Rules and Regulations (Set 2)
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Rules and Regulations (Set 2)






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Rules and Regulations (Set 2) Rules and Regulations (Set 2) Document Transcript

  • RULES AND REGULATIONS - SET 2 1. PLACEMENT OF INTRAOPERATIVE ARTERIAL LINES The decision to place an arterial line intraoperatively will be made by the Surgeon and the Anesthesiologist in concert. The Anesthesiologist will respond to the Surgeon=s request for such insertion. 8/19/86 2. MONITORING TEMPERATURE IN THE RECOVERY ROOM Monitoring of patient temperatures in the Recovery Room will continue if already initiated in the Operating Room. If not, continuous patient temperature monitoring may be by order from the Physician. 6/4/86 3. TIME LIMITATIONS FOR PHYSICIAN ATTENDANCE TO PHYSICIAN REFERRED PATIENTS When a triaged Class I or II patient presents to the Emergency Department, the Attending Physician will be notified. The Attending Physician will be required to respond to this call within 30 minutes or the patient will automatically be seen by the Emergency Medicine Physician on duty for determination of treatment needs. Once the Attending Physician responds appropriately, he/she will be required to either see the patient or give pertinent orders for evaluative testing. The Attending Physician must see the patient or make a treatment decision within one hour of having been notified of laboratory/testing results. Class III or IV patients will automatically be seen by the Emergency Medicine Physician unless the Attending Physician has called ahead to notify the Emergency Department of the patient=s circumstances and either gives appropriate orders or indicates his/her imminent arrival to see the patient. Variances to these procedures will be reported to the Executive Committee for resolution. 9/10/92 4. EMERGENCY ON-CALL PHYSICIAN RESPONSIBILITY The on-call Physician treating an Emergency Department patient shall be responsible for the follow up care of that patient, within the realm of the Physician=s on-call specialty and/or competence for a 30 day period from the date of the patient=s discharge from the Hospital. It shall be considered that the patient has severed the relationship with the Physician if the patient signs out against medical advice and the Attending Physician will no longer be responsible for the follow up care of that patient. 6/4/87 5. PEDIATRIC SURGERY CALL COVERAGE 1
  • If a Pediatric patient presents with a possible surgical problem and if that problem is clearly a surgical problem at the determination of the Emergency Department Physician, the Surgeon on-call should evaluate the patient for treatment or find appropriate care for the situation. 3/3/88 6. WALK-IN OB/GYN EMERGENCY DEPARTMENT PATIENTS All walk-in OB/GYN patients will be triaged by the Emergency Department staff. Problems detected that are unrelated to labor will be assessed by the ED Physician. If the problem identified in triage is related to labor or obstetrical care and does not display indication of infectious disease, the patient will be referred to Labor and Delivery to be assessed by the Nursing staff. The obstetrical Physicians will be available for consultation as required. 1/7/88 7. ON-CALL ASSIGNMENT New practitioners appointed to the Medical Staff shall be given a choice of on- call schedule assignments directly related to their specialty and clinical privileges. New Family Practice applicants shall make their preference known to the Chief of Family Practice who will advise Pediatrics and Medicine of their choice. 9/25/90 8. CALLING OF ATTENDING PHYSICIAN The Consultant should note on the order sheet when he is no longer on the case. The Attending Physician should be called by the Hospital staff initially unless a specific order to the contrary has been given. 11/29/85 9. USE OF VIDEOTAPING EQUIPMENT IN THE OPERATING DELIVERY SUITE A patient=s right to privacy is to be protected and the most optimal working environment for the Physician and surgical team is to be provided. Video cameras will not be permitted in the operating suite during Cesarean Section deliveries. Video cameras will be permitted at vaginal deliveries if there is no objection by the Physician(s) attending the delivery. Still pictures will be permitted with the authorization of the patient and Physicians involved at either type delivery. No exceptions are to be made. 7/9/92 Videotaping will not be allowed during the actual delivery, whether vaginal or by Cesarean. 10. PEDIATRICIAN ATTENDANCE AT ROUTINE C-SECTIONS Pediatricians request Adirect requests@ from the Obstetrician for their attendance at C-Sections and only in cases of fetal distress will Nursing staff calls be accepted. 9/2/86 2
