METHODIST HEALTH SYSTEM
MEDICAL STAFF POLICY MANUAL
Immediate Prior Version:
Current Version Approved by:
MDMC Executive Committee:
MCMC Executive Committee:
Corporate Medical Board:
Board of Directors:
July 25, 2006
January
January
January
January
9, 2007
12, 2007
16, 2007
23, 2007
ARTICLE 1 - INTRODUCTION ..................................................................................................................................1
ARTICLE 2 - PURPOSES .............................................................................................................................................1
ARTICLE 3 - DEFINITIONS .......................................................................................................................................1
ARTICLE 4 - MEDICAL STAFF APPOINTMENT ..................................................................................................1
4.1
NATURE OF MEDICAL STAFF APPOINTMENT .....................................................................................................1
4.2
QUALIFICATIONS FOR AND TERMS, CONDITIONS AND RESPONSIBILITIES OF APPOINTMENT .............................1
4.2.1 Qualifications for Appointment .....................................................................................................................1
4.2.2 Professional Liability Insurance ...................................................................................................................2
4.2.3 Responsibilities of Appointment ....................................................................................................................2
4.2.4 Authority to Appoint......................................................................................................................................2
4.2.5 Terms of Appointment ...................................................................................................................................2
4.2.6 Provisional Status .........................................................................................................................................3
4.2.6.1
4.2.6.2
4.2.6.3
Applicability ......................................................................................................................................................... 3
Continuation, Evaluation and Termination of Provisional Status ......................................................................... 3
Orientation Process............................................................................................................................................... 4
4.2.7 Primary System Hospital Affiliation .............................................................................................................4
4.2.8 Applicant’s Obligations ................................................................................................................................4
4.2.9 Participation in Teaching Programs as Teaching Staff ................................................................................4
4.2.9.1
4.2.9.2
Appointment Process ............................................................................................................................................ 4
Degree of Care/Management of Patient by House Staff ....................................................................................... 5
4.2.10 Compliance with Privacy Regulations ..........................................................................................................5
4.2.10.1
4.2.10.2
4.2.10.3
4.2.10.4
Adoption of Privacy Notice .................................................................................................................................. 5
Approval of Restrictions and Limitations............................................................................................................. 5
No Information Patients ....................................................................................................................................... 5
No Effect on Legal Regulations ........................................................................................................................... 5
4.3
ETHICS AND ETHICAL RELATIONS .....................................................................................................................6
4.3.1 Conflict of Interest ........................................................................................................................................6
4.3.1.1
4.3.1.2
4.3.1.3
Purpose ................................................................................................................................................................. 6
Definitions ............................................................................................................................................................ 6
Procedures ............................................................................................................................................................ 7
4.4
SCOPE OF CLINICAL PRIVILEGES .......................................................................................................................8
4.5
PEER REVIEW ....................................................................................................................................................8
4.5.1 Purpose .........................................................................................................................................................8
4.5.2 Objective .......................................................................................................................................................8
4.5.3 Guidelines .....................................................................................................................................................9
4.5.4 Privileged Committee Function ....................................................................................................................9
4.5.5 Definition ......................................................................................................................................................9
4.5.6 Process..........................................................................................................................................................9
ARTICLE 5 - APPOINTMENT OF INITIAL APPLICANT AND REAPPOINTMENT..................................... 12
5.1
DISCLOSURES .................................................................................................................................................. 12
5.2
BURDEN OF PROOF .......................................................................................................................................... 12
5.3
APPLICATION AND INITIAL APPOINTMENT ...................................................................................................... 12
5.3.1 Initial Application ....................................................................................................................................... 12
5.3.2 Corporate Credentials Committee Function............................................................................................... 14
5.3.3 Corporate Medical Board Responsibilities................................................................................................. 14
5.3.4 Favorable Recommendation by the Corporate Medical Board .................................................................. 15
5.3.5 Deferral of Application ............................................................................................................................... 15
5.3.6 Adverse Recommendation by Corporate Medical Board ............................................................................ 15
5.3.7 Final Action by Board of Directors ............................................................................................................ 16
5.3.8 Eligibility for Appointment after Adverse Recommendation ....................................................................... 16
5.3.9 Expedited Review Process for Initial Applicants ........................................................................................ 16
5.3.9.1
5.3.9.2
5.3.9.3
Purpose and General Requirements .................................................................................................................... 16
Expedited Processing Procedure ........................................................................................................................ 17
Criteria for Applying Process ............................................................................................................................. 17
5.3.10 Scheduled Review of Provisional Status for Active Category of Membership ............................................ 17
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5.4
MEDICAL STAFF RE-APPOINTMENT PROCESS ................................................................................................. 19
5.4.1 Practitioners' Obligation ............................................................................................................................ 19
5.4.2 Reappointment Application Process ........................................................................................................... 19
5.4.3 Department and Corporate Credentials Committee Review ....................................................................... 21
5.4.4 Corporate Medical Board Responsibilities................................................................................................. 23
5.4.5 Favorable Recommendation by the Corporate Medical Board .................................................................. 23
5.4.6 Deferral of Application ............................................................................................................................... 23
5.4.7 Adverse Recommendation by Corporate Medical Board ............................................................................ 23
5.4.8 Final Action by Board of Directors ............................................................................................................ 24
5.4.9 Eligibility for Reappointment After Adverse Recommendation .................................................................. 24
5.4.10 Reappointment Criteria .............................................................................................................................. 24
5.4.11 Conditional Reappointment ........................................................................................................................ 25
5.5
LEAVE OF ABSENCE ........................................................................................................................................ 25
5.5.1 General Leave of Absence .......................................................................................................................... 25
5.5.2 Leave of Absence for Military Service ........................................................................................................ 26
5.5.3 Inactive Status for Illness ............................................................................................................................ 26
5.6
MODIFICATION OF APPOINTMENT ................................................................................................................... 26
ARTICLE 6 - CLINICAL PRIVILEGES .................................................................................................................. 27
6.1
REQUEST FOR PRIVILEGES BY INITIAL APPLICANTS AND PROVISIONAL APPOINTEES...................................... 27
6.2
RE-DETERMINATION OF PRIVILEGES ............................................................................................................... 27
6.3
REQUESTS FOR NEW OR ADDITIONAL PRIVILEGES .......................................................................................... 27
6.3.1 Purpose ....................................................................................................................................................... 27
6.3.2 Policy .......................................................................................................................................................... 27
6.3.3 Definitions................................................................................................................................................... 28
6.3.3.1
6.3.3.2
6.3.3.3
6.3.3.4
General Procedure .............................................................................................................................................. 28
New Privilege ..................................................................................................................................................... 28
New Technology ................................................................................................................................................ 28
Special Procedure ............................................................................................................................................... 28
6.3.4 Procedure ................................................................................................................................................... 28
6.4
PRIVILEGES GRANTED TO DENTISTS ............................................................................................................... 30
6.5
PRIVILEGES GRANTED TO PODIATRISTS .......................................................................................................... 30
6.6
TEMPORARY PRIVILEGES ................................................................................................................................ 30
6.6.1 Temporary Privileges for Initial Applicant ................................................................................................. 30
6.6.2 Locum Tenens Privileges ............................................................................................................................ 31
6.6.3 Temporary Privileges for Specialized Teams ............................................................................................. 31
6.6.4 Temporary Privileges for the Care of a Specific Patient ............................................................................ 31
6.6.5 Special Requirements for Temporary Privileges ........................................................................................ 32
6.6.6 Termination of Temporary Privileges ......................................................................................................... 32
6.7
EMERGENCY PRIVILEGES ................................................................................................................................ 32
ARTICLE 7 - CORRECTIVE ACTION .................................................................................................................... 33
7.1
CORRECTIVE ACTION ...................................................................................................................................... 33
7.2
SUMMARY SUSPENSION .................................................................................................................................. 33
7.3
AUTOMATIC SUSPENSION OR REVOCATION .................................................................................................... 33
7.4
PRECAUTIONARY ADMINISTRATIVE SUSPENSION ........................................................................................... 33
7.5
MHS PRACTITIONER CONDUCT POLICY .......................................................................................................... 33
7.5.1 Policy .......................................................................................................................................................... 33
