san francisco general hospital

169 Pages·2014·0.85 MB·English

SAN FRANCISCO GENERAL HOSPITAL

MEDICAL STAFF

BYLAWS

2013-2014

Draft – May 20, 2014

1
TABLE OF CONTENTS Comment [U1]: Pages will need to be updated
PREAMBLE .......................................................................................................... 9
DEFINITIONS ....................................................................................................... 9
Academic Year ..................................................................................................................................................9
Affiliated Professional .....................................................................................................................................9
AssociateVice Dean ..........................................................................................................................................9
Attending Faculty (Supervisor) .....................................................................................................................1 0
Bylaws ..............................................................................................................................................................1 0
Chief of Clinical Service ................................................................................................................................1 0
Chief of Staff ...................................................................................................................................................1 0
Clinical Privileges or Privileges ....................................................................................................................1 0
Community Primary Care Service (CPC) ....................................................................................................1 0
Date of Receipt ................................................................................................................................................1 0
Department Chair ...........................................................................................................................................1 1
Director of Health ..........................................................................................................................................1 1
DPH ................................................................................................................................................................. 11
Ex officio .........................................................................................................................................................1 2
Executive AdministratorChief Executive Officer ....................................................................................... 12
Governing Body ..............................................................................................................................................1 2
House Staff......................................................................................................................................................1 2
Hospital ...........................................................................................................................................................1 2
Investigation ....................................................................................................................................................1 2
Licensed ...........................................................................................................................................................1 2
MEC ................................................................................................................................................................. 13
Medical Record ...............................................................................................................................................1 3
Medical Staff ...................................................................................................................................................1 3
Medical Staff Year ..........................................................................................................................................1 3
Notice ...............................................................................................................................................................1 3
Physician .........................................................................................................................................................1 3
PractitionerApplicantApplicant .................................................................. Error! Bookmark not defined.
Proctoring...................................................................................................... Error! Bookmark not defined.
Special Notice .................................................................................................................................................1 4
University ........................................................................................................................................................1 4
Other ................................................................................................................................................................1 4
ARTICLE I: NAME AND PURPOSES ........................................................... 14
1.1 Name ................................................................................................................................ 14
1.2 Purposes and Responsibilities ..................................................................................... 15
1.2-1 Collaborate ........................................................................................................................................1 5
1.2-2 Patient Care.......................................................................................................................................1 5
1.2-3 Professional Performance ................................................................................................................1 5
1.2-4 Educational Setting ..........................................................................................................................1 5
1.2-5 Community Health Education .........................................................................................................1 5
1.2-6 Self-Governance ...............................................................................................................................1 5
1.2-7 Communication ................................................................................................................................1 5
1.2-8 Continuous Quality Assessment......................................................................................................1 6
ARTICLE II: MEDICAL STAFF MEMBERSHIP ............................................. 16
0
2.1 General Qualifications ................................................................................................... 16
2.2 Basic Qualifications for Consideration of Application Active and Courtesy Medical
Staff….. ......................................................................................................................................... 16
2.2-1 Licensure ...........................................................................................................................................1 7
2.2-2 DEA ..................................................................................................................................................1 7
2.2-3 Board Certification ...........................................................................................................................1 7
2.2-4 Professional Liability Insurance ......................................................................................................1 9
2.2-5 Participation in Medicare, Medicaid and Other Federal Health Care Programs .......................... 20
2.3 Qualifications for Membership ...................................................................................... 20
2.3-1 Experience, Education and Training ............................................................................................... 20
2.3-2 Ethics .................................................................................................................................................2 0
2.4 Condition and Duration of Appointment ...................................................................... 21
2.4-1 Governing Body Action ...................................................................................................................2 1
2.4-2 Duration ............................................................................................................................................2 1
2.4-3 Clinical Privileges ............................................................................................................................2 1
2.4-4 Provide Care .....................................................................................................................................2 1
2.4-5 Shall Not Discriminate .....................................................................................................................2 1