  • 11. INCOMPLETE ABORTION Patients with incomplete abortions will generally be placed on the GYN unit. 6/3/86 12. PREGNANCY DOCUMENTATION In any instance of pregnancy, chart documentation is required. 1/9/86 13. BETA SUB UNIT TESTING AND/OR CHART DOCUMENTATION Preoperatively, Beta Sub Unit testing is to be performed on all females of child bearing potential. Alternatively, documentation must be placed in the record that the possibility of a concurrent pregnancy and possible complications have been discussed with the patient prior to the procedure. 12/3/85 (rev. 6/00) 14. GESTATIONAL AGE OF DELIVERIES Deliveries of less than 34 weeks gestation should not be attempted at MRMC. (8/22/86) unless emergency or extenuating circumstances exist. 15. EMERGENCY CONSULTATIONS Emergency consultation requests should be made directly from the Attending Physician to the Physician Consultant. 3/28/86 16. CHIEF OF PSYCHIATRY RESPONSIBILITIES The Chief of Psychiatry shall be a member of the Executive Credentials Committee. 1/7/88 17. NUCLEAR MEDICINE LICENSURE Physicians requesting inclusion on the Hospital=s Nuclear Medicine license must provide a copy of their own licensure. 18. RADIOLOGY FILM CHECKOUT POLICY Films taken locally or out of town will be released as long as the Physician and his address is known. Films that must be taken out of state for continued medical care will be copied at the expense of the Hospital. Attorneys will be required to pay for copies requested. 3/21/86 19. AGE LIMIT FOR OBSERVERS IN THE OPERATING ROOM 3
  • Any person authorized to observe in surgery must be at least 15 years of age or an accelerated student unless specific exception is granted by the Chief of Surgery. 6/23/92 20. OPERATING ROOM FIRST ASSISTANTS A. Cases that require Surgical Assistants 1. A First Assistant will be present in all cases in which the presence of an assistant will materially facilitate the procedure by providing exposure, hemostasis and other technical functions which help the Surgeon carry out a safe operation. The First Assistant may be a Physician, a Dentist with surgical privileges, an R.N., L.P.N., P.A., or a C.S.T. qualified by training or experience to work in this capacity. Non-Physician or non-Dentist First Assistants will be credentialed by the Hospital for this purpose. In those cases which are of sufficient magnitude to require a First Assistant, the Scrub Nurse or Scrub Technician may not double as a First Assistant. In any surgical procedure involving unusual hazard to life, a qualified Physician should be First Assistant. 2. In the event these rules do not seem properly implemented by the Attending Surgeon, the Charge Nurse will be responsible to report same to the proper authority. B. Qualifications of the non-Physician First Assistant should include but not be limited to: 1. Demonstrated proficiency in surgical scrub techniques and practices; 2. Knowledge and skill in applying principles of asepsis and infection control; 3. Appropriate knowledge of surgical anatomy, physiology, and operative procedures in which the individual assists; 4. Ability to assist in cardiopulmonary resuscitation; 5. Ability to perform effectively in stressful and emergency situations; 6. Ability to recognize safety hazards and initiate appropriate preventive and corrective action; 7. Ability to perform effectively and harmoniously as a member of the operative team; 8. Ability to demonstrate skill in behaviors unique to the First Assistant. C. Privileges of the Non-Physician First Assistant 1. Non-Physician First Assistant=s role should include: 4
  • a. Draping of the sterile field; b. Retracting for exposure; c. Cutting suture material; d. Closing wounds with the direct supervision of the Surgeon; e. Providing hemostasis by clamping, cauterizing or ligating only under direct supervision of the Surgeon; f. Application of the post-operative dressing; g. Assisting in any operative maneuver required in an urgent situation under the direct supervision of the Surgeon. 2. Non-Physician qualified First Assistants known to the Medical Staff on the basis of personal experience may be employed on a case- to-case basis. These personnel should be properly credentialed and insured. It is the Surgeon=s responsibility to arrange for these personnel to help on a case-by-case basis. 