7.5.2 Definitions................................................................................................................................................... 33
7.5.3 Procedure for Reporting and Handling Apparent Violations ..................................................................... 34
7.5.3.1
7.5.3.2
7.5.3.3
7.5.3.4
7.5.3.5
7.5.3.6
7.5.3.7
7.5.3.8
7.5.3.9
7.5.3.10
Reporting the Incident ........................................................................................................................................ 34
Documentation of the Incident ........................................................................................................................... 35
Investigation of the Incident ............................................................................................................................... 35
Review with the Practitioner .............................................................................................................................. 36
Conduct of a Level I Review .............................................................................................................................. 36
Conduct of a Level II Review ............................................................................................................................ 37
Conduct of a Level III Review ........................................................................................................................... 37
Conduct of a Level IV Review ........................................................................................................................... 37
Letters of Admonishment and Conditional Conduct Letters .............................................................................. 38
Practitioner Advocate ......................................................................................................................................... 38
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7.5.3.11
7.5.3.12
7.5.3.13
7.5.3.14
7.5.3.15
7.5.3.16
7.5.3.17
7.5.3.18
7.5.3.19
7.5.3.20
7.5.3.21
Documentation of the Meeting with the Practitioner .......................................................................................... 38
Outline of Formal Disciplinary Measures .......................................................................................................... 38
Exoneration of Practitioner................................................................................................................................. 39
Exclusion of Practitioner from the Hospital Facilities ........................................................................................ 39
Responsibility for Sponsored and/or Employed Individuals .............................................................................. 39
Presence of Counsel at Reviews ......................................................................................................................... 39
Confidentiality and Protection from Discovery .................................................................................................. 39
Order of Review ................................................................................................................................................. 40
Retention of Records .......................................................................................................................................... 40
The Corporate Credentials Committee Responsibility ....................................................................................... 40
Time of the Essence ........................................................................................................................................... 40
ARTICLE 8 - FAIR HEARING PROCEDURE ........................................................................................................ 40
ARTICLE 9 - MEDICAL STAFF CATEGORIES ................................................................................................... 41
9.1
TYPES OF CATEGORIES .................................................................................................................................... 41
9.2
ACTIVE MEMBERSHIP ..................................................................................................................................... 41
9.2.1 Category Description; Qualifications; Rights; & Responsibilities Active Status I ..................................... 41
9.2.2 Active Status II (Without Privileges) ........................................................................................................... 41
9.2.3 Senior Active Status .................................................................................................................................... 41
9.3
AFFILIATE CATEGORY .................................................................................................................................... 42
9.3.1 Consulting Affiliate ..................................................................................................................................... 42
9.3.2 Sponsored Attending Affiliate ..................................................................................................................... 42
9.3.3 Honorary Affiliate ....................................................................................................................................... 42
9.3.4 Departmental Affiliate ................................................................................................................................ 42
9.3.5 Temporary Affiliate ..................................................................................................................................... 42
9.3.6 Courtesy Affiliate ........................................................................................................................................ 42
9.4
ADMINISTRATIVE AND MEDICAL STAFF FUNCTIONS....................................................................................... 43
9.5
HOUSE STAFF .................................................................................................................................................. 43
ARTICLE 10 - ALLIED HEALTH PROFESSIONALS .......................................................................................... 44
10.1 RELATIONSHIP TO MEDICAL STAFF ................................................................................................................. 44
10.2 CATEGORIES, QUALIFICATIONS, APPLICATION PROCESS, MONITORING, AND IDENTIFICATION ...................... 44
10.2.1 Categories ................................................................................................................................................... 44
10.2.1.1
10.2.1.2
10.2.2
10.2.3
10.2.4
10.2.5
10.2.6
10.2.7
Allied Health Associates .................................................................................................................................... 44
Allied Health Assistants ..................................................................................................................................... 44
Qualifications ............................................................................................................................................. 44
Application Process .................................................................................................................................... 44
Monitoring of Approved Applicants............................................................................................................ 45
Identification ............................................................................................................................................... 45
Suspension and Exclusion of Allied Health Professionals .......................................................................... 45
Sponsoring Practitioner’s Responsibilities ................................................................................................. 45
ARTICLE 11 - MEDICAL STAFF ORGANIZATION AND OFFICERS ............................................................. 47
11.1 OFFICERS OF THE MEDICAL STAFF .................................................................................................................. 47
11.1.1 Annual Stipend ............................................................................................................................................ 47
11.1.2 Source of Funds .......................................................................................................................................... 47
11.1.3 Control of Funds ......................................................................................................................................... 47
ARTICLE 12 - CORPORATE MEDICAL STAFF COMMITTEES ...................................................................... 48
12.1 COMPOSITION AND APPOINTMENT .................................................................................................................. 48
12.2 AUTHORITY TO DELEGATE .............................................................................................................................. 48
12.2.1 Special Committees ..................................................................................................................................... 48
12.2.2 Standing Special Committees ...................................................................................................................... 48
12.3 CORPORATE MEDICAL BOARD ........................................................................................................................ 48
12.4 CORPORATE GRADUATE MEDICAL EDUCATION COMMITTEE.......................................................................... 48
12.5 OTHER CORPORATE MEDICAL STAFF COMMITTEES ........................................................................................ 48
12.5.1 Corporate Bylaws and Policies Committee: ............................................................................................... 48
12.5.2 Corporate Credentials Committee .............................................................................................................. 49
12.5.3 Medical Staff Health Subcommittee ............................................................................................................ 49
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12.5.3.1
12.5.3.2
Creation .............................................................................................................................................................. 49
MHS Practitioner Health Policy ......................................................................................................................... 50
12.5.4 Corporate Clinical Ethics Committee ......................................................................................................... 54
12.5.4.1
System Hospital Clinical Ethics Consult Teams ................................................................................................ 55
12.5.5 MHS Medical Staff Policy and Guidelines Committee ............................................................................... 56
12.5.6 Corporate Health Information Management Committee ............................................................................ 57
ARTICLE 13 - SYSTEM HOSPITAL MEDICAL STAFF COMMITTEES ......................................................... 58
13.1 COMPOSITION AND APPOINTMENT .................................................................................................................. 58
13.2 AUTHORITY TO DELEGATE .............................................................................................................................. 58
13.2.1 Special Committees ..................................................................................................................................... 58
13.2.2 Standing Special Committees ...................................................................................................................... 58
13.3 EXECUTIVE COMMITTEE ................................................................................................................................. 58
13.4 SUCCESSION & LEADERSHIP COMMITTEE ....................................................................................................... 58
13.5 OTHER SYSTEM HOSPITAL MEDICAL STAFF COMMITTEES ............................................................................. 58
13.5.1 Professional Care Audit/Review Committee ............................................................................................... 58
13.5.2 Utilization Management Committee ........................................................................................................... 60
13.5.3 Medical Staff Quality Council .................................................................................................................... 61
ARTICLE 14 - MEDICAL STAFF CLINICAL DEPARTMENTS AND SECTIONS .......................................... 62
14.1 ORGANIZATION ............................................................................................................................................... 62
14.2 OTHER MATTERS RELATED TO MEDICAL STAFF CLINICAL DEPARTMENTS .................................................... 62
14.2.1 Qualifications, Selection, and Tenure of Department Chairmen ................................................................ 62
14.2.1.1
14.2.1.2
14.2.1.3
14.2.1.4
14.2.1.5
Qualifications ..................................................................................................................................................... 62
Term of Office .................................................................................................................................................... 62
Method of Election ............................................................................................................................................. 62
Removal of Departmental Officers ..................................................................................................................... 63
Department Officers with Contractual Relationship ........................................................................................... 63
14.2.2 Duties of Department Chairmen ................................................................................................................. 63
14.2.3 Functions of Departments ........................................................................................................................... 64
14.2.4 Assignment to Departments ........................................................................................................................ 65
ARTICLE 15 - MEDICAL STAFF MEETINGS ...................................................................................................... 66
15.1 REGULAR MEETINGS ....................................................................................................................................... 66
15.2 ANNUAL MEETING .......................................................................................................................................... 66
15.3 SPECIAL MEETINGS ......................................................................................................................................... 66
15.4 ATTENDANCE AT MEDICAL STAFF MEETINGS ................................................................................................ 66
15.4.1 Requirements .............................................................................................................................................. 66
