BAYSHORE COMMUNITY HOSPITAL
EMERGENCY MEDICINE
RULES AND REGULATIONS
1. DEFINITION:
The Department of Emergency Medicine will be composed of physicians who are either
Board Certified of Board Eligible in Emergency Medicine.
2. APPOINTMENTS:
Appointment will be made by the procedures outlined in the Medical Staff Bylaws.
Emergency privileges may be granted as they are outlined in the Bylaws.
All new appointments to the Emergency Department service shall be provisional
/probationary appointments. Provisional appointments shall be for a period of twelve
(12) months. At the end of that time, or after one twelve (12) month extension, upon
the recommendation of the Chair of the Emergency Department, the Provisional
appointment will be changed to full appointment for up to two (2) years.
In order to achieve Full Attending status, the physician must be Board Certified in
the appropriate specialty and must have served a minimum of one year as an Associate
Attending.
3. RANKS:
Ranks will be recommended by the Chair of the Department of Emergency Medicine
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
Emergency Medicine 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
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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:
Privileges will be extended to all members of the Department of Emergency Medicine in
accordance with their recognized skills, training, established precedence and according
to the delineation of privileges.
5. SUPERVISION:
Supervision will be carried out by the Chair for as long a period as he/she deems
necessary. The Chair will utilize all of the quality assurance procedures, chart review,
and personal observation to assist in supervision.
6. DEPARTMENT CHAIR:
The Department Chair will be appointed by the E.D. physician group. There are no term
limits and the ED Chair may be reappointed an unlimited number of times. The Chair will
appoint someone else from the E.D. group to act as Vice Chair.
7. MEETINGS:
Department meetings will be held monthly, no less than 10 times annually. A
permanent record of these meeting will be kept. The E.D. Chair or his designee will
chair these meetings. Topics will include Q.I. activity results; reports of complaints,
Policies and Procedures, interesting and informative E.D. cases and any other topics the
department members feel are appropriate.
8. VOTING PRIVILEGES:
Voting privileges for Medical Staff elections shall be granted in accordance with the
bylaws and the Rules and Regulations of the Medical Staff of Bayshore Community
Hospital.
9. PEER REVIEW AND QUALITY MONITORING:
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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
 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
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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 Multi-Disciplinary Peer Review
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 chair 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
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
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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
be considered in aggregate when reviewing data for reappointment. All practitioners are
subject to review.
These Rules and Regulations are specifically directed to members of the Department
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of Emergency Medicine and are in conformance with the published Bylaws and Rules
and Regulations of the Medical Staff and these rules must be reviewed and approved
annually.
Approved by the Executive Committee 10/17/89
Amended: January 1994
July 2008
July 2014
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