21. CONFIDENTIALITY OF MINUTES In order to protect the confidentiality of peer review information contained in the minutes of each Section/Subsection/Committee, such minutes will not be distributed to the medical Staff via attachment to the groups= agendas. A copy of the minutes will be sent to the Chief/Chairman prior to each meeting. Physicians= names or Hospital identification numbers will not be recorded in the minutes but each will be assigned an alphabetical code at random with a key code attached to the original minutes. 3/9/89 22. CHART SIGNATURE REQUIREMENTS The Practitioner performing a procedure (H&P, etc.) must be the one to dictate and sign the record. Physician=s Nurse Assistants, if credentialed to do so, may dictate a discharge summary for the sponsoring Physician=s countersignature but must also sign his/her dictation. 2/8/90 23. CHEMICAL SUBSTANCE USE/ABUSE OBSERVATION Any observation of chemical substance use/abuse by a Physician which is observed by a Hospital employee should be immediately reported to the appropriate Section Chief. 9/1/88 24. CONSULTATION REFUSAL A consultation may be refused unless the Physician being consulted is on call for the Emergency Department. 9/1/88 25. FREELANCE SURGICAL ASSISTANTS 5
  • Applicants will be required to submit an application with a statement from each Surgeon he/she will be assisting stating the Surgeon=s willingness to assume responsibility as sponsoring Physician of the applicant for the specified period of time, proof of the applicant=s insurance coverage, and specific privileges requested. 7/7/88 26. AUTOPSY FEES If an autopsy is ordered by a Physician and is considered medically necessary, the Hospital will assure funding is available for this service. 5/5/88 27. OUTSIDE REPORTS When an invasive procedure that is going to be done is the direct result of a pathology report, laboratory data, or x-ray done outside the Hospital, the results shall be documented and a copy of that report must be available on demand. 10/1/87 28. CASE REVIEW The Attending Physician is to be notified of any case review after evaluation by the Section Chief and if further investigation is recommended. 9/4/86, rev. 9/23/97 29. CONSULTATION PROCESS A consultant on a case should obtain authorization from the Attending Physician before calling in another consultant. 4/10/86 30. ADMISSIONS REVIEW The Chief of Service is to review the first 10 admissions of each Associate Medical Staff member in his service. 1/9/86 31. ADVANCEMENT TO ACTIVE MEDICAL STAFF All Section Chiefs, or their appointed representative, shall have the responsibility of reviewing all charts of admissions during the Associate year (maximum 10) by those Physicians being considered for Active Medical Staff appointment. 11/14/85 32. PATIENT MOVE FROM TELEMETRY If a patient is originally admitted to telemetry, it is permissible to move this patient as needed with authorization of the Attending Physician. 10/3/85 6
  • 33. ORDERING FORMULARY AND NON-FORMULARY DRUGS Physicians will be required to prescribe drugs within various formulary categories established to support efficiency and cost containment strategies at Munroe Regional Medical Center. A. Formulary recommendations will be developed by the Pharmacy and Therapeutics Committee for approval by the Executive Committee of the Medical Staff. B. Approved formulary drugs will be dispensed by the Pharmacy as ordered. C. If a drug is ordered that is not on the current formulary, such drug will not be stocked in the Pharmacy for dispensing. The ordering Physician must obtain the approval of the Chairman of the Pharmacy and Therapeutics Committee for an exception to have a non-formulary drug available through the Pharmacy. D. If a drug is ordered that is currently under study or has not yet been considered for formulary development, the Pharmacy will dispense the drug as ordered until such formulary is developed and/or finalized. 5/14/92 34. IMPAIRED PHYSICIANS The responsibility for investigating impaired (alleged or proven) physicians and/or allied health professionals (AHPs) that are credentialed by the Medical Staff at Munroe Regional Medical Center (MRMC) shall be transferred to the Physician Recovery Network (PRN). The Physician Recovery Network is a Committee of the Florida Medical Association having authority, through an understanding with the Florida Board of Medicine, to investigate, monitor and integrate Physicians who are impaired by substance abuse, psychological or physical illness. AHPs will be reported to the appropriate professional organized equivalent to the PRN or, alternatively, to their respective Board. This policy is intended only to regulate management of impaired staff and shall neither supersede nor limit, without prior written waiver of an affected practitioner, the operation of the Medical Staff bylaws nor limit the Board in its final authority to make a disposition. PROCEDURE: The following steps are to be followed universally to ensure the uniformity and fairness of the investigating process. ASuspicious Behavior@ is defined as an instance in which a fellow physician, AHP, Hospital employee, patient, their family or other person, witnesses 7