15.4.2 Exclusion from Attendance Requirement .................................................................................................... 66
15.5 NOTIFICATION, QUORUM AND AGENDA .......................................................................................................... 66
15.5.1 Notification ................................................................................................................................................. 66
15.5.2 Quorum ....................................................................................................................................................... 66
15.5.3 Agenda ........................................................................................................................................................ 67
15.5.3.1
15.5.3.2
Regular Meeting Agenda .................................................................................................................................... 67
Special Meeting Agenda..................................................................................................................................... 67
ARTICLE 16 - DEPARTMENTAL AND COMMITTEE MEETINGS ................................................................. 68
16.1 REGULAR MEETINGS ....................................................................................................................................... 68
16.1.1 Frequency of Meetings................................................................................................................................ 68
16.1.2 Purpose and Record Requirements ............................................................................................................. 68
16.1.2.1
16.1.2.2
Purpose of Meetings ........................................................................................................................................... 68
Record of Meetings ............................................................................................................................................ 68
16.2 SPECIAL MEETINGS ......................................................................................................................................... 68
16.3 ATTENDANCE REQUIREMENTS – DEPARTMENT AND COMMITTEE MEETINGS ................................................. 68
16.4 OTHER MATTERS RELATED TO DEPARTMENT AND COMMITTEE MEETINGS ................................................... 69
16.4.1 Notification ................................................................................................................................................. 69
16.4.2 Quorum ....................................................................................................................................................... 69
16.4.3 Committee and Departmental Manner of Action ........................................................................................ 69
16.4.4 Rights of Ex-Officio Members ..................................................................................................................... 69
16.4.5 Departmental and Committee Reports ........................................................................................................ 69
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ARTICLE 17 - RULES OF ORDER .......................................................................................................................... 69
ARTICLE 18 - IMMUNITY FROM LIABILITY..................................................................................................... 69
ARTICLE 19 - AMENDMENTS TO BYLAWS, POLICIES AND DEPARTMENT RULES ............................. 70
19.1 MEDICAL STAFF BYLAWS ............................................................................................................................... 70
19.2 POLICIES ...................................................................................................................................................... 70
19.2.1 Process to Amend Policies .......................................................................................................................... 70
19.2.1.1
19.2.1.2
19.2.1.3
19.2.1.4
19.2.1.5
Requests for Amendments, Modifications and Repeal ....................................................................................... 70
Action of Medical Staff Bylaw and Policies Committee .................................................................................... 70
Action of Executive Committee ......................................................................................................................... 70
Action of the Corporate Medical Board ............................................................................................................. 70
Action of the Board of Directors ........................................................................................................................ 70
19.2.2 Notification to the Medical Staff ................................................................................................................. 71
19.3 DEPARTMENT RULES ...................................................................................................................................... 71
ARTICLE 20 - GENERAL PROVISIONS ................................................................................................................ 71
ARTICLE 21 - ADMISSION AND DISCHARGE OF PATIENTS ......................................................................... 72
21.1
21.2
21.3
21.4
21.5
21.6
21.7
21.8
21.9
21.10
21.11
PATIENT ADMISSION ....................................................................................................................................... 72
TYPES OF CASES ADMITTED............................................................................................................................ 72
INFECTIOUS PATIENTS ..................................................................................................................................... 72
ADMISSION PRIORITIES ................................................................................................................................... 72
ASSIGNMENTS BY PATIENT CARE UNIT AND PATIENT TRANSFERS ................................................................. 72
GENERAL CONSENT TO TREATMENT FORM..................................................................................................... 73
INFORMED CONSENT ....................................................................................................................................... 73
UTILIZATION REVIEW ..................................................................................................................................... 73
DISCHARGE OF PATIENT .................................................................................................................................. 73
PRONOUNCEMENT OF DEATH .......................................................................................................................... 73
AUTOPSIES ...................................................................................................................................................... 73
ARTICLE 22 - MEDICAL RECORDS ...................................................................................................................... 74
22.1
22.2
22.3
22.4
22.5
22.6
22.7
22.8
22.9
22.10
22.11
22.12
22.13
22.14
22.15
RESPONSIBILITY FOR MEDICAL RECORD ......................................................................................................... 74
HISTORY AND PHYSICAL EXAMINATION REPORT............................................................................................ 74
RECORDS BY HOUSE STAFF AND TEACHING PHYSICIAN ................................................................................. 74
PROGRESS NOTES............................................................................................................................................ 74
REPORTS ...................................................................................................................................................... 75
CONSULTATION CONTENT............................................................................................................................... 75
SYMBOLS AND ABBREVIATIONS ...................................................................................................................... 75
DISCHARGE SUMMARY ................................................................................................................................... 75
COMPLETION OF THE MEDICAL RECORD ......................................................................................................... 76
AUTHENTICATION OF ROUTINE ORDER ........................................................................................................... 76
RELEASE OF PATIENT INFORMATION ............................................................................................................... 76
MEDICAL RECORDS ARE PROPERTY OF THE HOSPITAL ................................................................................... 76
AVAILABILITY OF MEDICAL RECORDS ............................................................................................................ 76
FILING OF MEDICAL RECORD .......................................................................................................................... 77
MEDICAL RECORD IN THE EMERGENCY ROOM ............................................................................................... 77
ARTICLE 23 - GENERAL CONDUCT OF CARE .................................................................................................. 78
23.1 DEFINITIONS OF PHYSICIAN ROLES IN THE HOSPITAL ..................................................................................... 78
23.1.1 Attending Physician .................................................................................................................................... 78
23.1.2 Referring Physician .................................................................................................................................... 78
23.1.3 Primary Care Physician ............................................................................................................................. 78
23.1.4 Admitting Physician .................................................................................................................................... 78
23.1.5 Consulting Physician .................................................................................................................................. 79
23.1.6 Covering Physician ..................................................................................................................................... 79
23.2 CONSULTATIONS ............................................................................................................................................. 79
23.3 CLARIFICATION ............................................................................................................................................... 79
23.4 ORDERS FOR TREATMENT SHALL BE IN WRITING ........................................................................................... 80
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23.5
23.6
23.7
23.8
PRESCRIPTIONS DURING THE PATIENT'S HOSPITALIZATION ............................................................................ 80
LABORATORY WORK ...................................................................................................................................... 80
PATIENTS ADMITTED FOR DENTAL SERVICES ................................................................................................. 80
PATIENTS ADMITTED FOR PODIATRIC SERVICES ............................................................................................. 81
ARTICLE 24 - EMERGENCY SERVICES .............................................................................................................. 82
24.1 CALL SCHEDULE ............................................................................................................................................. 82
24.1.1 On-Call Practitioner Must Come To the ED When Called ......................................................................... 82
24.1.2 Disputes Over Need to Respond ................................................................................................................. 82
24.1.3 Assistance in Screening and/or Stabilization .............................................................................................. 82
24.1.4 Ability to Pay Not To Be Considered .......................................................................................................... 82
24.1.5 Timely Response ......................................................................................................................................... 82
24.1.6 Justification for Delay ................................................................................................................................ 83
24.1.7 Follow-Up Care .......................................................................................................................................... 83
24.1.8 Disciplinary Actions ................................................................................................................................... 83
24.1.9 Definitions................................................................................................................................................... 83
24.2 DISASTER PLANS ............................................................................................................................................. 84
24.3 DISASTER PRIVILEGES..................................................................................................................................... 84
24.3.1 Purpose ....................................................................................................................................................... 84
24.3.2 Policy .......................................................................................................................................................... 84
24.3.3 Procedure ................................................................................................................................................... 84
ARTICLE 25 - GENERAL .......................................................................................................................................... 86
25.1
25.2
25.3
CONFIDENTIALITY OF MEDICAL STAFF FILES ................................................................................................. 86
ASSESSMENT FOR MEDICAL STAFF MEMBERS ................................................................................................ 86
HOSPITAL ORIENTATION ................................................................................................................................. 86
METHODIST HEALTH SYSTEM MEDICAL STAFF PRACTITIONERS NOTICE OF PRIVACY
PRACTICES ................................................................................................................................................................. 87
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MEDICAL STAFF POLICIES
ARTICLE 1 - INTRODUCTION
Pursuant to Article 19.2 of the Bylaws, the Medical Staff through the Corporate Medical Board has
established certain policies and procedures to carry out further and in more detail describe the general
provisions, concepts, policies, principles and obligations set out in the Bylaws. This Policy manual contains
those more detailed policies and procedures, and the provisions set forth in this Medical Staff Policy Manual
are the “Policies” as that term is used in the Bylaws.
