I. MEMBERSHIP SUTTER MEDICAL CENTER, SACRAMENTO RULES AND REGULATIONS DEPARTMENT OF OBSTETRICS AND GYNECOLOGY SCHEDULED REVIEW: 10/2015 The Department of Obstetrics and Gynecology will consist of those doctors limiting their work to this field of medicine and who meet at least one of the following criteria: l. Physicians who are certified by the American College of Obstetrics and Gynecology; OR 2. Physicians who have completed an approved Obstetric/Gynecology Residency; OR 3. Physicians with 10 years of hospital experience in a TJC accredited hospital and have exercised similar privileges to those being requested. II. OFFICERS 2.1 There shall be the following officers of the Department of Obstetrics and Gynecology, selected as set forth in the Medical Staff Bylaws: A. Chief B. Vice-Chief C. Secretary D. Members-at-Large 2.2 Term of office will be two years. Officers will not serve for more than two consecutive terms in any one office, but may be reelected after a lapse of two years. 2.3 Qualifications The Department Chief and Vice-Chief shall: A. Be board certified or board admissible in the specialty, as required by California hospital licensure regulations. B. Have demonstrated clinical competence in obstetrics and gynecology sufficient to demand the respect of the members of the department. C. Have an understanding of the purposes and functions of the Staff organization and a demonstrated willingness to assure that patient safety takes precedence over all other concerns. D. Be (and remain during tenure in office) a member in good standing of the Active medical staff.
Page 2 2.4 Duties A. The Department Chief shall: l. Ensure the effective performance of all Department functions as set forth in the Medical Staff Bylaws. 2. In conjunction with the Chief of Staff and the Department Administrative Committee, establish objectives for ensuring the quality of medical care within the Department, and assist in developing programs to achieve these objectives. 3. Ensure the establishment, maintenance and enforcement of professional standards within the Department and the continuing improvement of the quality of care rendered in the Department. 4. Exercise such authority as he/she deems necessary so that at all times in his Department patient welfare takes precedence over all other concerns. 5. In conjunction with the Medical Education Coordinator and the Department Administrative Committee, ensure that programs for the continuing education of members of his/her Department are established and periodically evaluated. 6. Establish and enforce in conjunction with the Chief of Staff and the Department Administrative Committee, written policies, rules and regulations for the Department that shall be reviewed at least every three years. 7. Supervise, or cause to be supervised, all staff members and allied health professionals holding temporary privileges or a probationary appointment in the Department. 8. Keep the staff members and allied health professionals in his/her Department informed as to established Departmental objectives and policies and the progress being made toward fulfillment of those objectives and policies. 9. Implement any medical care policies and procedures adopted by the Board as they pertain to his/her Department. 10. At least biannually and with the assistance of the Department Administrative Committee, review the privileges granted staff members and allied health professionals in his/her Department for the purpose of making recommendations for the maintenance, increase, or reduction of such privileges. These recommendations are based on a review of records
Page 3 performed by the peer review committees as well as other sources of information concerning the practitioner's clinical performance and his/her satisfactory compliance with applicable Medical Staff, Department and hospital policies. 11. Chair all Department meetings; receive recommendations concerning medical care policies and procedures and report pertinent recommendations to the Chief of Staff and the Medical Executive Committee. 12. Serve as an ex-officio member of all committees of the Department and attend such committee meetings as deemed necessary for adequate information flow. 13. Ensure that records of performance are maintained and updated for all members of the Department. 14. Report on activities of the Medical Staff to the Board when called upon to do so by the Chief of Staff or the Chief Executive Officer. 15. Be a member of the Medical Executive Committee. 16. Oversee the Department's compliance with the requirements of Title 22, California Code of Regulations and the Joint Commission on Accreditation of Healthcare Organizations, insofar as they relate to the Medical Staff within the Department of Obstetrics and Gynecology. B. The Department Vice-Chief shall: 2.5 Authority l. Assist the Department Chief in the performance of duties and, in the absence or disability of the Department Chief, shall be responsible to perform the duties of the Chief. 2. Chair departmental committees as requested by the Department Chief. 3. Chair the Obstetric Quality Assessment Committee. A. The Department Chief shall have authority: l. To suspend temporarily the privileges of any member of the Department whenever the personal or professional conduct of the member is such that a failure to take action may result in an imminent danger to the health of any individual or result in a severe disruption of Medical Staff or Hospital operations of a type that might result in danger to the health of any individual. Consultation with Chief of Staff as stipulated in the Medical Staff Bylaws is required.