  • inappropriate behavior from a Physician or AHP during the exercise of his/her professional duties. These incidents may include, but are not restricted to, perceived problems with judgement, behavior, speech, alcohol odor, emotional outbursts, diminished capacity, depression, illness or substance abuse. The same definition and procedures will apply to AHPs who are credentialed by the Medical Staff and are not employees of MRMC. If a Physician or AHP witnesses such an event, it should be reported immediately to the President of the Medical Staff. If the Physician in question is the President, or if the President is not available, then the report should be made to the President-Elect or Secretary/Treasurer of the Medical Staff. It is of extreme importance that the President or replacement be contacted immediately regardless of time, date, or availability. If a Nurse or other Hospital employee encounters a similar problem, the individual=s supervisor should be informed immediately. The supervisor, if in agreement with the employee, will likewise report to the President of the Medical Staff immediately. Any complaint as outlined above from patient or family member should be directed immediately to the President of the Medical Staff. A report from the supervisor to Administration will be made per Hospital protocols. Upon receiving notice (delayed or immediate), the President of the Medical Staff should promptly contact a second Physician from the Medical Executive Committee (MEC) and an ex-officio consulting Physician Recovery Network member and at once, together, conduct an interview with the Physician/Practitioner in question. The President of the Medical Staff may discuss the situation with the MRMC Administration prior to or after this step. If both investigating doctors agree the report is completely without foundation, then no further investigatory action would be taken. The purpose of this step is to screen out frivolous complaints or problems not related to impairment (i.e. bedside manner, financial issues, quality complaints). Any matter that may in any way be reasonably related to a potential impairment must proceed through investigation and testing. A written report of any incident that is dismissed will be made and forwarded to the MEC for notification and/or discussion. The conclusion of the Committee will be included in the Physician=s/Practitioner=s quality file. All complaints not dismissed on the basis that they are lacking in foundation or are unrelated to impairment, shall be referred for testing (testing referral). ALL Physician/Practitioners and AHPs who are subject to a testing will undergo both of the following areas of testing: 1) chemical testing to include urine drug screen and serum alcohol level and 2) physiological testing to include a medical/psychiatric evaluation. Urine drug testing and alcohol levels shall be initiated on the spot following Hospital established policies for collection of such specimens. PRN will be notified of the incident so that they can initiate medical/ psychiatric evaluation at their own discretion. In the event the testing referral subject refuses any testing, his/her medical privileges will be suspended at once. The investigating physicians will also notify 8
  • PRN of this event as soon as possible. The matter will be presented to the MEC as soon as feasible. Whenever a Medical Staff member=s conduct appears to require immediate action be taken to protect the life or well being of patient(s) or whenever the member=s conduct presents a danger of immediate and serious harm to the life, health or safety of any patient, prospective patient, himself or herself, or other person, the President, the Chairman of the Department in which the member holds privileges or the CEO may summarily restrict or suspend the Medical Staff membership or clinical privileges of such member, pursuant to the Medical Staff Bylaws. The PRN will report findings and recommendations to both the MEC and to the Hospital Administration. The MEC shall follow the PRN=s recommendations in full unless a unanimous vote of the MEC (excluding the professional under question) rejects or modifies the recommendations of the PRN. A written report of all investigations and tests related to suspected impairment shall be made and forwarded to the MEC for notification and discussion. The conclusion of the Committee