BAYSHORE COMMUNITY HOSPITAL
PATHOLOGY DEPARTMENT RULES AND REGULATIONS
I.
INTRODUCTION
Pursuant to the bylaws of the medical and dental staff of Bayshore Community Hospital, the
Department of Pathology has adopted the following rules and regulations in order to implement,
more specifically, the general principles set forth in said bylaws.
II.
PURPOSE OF DEPARTMENT:
The Department of Pathology is committed to:
1.
Providing the best possible patient care in Pathology at Bayshore
Community Hospital.
2.
Achieving and maintaining a high level of knowledge and skill by the members of the
Department.
3.
Providing a scholarly environment in the department, including the encouragement of
teaching and education.
4.
Promoting and supporting the reputation of Bayshore Community Hospital in general and of
this Department in particular.
TO FULFILL THESE OBJECTIVES, THE RULES AND REGULATIONS OF THIS DEPARTMENT
ARE HEREBY DECLARED.
III.
DEPARTMENT ORGANIZATION:
The Pathology Department is comprised of physicians with specialty training in the field of Anatomic
Pathology and Clinical Pathology. Other subspecialties of Pathology are encouraged but not
required for membership.
IV.
GENERAL RULES FOR MEMBERSHIP (APPOINTMENT):
1.
An applicant for membership must hold a current license to practice medicine and
pathology in the State of New Jersey.
2.
A new applicant for appointment to the department must have completed, prior to
the date of application, a Residency program approved by the American Board of
Pathology.
3.
A new applicant must have completed education and training required to take the Boards
and must be Board Certified/Board Eligible, as defined by the American Board of
Pathology.
3.1
Board Certification must be attained within five (5) years
completion of residency or fellowship training program.
4.
In order to insure that an applicant for membership shall be able to provide
continuous and timely service to the department, the personal residence must be located
thirty (30) minutes driving time from the Medical Center.
V.
MEMBERSHIP CATEGORIES:
The members of the Department shall be designated in their appointments as Provisional
Attending, Assistant Attending, Associate Attending, Full Attending and Senior Attending. The
privileges, prerogatives, duties and responsibilities of these various categories follow:
1.
2.
3.
ACTIVE STAFF
All members of the Active Staff shall hold rank. The ranks of the Active Staff shall be
Provisional Attending, Assistant Attending, Associate Attending, Full Attending and Senior
Attending.
With the exception of Provisional Attendings, appointments to the Active Staff shall be for a
term of two (2) years.
With the exception of Provisional Attendings, Active Staff members shall be responsible for
Department of Pathology Rules & Regulationspg. 2 of 5
4.
5.
6.
the conduct of the affairs of the department and shall have the privilege to vote in all
department deliberations except department elections. Voting by proxy will not be
permitted.
Departmental affairs include but are not limited to: diagnostic, administrative, quality
assessment, and educational. The Chair shall make all assignments for On-Call coverage.
Senior Attendings may be exempted from on-call coverage at their written request.
Active Staff members shall arrange for an alternate to scheduled coverage when they are
not available.
Active Staff members shall attend not less than 50% of all regular and special meetings of
the department. Unexcused absence from more than 50% of such meetings will be cause
for corrective action as set forth in the Medical Staff Bylaws.
A.
FULL ATTENDING: Shall confine his/her hospital practice to the
Department of Pathology. This applies to all cases. The duties of the Attending
shall be assigned by the Chair, such as Committee meetings or other
assignments.
B.
ASSOCIATE ATTENDING: The Associate Attending is Junior to
the Full Attending. The duties of the Associate Attending shall be assigned by the
Chair after consultation with the Attendings.
7.
Associate Attendings may be promoted to Full Attending status after a two-year
period of serving as an Associate Attending provided they have fulfilled their obligations to
the Department in a satisfactory manner.
A.
ASSISTANT ATTENDING: The Assistant Attending is Junior to the Associate
Attending. The duties of the Assistant Attending shall be assigned by the Chair
after consultation with the Attendings.
8.
Assistant Attendings will be promoted to Associate Attending status after two years
provided that all responsibilities have been carried out to Department standards.
REGIONAL STAFF
1.
Regional Staff shall be composed of members of the Departments of Pathology of
the Ocean Medical Center and Jersey Shore University Medical Center divisions who will
provide services at the Bayshore Community Hospital division on an as-needed basis.
