BAYSHORE COMMUNITY HOSPITAL
DEPARTMENT OF SURGERY
RULES AND REGULATIONS
1. DEFINITION:
The Department of Surgery will be composed of all surgeons and surgical subspecialists.
Chair
The Chair of the Department must hold the rank of Full Attending and will be
elected for a two (2) year term at a departmental meeting held in September.
This term of office will commence on January 1. A Chair may be re-elected for
another two (2) year term and then must remain out of office for a period of one
term.
Vice Chair
The Vice Chair of the Department of Surgery shall be chosen by the Department
Chair.
2. APPOINTMENTS:
Appointment to the Surgical Service is accomplished by application to the Staff,
recommendation by the Department Chair and approval by the Credentials Committee,
Executive Committee, Professional Care Committee, and Board of Trustees. At the time
of approval by the Credentials Committee, the Chair of the Department will recommend
the rank of the incoming surgeon based on several requirements. All new applicants will
be evaluated by the Department Chair prior to appearance at the Credentials
Committee. At that time, the Chair will ascertain whether or not the surgeon intends to
become a fully functioning member of the Hospital and Medical Staff and would be
primarily utilizing Bayshore Hospital. The Chair and the applicant will decide whether
he/she should be placed on the Active or Regional (Active) Staff. Very infrequently
would a new member be admitted at the Associate Attending or Full Attending level. If
a surgeon has six (6) or more admissions or provides services to twenty-five (25) or
more hospital-based patients, he/she will be asked to assume the responsibilities of an
Assistant Attending.
All initial appointments to the Surgical Staff shall be Provisional/probationary
appointments. Provisional appointments shall be for a period of twelve (12) months
which may be extended once for an additional twelve (12) months. The practitioner
shall be notified, in writing, by the Chair of Surgery when the Provisional period is to be
extended. If, after the extension of the Provisional period has expired, a practitioner is
not appointed to the Staff, the Staff appointment shall be deemed to be terminated.
3.
RANKS:
BAYSHORE COMMUNITY HOSPITAL
Department of Surgery - Rules and Regulations
2
Ranks will be recommended by the Chair of the Department of Surgery who will utilize
the procedures outlined in the Medical Staff Bylaws to have these recommendations
confirmed.
a) Assistant Attending
Assistant Attending is the usual entering rank for full-time Department of
Surgery physicians and carries with it the responsibilities of being present in the
hospital or providing equivalent coverage for any hours assigned. Assistant
Attendings are expected to attend all Department meetings and to participate in
hospital functions related to patient care.
b) Associate Attending
The rank of Associate Attending is available for those physicians who have
served as Assistant Attending for a minimum of at least one year. This rank will
be considered for those who have demonstrated excellence in emergency care
performance. The rank is not automatic and attitude will be considered by the
Chair when promoting a physician to this rank.
c) Full Attending
In order to achieve Full attending status, the physician must be Board Certified in
the appropriate specialty and filed in the medical staff office, and must have
served a minimum of one year as an Associate Attending. The Physician must
fulfill all of the requirements and obligations and show more than an active
interest in the hospital.
4. PRIVILEGES:
Requests for levels of privileges require a list of operations performed during the last
five (5) years.
When new privileges for procedures are requested, the surgeon must present
documentation indicating attendance at courses, where and how long the courses were
and the name of the sponsoring organization. After approval by the Chair of Surgery,
the request will be presented to the Credentials Committee, Executive Committee, and
the Board of Trustees with recommendations for performance of the procedure with or
without supervision.
The Chair of Surgery will review the documents presented by the applicant to include
specifically training and experience in each area of surgery for which the applicant
intends to ask for privileges. These documents should be specific insofar as experience
in the given area is concerned, whether by number of cases or length of time spent on a
particular service, recommendations from the Chairs of the Services, and if possible,
total number of cases as operating surgeon or assistant.
When a surgeon who already has privileges in one area requests privileges in either
another area of surgery or in a new technique of surgery, that surgeon must present to
BAYSHORE COMMUNITY HOSPITAL
Department of Surgery - Rules and Regulations
3
the Chair of Surgery, for forwarding to the Executive Committee, Credentials
Committee, and the Board of Trustees, evidence of attendance at a continuing medical
education function such as a course or a group of courses. The surgeon must present
written evidence of attendance and, if possible, a graduation type certificate from the
institutions
where he/she received training. With this new addition to the surgeon’s privileges
delineation, a supervisory period will be designated on each occasion. When these new
privileges have been approved, the Medical Staff Manager will send written notification
to the Operating Room.
In the biennial reapplication and redelineation of privileges of all surgeons, appraisal of
a surgeon’s competency in performing certain procedures will be carried out.