will be included in the suspect physician/Practitioner=s quality file. REHABILITATION Hospital and Medical Staff leadership should assist the Physician in locating a suitable rehabilitation program. A Physician shall not be reinstated until it is established, to the Hospital=s satisfaction, that the Physician has successfully completed a program in which the Hospital has confidence. REINSTATEMENT Upon sufficient proof that a Physician who has been found to be suffering an impairment has successfully completed a rehabilitation program, the Hospital, in its discretion, may consider that Physician for reinstatement to the Medical Staff. In considering an impaired Physician for reinstatement, the Hospital and its Medical Staff leadership must consider patient care interests paramount. The Hospital must first obtain a letter from the Physician Director of the rehabilitation program where the Physician was treated. The Physician must authorize the release of this information. That letter shall state: 1. Whether the Physician is participating in the program; 2. Whether the Physician is in compliance with all of the terms of the program; 3. Whether the physician attends AA meetings regularly (if appropriate); 4. To what extent the Physician=s behavior and conduct are monitored; 9
  • 5. Whether, in the opinion of those doctors, the Physician is rehabilitated; 6. Whether an after care program has been recommended; 7. Whether, in his or her opinion, the Physician is capable of resuming medical practice and providing continuous, competent care to patients. The Physician must inform the Hospital of the name and address of his or her primary care physician, and must authorize that Physician to provide the hospital with information regarding his or her condition and treatment. The Hospital has the right to require an opinion from other physician consultants of its choice. From the primary care Physician the Hospital needs to know the precise nature of the Physician=s condition, and the course of treatment as well as the answers to the questions posed above in L 5 and 7. Assuming all the information received indicates that the Physician is rehabilitated and capable of resuming care of patients, the Hospital must take the following additional precautions when restoring clinical privileges: 1. The Physician must identify one Physician who is willing to assume responsibility for the care of his or her patients in the event of his or her inability or unavailability; 2. The Physician shall be required to obtain periodic reports for the Hospital from his or her primary Physician - for a period of time specified by the Chief Executive Officer and the President of the Medical Staff - stating that the Physician is continuing treatment or therapy, as appropriate, and that his or her ability to treat and care for patients in the Hospital is not impaired. The Physician=s exercise of clinical privileges in the Hospital shall be monitored by the Department Chairperson or by a Physician appointed by the Department Chairperson. The nature of that monitoring shall be determined by the Credentials Committee after its review of all of the circumstances. All requests for information concerning the impaired Physician shall be forwarded to the Chief Executive Officer for response. rev. 9/23/97 35. PHYSICIAN ASSISTANT STUDENTS All Physician Assistant (PA) students requesting rotation with an individual Physician on the Medical Staff must complete an application, provide proof of insurance through their program or individual medical malpractice carrier, provide a letter from their sponsoring Physician. Orders written by a student in the patient=s chart may not be taken off until countersigned by the sponsoring Physician. All entries in the chart must be countersigned by the sponsoring Physician. Students may only participate in procedures under the direct observed supervision of their sponsoring Physician. 2/7/91 10
  • 36. ICU CONSULTATION REQUIREMENTS Those patients admitted to the ICU who meet ICU admission criteria based on severity of illness shall have management by a Physician or oral/maxillofacial surgeon credentialed for such care, or shall have specialty consultation for specific organ system failure, or shall have multi-specialty consultation for multi- system failure. 