ARTICLE 2 - PURPOSES
The purposes of the medical staff organization are as expressly stated in the Bylaws.
ARTICLE 3 - DEFINITIONS
Unless expressly stated otherwise, capitalized terms contained in this Policy Manual shall have the same
meaning as given in the Bylaws.
ARTICLE 4 - MEDICAL STAFF APPOINTMENT
4.1
Nature of Medical Staff Appointment
The Nature of Medical Staff Appointment is as set forth in the Bylaws. Additional requirements,
policies and rules related to initial application, appointment and reappoint including the process for
initial application, appointment and reappointment are set forth in Article 5 of these Policies.
4.2
Qualifications for and Terms, Conditions and Responsibilities of Appointment
4.2.1 Qualifications for Appointment
In order to qualify for appointment on the Medical Staff, a Physician, Dentist, or Podiatrist
must:
1.
Be licensed to practice in the State of Texas;
2.
Provide documentation establishing his or her:
(i)
background, including satisfactory experience and training,
(ii)
demonstrated competence,
(iii)
mental and physical status,
(iv)
compliance with the Bylaws, the Policies, Medical Staff rules, and MHS and
System Hospital policies, and bylaws,
(v)
good character and reputation,
(vi)
adherence to the ethics of his profession, and
(vii)
ability to work with others.
The documentation must be of sufficient adequacy to assure the Medical Staff and
the Board of Directors that he or she will be effective Medical Staff members and
will provide a high quality of medical care in an efficient manner to any patient
admitted or treated by them.
3.
As appropriate, participate in Federal and State health care programs;
4.
Possess and maintain current registrations for prescribing medications with the
Drug Enforcement Agency (DEA) and Department of Public Safety (DPS) as
applicable
5.
Have, at all times, professional liability insurance in amounts as specified in the
Policies,
6.
Furnish proof of the insurance required,
7.
As applicable, meet the Citizenship requirements of the Medical Staff, and
MHS Medical Staff Policies
Page - 1
8.
Provide immediate written notice to the Chief Executive Officer and the medical
staff services department of any failure to renew, cancellation, reduction, denial of
coverage, or other changes resulting in less coverage than is required for medical
staff appointment.
No Physician, Dentist, or Podiatrist shall be entitled to appointment to the Medical Staff or
to the exercise of particular clinical privileges in a System Hospital merely by virtue of the
fact that he is duly licensed to practice medicine, dentistry, or podiatry in the State of
Texas or any other state, or that he is a member of any professional organization, or that
he has had in the past, or presently has such privileges at another hospital. Sex, race,
creed, and/or national origin are not used in making decisions regarding the granting or
denying of medical staff membership or clinical privileges.
4.2.2
Professional Liability Insurance
In order to qualify for appointment on the Medical Staff, each Physician, Dentist, or
Podiatrist must have a minimum of $200,000/occurrence and $600,000/aggregate
professional liability insurance at all times.
4.2.3
Responsibilities of Appointment
Each Practitioner shall:
(i)
Abide by the Bylaws, the Policies, and by all other established standards, policies,
and rules of the Medical Staff, MHS, and the System Hospitals;
(ii)
Discharge such staff, departmental, committee and System Hospital functions for
which he is responsible for as a result of staff category assignment, appointment,
election or otherwise;
(iii)
Treat other Medical Staff members and System Hospital staff and administration
personnel with respect and courtesy;
(iv)
Promptly notify the MHS Medical Staff Office of the revocation or suspension of the
Practitioner’s professional license, or the imposition of terms of probation or
limitation of practice or program participation by any state, or federal agency
(including Medicare or Medicaid), or the filing of charges, by the United States
Department of Health and Human Services, or any law enforcement agency or
health regulatory agency of the United States or the State of Texas, or of the filing
of a claim against the Practitioner alleging professional liability; and
(v)
Provide services to indigent patients and other patients who do not have a
personal Physician, Dentist or Podiatrist in accordance with the coverage schedule
adopted by the Practitioner’s department.
4.2.4
Authority to Appoint
Initial appointment, reappointment, modification of appointment, or revocation of
appointment from the Medical Staff shall be made by the Board of Directors only after
there has been a recommendation from the Medical Staff as provided in these Bylaws.
However, in the event of unwarranted delay (one hundred and eighty days from the date
the fully completed application and all follow-up information has been received by the
Medical Staff) on the part of the Medical Staff in making its recommendations, the Board
of Directors shall have authority to act without the recommendation of the Medical Staff
based upon the documented evidence of the applicant meeting the qualifications set forth
in the Bylaws and Policies.
4.2.5
Terms of Appointment
Initial appointment shall be for twenty-four months. Reappointments to the active staff
category may be for a period of less than twenty four months but in no event shall be for a
period of more than twenty four months. Initial appointment to the active staff shall be
provisional as explained in Article 4.2.6.1 of these Policies. Such provisional status may be
reviewed at any time, but must be reviewed pursuant to Article 4.2.6.2 of the Policies after
twelve (12) months, and pursuant to the procedure described in Article 5.3 of the Policies,
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such review shall result in a recommendation of termination of appointment or
continuation of provisional status for the remainder of the initial appointment.
4.2.6
Provisional Status
4.2.6.1
Applicability
4.2.6.2
Continuation, Evaluation and Termination of Provisional Status
Initial appointment (or appointment after cessation of medical staff
membership) to any category of the Medical Staff (other than honorary and
courtesy affiliate) shall be provisional. During their initial appointment,
Practitioners having provisional status shall be considered applicants for
membership or affiliate status, as the case may be, and will
participate/undergo proctoring as requested. Other rules, regulations, policies
and procedures related to provisional status and the mentoring programs are
set forth in these Policies.
(1) The purpose of provisional status is to provide for continuing evaluation of
the Practitioner's qualifications. Even though the appointment is for a
stated period, it is subject to earlier termination at any time by action of
the Board of Directors, and privileges may be suspended immediately
under the process in Article 7 of the Bylaws. Consideration of whether
provisional status should be continued may be initiated at any time and
the process described in Article 5.3.11 of these Policies shall apply with a
schedule appropriate for the circumstances.
(2) The qualifications of a provisional appointee to the active category of the
Medical Staff shall be reviewed after twelve (12) months. The
Practitioner's appointment shall terminate automatically at such time
unless the Practitioner has demonstrated during the first twelve months of
the appointment, full compliance with all Medical Staff and departmental
meeting attendance requirements and substantial compliance with all
hospital and Medical Staff policies, bylaws, and rules. In accordance with
the process described in Article 5.3.11(6), the review shall result in a
recommendation of either termination of appointment or continuation of
provisional status for the remainder of the initial appointment.
(3) During the provisional period, the appointee to the active category shall
attend a sufficient number of patients to permit an adequate evaluation of
the appointee's qualifications. In the event that there is a lack of
information concerning the Practitioner’s provision of medical care in a
System Hospital because the Practitioner’s practice is primarily officebased, the Practitioner may be granted privileges based upon other
information confirming professional competency, but subject to the
requirements for supervision and/or monitoring developed by the
applicable clinical department. By the end of the provisional period, the
appointee must demonstrate full compliance with all requirements
applicable to Medical Staff membership and meet any additional
requirements as may be assigned by the department, corporate
credentials committee, or Corporate Medical Board; otherwise, the
appointment shall expire and privileges shall be terminated automatically.