2.4-6 Division of Fees ...............................................................................................................................2 1
2.5 Harassment Prohibited .................................................................................................. 21
2.6 Nondiscrimination .......................................................................................................... 22
2.7 Effect of Other Affiliations ............................................................................................. 22
2.8 Basic Responsibilities of the Medical Staff ................................................................. 22
ARTICLE III: CATEGORIES OF THE MEDICAL STAFF ............................... 24
3.1 Active Medical Staff ........................................................................................................ 24
3.2 Courtesy Medical Staff ................................................................................................... 24
ARTICLE IV: APPOINTMENT AND REAPPOINTMENTS .............................. 25
4.1 General ............................................................................................................................ 25
4.1-1 Application Process ..........................................................................................................................2 5
4.1-2 Application Content .........................................................................................................................2 5
4.1-3 Completion of Application ..............................................................................................................2 6
4.1-4 Application Misrepresentation or Omission ................................................................................... 27
4.1-5 Effect of Application ........................................................................................................................2 7
4.1-6 Applicant’s right to be informed .....................................................................................................2 8
4.2 Initial Appointment Process .......................................................................................... 28
4.2-1 Applicant’s Receipt of Medical Staff Information......................................................................... 28
4.2-2 Completed Application ....................................................................................................................2 8
4.2-3 Incomplete Application ....................................................................................................................2 9
4.2-4 Recommendation for Medical Staff Membership and Clinical Privileges ................................... 29
4.2-5 Credentials Committee Review and Action ................................................................................... 29
4.2-6 Medical Executive Committee Review and Action ....................................................................... 30
4.2-7 Governing Body Review and Action .............................................................................................. 31
1
4.3 Reappointment Process ................................................................................................ 32
4.3-1 Frequency .........................................................................................................................................3 2
4.3-2 Reappointment Application Process ............................................................................................... 32
4.3-3 Recommendation for Reappointment ............................................................................................. 32
4.3-4 Additional Considerations for Reappointment ............................................................................... 33
4.3-5 Credentials Committee Action ........................................................................................................3 3
4.3-6 Medical Executive Committee Action ............................................................................................ 34
4.3-7 Term of Reappointment ...................................................................................................................3 4
4.3-8 Failure to Return a Completed Reappointment Application ......................................................... 34
4.3-9 Reinstatement ...................................................................................................................................3 5
4.4 Access to Own Credentials File .................................................................................... 36
4.5 Right to Request Corrections/Additions ...................................................................... 36
4.6 Reapplication After Adverse Decision ......................................................................... 37
4.7 House Staff ...................................................................................................................... 38
4.8 Affiliated Professionals .................................................................................................. 38
4.8-1 General ..............................................................................................................................................3 8
4.8-2 Role of Medical Staff .......................................................................................................................3 9
4.8-3 Appointment .....................................................................................................................................4 0
4.8-4 Reappointment ..................................................................................................................................4 3
4.8-5 Corrective Action .............................................................................................................................4 3
ARTICLE V: CLINICAL PRIVILEGES ............................................................ 43
5.1 Clinical Privileges ........................................................................................................... 44
5.1-1 Process ..............................................................................................................................................4 4
5.1-2 Education, Training and Experience ............................................................................................... 44
5.1-3 Evaluation .........................................................................................................................................4 4
5.2 Temporary Privileges ..................................................................................................... 44
5.2-1 Pending Application for Permanent Medical Staff Membership .................................................. 45
5.2-2 Application and Review...................................................................................................................4 5
5.2-3 General Conditions...........................................................................................................................4 6
5.3 Visiting Privileges ........................................................................................................... 47
5.3-1 To Meet a Specific Need .................................................................................................................4 7
5.3-2 General Conditions...........................................................................................................................4 8
5.4 Emergency Situations .................................................................................................... 49
5.4-1 Medical Staff Members and Credentialed Affiliated Professionals .............................................. 49
5.5 Disaster Privileges ......................................................................................................... 49
5.6 Proctoring ........................................................................................................................ 51
5.6-1 General ..............................................................................................................................................5 1
5.6-2 Function and Responsibility of the Proctor .................................................................................... 51
5.6-3 Responsibility of the Procteree........................................................................................................5 2
5.6-4 Proctoring Duration ..........................................................................................................................5 2
5.6-5 Reciprocal Proctoring ......................................................................................................................5 3
2
ARTICLE VI: ROUTINE MONITORING AND EDUCATION AND
CORRECTIVE ACTION ...................................................................................... 53
6.1 Routine Monitoring and Education, Including Verbal and Written Counseling ....... 54
6.1-1 Responsibilities of the Chiefs of the Clinical Services .................................................. 54
6.1-2 Quality of Patient Care - Education, Monitoring and Investigation and Response
to Concerns Identified ..............................................................................................................................5 4
6.1-3 Professional Standards of Behavior .................................. Error! Bookmark not defined.