Consideration will be given to the recency of performance of the procedure,
postgraduate courses, continuing medical education, and other educational material
which may have a bearing on the competency of the surgeon’s performance. It is
conceivable that a surgeon who has not performed a procedure for some time may be
asked to demonstrate his/her competency in that particular procedure or procedures,
either by proof of further study or practice or by supervision.
Operating Room privileges will be extended to all members of the Department of
Surgery in accordance with their recognized skills, training, established precedence and
according to delineation of privileges.
If one or more members of the Medical Staff desire privileges that differ significantly
from the scope of practice implied by the privileges already granted to that (or those)
individuals, such individuals should make application to the Chair of his/her
Department, for such privileges, in writing. The Chair of the Department will then (with
the aid of an ad hoc committee which he/she will appoint if he/she so desires):
a) for new procedures or expanded scope of care at this institution, make a
recommendation to the Credentials Committee regarding the advisability of
granting the privileges and, where indicated, the cost efficiency of such care.
b) provide the Credentials Committee with proposed criteria for the granting of
privileges for the new procedure or expanded scope of care.
c) make an individual recommendation to the Credentials Committee regarding the
practitioner requesting the privileges.
d) propose a mechanism to the Credentials Committee for enhanced monitoring
and evaluation of clinical performance and outcomes.
The Credentials Committee will then act upon the aforementioned matters and refer its
recommendations to the Executive Committee and then to the Board of Trustees of the
Hospital for final action.
BAYSHORE COMMUNITY HOSPITAL
Department of Surgery - Rules and Regulations
4
If the privileges “cross over” departmental or service lines, the application will be
reviewed by the Chair r of each of the involved departments. If the Chair of the
Department fails to make any recommendations within sixty (60) days, the application
may be referred by the individual practitioner to the Medical Executive Committee.
Should the decision by the Executive Committee be unfavorable to the requesting
practitioner, he/she may appeal the decision through the usual due process described in
the Bylaws.
When the privileges requested have been approved by the Executive Committee, the
new privileges will be recorded in the practitioner’s privilege record and distributed in
the usual manner.
Renewal of privileges within the Department of Surgery will be based on consideration
of the following:
a)
b)
c)
d)
e)
f)
g)
h)
i)
j)
k)
l)
m)
n)
o)
p)
q)
r)
s)
t)
Basic medical knowledge
Professional judgment
Sense of responsibility
Ethical conduct
Competence and skill
Cooperativeness, ability to work with others
Reasonable use of hospital facilities (admission of patients to the Hospital not
generated by E.D. call)
Appearance
History and physical exam taking
Record keeping
Case presentations
Patient management
Physician-patient relationship
Ability to understand/speak English
Participation in Medical Staff affairs
Physical and mental capabilities
Continuous professional education
Prompt and timely completion of medical records
Attendance at Quarterly Staff, department/section and committee meetings
Reasonable use of Hospital facilities
Additionally, renewal of privileges will be affected by being cited by:
a)
b)
c)
d)
e)
Utilization Review
Multi-Disciplinary Peer Review Committee
Infection Control Committee
Credentials Committee
Executive Committee
BAYSHORE COMMUNITY HOSPITAL
Department of Surgery - Rules and Regulations
5
f) Professional Care Committee
5. SUPERVISION:
Every new surgeon who comes into the Surgical Service will have a period of
supervision, the duration and nature of which will vary at the department Chair’s
discretion taking into account the privileges requested. The supervision consists of
having any Assistant, Associate, or Full Attending on the Surgical Service review the
chart preoperatively to include the necessity for surgery, the type of surgery to be done,
and to observe the surgeon in the Operating Room, and then to check the follow-up
care of the patient during the hospital stay, including postoperative orders.
Each time an operative case is performed, the supervising surgeon must complete a
Surgical Proctor’s Report which will be sent by the Supervisor of the Operating Room to
the Medical Staff Manager for inclusion in the surgeon’s file. No definite number of
required cases is listed as far as being removed from supervision is concerned.
A surgeon is removed from supervision by the Chair of Surgery on the advice of the
surgeons who have participated in the supervisory period. This notification will be in
writing by the Chair to the surgeon, to the Operating Room Supervisor, and to the
Medical Staff Manager who will make the other departments of the Hospital aware of
this removal from supervision. Minor cases defined as short, uncomplicated, requiring
local anesthesia and regarded by the Surgical Staff as minor surgery do not require
supervision. Exceptions for practicing seasoned surgeons can be done by chart review
at the discretion of the Chair. The Chair will inform the Chair of Peri-operative Services
when this will be the case.
6. CONSULTATIONS:
If the family of the patient requests a second opinion, or, in fact, requests that
treatment be taken over by another physician, that second opinion, transfer, or
examination cannot occur without the explicit permission of the attending in charge.
This permission can be given verbally to the nurse on the floor and/or written on the
chart, but without any question whatsoever, the second doctor cannot approach the
patient or review his/her records or X-rays without this permission.