Page 4 2. To require consultations whenever, in his/her discretion, it is deemed necessary. 3. To appoint the chairperson and members of all committees within his/her Department. B. When acting in the role of, or at the direction of, the Department Chief, the Vice- Chief shall have authority described in paragraph A above. 2.6 Accountability and Relationships A. The Department Chief shall: l. Be immediately responsible to the Chief of Staff. 2. Regularly report to the Chief of Staff and the Medical Executive Committee regarding: (a) (b) (c) (d) (e) (f) The discharge of the functions of the Department of Obstetrics and Gynecology. The quality of medical care rendered in the Department as reflected by ongoing quality assessment programs. All disciplinary actions in progress or being contemplated regarding any member of the Department. All pending applications for appointment to the Department and privileges requested. All requests by any member or allied health professional in the Department for changes in privileges or staff classification. The conduct or professional performance of any member of allied health professional in the Department, or any other matter when so requested by the Chief of Staff or the Medical Executive Committee. 3. Keep the Chief of Staff informed of all violations of Hospital policies, which put patient welfare in jeopardy, and report on what action is being taken to prevent such incidents from recurring. 4. Keep the Chief of Staff apprised of the progress being made toward attaining those objectives which have been agreed upon for the Department. B. The Vice-Chief shall be accountable to the Department Chief. When acting in the capacity of Department Chief, the Vice-Chief shall be accountable as described in paragraphs A l through 4 above.
Page 5 2.7 Qualifications for Secretary Will be a member of the Active Staff (and remain so during the tenure of office). 2.8 Duties of Secretary A. The Department Secretary shall l. Ensure that accurate and complete minutes of the Administrative Committee and the Department meetings are maintained. 2. Perform additional duties as may be assigned from time to time. 3. In the absence or disability of the Department Chief and Vice-Chief, perform all the duties of the Department Chief. 4. Chair the Gynecology Quality Assessment Committee. 2.9 Qualifications for Members-at-Large Will be a member of the Active Staff (and remain so during the tenure of office). 2.10 Duties of Members-at-Large Will serve on the Administrative Committee of the Department as representatives of the Department of Obstetrics and Gynecology. III. DEPARTMENT MEETINGS 3.l Department meetings may be held monthly. IV. COMMITTEES 4.1 A Perinatal Morbidity/Mortality Conference will be held monthly. Members of the Department shall be encouraged to attend these meetings. 4.2 Ob/Gyn Administrative Committee A. Members shall be the three elected officers, two or more members-at-large (one elected and one to three appointed by the Department Chief), and the immediate past Department Chief. A representative of hospital administration (appointed by the Chief Executive Officer), a representative of Perinatal Services, Family Practice, Pediatrics and Ob Anesthesia shall be nonvoting members. Other representatives, either permanent or temporary, will be appointed by the Obstetrics/Gynecology Administrative Committee.