VI.
OFFICERS:
The Officers of the Department shall be:
1.
Chair
2.
Vice Chair
REQUIREMENTS OF OFFICERS:
Officers must be members of the Active Staff. The Chair must also hold the rank of Full Attending
and be Board Certified by the American Board of Pathology. The Vice-Chair must hold the rank of
Full Attending and be Board Certified.
ELECTION OF OFFICERS:
1.
Officers shall be elected for a term of one (1) year and shall take office on January
1st following the election at the October Department meeting.
Department of Pathology Rules & Regulationspg. 3 of 5
2.
Notwithstanding anything to the contrary in these Rules and Regulations, all members
(except Provisional status) in good standing shall be eligible to make nominations and to
vote. Only Full Attendings can hold office.
Officers shall be elected as follows:
At an October meeting of the Department, Full Attendings, Associate Attendings, Assistant
Attendings shall make nominations for Officers from the floor. A quorum of at least
seventy-five percent (75%) of members eligible to vote in elections for department officers
must be present.
If only one individual is nominated for an elected office, said individual shall be deemed
elected to that office by acclamation of the Staff members eligible to vote.
If more than one Full Attending individual is nominated for an elected office then the Staff
members eligible to vote shall elect one individual to fill such office by closed ballot. The
nominee for an office shall be deemed elected upon receiving a majority of votes cast by
eligible members at the election. Such election shall be subject to the reasonable approval
of the Board of Trustees. Proxy votes will not be allowed.
3.
An elected Officer may resign by giving written notice to the President of the
Medical Staff and to the President of the Medical Center. Resignation shall be effective
only when accepted by the Board of Trustees.
4.
The Full-Attending members of the Department may, for cause, recommend to the
Medical Executive Committee removal, suspension or regulation of the activities of an
Officer(s). Cause shall include failure to perform adequately the duties and responsibilities
assigned to said Officer. Prior to such removal, suspension or regulation, said Officer shall
be entitled to make an appearance that shall not constitute a formal hearing and the Officer
shall not be entitled to be represented by Counsel.
5.
Any Leave of Absence of ninety (90) days or more involving a Chair of Assistant
Chair will necessitate the appointment of a new Chair or Assistant Chair.
6.
In the event of a vacancy in the Office of Chair, the Assistant Chair shall assume
the duties and responsibilities of the Chair of the unexpired portion of the term.
In the event of a vacancy in the Office of Assistant Chair, the Chair shall appoint a member
to fill such vacancy for the unexpired portion of the term.
DUTIES & RESPONSIBILITIES OF OFFICERS
CHAIR:
Pursuant to Bayshore Medical Staff Bylaws, the Chair shall have the following duties and
responsibilities:
1. Be responsible for the supervision of the Administrative and Medical affairs of the
Department including a continuing review of the privileges of each member of the
Department. Where appropriate, records should be maintained.
2. Serve on the Executive Committee and represent the Department at the meetings of
same. In addition, communicate at departmental meetings, the activities of the Medical
Executive Committee.
3. Recommend to the Medical Staff the criteria for privileges in the Department.
4. Recommend privileges for each member in the Department.
5. Assure that the quality and appropriateness of patient care provided in the Department
are monitored and evaluated. A record should be maintained that includes the
resultant conclusions, recommendations and actions taken.
6. In accordance with the Medical Staff Bylaws, the Chair may temporarily suspend
privileges of an individual who is found to be unable to perform his or her duties in a
professional manner.
7. Investigate complaints brought against members of the Department and have ultimate
Department of Pathology Rules & Regulationspg. 4 of 5
8.
9.
10.
11.
responsibility for written reports and recommendations submitted to the Medical
Executive Committee.
Impose the requirement of proctoring upon any Department member provided such
action is necessary for the purpose of insuring the delivery of quality health care to
patients of the supervised member.
Call special meetings of the Department and appoint the Department Committees.
Appoint Department members to special committees.
Perform such other functions as are set forth in the Medical Staff Bylaws and in these
Rules and Regulations.
VICE CHAIR:
The VICE Chair shall have the following duties and responsibilities:
1.
In the absence of the chair, perform the duties and responsibilities of the
Chair. This includes, but is not limited to, attendance at the meetings of the
Medical Executive Committee meetings and the right to vote on all Medical
Executive Committee matters.