(4) During the provisional period, an appointee to the active category of the
Medical Staff may be assigned to departmental or Medical Staff
committees, excluding corporate standing committees, and is eligible to
vote at the meetings of such committees. Such appointee is not eligible to
hold committee chairmanship, or to vote on departmental or Medical Staff
policies, or departmental or Medical Staff offices, provided however, for
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the first three years from the date a new System Hospital opens
provisional active members are entitled to hold committee chairmanship
positions and vote on department rules and policies.
4.2.6.3
4.2.7
Orientation Process
Each new applicant appointed to provisional status shall attend, prior to or
during the first twelve (12) months of his/her provisional appointment, the
Medical staff orientation program. The program is designed to give the
provisional status appointee general background information of the Medical
Staff organizational structure and the appointee’s responsibilities and
obligations as a Medical Staff member. Failure to attend the orientation
program within the first twelve months of his/her provisional appointment shall
result in automatic termination of a provisional appointee’s appointment
without a right to appeal or hearing, and the provisional appointee shall not be
entitled to re-apply for Medical Staff membership for one year.
Primary System Hospital Affiliation
Each appointee to the Medical Staff shall designate a System Hospital for his primary
practice site. Although a majority of the medical care provided by a Practitioner shall be at
his/her primary practice site, the Practitioner may admit and treat patients at other System
Hospitals in accord with his delineation of privileges.
In its deliberations with respect to a Practitioner's primary System Hospital affiliation, the
corporate credentials committee shall consider the designation by the applicant of his
primary System Hospital affiliation. The System Hospital at which the Practitioner provides
a majority of his medical care in the MHS system will be the Practitioner's primary System
Hospital. However, the corporate credentials committee's recommendation shall be based
upon, in the case of an initial applicant, the Practitioner's planned utilization of the hospital
facilities, and in the case of a reappointment, the Practitioner's actual utilization of hospital
facilities based upon all relevant information including admissions, outpatient procedures,
consultations, and other involvement in patient care. A Practitioner may request a change
in primary System Hospital affiliation at any time but only once in each Medical Staff year.
Such requests shall be made in writing, and directed to the corporate credentials
committee for its recommendation. Recommendations of the corporate credentials
committee on primary System Hospital designation shall be submitted to the Corporate
Medical Board and Board of Directors for approval.
4.2.8
Applicant’s Obligations
Each application for staff appointment shall be signed by the applicant and shall contain
the applicant's specific acknowledgement of the obligation to provide continuous care and
supervision of his patients; to abide by the Bylaws, the Policies, the MHS bylaws and all
other established standards, policies, and rules of the Medical Staff, MHS and the System
Hospitals; to accept and faithfully discharge department and committee assignments; and
to participate in fulfilling the requirements for providing emergency care.
4.2.9
Participation in Teaching Programs as Teaching Staff
4.2.9.1
Appointment Process
A Practitioner on the Medical Staff wishing to volunteer to participate in the
teaching program must submit his credentials to the Director of Postgraduate
and Continuing Education and appropriate department chairman.
The training directors review the requests to participate in their respective
teaching programs and subsequently submit their recommendations for
approval to the Corporate Graduate Medical Education Committee.
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The Corporate Graduate Medical Education Committee shall make the final
decision on whether a Practitioner shall be authorized to participate in the
teaching program.
4.2.9.2
Degree of Care/Management of Patient by House Staff
Selection of Physicians to the House Staff is governed by the residency
selection process of MHS. The degree of responsibility for patient management
conferred upon the House Staff is at the discretion of the Practitioner
supervising the House Staff member. The medical record should reflect the
involvement of the teaching Practitioner in the management of a patient
treated by a House Staff member.
4.2.10 Compliance with Privacy Regulations
All members of the Medical Staff and any Physician, Dentist or Podiatrist granted privileges
to practice at any System Hospital shall comply with the Privacy Regulations.
4.2.10.1
Adoption of Privacy Notice
4.2.10.2
Approval of Restrictions and Limitations
For all healthcare activities performed by any Practitioner (whether a member
of the medical staff or not) at a System Hospital or a facility operated by a
System Hospital, the Notice of Privacy Practices ("Notice") appended to these
Policies shall be used to meet the notice of privacy practices requirements
imposed on all such Practitioners under the Privacy Regulations.
With regard to health care activities performed by any Practitioner (whether a
member of the medical staff or not) at a System Hospital or a Facility operated
by a System Hospital and unless approved in advance by the Corporate
Medical Board, no Practitioner shall have authority to agree or behalf of any
other Practitioner to any restrictions on the uses and disclosures of protected
health information specifically or generally described in the Notice.
With regard to health care activities performed by any Practitioner (whether a
member of the Medical Staff or not) at a System Hospital or a facility operated
by a System Hospital and unless approved in advance by the Corporate
Medical Board, no Practitioner shall authority to agree on behalf of any of any
other Practitioner to communicate with a patient in or at any particular
manner, way or time.
Any restriction, limitation agreed to or other agreement made by any
Practitioner related to the Notice or the Privacy Regulations shall only be
binding on the Practitioner making such agreement and shall not have any
effect on any other Practitioner unless approved by the Corporate Medical
Board in advance.
4.2.10.3
No Information Patients
4.2.10.4
No Effect on Legal Regulations
In accordance with the Privacy Regulations and MHS policies, a System
Hospital may agree to the requests of a patient to be a no information patient.
In such circumstances, Practitioners shall follow the MHS policy with regard to
not disclosing the identity of the patient in question.
Nothing contained in the Bylaws or Policies or done by any Practitioner in
furtherance of the Bylaws or Policies related to the Privacy Regulations shall in
any way have any impact on or in any way change or be considered in
determining the legal relationship any Practitioner has with any other
Practitioner or with MHS or with any System Hospital, provided however,
MHS Medical Staff Policies
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corrective action in accordance with the Bylaws may be taken against any
Practitioner who violates any Bylaw or Policy related to the Privacy
Regulations.
4.3
Ethics and Ethical Relations
Provisions dealing with ethics and ethical relations are set forth in the Bylaws.
4.3.1
Conflict of Interest
4.3.1.1
Purpose
4.3.1.2
Definitions
The purpose of this Section 4.3.1 is to reduce the circumstances in which
actions or recommendations of the Medical Staff and the Medical Staff
committees are influenced by potential conflicts of interests.
(1) Associate: A person is an Associate of a physician on the medical staff if
any of the following apply:
The person is a partner (or co-owner of a medical practice), employee, or
employer of the physician on the medical staff;
The person has a regular arrangement with the physician on the medical
staff to share call coverage (the fact that a physician may occasionally
switch call coverage responsibilities with another physician does not,
in and of itself, make either physician an Associate of the other);
The person has a direct family relationship with the physician on the
medical staff. Direct family relationship means the person is a spouse,
descendant, ascendant or sibling of the physician, or the spouse of
any such person;
The person has a financial relationship with the physician on the medical
staff such as having, directly or indirectly, through business,
investment or family:
i.
ii.
an ownership or investment interest in any entity with the
physician on the medical staff including, but not limited to, joint
venture arrangements; or
a compensation arrangement with the physician on the medical
staff including, but not limited to, shared office space
arrangements.
Financial relationship includes direct and indirect remuneration as well
as gifts or favors that are substantial in nature. A financial relationship
is not necessarily a conflict of interest. Under subsection (c) (ii) below,
a person who has a financial relationship may have a conflict of
interest only if the Corporate Medical Board or a committee appointed
by the Corporate Medical Board determines that a conflict of interest
exists.
(2) Competitor: A person is a competitor of a physician on the medical staff if
any of the following apply:
(A) The person practices in the same specialty as the physician on the
medical staff; or
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(B) The person is privileged to perform the same procedures as the
physician on the medical staff.
