctoring/observation requirements to contact a proctor and provide the date and time of the procedure. In addition, the name of the proctor/observer must be identified at the time the procedure is scheduled. A physician's failure to provide the name of the proctor/observer may delay the scheduling of the case.
Department of Ob~Gyn Rules & Regulations, page 5 D. It is the responsibility of the proctor/observer to review the practitioner objectively and in a forthright manner. The duration of observing a specific privilege/procedure shall be that which is long enough to adequately complete the proctoring evaluation form in its entirety. The observer must be able to adequately comment on the practitioner's patient management, including competence, skills, technique, and demeanor. E. The findings of proctoring/observation shall be documented in writing on approved forms, and submitted to the Medical Staff Services Office for inclusion in the practitioner's credentials file. Completed proctoring forms shall be considered confidential and protected from discovery under Evidence Code 1157. F. Proctoring evaluation forms which include specific comments, issues, or adverse findings, shall be brought to the attention of the Chairperson of the Department upon receipt in the Medical Staff Services office. G. Procedures performed on an emergency basis shall be excluded from concurrent proctoring/observation requirements. However, retrospective review of the procedure will be conducted to evaluate the medical management and ascertain that the procedure was indeed emergent in nature. H. When proctoring/observation requirements have been satisfied, it shall be the responsibility of the Department to evaluate the written proctoring/observation evaluation reports and make recommendations to the Medical Executive Committee on the findings. I. The waiver of proctoring may be granted by the Department if the physician is actively practicing in the community and two department members have directly observed the new physician and provide letters of recommendation for waiver of proctoring. XI. GENERAL RULES AND REGULATIONS APPLICABLE TO ALL DEPARTMENT MEMBERS: Consultation Policy: The Department shall follow the Consultation policy as defined in the General Medical Staff Rules and Regulations. Patient Visitations: All obstetric or gynecologic patients shall be examined at least daily by their physician. Exception to this would be a morning discharge of an obstetric patient. Medical Records: Prenatal Records: The attending physician shall submit the original or a legal copy of his/her patient's prenatal record to the Delivery Suite one (1) month prior to expected delivery. The attending physician shall complete an admission note at the time of his/her patient's admission, detailing any interval changes in history, physical examination, or clinical course which may have occurred since the last entry of such information on to the patient's prenatal record. Tissue Examinations: Placentas removed in the course of operative and non-operative delivery shall be sent for pathological examination at the discretion of the Obstetrician. Attendance at Delivery: Delivery by Cesarean Section or Vaginal Deliveries with Fetal Distress: For Cesarean or fetal distress deliveries, there must be neonatal resuscitation trained personnel for care of the newborn. Elective Cesarean Section Deliveries: In the case of an emergency, the case can be started prior to the arrival of the assistant surgeon. L&D nurses can, at a physician's request, be asked to call the assistant surgeon. When a physician makes this request, he/she must give the nurse two or three names of physicians to call.