2.
Act as the QA coordinator for the Department regularly reporting to the Chair.
3.
Perform such duties and responsibilities as the Chair may from time to
time assign to the Assistant Chair and as are commonly assigned to such office.
VII.
MEETINGS:
In accordance with the Bayshore Medical Staff Bylaws, the following Rules and Regulations will
apply:
1. The Chair or his/her designee shall preside at all Department meetings.
2. Meetings will be held on such day of the month and at such time and place, as the Chair
shall appoint but no less than quarterly.
a. The Meeting held in the month of October shall also be the Annual Meeting of the
Department, at which time elections shall take place.
b. Ordinary meetings will include:
i. Business matters.
ii. Quality Improvement/Quality Control matters.
3. Case presentations, didactic lectures or other continuing education (optional) will be
presented.
4. Fifty percent (50%) of the Active members constitute a quorum for the transaction of
business at any meeting of the Department.
5. Each Active member present at a duly convened meeting of the Department shall be
entitled to cast one vote on each matter submitted to a vote at said meeting. Each matter
submitted to a vote at a duly convened meeting of the Department shall be decided by
majority vote of the Active Staff members present at said meeting and eligible to vote.
6. The Agenda of regular monthly meetings, as well as the Agenda for any special meetings,
will be under the direction of the Chair of the Department.
7. The Chair may invite individuals to attend meetings, but these individuals shall not vote or
be counted in determining the existence of a quorum and may be excluded from any
Executive Session by a majority vote of the Active Staff members present.
VIII.
PROCTORING:
1.
Provisional members shall be subject to proctoring by a member of the Active Staff
for a period of one year. This period may be extended for an additional year at the
discretion of the Chair according to the experience and qualifications of the newly
appointed member.
Department of Pathology Rules & Regulationspg. 5 of 5
3.
2.
Active Staff members shall have the duty and responsibility of serving as proctors
of the Provisional members.
Each proctor must submit a completed evaluation form to the Department Chair.
4.
Provisional members under proctoring can finalize Surgical Pathology reports and
clinical consults only with the knowledge and consent of their proctor.
5.
The Chair of the Department will formally notify the affected members of the
termination, extension or change of the period or type of proctoring.
IX.
PRIVILEGES:
1.
Staff status shall be reviewed biannually and recommendations made by the Chair
for reappointment or advancement.
2.
Reappointment and promotion shall be in accordance with the Medical Staff
Bylaws and will include:
A.
Turn around time of surgical pathology specimens and cytology
(GYN and NON-GYN*
B.
Accuracy of correlation with frozen section diagnosis and permanent
section slide evaluation*
C.
Accurate correlation of the pathologists’ diagnosis and those rendered by
outside consultants*
D.
Evidence of specialty specific CME activity
E.
Review of any complaints, QA referrals, litigation
F.
Attendance at assigned committees and departmental meetings
G.
Appropriate communication with colleagues, house staff, laboratory staff
and patients (where appropriate).
* Thresholds as documented in the Department Performance Improvement Program
3.
In addition to the satisfactory of the general criteria listed above, an Active Staff
member may be advanced in rank according to the Medical Staff Bylaws.
4.
The Chair shall make recommendations regarding promotions and changes in
accordance to Medical Staff Bylaws.
X.
ADOPTION:
These Rules and Regulations shall be adopted at a Regular or Special meeting of the Department
in accordance with the requirements of the existing Rules and Regulations. These Rules and
Regulations shall become effective when endorsed by the Medical Executive Committee and
approved by the Board of Trustees. They will then replace all previous Pathology Department rules.
XI.
REVISIONS:
These Rules and Regulations may be amended, altered or repealed or new Rules and Regulations
may be adopted by affirmative vote of a majority of the Active Staff members present at any duly
convened meeting of the Department announced by Agenda. They will be reviewed annually and
any amendment(s) shall become effective when approved by the Board of Trustees.
XII.
CONFLICTS WITH MEDICAL STAFF BYLAWS:
In any cases where the Rules and Regulations of the Department conflict with the Medical Staff
Bylaws, the Medical Staff Bylaws will prevail.
Approved by Department of Pathology 9/2013
Approved by Medical Executive Committee 10/2013
Revised by Department of Pathology 4/2014
Revised 7/2014