If there should be an occurrence where a surgeon refuses to give permission to another
doctor to examine, render an opinion, or take over a case, the Chair of Surgery first, the
President of the Medical Staff second, and the President of the Hospital third should be
approached to help obtain that permission. If there is an urgent or emergency situation,
any one of these three officials could be contacted by telephone to arbitrate the
situation and to help make a decision.
7. ELECTION FOR DEPARTMENT CHAIR :
VOTING PRIVILEGES
BAYSHORE COMMUNITY HOSPITAL
Department of Surgery - Rules and Regulations
Voting privileges for Medical Staff elections shall be granted in accordance with the
Bylaws, Rules and Regulations of the Medical Staff of Bayshore Community Hospital.
All interested members running for Chair will be screened. Only surgeons who are Full
Attending/ Board Certified and who are qualified to vote and not on suspension will be
considered. No nominations will be obtained from the floor at the September Surgical
Staff meeting. Only the members of the Department Eligible Voters that year will be
permitted to vote.
8.
PEER REVIEW AND QUALITY MONITORING:
The Department will perform regular quality monitoring. This quality monitoring will
include Ongoing Professional Practice Evaluation (OPPE) and Focused Professional
Practice Evaluation (FPPE) as outlined in Section III of the Medical Staff Rules and
Regulations.
Focused Professional Practice Evaluation (FPPE)
A FPPE will be conducted in the following situations:
1. For all new department members. The FPPE occurs during the period in
which the new practitioner is on supervision.
2. When a practitioner requests a new privilege.
3. When any other below triggers are met:
 A single event that resulted in a mortality or caused significant harm;
 A single event that may/can cause significant harm if repeated;
 An identified pattern that has negatively impacted on the health of the
patient;
 An identified pattern that has the potential to adversely impact on the
health of the patient;
 Complaints by patients, family members or designated legal
representatives of a patient regarding care/treatment.
 Deviation from an expected range of values resulting from PI data
collection.
 Adverse or negative performance trend over six consecutive months of
Ongoing Professional Practice Evaluation (OPPE).
 Repeated failure to follow hospital or medical staff policy.
 Notice from any regulatory or peer review agency
4. When conducting a review, any or all of the following aspects may be
considered
 Through patient care, medical/clinical knowledge
 Practice based learning and improvement
 Interpersonal communication skills
 Professionalism
 Systems based practice
 Patient safety
6
BAYSHORE COMMUNITY HOSPITAL
Department of Surgery - Rules and Regulations
7
 Medical management
 Medication use
 Patient outcomes data
5. Resources to utilize –
Data may be gathered from:
 Chart review
 Direct observations
 Statistical reviews
 Proctoring
 Peer references
 Interviews
Reviews will be conducted in-house unless it is determined that for reasons of conflict or
insufficient expertise that an outside reviewer is required. This decision may be made by
the departmental Chair, the chairperson of the Multi-Disciplinary Peer Review
committee, or the chairperson of the committee.
At the conclusion of the investigative process the appropriate medical staff PI
committee will assign an alpha identifier to each event as follows:
A
B
C
D
E
Routine/Acceptable Care
Non-Routine/Acceptable Care
Routine or Non-Routine/Questionable Care/Questionable variation from
evidence based medical care
Non-Acceptable Care/Variation from evidence based medical care
Inadequate Documentation
Corrective action plans are required whenever a variance from the standard of care has
resulted in an adverse patient event and/or demonstrated a pattern of sustained non
compliance has occurred.
The corrective action plan shall be developed with the guidance of the VP for Medical
Affairs, the Multi-Disciplinary Peer Review Committee and the appropriate chief of
service.
The Corrective action plan shall be specific for the event, contain achievable actions,
goals, and a timeframe for compliance and reporting of progress to the appropriate
committee/subcommittees as designated. See Medical Staff Bylaws, Article IX,
Corrective Action.
Ongoing Professional Practice Evaluation (OPPE) - Periodic performance reviews of all
current medical and affiliated staff will be conducted. This also will include physician
assistants and nurse practitioners. OPPE data will be collected and placed in the
physician’s file for review by the departmental Chair or his designee. Available data will
BAYSHORE COMMUNITY HOSPITAL
Department of Surgery - Rules and Regulations
8
be reviewed every six months and may come from various sources and reports. Not all
reports will be required to be reviewed simultaneously.
The following data may be reviewed:
 Information acquired through periodic chart review
 Direct observation
 Monitoring of diagnostic or treatment techniques
 Discussion with other individuals involved in the care of the patient
including consulting physicians, nursing and administrative personnel
 Reports compiled medical records, obtained by extraction from the EMR
or data collection agency, or other hospital departments.
 Other sources as deemed appropriate.