Page 6 B. The committee shall meet monthly to assist the Department Chief in the formulation and enforcement of Department policies, programs, and objectives and to help ensure the effective performance of all functions of the Department. Minutes of the meetings will be maintained. C. Among the duties and authority of the committee are l. Developing criteria for granting privileges in the Department. 2. Evaluating all applicants for membership or privileges in the Department, and making recommendations on such applications to the Credentials Committee and the Medical Executive Committee. 3. Formulating rules and regulations for the Department, subject to the approval of the department members, the Medical Executive Committee and the Board. D. The committee is accountable to the Department Chief. 4.3 Peer Review Committees (Obstetrical Quality Assessment Committee and Gynecological Quality Assessment Committee) A. The Peer Review Committees will meet at least quarterly to perform their assigned duties. Minutes will be maintained. B. The committees shall be comprised of at least three Active Staff members appointed by the Department Chief. C. The Peer Review Committees will l. Develop and perform audits and proctoring of medical care delivered by members of the Department. 2. Develop recommendations for corrective action, based on audit results. 3. Be accountable to the Department Chief and the Ob-Gyn Administrative Committee. 4.4 Other temporary committees as may be required for conduct of Department business will be appointed by the Chief of the Department. V. CONSULTATIONS-OPERATIVE PERMITS 5.l Refer to General Rules and Regulations of the Sutter Medical Center s Medical Staff for policies concerning consultations and surgical permits. In addition, all staff members shall comply with state and federal regulations relating to sterilization consents.
Page 7 5.2 Consultation with a staff member with full privileges in obstetrics is urged in all seriously ill obstetrical patients, in cases of doubtful diagnosis or treatment, or in complications with the potential of great risk to mother and baby. The consultation will be recorded in the patient's hospital chart. 5.3 In case of extreme emergency, as many obstetrical and gynecology specialists as needed will be called by the original consultant and will serve in any capability needed. VI. PROGRESS NOTES 6.l Detailed notes will be required on the chart in the following types of obstetrical cases: A. Mid forceps B. Breech C. Diabetes D. Pregnancy induced hypertension E. Postpartum hemorrhage F. Multiple pregnancies G. Stillbirth H. Premature delivery I. Oxytocin induction J. Oxytocin augmentation K. Management of preterm labor L. All cases in which there are any significant complications 6.2 Sufficient progress notes will be recorded on all complications so that the patient's course in the hospital can be reconstructed if necessary. 6.3 An interval note must be placed on the chart of each labor patient admitted to the hospital. This notation must include any changes that may have occurred in the patient's status since the last office visit recorded in the prenatal record. VII. PROCTORING 7.l All physicians admitted to the Provisional Staff in the Department of Obstetrics and Gynecology will be monitored under the auspices of the Department Administrative Committee in the following manner: Using at least two different Active Staff members, the physician will be proctored on the first six gynecology procedures, to include one vaginal and one abdominal hysterectomy (Trachelectomy can be accepted), one C-Section and one circumcision (if requested). Other proctoring may be required as stipulated in any specific criteria for privileges. At least onehalf of the proctoring must be performed by a non-associate and at least three cases must be Sutter cases. Proctoring reports from other area hospitals may be submitted for consideration so long as the proctor is a Active staff member at their own facility, in good
Page 8 standing at that facility and privileged for the procedure they are proctoring, and so long as the other hospital's form is at least as comprehensive as Sutter's form (if not, a Sutter form shall be completed). Note: Should there be no opportunity to schedule a vaginal hysterectomy during the Provisional period, another major procedure will be substituted for proctoring. When a vaginal hysterectomy is scheduled, either during or post-provisional Staff, a proctor shall be obtained. Upon completion of the observation, the proctor will provide written information to the Chief of the Department concerning the procedure, technique, indications for surgery and any additional comments as he/she desires. Consulting staff members will be required to submit six proctoring reports from their primary hospital provided the proctoring is not older than five years at the time of appointment to the Sutter Medical Center s Medical Staff. If proctoring reports are older than five years, the proctor may be the attending physician who should comment on the outcome of the case. 7.2 Family Practitioners performing obstetric/gynecology procedures may be proctored by a Family Practitioner or by a member of the Obstetric/Gynecology Department with the same privileges. VIII. PRIVILEGES 8.1 Obstetrical and gynecological privileges in the Department may be recommended for physicians who have active status with, or are certified by, the American Board of Obstetrics/Gynecology or who demonstrate equivalent qualifications, experience and training. 8.2 Limited Obstetric and Gynecologic privileges will be recommended for physicians who make application to the Ob-Gyn Administrative Committee and who show evidence of appropriate training and experience in the privileges for which they apply. 8.3 Continued privileges in the Department shall require: (1) satisfactory results in any audit or review conducted by any section, department or medical staff committee concerned with quality of care; or satisfactory correction of any problem noted through any such review; and (2) continued satisfactory performance of medical staff responsibilities and continued good standing on the Medical Staff. IX. SURGICAL ASSISTANT A surgical assistant is required on all asterisked procedures on the department privilege list. The operating physician must assure that an assistant is available on the unit before surgery commences, and should have already determined when the assistant would be needed for the case.