(3) Conflict of Interest. A Conflict of Interest exists when a Practitioner on or
with an ability to influence a Medical Staff committee votes or influences
such committee’s recommendation or action on a matter concerning such
Practitioner’s Associate or Competitor. Because recommendations made or
actions taken by or at the Medical Staff department level are always
reviewed and approved at higher levels of the medical staff, the
applicability of this policy at the department level will be left to the
determination of the department (e.g., credentialing recommendations by
Department Chairs to the Corporate Credentialing Committee).
4.3.1.3
Procedures
(1) Duty to Disclose. Each Practitioner who is on any committee of the Medical
Staff must disclose to the committee, prior to the committee’s vote on any
matter involving an Associate or Competitor, the fact that such matter
involves such Practitioner’s Associate or Competitor and the general nature
of such relationship.
(2) Determining Whether a Conflict of Interest Exists. If, after disclosure or
discovery of a potential Conflict of Interest, a question remains as to the
existence of a Conflict of Interest, the Corporate Medical Board shall make
a final determination. If the question of a Conflict of Interest arises at the
Corporate Medical Board level, the disinterested members of the Corporate
Medical Board shall decide the matter. After discussion, the Practitioner in
question shall leave the committee meeting while the determination of a
Conflict of Interest is discussed and voted upon.
(3) Procedures for Addressing Conflicts of Interest:
(A) A Practitioner with an actual or potential Conflict Interest may make a
presentation at the committee meeting, but after such presentation,
he or she shall leave the meeting during the final discussion prior to,
and the vote on, the transaction or arrangement that results in the
Conflict of Interest.
(B) The committee or chairperson of the committee may, if deemed
advantageous, appoint a disinterested person or committee to
investigate alternatives to the proposed action to be taken by the
committee concerning the Associate or Competitor. The appointment
of such person or committee shall be at the complete discretion of the
committee chair and the committee, and the Associate or Competitor
involved shall have no right to require such an appointment.
(C) After consideration of the matter, including the recommendations of
any person or committee appointed under section (iii) (B) above, the
committee shall vote on the matter in question.
(4) Violations of This Section:
(A) If a committee or Medical Staff member has reasonable cause to
believe that a Practitioner has failed to disclose actual or possible
Conflicts of Interest, it, he or she shall inform the Corporate Medical
Board of such. The Corporate Medical Board will review the basis of
the allegation and, if the Corporate Medical Board deems it
MHS Medical Staff Policies
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appropriate, will inform the Practitioner believed of not making such
disclosure of the basis for such belief and afford him or her an
opportunity to explain the alleged failure to disclose.
(B) If, after hearing the response of such person and making such further
investigation as may be warranted in the circumstances, the Corporate
Medical Board determines that the Practitioner has in fact failed to
disclose an actual or possible Conflict of Interest and such nondisclosure has resulted in an action taken or recommendation made by
the Medical Staff which it would not have taken or made had the
disclosure been made, the Corporate Medical Board shall recommend
to the Board appropriate disciplinary and corrective action.
(C) An action taken or recommendation made by the Medical Staff is not
void or voidable solely for that reason or solely because the
Practitioner with a Conflict of Interest is present at or participates in
the meeting of the committee that took the action or made the
recommendation, or solely because such Practitioner’s vote is counted
for that purpose, if:

the material facts as to the Conflict of Interest are disclosed or are
known to the committee, and the committee in good faith
approved the action or recommendation by the affirmative vote of
a majority of the committee members who have no Conflict of
Interest concerning the matter in question and even though the
disinterested committee members are less than a quorum; or

the material facts as to the Conflict of Interest are made known to
a higher level committee in the Medical Staff or to the Board and
the action or recommendation is approved in good faith at such
higher level.
(5) Determining Quorum Requirements: Practitioners with actual or potential
Conflict of Interests may be counted in determining the presence of a
quorum at a meeting of a committee that takes the action or makes the
recommendation.
4.4
Scope of Clinical Privileges
Provisions dealing with scope of clinical privileges are set forth in Articles 4.4 and 6 of the Bylaws
and Article 6 of these Policies.
4.5
Peer Review
4.5.1
Purpose
Peer review is one component of the performance improvement process at Methodist
Health System. The goals of the peer review process are to identify opportunities for
improvement and to provide constructive feedback related to the performance of the
Medical Staff. The process provides for practitioner education, improving system deficits
and identifying best practices which contribute to the quality of care for the patient
populations served. In addition, peer review provides a framework for assessing the
competency for privilege delineation of practitioners at Methodist Health System.
4.5.2
Objective
The peer review process is designed to be structured, consistent, timely, impartial,
balanced, useful and ongoing.
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4.5.3
Guidelines
The Medical Staff develops minimum criteria for case review. Criteria developed will be
reviewed at least every two years by the clinical departments and may be modified or
changed from time to time based on services, reports from risk management, or other
trends identified by quality monitoring. Criteria will be developed based on high risk, high
volume, and new procedures or services.
4.5.4
Privileged Committee Function
This policy is implemented to assist and be utilized by those hospital and medical staff
committees and/or agents of such committees as part of the peer review process
developed, implemented and overseen by the quality committee(s) and credentialing
committee(s) established by the Board of Directors. As such, all meetings discussions,
documents, recommendations and actions held, prepared, made or taken as outlined in or
pursuant to the objectives or process established in or pursuant to these guidelines are
considered privileged and protected.
4.5.5
Definition
Peer review is an evaluation by unbiased practitioners (peers). A peer is an individual
reviewing another’s performance in the same profession (e.g. physician to physician,
podiatrist to podiatrist, dentist to dentist, CRNA to CRNA, etc.).
4.5.6
Process
1.
Cases are identified using the predetermined screening criteria established by
individual departments. Cases may also enter the peer review process when
referred by others (e.g. complaints, risk management, medical staff committees,
etc.). Case review should be accomplished as close to the date of the event as
possible.
2.
Quality Management staff use a standard format to summarize a case prior to
referral to the appropriate Medical Staff Department. Cases requiring review are
referred to the Department Chair or designee for assignment of peer review by an
unbiased practitioner.
3.
Peer review is ongoing. The assigned practitioner conducts a review of the medical
record and at a minimum documents the following:
a. conclusions about the quality of care provided.
b. specific findings and recommendations related to the identified issue.
c. pertinent comments or feed back related both to practice strengths and
opportunities for improvement in medical management.
4.
The conclusions reached by the practitioner assigned to conduct the review should
specifically address the issues for which the peer review was conducted, including,
as appropriate, reference to the literature and relevant clinical practice guidelines.
Upon completion of the review points may be assigned regarding the quality and
outcome of care related to the medical staff involvement. (see review sheet for
points categories).
In the event a Practitioner receives points as a result of the initial peer review
he/she will have a reasonable opportunity to respond in writing to the appropriate
peer review committee before final points are assigned. Failure of the Practitioner to
exercise the right to respond within the time provided will result in points being
assigned without the Practitioner’s response.
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5.
The Clinical Outcomes staff will provide a summary report to the Medical Staff
Departments and Medical Staff Quality Council of the number of cases reviewed,
summary of the findings, conclusions and outcome. The department chair will
identify and recommend appropriate measures to address any identified quality of
care concern or opportunity for improvement. Any action taken for each case
reviewed, together with the final disposition, will be documented.
6.
Peer review conclusions are tracked over time and actions taken based on peer
review are monitored for effectiveness. Profile data sheets, peer review forms, and
data collection worksheets for performance improvement activities are maintained
in each practitioner’s quality file. This Practitioner specific information will be
considered during reappointment of the practitioner or when deemed necessary
based on findings.
7.
A focused review or quality improvement plan for a Practitioner may be requested if,
without acceptable justification, the Practitioner has accumulated “8” points during a
reappointment cycle or for any one case that accumulates “3” points as having
potential issues with quality of patient care. Such reviews or quality improvement
plans will be tailored to the individual issues identified (examples may include; focus
on certain diagnoses, procedures, practice patterns, patient safety issues etc.) and
may cover all or a sample of all admissions of the Practitioner in question.