6.1-4 Investigation in Response to Alleged Disruptive and Inappropriate Behavior
Error! Bookmark not defined.
6.1-5 Medical Executive Committee Approval is not Required and Procedural Rights
are not Triggered ...................................................................................... Error! Bookmark not defined.
6.2 Criteria for Initiation of Corrective Action .......................... Error! Bookmark not defined.
6.3 Initiation ................................................................................. Error! Bookmark not defined.
6.4 Formal Investigation ............................................................ Error! Bookmark not defined.
6.5 Medical Executive Committee Action ................................. Error! Bookmark not defined.
6.6 Procedural Rights ........................................................................................................... 64
6.7 Initiation of Governing Body ......................................................................................... 64
6.8 University ........................................................................................................................ 65
6.9 Criteria for Initiation ....................................................................................................... 65
6.10 Medical Executive Committee Action ........................................................................... 66
6.11 Procedural Rights ........................................................................................................... 66
6.12 Initiation by the Governing Body .................................................................................. 67
6.13 Licensure ......................................................................................................................... 68
6.14 DEA Certificate ............................................................................................................... 69
6.15 Medical Records ............................................................................................................. 69
6.16 Procedural Rights ........................................................................................................... 69
6.17 Notice of Automatic Suspension and Transfer of Patients ........................................ 70
6.18 Automatic Termination .................................................................................................. 70
ARTICLE VII: HEARINGS AND APPELLATE REVIEWS ............................... 70
7.1 General Provisions ......................................................................................................... 70
7.2 Grounds for Hearing ...................................................................................................... 71
7.3 Requests for Hearing ..................................................................................................... 72
3
7.3-1 Notice of Action for Proposed Action .................................................................................. 72
7.3-2 Request for Hearing ...................................................................................................................7 3
7.3-3 Hearings Prompted by Governing Body Action ............................................................... 73
7.3-4 Time and Place for Hearing .....................................................................................................7 3
7.3-5 Notice of Charges .......................................................................................................................7 4
7.3-6 Judicial Review Committee .....................................................................................................7 4
7.4 The Hearing Procedure .................................................................................................. 75
7.4-1 The Hearing Officer ....................................................................................................................7 5
7.4-2 Representation .............................................................................................................................7 6
7.4-3 Postponements and Extensions ............................................................................................ 77
7.4-4 Failure to Appear or Proceed ..................................................................................................7 7
7.4-5 Discovery .......................................................................................................................................7 7
7.4-6 Objections to Introduction of Evidence Previously Not Produced for the Medical
Staff….. ..........................................................................................................................................................7 8
7.4-7 Pre-Hearing Document Exchange ......................................................................................... 79
7.4-8 Witness Lists ................................................................................................................................7 9
7.4-9 Procedural Disputes...................................................................................................................7 9
7.4-10 Record of Hearing ..................................................................................................................8 0
7.4-11 Rights of the Parties..............................................................................................................8 0
7.4-12 Rules of Evidence ..................................................................................................................8 1
7.4-13 Burdens of Presenting Evidence and Proof ................................................................. 81
7.4-14 Adjournment and Conclusion ............................................................................................ 82
7.4-15 Basis for Decision ..................................................................................................................8 2
7.4-16 Decision of the Judicial Review Committee ................................................................. 82
7.5 Appeal .............................................................................................................................. 83
7.5-1 Time for Appeal............................................................................................................................8 3
7.5-2 Grounds for Appeal ....................................................................................................................8 3
7.5-3 Time, Place, and Notice ............................................................................................................8 3
7.5-4 Nature of Appellate Review .....................................................................................................8 4
7.5-5 Final Decision ...............................................................................................................................8 4
7.5-6 Further Review .............................................................................................................................8 5
7.5-7 Right to One Hearing Only .......................................................................................................8 5
7.6 Exceptions to Hearing Rights ....................................................................................... 85
7.6-1 Exclusive Use Departments ....................................................................................................8 5
7.6-2 Hospital Contract PractitionerApplicantApplicants ........................................................ 86
7.6-3 Affiliated Professionals, House Staff, Medical Students and Trainees .................... 87
7.6-4 Denial of Applications for Failure to Meet the Minimum Qualifications .................. 87
7.6-5 Automatic Suspension or Limitation of Privileges .......................................................... 87
ARTICLE VIII: STRUCTURE OF THE MEDICAL STAFF ............................... 88
8.1 Medical Staff Year ........................................................................................................... 88
8.2 Officers of the Medical Staff .......................................................................................... 88
8.2-1 Qualifications of Officers .........................................................................................................8 8
8.2-2 Election of Chief of Staff-Elect ............................................................................................... 88
8.2-3 Term of Office ...............................................................................................................................8 9
8.2-4 Vacancies in Office .....................................................................................................................8 9
