DEPARTMENT
The Department of Anesthesia (referred to hereafter as "the Department") of the Lucile Salter Packard Children's
Hospital at Stanford (referred to hereafter as "the Hospital") exists to provide anesthesia and pain control to obstetric patients, and anesthesia to infants, children, adolescents and for appropriate adults who continue to suffer from disorders which began in childhood. In addition to the physician members of the Department, there is a resident staff of physicians who are in training in pediatric and obstetric anesthesiology, and advanced practice nurses. The
Department comprises three clinical services: Pediatric Anesthesia, Pediatric Pain Management, and Obstetric
Anesthesia. The Department provides the following services:
1. The management of patients who are rendered unconscious and/or insensible to pain and/or stress during surgical and certain other procedures.
2. The management of patients who are rendered unconscious and/or insensible to pain during obstetric surgical procedures and who are provided analgesia during labor and childbirth.
3. The management of acute and chronic pain, and side effects of other therapy
4. The management of patients in intensive care units.
5. The evaluation and management of patients before and during procedures performed under moderate and deep sedation.
Department Head
The Head of the Department shall be a physician member of the medical staff, specializing in pediatric anesthesiology, who has overall administrative responsibility. The Head is responsible to the Chief of Staff of the
Hospital for administrative activities related to the Department. All anesthesiologists and those in training in anesthesia are responsible to the head of the Department for all matters relating to the delivery of anesthesia services to patients of the Hospital. In his absence, the Head designates an Acting Head. The responsibilities of the
Head of the Department of Anesthesia include, but are not limited to, the following:
1. Determine the professional and administrative activities within the clinical department including, but not limited to, the quality of patient care rendered by members of the Department in any area of the facility, including surgical and intensive care.
2. Devise and revise Department rules and regulations directly pertaining to professional medical care, and submit such Department rules and regulations to the Medical Board;
3. Recommend privileges for all individuals with primary anesthesia responsibility, which shall be processed through established medical staff channels.
4. Transmit to the appropriate authorities as required in the Medical Staff Bylaws the Department’s recommendations concerning appointment, reappointment, delineation of clinical privileges, and disciplinary action with respect to members of the Department;
5. Ensure that Hospital policies and Medical Staff Bylaws and Rules and Regulations are observed;
6. Notify the Medical Board if it appears that the activities of a member of the Department:
 jeopardize or may jeopardize the safety or best interest of a patient;
 raise a question regarding the competence, judgment, ethics, personal stability, moral character or qualification of that member;
 violate the Bylaws and Rules and Regulations of the Medical Staff, or Hospital policies and procedures published and approved by the Hospital Administration; or
 constitute conduct that is disruptive of Hospital operations.
The procedure for review shall be in accord with Article 7.2 of the Bylaws of the Medical Staff.
7. Implement within the Department actions taken by the Medical Board;
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8. Recommend to the administration and medical staff the type and amount of equipment necessary for administering anesthesia and for related resuscitative efforts, ensuring that at least an annual review is conducted that such equipment is available.
9. Develop regulations concerning anesthetic safety.
10. Supervise the operation of the Day Surgery/Post Anesthesia Care Unit (DS/PACU).
11. Perform such other duties commensurate with his or her office as may from time-to-time be assigned by the
Chief of Staff of the Hospital, the Medical Board, or the Board of Directors.
Director of Obstetric Anesthesia
The Director of the Obstetric Anesthesia Service supervises the operation of all obstetric anesthesia services and has similar responsibilities to those of the Department Head for patients in in the Johnson Center for Pregnancy and the Newborn. These responsibilities include:
Determine the professional and administrative activities within the clinical division including, but not limited to, the quality of patient care rendered by members of the Department in any area of the Johnson Center, including surgical and postoperative care.
1. Devise and revise Department rules and regulations directly pertaining to professional medical care in the
Johnson Center, and submit such rules and regulations to the Department Head;
2. Recommend privileges for all individuals with anesthesia responsibility in the Johnson Center, which shall be processed through established medical staff channels.
3. Transmit to the appropriate authorities as required in the Medical Staff Bylaws the Department’s recommendations concerning appointment, reappointment, delineation of clinical privileges, and disciplinary action with respect to members of the Department who have clinical activity in the Johnson Center;
4. Ensure that Hospital policies and Medical Staff Bylaws and Rules and Regulations are observed;
5. Notify the Department Head if it appears that the activities of a member of the division:
 jeopardize or may jeopardize the safety or best interest of a patient;
 raise a question regarding the competence, judgment, ethics, personal stability, moral character or qualification of that member;
 violate the Bylaws and Rules and Regulations of the Medical Staff, or Hospital policies and procedures published and approved by the Hospital Administration; or
 constitute conduct that is disruptive of Hospital operations.
The procedure for review shall be in accord with Article 7.2 of the Bylaws of the Medical Staff.