Individuals selected to participate in development of a focused review or quality
improvement plan will be appointed by the Chair of the Department or the President
of the Medical Staff. Whenever a focused review or quality improvement plan is
initiated, the Practitioner in question will be notified in writing of the reason for the
review
A focused review or quality improvement plan will have measurable expectations
that have been reviewed with the Practitioner involved, be in effect for no less than
3 months with sufficient data to determine the Practitioner’s performance, and there
will be periodic regular feedback to the Practitioner regarding compliance with the
measurements. The focused review or quality improvement plan may be extended,
in whole or in part (or new review or plan developed), by the Department Chair, the
Corporate Credentials Committee and/or the Corporate Medical Board if the review
does not show progress of the Practitioner’s ability to practice medicine within the
community standard of care or if, in any such individual’s or body's determination, a
need exists otherwise to continue the review or plan.
8.
An outside review may be requested by the Department Chair, Medical Executive
Committee, Corporate Medical Board or an administrative officer of the hospital or
Board of Directors when:
a.
new technology is involved and the medical staff or hospital does not have
the necessary tools to assess whether a medical staff member requesting
privileges possesses the required skills and competence;
b.
internal reviewers submit conflicting or vague recommendations or fail to
agree;
c.
a recommendation may result in an adverse action;
d.
a System Hospital faces or has faced a threatened or actual medical
malpractice suite;
e.
the review could be interpreted as competitive;
f.
those available to review the record are partners of the Practitioner and do
not feel comfortable performing the review;
g.
those available to review the record do not have sufficient expertise to
perform the review
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9.
In any situation where it appears that a disciplinary proceeding may be instigated
against a Practitioner that could result in the substantial loss or termination of
his/her clinical privileges, the advice and guidance of the Legal Affairs Department
should be sought by those persons who are involved in this phase of the peer
review process.
10.
Recommendations that may result in an adverse action against a practitioner will
be carried out in accordance with the Medical Staff Bylaws.
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ARTICLE 5 - APPOINTMENT OF INITIAL APPLICANT AND REAPPOINTMENT
5.1
Disclosures
By applying for appointment or reappointment to the Medical Staff, each applicant:
(i)
signifies his willingness to appear for interviews in regard to his application;
(ii)
authorizes hospital and Medical Staff representatives, both during the application process
and as long as he holds a Medical Staff appointment, to consult with members of medical
staffs of other hospitals with which the applicant has been associated, as well as other
persons and entities who may have information concerning the applicant's behavior,
competence, professional qualifications and ethics;
(iii)
consents to the inspection by the Corporation and the Medical Staff of all records that may
be pertinent to the evaluation of the applicant's behavior, professional qualifications and/or
competence to perform the clinical privileges he requests;
(iv)
releases all Hospital Representatives from any liability for their acts performed in Good
Faith in connection with evaluating the applicant and his credentials and making
recommendations concerning his appointment and clinical privileges;
(v)
releases all individuals and organizations from any liability for providing information to the
hospital and/or Medical Staff in Good Faith concerning the applicant's competence, ethics,
character, behavior, and reputation, and other qualifications for staff appointment and
clinical privileges, including otherwise privileged or confidential information;
(vi)
authorizes and consents to Hospital Representatives providing to other hospitals, medical
associations, licensing boards, and other organizations concerned with provider
performance and the quality and efficiency of patient care with any information relevant to
the applicant’s provision of and the quality and efficiency of patient care that the
Corporation or Medical Staff may have concerning him, and releases Hospital
Representatives from liability for so doing, provided that such furnishing of information is
done in Good Faith and without Malice;
(vii)
agrees that: (1) any false or erroneous information provided by the applicant in the
application or during the application process can result in denial of the application; and (2)
in such event, the applicant shall not be entitled to a hearing including any of the fair
hearing processes set out in these Bylaws or the Policies; and
(viii)
agrees to keep the information and matters that are normally kept confidential in a
hospital setting confidential including, but not limited to, information discussed in or
matters pertaining to hospital and medical staff committees and the obligations of patient
confidentiality as set forth in the Privacy Regulations.
5.2
Burden of Proof
The applicant or Practitioner, as the case may be, shall have the burden of producing Clear and
Convincing Evidence establishing that he has met all qualifications required by these Bylaws, the
Policies and other rules, regulations and policies related to appointment and reappointment.
5.3
Application and Initial Appointment
5.3.1
Initial Application
(1)
Each initial applicant to the Medical Staff shall submit an application on a
prescribed form. The form shall be presented to the Medical Staff services
department, which acts on behalf of the corporate credentials committee and the
Corporate Medical Board. Such application shall include, but not be limited to
information on the following: professional references, medical education including
internship and residency, liability insurance, the voluntary or involuntary
termination of hospital medical staff membership, previously successful or
currently pending challenges to any licensure or registration (state or district, Drug
Enforcement Administration), the voluntary or involuntary relinquishment, denial,
limitation, reduction, or loss of such licensure or registration or clinical privileges at
another hospital, and any professional liability claims.
MHS Medical Staff Policies
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(2)
A criminal background check is incorporated into the credentialing process to
provide an efficient method of assisting in the verification of information contained
in a Medical Staff or Allied Health Professional’s application and to assist in
identifying those individuals who are not qualified or otherwise do not meet
Methodist Health System’s (MHS) standards for membership and privileges. It is
the policy of the MHS Medical Staff to conduct a criminal background check on all
initial medical staff and allied health professional applicants to assist in verifying
identity, qualifications, ability and character tow work in the healthcare
environment.
Upon receipt of an application for membership and privileges from a physician,
dentist, podiatrist, or allied health professional, the Medical Staff Office will submit
the required information to an appropriate vendor for initiation of the background
check. The report will be printed and placed in the practitioner’s file for review by
the Department Chair and/or Credentials Committee. An application will be
considered incomplete if the criminal background check report is not included.
MHS’s background report is considered proprietary information. Although the
results should be discussed with the applicant, and the applicant should be given
an opportunity to correct any errors contained in the report, the actual report
should not be released to the applicant or any third party. Peer Review
Committees and Department Chairs involved in the decision making process may
view the report within the credentials file. When adverse information is obtained,
the applicant will be sent a certified letter requesting further details regarding the
event. If the applicant chooses to pursue the application process, the application
(along with the additional information forwarded by the applicant) will be
forwarded through the committee process for Department, Credentials Committee,
Medical Executive Committee, Corporate Medical Board, and Board of Directors
consideration.
(3)
The applicant shall designate the following:
(i)
the Medical Staff category and the department/section within which
appointment is sought;
(ii)
the privileges sought; and
(iii)
the System Hospital at which he shall be obligated to fulfill his Medical
Staff obligations.
(4)
The applicant shall sign a statement on the application form that he has received
the Bylaws and the Policies and agrees to be bound by the terms thereof, as
revised from time to time, in all matters relating to consideration of his application
without regard to whether he is or is not granted appointment and/or clinical
privileges, and that if appointed, he agrees to comply with the policies and
procedures of MHS and of each System Hospital in which he attends patients.
Ignorance of any specific provision, term or condition of the Bylaws or Policies
shall not be grounds for failure to abide by such provision, term or condition.
(5)
The applicant has the responsibility to produce a complete application. The
application will be considered complete when all questions in the application form
have been answered, all requested information and supporting documentation has
been received, and sufficient information to evaluate the applicant's qualification
has been furnished in the judgment of the Medical Staff and the Corporation.
(6)
Once completed, the department chairman of the designated primary System
Hospital shall prepare a recommendation to the corporate credentials committee
concerning appointment and clinical privileges. The department chairman may
seek the recommendation of the department credentials committee or the
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department’s executive committee sitting as its credentials committee. The
department chairman may seek the recommendation of the appropriate chief
within the corporate Medical Staff if such specialty is not represented at the
primary System Hospital. The department chairman of the applicant's designated
primary System Hospital is responsible for presenting recommendations to the
corporate credentials committee. The recommendation(s) regarding appointment
and clinical privileges may include terms of supervision, monitoring, probation,
admonitions, and/or other limitations as deemed necessary and appropriate by the
department chairman.