Rules & Regulations, page 6 Patients Under Regional Analgesia: Patients should be monitored in an appropriate manner while under the effects of anesthesia or regional analgesia during active labor, delivery, and the immediate post-partum period. J. Labor and Delivery: Induction of Labor: Elective inductions should be limited to vertex or breech presentations, and adequate fetal size as determined clinically and/or by radiological means within two (2) weeks of term. Labor should be induced or augmented only after a thorough examination of both the mother and the fetus, and the indications for and method of induction or augmentation have been documented. When any oxytocic drug or cervical ripening agent is used, a physician who has privileges to perform cesarean deliveries should be readily available should problems arise. A physician or qualified nurse should perform a cervical examination immediately prior to the initiation of oxytocin infusion. Oxytocic intravenous drips will be administered only through microdrip devices or controlled measuring devices. All patients receiving oxytocic drugs will be continuously monitored. Scheduling for induction must be cleared through the Obstetric Supervisor, in order to determine the existing labor patient census. Vaginal Birth After Cesarean Section (VBAC) - Current ACOG Guidelines will be followed. K. RH Immune Globulin Administration: All Rh negative patients who are eligible will be given Rh immune globin such as RhoGam as ordered by the physician. Criteria used in selecting candidates for injection of RhoGam is that which is contained in the Physician Desk Reference (PDR). L. Diagnostic Testing: Hepatitis B Testing: All obstetric patients shall be tested for HBsAg during the course of their prenatal care, the results of which shall be available at the time of patient admission for delivery. If a woman has not been tested prenatally, or if test results are not available at the time of admission for delivery, HBsAg testing shall be performed a the time of admission, or as soon as possible thereafter. VORL Testing: All obstetric patients shall be VORL tested during the course of their prenatal care. the results of which shall be available at the time of patient at the time of admission for delivery. Pregnancy Test: Women with reproductive capacity shall have a pregnancy test within 7 days of a gynecologic surgery. M. Emergency Department Call Panel: The following are guidelines for Panel participation: 1. Regardless of their category of Medical Staff membership. all Department members shall be required to participate on the Emergency Department Call Panel. Exceptions may be made depending upon the physician's specialty of practice (Le., gynecologists, fertility specialists. etc.). 2. When consultative services are needed by a Panel Physician, the choice of an appropriate consultant shall be at the discretion of the Panel PhYSician. However, the physician is encouraged to utilize the Panel Consultant on the schedule at the time services are needed. 3. Once the Emergency Department schedule is prepared and distributed, it is the responsibility of the panel Physician to make alternative arrangements for coverage. The physician shall be responsible for communicating any changes to the Panel to the Emergency Department in a timely manner. 4. Panel rotation is by individual physician on a rotating basis. The frequency of rotations may be daily or weekly as the need is demonstrated.
;I Department of Ob-Gyn Rules & Regulations, page 7 N. Accountability: As members of the Medical Staff, Department members agree to follow and be held accountable to, the Bylaws of the Medical Staff, the General Rules and Regulations of the Medical Staff, these Departmental Rules and Regulations, and Hospital and Medical Staff policies and procedures. In addition, the Department may elect to develop their own policies and procedures. Once approved within the framework of the Medical Staff, such policies and procedures shall be a part of these Rules and Regulations. O. Medical Liability Insurance Coverage: Department of OB/GYN members shall maintain in force, at all times, sufficient medical liability insurance for those privileges/procedures approved by the Department. The minimum amount of coverage shall be $113 million, or as otherwise determined by the Medical Executive Committee, pursuant to the Bylaws of the Medical Staff. If a Department member fails to maintain sufficient medical liability insurance, the procedure outlined in the Bylaws of the Medical Staff shall be followed. XII. XIII. CONDUCT: Professional conduct of the members of the Department of OB/GYN shall be subject to the provisions of the Bylaws and Rules and Regulations of the Medical Staff, and shall assure that the standard of care given to patients shall be in keeping with locally accepted levels of quality patient care. Evaluation of the professional and clinical care rendered by members of this Department shall be the responsibility of the Department Chairperson, and subject to the ultimate authority of the Medical Executive Committee and Board of Trustees. AMENDMENTS: At a minimum, these rules and regulations shall be reviewed and amended on an annual basis. Amendments may be made upon the motion of any Active member of the Department. Such motions must be brought to a vote of the Active Staff members of the Department, with majority vote required for adoption. Amendments must be ratified by the Hospital's Board of Trustees, on the recommendation of the Medical Executive Committee. XIV. APPROVALS: As evidenced by the following signatures, these Rules and Regulations have been adopted by the Department of OB/GYN. with acceptance by the Medical Executive Committee, and approval by the Hospital's Board of Trustees. ~~~~------~~ Chairperson, Departl'l"\QDNlIt' \ \_\ =03=/2~4/=20~1~1 Date Medical Executive Committee 04/04/2011 Date Approvals: Department of OB/Gyn 03/24/2011 Medical Executive Committee 04/04/2011 Medical Affairs Committee 05/16/2011 Community Ministry Board 06/16/2011