4/25/94 37. CONFIDENTIALITY OF RECORDS Physician personnel files may be released to: 1. A duly constituted Committee of the Medical Staff at any regular or special meeting; 2. The Chief of the Physician=s clinical Department; 3. An elected officer of the Medical Staff; 4. Any regular or special meeting of the Board of Directors of Munroe Regional Health System, Inc. d/b/a Munroe Regional Medical Center; 5. An elected officer of the Board of Directors; 6. The Chief Executive Officer or his designee member of the Hospital management team. Exception; the Physician may see only that portion of his personal file which he himself supplied to the Medial Staff office. Section and/or Committee minutes may be released to: 1. An elected officer of the Medical Staff acting in an official capacity; 2. The Chairman or a member of that Committee; 3. An officer of the Board of Directors; 4. The Chief Executive Officer or his designee member of the Hospital management team; 5. Any regular or special meeting of the Executive Committee; 6. Any regular or special meeting of the Board of Directors. The subject documents are the property of Munroe Regional Medical Center and the Medical Staff and may not be removed from the Hospital premises for any purpose. Any request received for the above information from outside agencies, by subpoena or by any person or agency other than those noted above, shall be referred to the Vice-President Medical Affairs. Such requests require prior authorization from the President of the Medical Staff or the Chief Executive Officer or their designee. 12/4/86 38. MEDICAL INDICATIONS FOR AUTOPSY 11
  • The performance of an autopsy as a quality improvement tool is well known. Therefore, autopsies should be sought in all deaths which meet the following criteria as developed by the College of American Pathologists: 1. Deaths in which autopsy may help to explain unknown and unanticipated medical complications to the Attending Physician; 2. All deaths in which the cause of death is not known with certainty on clinical grounds; 3. Deaths in which autopsy may help to allay concerns of the family and/or the public regarding the death, and to provide reassurance to them regarding same; 4. Unexpected or unexplained deaths occurring during or following any dental, medical, or surgical diagnostic procedures and/or therapies; 5. Deaths of patients who have participated in clinical trials (protocols) approved by Institutional Review Boards; 6. Unexpected or unexplained deaths which are apparently natural and not subject to a forensic medical jurisdiction; 7. Natural deaths which are subject to, but waived by, a forensic medical jurisdiction such as persons dead on arrival at hospitals, deaths occurring in the Hospital within 24 hours of admission, and deaths in which the patient sustained or apparently sustained an injury while hospitalized; 8. Death resulting from high-risk infectious and contagious diseases; 9. All obstetric deaths; 10. All neonatal and pediatric deaths; 11. Deaths at any age in which it is believed that autopsy would disclose a known or suspected illness which also may have a bearing on survivors or recipients of transplant organs; 12. Deaths known or suspected to have resulted from environmental or occupational hazards. 3/14/91 In accordance with Florida Statute 406.11 (Examinations, Investigations, and Autopsies. 39. SCOPE OF CLINICAL PRIVILEGES All areas of patient care shall have access to the scope of clinical privileges granted to each practitioner on the Medical Staff of Munroe Regional Medical Center. The Medical Staff office shall be the central repository for all professional files of practitioners on the Medical Staff of the Hospital including those non-physician members that are granted clinical privileges by the Hospital=s Board. The Medical Staff Office shall have the responsibility of maintaining such information via the clinical privilege selection cards contained in the professional file. 12
  • Specific patient care areas (i.e. Surgical services, Heart Center, GI lab, OB/GYN services) shall be provided with copies of appropriate current privilege selection cards upon their approval by the Hospital Board and authorizing signature by the appropriate Section Chief. These copies are to be maintained in a secure area in the specific patient care unit. Other requests for clinical privilege information may be obtained from the Medical Staff Office. If such request should occur during such hours when there is not Medical Staff personnel present, the Administrator on-all should be contacted. The Administrator on-call shall have the option of providing the information himself/herself, calling the Vice-President of Medical Affairs through the Hospital operator for assistance, calling the Medical Staff Liaison through the Vice- President of Medical Affairs for assistance, or authorizing security to admit the Nursing Supervisor to the Medical Staff office where such information is maintained in the practitioner=s professional file. 1/31/94 13