Aspects of OPPE to be considered may include, but should not be limited to, any of the
items below:
 Medical assessment and treatment of patient
 Adverse privileging decision
 Use of medications.
 Use of blood and blood components
 Appropriateness and outcome of operative and other procedures.
 Appropriateness and clinical practice patterns including length of stay,
denials, avoidable days.
 Significant departures from established patterns of clinical practice,
department specific indicators, meeting criteria for autopsies.
 Sentinel event data, patient safety data including Do Not Use
abbreviations. Accurate, timely and legible completion of medical records
including time and quality of H&P’s and operative notes. Number of
unsigned telephone orders. Patient complaints, coordination of care
treatment and services with other practitioners and hospital personnel.
 Mobidity and Mortality data.
 Use of consultants.
 Other relevant criteria as determined by the medical staff, returns to the
OR, returns to the ED, return of infections including surgical site
infections, central line infections, ventilator acquired pneumonia.
 Hand washing.
 Critical events.
 Core measures compliance.
Information derived from OPPE may be used to determine whether:
 To Continue
 To limit
 To revoke any existing privileges
 To initiate a problem specific focused professional practice review (FPPE).
Actions may be taken when deficiencies in OPPE become apparent and need not wait
until the bi-annual reappointment process. Data from each 6 month evaluation should
BAYSHORE COMMUNITY HOSPITAL
Department of Surgery - Rules and Regulations
9
be considered in aggregate when reviewing data for reappointment. All practitioners are
subject to review.
9. MEETINGS/ATTENDANCE:
Departmental meetings will be held bimonthly, on the third Thursday of the month at
7:30 a.m. Permanent records of these meetings will be kept.
10. OPERATING ROOM:
b) Supervision
Every surgeon, no matter what his/her specialty, when entering the
Operating Room to perform a surgical procedure or assist in a surgical
procedure, is under the direct supervision, observation, and control of the
Chair of the Department of Surgery. This specifically applies, not only to
surgeons and oral surgeons, but also to the occasional internist, such as a
gastroenterologist or medical pulmonary specialist who requests the use of
the Operating Room to provide proper care to a patient.
11. EMERGENCY ROOM ASSIGNMENT:
Everyone on the Surgical Service is expected to rotate on Emergency Department call
within his/her specialty. Regional Staff members and Senior Attending members do not
rotate although they may be required to take E.D. call at the discretion of the Chair
based on Hospital need. Assistant, Associate, and Full Attending members normally
take their turn at Emergency Department call. Some surgeons who have offices and
practices which are primarily in another area may request not to be placed on
Emergency Department call, and consideration will be given to their request.
Assignment to E.D. call is completed by the Chair of Surgery each Fall for the coming
year. Since E. D. call in the surgical specialties at Bayshore Community Hospital is a
privilege rather than a duty, assignment will be based on the following:
a)
b)
c)
d)
e)
f)
g)
h)
i)
j)
k)
l)
Basic medical knowledge
Professional judgment
Sense of responsibility
Ethical conduct
Competence and skill
Cooperativeness, ability to work with others
Reasonable use of Hospital facilities (admission of patients to the Hospital not
generated by E.D. call)
Appearance
History and physical exam taking
Record keeping
Case presentations
Patient management
BAYSHORE COMMUNITY HOSPITAL
Department of Surgery - Rules and Regulations
m)
n)
o)
p)
q)
r)
s)
t)
10
Physician-Patient relationship
Ability to understand/speak English
Participation in Medical Staff affairs
Physical and mental capabilities
Continuous professional education
Prompt and timely completion of medical records
Attendance at Quarterly Staff, department/section and committee meetings
Location of office with obvious little chance of admitting patients to the Hospital
through that office practice
In addition, assignment will be affected by citation by:
a)
b)
c)
d)
Utilization Review
Multi-Disciplinary Peer Review Committee
Infection Control Committee
Executive Committee
12. INABILITY TO BOOK 7:30 A.M. CASES DUE TO LACK OF HISTORY
AND PHYSICAL REPORTS ON CHARTS:
Any surgeon whose 7:30 a.m. case is delayed 3 times because a History and Physical
report is not on the chart will not be allowed to book a 7:30 a.m. case for 6 months.
These Rules and Regulations are specifically directed to the members of the Department
of Surgery; however, they do not supersede the Medical Staff Bylaws.
These Rules and Regulations are specifically directed to members of the Department
of Surgery and are in conformance with the published Bylaws and Rules and
Regulations of the Medical Staff and must be reviewed and approved annually.
Approved by the Executive Committee 4/20/93
Revised 6/15/93
Revised 1/94
Revised 5/94
Revised 8/1/95
Revised 12/95
Revised 2/97
Revised 10/02
Revised 05/05
Revised 11/07
Revised 4/08
Revised 5/08
Revised 7/14