6. Implement within the division actions taken by the Medical Board and Department;
7. Recommend to the Department Head or Johnson Center Administration the type and amount of equipment necessary for administering anesthesia and for related resuscitative efforts in the Johnson Center, ensuring that at least an annual review is conducted that such equipment is available.
8. Develop regulations concerning obstetric anesthetic safety.
9. Supervise the operation of the Johnson Center Post Anesthesia Care Unit.
10. Perform such other duties commensurate with his or her office as may from time-to-time be assigned by the
Chief of Staff of the Hospital, the Medical Board, or the Board of Directors, or the Department Head.
Director of the Post Anesthesia Care Unit
Supervises the operation of the Day Surgery/Post Anesthesia Care Unit (DS/PACU).
Director of the Pain Management Service
The Director of the Pain Management Service supervises the operation of all pediatric pain management services.
These responsibilities include supervision and management of both the inpatient pain management consultation service, the inpatient pain attending service, and the outpatient pain management clinic. These responsibilities include:
1. Determine the professional and administrative activities pertaining to pediatric pain management.
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2. Devise and revise Department rules and regulations directly pertaining to pain management, and submit such rules and regulations to the Department Head, who in turn will submit to the Medical Board;
3. Ensure that Hospital policies and Medical Staff Bylaws and Rules and Regulations pertaining to pain management are observed;
4. Implement within the division actions taken by the Department and/or Medical Board;
5. Recommend to the Department Head and medical staff the type and amount of equipment necessary for managing pain, ensuring that at least an annual review is conducted that such equipment is available.
6. Develop regulations concerning pain management safety.
Perform such other duties commensurate with his or her office as may from time-to-time be assigned by the
Department Head.
Executive Committee
1. The Department’s Executive Committee is appointed by the Head of the Department.
2. The Executive Committee has the authority to establish or change Policies and Procedures, Practice Guidelines, and Departmental Rules and Regulations subject to the approval of the relevant Hospital Governing Bodies and committees.
RULES AND REGULATIONS
Members of the Department acknowledge their obligation to abide by the Bylaws and Rules and Regulations of the
Medical Staff of the Hospital as approved by its Medical Board and Board of Directors, Departmental Rules and
Regulations, and the Clinical Service Guidelines.
MEMBERSHIP
Members of the Medical Staff whose practices include pediatric or obstetric anesthesia constitute the Department of
Anesthesia of the Hospital. Membership in the Department shall not be denied on the basis of race, color, creed, sex, national origin, ancestry, age, disability, medical disability, marital status, gender or sexual orientation.
The members of the Department are responsible for the quality of medical care rendered to patients in their Hospital
Services and Clinics, and for the maintenance of proper medical care standards. In order to accomplish these ends, it is expected that the members will:
1. Adhere to Medical Staff Bylaws and Rules and Regulations .
2. Meet all qualifications for appointment as a physician to the medical staff at the Hospital in accordance with the Bylaws.
3. Be certified by, or in the certification process of, the American Board of Anesthesiology or its equivalent.
4. Maintain satisfactory medical records in accord with published standards established by the Medical Board as well as licensing accrediting agencies. To facilitate and encourage compliance to this end, a member of the Medical Information Committee will report at each Department Meeting;
5. Attempt to obtain autopsies in numbers sufficient to maintain a satisfactory standard for ongoing educational programs; and
6. Obtain necessary consultations as outlined in Section III of the Medical Staff Rules and Regulations.
MEETINGS
Quarterly clinical conferences are held throughout the year. Members of the Department are expected to attend these conferences. The clinical conference(s) serve three purposes:
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1.To provide a forum for reviewing clinical service activities and professional performances including anesthetic complications.
2.To provide a forum for the announcement and discussion of changes in major policies relative to clinical anesthesia services prior to their implementation.;
3.To serve as a measure for obtaining credit for continuing education. Records of the content of each clinical conference will be kept.
Quarterly meetings are held by the Obstetric Anesthesia Service for Department members whose activities are primarily in the Johnson Center to serve the purposes detailed in 1 and 2 above. Review of obstetric anesthesia clinical service activities and anesthetic complications also occurs in clinical conferences held several times annually as part of the Anesthesia Department Grand Rounds series. Members of the Department with clinical privileges in obstetric anesthesia are expected to attend these meetings and credit for continuing education can be obtained.
PRIVILEGES
Application for membership shall be processed by the Department in accordance with the procedures delineated in
Articles V and VI of the Bylaws of the Medical Staff of the Hospital.
1. Requests for general and special clinical privileges shall be processed by the Department in accordance with the procedures outlined in the Bylaws of the Medical Staff.
2. Determination of Privileges in the Department shall be based upon an applicant's documented training, experience, demonstrated ability, professional competence and professional ethics.