Page 9 X. VAGINAL DELIVERY It is recommended that an assistant (M.D. or R.N.) be available at breech deliveries. XI. DEPARTMENT POLICIES AND PROCEDURES The policies and procedures of the Department are as recorded in the Nursing Policy and Procedure Manual and shall be followed. XII. STERILIZATION Hysterectomy for the sole purpose of sterilization is not considered appropriate treatment. XIII. BIRTH AND DEATH CERTIFICATES 13.1 Each "live birth" and each "fetal death" in which the fetus has advanced to or beyond the twentieth week of in-utero gestation shall be registered with the local registrar of births and deaths. 13.2 "Live birth" means the complete expulsion or extraction from its mother of a product of conception (irrespective of the duration of the pregnancy) which, after such separation, breathes, or shows any other evidence of life such as beating of the heart, pulsation of the umbilical cord, or definite movement of the voluntary muscles, whether or not the umbilical cord has been cut or the placenta is attached. 13.3 "Fetal death" means a death prior to the completion, expulsion or extraction from its mother of a product of conception (irrespective of the duration of the pregnancy); the death is indicated by the fact that after such separation, the fetus does not breathe or show any other evidence of life such as beating of the heart, pulsation of the umbilical cord or definite movement of the voluntary muscles. XIV. EMERGENCY ROOM COVERAGE The department will provide the Emergency Rooms with a list of members who will provide backup to the emergency room physicians. If a physician from that list does not respond, the Department Chief will be notified. Physicians who serve on the Emergency Room call list for obstetrics must hold the privilege for Limited Obstetric Ultrasound. Participation on the gynecology no-doctor call schedule is mandatory for physicians with gynecology privileges. Physicians who are age 65 years and older are exempt from serving on this call schedule.
Page 10 XV. ALLIED HEALTH PROFESSIONALS All Allied Health Professionals will be subject to training and supervision requirements as developed by the Department and approved by the Interdisciplinary Practices Subcommittee, the Medical Executive Committee and the Board. XVI. REVISION OF DEPARTMENT RULES AND REGULATIONS 16.l The Rules and Regulations of the Department of Obstetrics and Gynecology will be reviewed at least every three years and revised as necessary. 16.2 Proposed revisions will be submitted to the voting members of the Department for approval and will become effective upon approval of the department members, the Medical Executive Committee and the Board of Trustees. APPROVED BY: Obstetrics/Gynecology Administrative Committee DATE: 10/22/2012 APPROVED BY: Medical Executive Committee DATE: 11/27/2012 APPROVED BY: Ob/Gyn Department (Vote) DATE: 01/9/2013 APPROVED BY: Medical Policy Committee DATE: 12/6/2012 APPROVED BY: Board of Trustees DATE: 12/10/2012 Developed: Reviewed: 5/96; 11/96 Revised: 7/89; 8/91; 4/93; 5/94; 10/96; 6-97; 12/00; 6/03; 5/08, 10/12