8.2-5 Duties of Officers ........................................................................................................................9 0
8.2-6 Removal of Officers ....................................................................................................................9 3
4
ARTICLE IX: CLINICAL SERVICES ............................................................... 93
9.1 Organization of Clinical Services.................................................................................. 93
9.1-1 Overall Supervision ....................................................................................................................9 3
9.1-2 Clinical Services ..........................................................................................................................9 3
9.2 Qualifications, Selection and Tenure of Chiefs of Clinical Services......................... 94
9.2-1 Qualifications ...............................................................................................................................9 4
9.2-2 Selection of a Chief ....................................................................................................................9 5
9.2-3 Review .............................................................................................................................................9 6
9.2-4 Removal ..........................................................................................................................................9 7
9.2-5 Vacancy ..........................................................................................................................................9 8
9.3 Functions of Chiefs of Clinical Services ...................................................................... 99
9.3-1 Credentialing/privileging ..........................................................................................................9 9
9.3-2 Performance Improvement ....................................................................................................1 00
9.3-3 Education and Research ........................................................................................................1 01
9.3-4 Administration ............................................................................................................................1 01
9.4 Functions of Clinical Services .................................................................................... 104
9.5 Assignment to Clinical Service ................................................................................... 105
ARTICLE X: COMMITTEES OF THE MEDICAL STAFF ............................. 105
10.1 Designation ................................................................................................................... 105
10.2 General Provisions ....................................................................................................... 106
10.2-1 Ad Hoc Committees ............................................................................................................1 06
10.2-2 Parliamentary Procedure ...................................................................................................1 06
10.2-3 Scheduling ..............................................................................................................................1 06
10.2-4 Appointment of Chairs of Committees .........................................................................1 06
10.2-5 Membership Appointment ................................................................................................. 107
10.2-6 Quorum ....................................................................................................................................1 07
10.2-7 Manner of Action ..................................................................................................................1 08
10.2-8 Attendance Requirements ................................................................................................1 08
10.2-9 Notice of Meetings ...............................................................................................................1 08
10.2-10 Minutes and Reporting .......................................................................................................1 08
10.2-11 Special Meetings ..................................................................................................................1 10
10.2-12 Terms of Committee Members ........................................................................................1 10
10.2-13 Removal ...................................................................................................................................1 10
10.2-14 Vacancies ................................................................................................................................1 11
10.3 Medical Executive Committee ..................................................................................... 111
10.3-1 Composition of MEC ...........................................................................................................1 11
10.3-2 Attendance and Voting .......................................................................................................1 11
10.3-3 Officers and At-Large Members ......................................................................................1 12
10.3-4 Duties of MEC ........................................................................................................................1 13
10.4 Nominating Committee ................................................................................................ 115
10.4-1 Composition ...........................................................................................................................1 15
10.4-2 Duties .......................................................................................................................................1 15
10.4-3 Meetings ..................................................................................................................................1 16
5
10.5 Joint Conference Committee ....................................................................................... 116
10.5-1 Composition ...........................................................................................................................1 16
10.5-2 Duties .......................................................................................................................................1 17
10.5-3 Meetings ..................................................................................................................................1 17
10.6 Ambulatory Care Committee ....................................................................................... 117
10.6-1 Composition ...........................................................................................................................1 17
10.6-2 Duties .......................................................................................................................................1 18
10.6-3 Meetings ..................................................................................................................................1 20
10.7 Bylaws Committee ........................................................................................................ 120
10.7-1 Composition ...........................................................................................................................1 20
10.7-2 Duties .......................................................................................................................................1 20
10.7-3 Meetings ..................................................................................................................................1 20
10.8 Cancer Committee ........................................................................................................ 121
10.8-1 Composition ...........................................................................................................................1 21
10.8-2 Duties .......................................................................................................................................1 21
10.8-3 Meetings ..................................................................................................................................1 22
10.9 Credentials Committee ................................................................................................ 122
10.9-1 Composition ...........................................................................................................................1 22
10.9-2 Duties .......................................................................................................................................1 23