3. Applicants for privileges must submit, on forms approved by the Medical Board, to the Department the following: a) A completed application for medical staff membership and clinical privileges requested and a
resume of prior training and experience relevant to privileges requestedb) References from other accredited institutions who can attest to the applicant's medical
performance at that institution. A resume of the number and types of medical procedures
performed in other accredited hospitals by the applicant during the immediately preceding three
years may be required in support of an application for medical privileges. c) Demonstrated current competence to recognize and manage anesthetic-related complications. d) Evidence of qualification, which must include evidence of completion of a residency in anesthesiology, certification or progress toward certification by the American Board of
Anesthesiology or its equivalent, and may include evidence of completion of subspecialty fellowship training, previous professional record of the applicant, or other documented information.
4. The Department may recommend approval or denial of all or part of the privileges requested, or may recommend such restrictions on the applicant as deemed appropriate by the Department Head (or Obstetric anesthesia service chief).
5. All privileges initially granted shall be provisional until the Credentials Committee has acknowledged that the applicant has demonstrated competence in the exercise of those clinical privileges.
6. During the provisional period, the performance of the applicant shall be proctored by a member of the
Department appointed by the Department Head. The Department shall develop guidelines regarding the minimum number of proctors required, the minimum number and type of activities that must be proctored, and the method of proctoring. All such guidelines must be approved by the Medical Board.
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7. After the provisional period has been completed, upon receipt of the recommendation of the proctor, a reevaluation will be carried out and a recommendation made to the Credentials Committee of the Medical
Board by the Department regarding advancement to regular status or continuation of provisional status.
8. The privileges that may be recommended by the Department are on the clinical privileges request forms.
Members must meet the criteria for membership and clinical privileges.
Temporary Privileges
The Head of the Department of Pediatric Anesthesia may recommend temporary privileges for a qualified physician to the Chief of Staff of the Packard Children's Hospital in accordance with the Bylaws.
Reappointments
Reappointments will be processed every two years in accordance with the Medical Staff Bylaws. Members must be in compliance with the Bylaws and Rules and Regulations of the Medical Staff, Rules and Regulations of their
Department, and be able to document continued competence in the privileges requested in order to maintain membership and clinical privileges.
Privileges may not be renewed, or the Department may require continued or additional proctoring. Evidence justifying such actions include, but is not limited to:
1. Written complaints about professional performance.
2. Malpractice litigations resulting in court judgments against the physician.
3. Notice of disciplinary action or reprimands.
4. Critical review of anesthesia records and patient charts.
5. Physical or mental disabilities affecting performance.
6. Low activity levels since last reappointment.
7. Failure to abide by or meet the requirements of the Medical Staff Bylaws, approved policies and procedures, or the rules and regulations of the Department including the seeking of appropriate consultation for complex anesthetic problems.
8. Failure to be certified by the American Board of Anesthesiology (or its equivalent) or to maintain adequate progress toward Board certification.
The application shall in all respects be processed in the same manner as applies under Article V of the Bylaws of the
Medical Staff and the applicant shall in all respects have the same rights and be subject to the same requirements as apply under Articles V and VII.
DEPENDENT PRACTITIONERS
Dependent practitioners who wish to treat patients at this facility may apply for Allied Health Professional membership if they meet the following criteria:
1. Hold a license, certificate, or other legal credential as required by California law that authorizes them to provide professional health services in an approved category of Allied Health Professional.
2. Be able to document appropriate education, training and experience as outlined in the Medical Staff Bylaws.
3. Shall be subject to the supervision or direction of a member of the Medical Staff who has been granted privileges to provide such supervision.
4. Must comply with all requirements stated in the Medical Staff Bylaws.
GENERAL RULES FOR THE TREATMENT OF PATIENTS
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1.The anesthesiologist’s responsibilities to patients include: a) Preanesthetic evaluation b) Medical direction of trainees, nurs es, physician’s assistants, and technicians who assist in the technical aspects of anesthesia care. c) Medical management to optimize the patient’s condition prior to the administration of an anesthetic. d) Medical management to optimize the patient’s condition until recovered from the effects of anesthesia.
2.The same quality of anesthetic care will be available for all Hospital patients twenty-four hours a day, seven days a week.
EVALUATION OF THE CARE OF PATIENTS
In accordance with the Hospital-wide Performance Improvement Plan, the Medical Staff will evaluate the quality of care using:

Adherence to best practices as outlined in clinical pathways;

Performance with respect to quality indicators;

Peer review activities which include, but are not limited to, individual case review, medication usage, blood usage, medical record and surgical case review
CONSULTATION
Subspecialty consultations should be obtained by the primary attending physicians whenever they are necessary for optimal patient care. A consultation may also be requested at the discretion of the Head of the Anesthesia
Department or the Chief of Staff of the Hospital, after notification of the primary attending, if:
1. the diagnosis is obscure;
2. there is doubt as to the best diagnostic or therapeutic measures;
3. requested by the patient (or responsible party if the patient is not capable or has not reached his or her majority); or
4. the admission is the result of attempted suicide or a suicidal gesture. In this case, a psychiatric consult is mandatory.
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