10.9-3 Meetings ..................................................................................................................................1 23
10.9-4 Subcommittees .....................................................................................................................1 23
10.10 Critical Care Committee ............................................................................................... 124
10.10-1 Composition ...........................................................................................................................1 24
10.10-2 Duties .......................................................................................................................................1 24
10.10-3 Meetings ..................................................................................................................................1 25
10.10-4 Subcommittee .......................................................................................................................1 25
10.11 Ethics Committee ......................................................................................................... 126
10.11-1 Composition ...........................................................................................................................1 26
10.11-2 Duties .......................................................................................................................................1 26
10.11-3 Meetings ..................................................................................................................................1 26
10.12 Infection Control Committee ....................................................................................... 126
10.12-1 Composition ...........................................................................................................................1 27
10.12-2 Duties .......................................................................................................................................1 28
10.12-3 Meetings ..................................................................................................................................1 29
10.13 Medical Staff Well Being Committee .......................................................................... 129
10.13-1 Composition ...........................................................................................................................1 29
10.13-2 Duties .......................................................................................................................................1 29
10.13-3 Meetings ..................................................................................................................................1 30
10.14 Operating Room Committee ........................................................................................ 131
10.14-1 Composition ...........................................................................................................................1 31
10.14-2 Duties .......................................................................................................................................1 31
10.14-3 Meetings ..................................................................................................................................1 31
10.15 Pharmacy and Therapeutics Committee .................................................................... 131
10.15-1 Composition ...........................................................................................................................1 31
10.15-2 Duties .......................................................................................................................................1 32
6
10.15-3 Meetings ..................................................................................................................................1 33
10.15-4 Subcommittees .....................................................................................................................1 33
10.16 Performance Improvement and Patient Safety Committee ...................................... 135
10.16-1 Composition ...........................................................................................................................1 35
10.16-2 Duties .......................................................................................................................................1 36
10.16-3 Meetings ..................................................................................................................................1 37
10.16-4 Subcommittees .....................................................................................................................1 37
10.17 Substance Abuse Committee ...................................................................................... 149
10.17-1 Composition ...........................................................................................................................1 49
10.17-2 Duties .......................................................................................................................................1 50
10.17-3 Meetings ..................................................................................................................................1 51
10.18 Information Systems Committee ................................................................................ 151
10.18-1 Composition ...........................................................................................................................1 51
10.18-2 Duties .......................................................................................................................................1 52
10.18-3 Meetings ..................................................................................................................................1 52
ARTICLE XI: MEETINGS OF THE WHOLE MEDICAL STAFF .................... 155
11.1 Annual Meeting ............................................................................................................. 155
11.2 Voting ............................................................................................................................. 156
11.3 Special Meetings .......................................................................................................... 156
ARTICLE XII: CONFIDENTIALITY OF INFORMATION; IMMUNITY AND
RELEASES…… ............................................................................................... 158
12.1 Authorization and Conditions ..................................................................................... 158
12.2 Confidentiality of Information ..................................................................................... 158
12.2-1 General.....................................................................................................................................1 58
12.2-2 When Disclosure is Permitted .........................................................................................1 59
12.2-3 Breach of Confidentiality ...................................................................................................1 60
12.2-4 Immunity from Liability ......................................................................................................1 60
12.2-5 Activities and Information Covered ...............................................................................1 61
ARTICLE XIII: CONFLICTS AND DISPUTE RESOLUTION ......................... 161
13.1 Conflicts and Disputes between the Medical Staff and the MEC ........................... 161
13.2 Conflicts and Disputes between the Medical Staff and the Governing Body ....... 162
ARTICLE XIV: RULES AND REGULATIONS ............................................... 163
14.1 Rules and Regulations of the Medical Staff ............................................................... 163
14.2 Rules and Regulations of the Clinical Services ........................................................ 164
7
ARTICLE XV: ADOPTION AND AMENDMENT ............................................ 164
15.1 Medical Staff Responsibility ........................................................................................ 164
15.2 Amendments ................................................................................................................. 165
15.3 Method ........................................................................................................................... 165
15.4 Corrections.................................................................................................................... 166
15.5 Urgent Amendments .................................................................................................... 166
8