5.3.2
5.3.3
Corporate Credentials Committee Function
(1)
The corporate credentials committee shall examine the evidence submitted by the
applicant and shall determine, through information contained in references given
by the applicant and from other sources available to the committee, including an
appraisal from the clinical department in which privileges are sought, whether the
applicant has established and meets the necessary qualifications for the category
of staff appointment and the clinical privileges requested. Each specialty section or
department in which the applicant requests clinical privileges shall provide the
corporate credentials committee through the department representative with
specific, written recommendations for delineating the applicant's clinical privileges
and these recommendations shall be made a part of the corporate credentials
committee's report to the Corporate Medical Board.
(2)
Within sixty (60) days after receipt of the completed application for appointment,
the corporate credentials committee shall transmit, to the Corporate Medical Board
and the Executive Committee of each System Hospital's medical staff, the
completed application, a written report of the committee's investigation, and a
recommendation that the applicant: (i) be appointed to provisional status, with the
privileges requested; (ii) be appointed to provisional status with specified
limitations in the appointment and/or privileges requested; or (iii) be denied
Medical Staff appointment.
(3)
The Corporate Medical Board shall not act on the corporate credentials
committee's recommendations until reports on the applicant have been received
from the Executive Committees of each System Hospital. Each Executive
Committee shall make a recommendation that the applicant: (i) be appointed to
provisional status with the privileges requested; (ii) be appointed to provisional
status with specified limitations in the appointment and/or privileges requested; or
(iii) be denied medical staff appointment.
(4)
When any application is returned to the corporate credentials committee from the
Corporate Medical Board for further consideration or reconsideration, the
committee shall complete its deliberations no later than the second scheduled
meeting of the Corporate Medical Board after the application is returned, and shall
submit a recommendation to the Corporate Medical Board that the applicant be: (i)
appointed to provisional status with the clinical privileges requested; (ii) appointed
to provisional status with specified limitations in the appointment and/or privileges
requested; or (iii) denied medical staff appointment.
Corporate Medical Board Responsibilities
The Corporate Medical Board, at its next regular meeting after receipt of the application
and the report and recommendations of the corporate credentials committee and the
Executive Committee, shall determine whether to recommend that the applicant be
appointed to the Medical Staff or make the determination that the application be deferred
for further consideration or rejected for Medical Staff appointment.
MHS Medical Staff Policies
Page - 14
5.3.4
Favorable Recommendation by the Corporate Medical Board
(1)
When the recommendation of the Corporate Medical Board is favorable to the
applicant, the Chief Executive Officer shall promptly forward it together with all
supporting documentation, to the Board of Directors.
(2)
The Board of Directors or its duly authorized committee, at its next regular
meeting after receipt of the Corporate Medical Board's recommendation, will act
on the application and may appoint the applicant to the staff, with a delineation of
the clinical privileges which the applicant may exercise.
(3)
In the event the Board of Directors' decision is contrary to the recommendation of
the Corporate Medical Board, the Board of Directors shall submit the matter to a
joint conference committee for review and recommendation before taking final
action. If the applicant has not been extended the opportunity to have and is
entitled to a hearing pursuant to Article 8 of the Bylaws, the joint conference
committee shall defer making its recommendation until either the applicant waives
such opportunity or the committee receives and considers the recommendation of
the hearing panel report after such hearing.
5.3.5
Deferral of Application
If the Corporate Medical Board defers the application for further consideration, it must act
upon the application within two consecutively scheduled meetings with a subsequent
recommendation to either appoint with specified clinical privileges or reject the applicant
for staff appointment.
5.3.6
Adverse Recommendation by Corporate Medical Board
(1)
When the recommendation of the Corporate Medical Board is adverse to the
applicant, either in respect to the denial of or limitation to appointment or clinical
privileges requested, the Chairman of the Corporate Medical Board shall notify the
applicant (by certified mail, return receipt requested) within ten (10) days after
such decision is made. Not until the applicant has been deemed to have waived his
right to a hearing as provided in Article 8 of the Bylaws or has exercised the right
and the Corporate Medical Board has reviewed and considered the report of the
hearing panel and reaffirmed the adverse recommendation, will that
recommendation be forwarded to the Board of Directors.
(2)
After the Corporate Medical Board has considered the report and recommendation
of the hearing panel and the hearing record, the Corporate Medical Board's
reconsidered recommendation shall be forwarded with all pertinent documentation
to the Board of Directors.
(3)
The Board of Directors or its duly authorized committee, at its next regular
meeting after receipt of the Corporate Medical Board's recommendation, will act
on the application. The Board of Directors' decisions shall be conclusive, except
that the Board of Directors may refer the matter back to the Corporate Medical
Board for further reconsideration and in so doing shall state the reasons for such
action and shall set a time limit within which a subsequent reconsidered
recommendation to the Board of Directors shall be made. At its next regular
meeting after receipt of any subsequent reconsidered recommendation and
pertinent information pertaining to the matter, the Board of Directors shall either
appoint the applicant to the staff, with a delineation of the clinical privileges which
the applicant may exercise, or reject him for staff appointment.
(4)
In the event the Board of Directors' decision is contrary to the recommendation of
the Corporate Medical Board, the Board of Directors shall submit the matter to a
joint conference committee for review and recommendation before taking final
MHS Medical Staff Policies
Page - 15
action. If the applicant has not been extended the opportunity to have a hearing
pursuant to Article 8 of the Bylaws, the joint conference committee shall defer
making its recommendation until either the applicant waives such opportunity or
the committee receives and considers the recommendation of the hearing panel
report after such hearing.
5.3.7
Final Action by Board of Directors
When the Board of Directors has taken final action on any application for appointment to
the Medical Staff, it shall send notice of such decision including a statement of the basis of
such decision through the Chief Executive Officer to the applicant. If such decision is
adverse, the notice to the applicant shall be by certified mail, return receipt requested.
5.3.8
Eligibility for Appointment after Adverse Recommendation
(1)
An applicant may withdraw his application for appointment or for the privileges in
question, as the case may be, by written request any time prior to the meeting of
the hearing panel or fair hearing committee, but in so doing shall not be eligible to
reapply with respect to the subject matter of the adverse recommendation for a
period (i) in the case of a denial of appointment to the medical staff, of one (1)
year, or (ii) in the case of denial of certain requested privileges, of six (6) months.
Such period shall commence on the date such application is withdrawn.
5.3.9
(2)
Upon final action of the Board of Directors which is adverse to the applicant, the
applicant shall not be eligible to reapply with respect to the subject matter of the
adverse action for a period of one (1) year from the date of the final action of
Board of Directors.
(3)
Any reapplication submitted after withdrawal pursuant to subsection (1) above or
after final action of the Board of Directors shall be accompanied with Clear and
Convincing Evidence demonstrating that the basis for such previous adverse
recommendation no longer exists.
Expedited Review Process for Initial Applicants
5.3.9.1
Purpose and General Requirements
The purpose of an expedited approval process for uncomplicated applications
for appointment to the Medical Staff is to speed up the approval process for
applicants as well as use Practitioner and hospital staff time more efficiently.
All completed initial applications without initial adverse reviews may be
submitted for expedited approval in accordance with this Article 5.3.10.
Applicants for privileges are ineligible for the expedited process if any of the
following has occurred:
The applicant submits an incomplete application (incomplete means if any
sections of the application are left blank or additional documentation is not
provided).
The medical staff executive committee makes a final recommendation that is
adverse or has limitations.
The expedited approval process set forth herein applies only to completed
initial applications. In accord with these Policies [Article 5.3.1(4)], an
application is considered complete when all questions in the application have
been answered, all requested information and supporting documentation has
been received, and sufficient information to evaluate the applicant’s
qualifications has been furnished. If controversial issues are discovered within
MHS Medical Staff Policies
Page - 16
the initial application or are discovered as part of the initial application
process, or the chair of the clinical department does not approve the
application for expedited approval, the application will be processed through
the usual committee structure.
5.3.9.2
Expedited Processing Procedure
The process for expedited approval shall include review and approval of the
file by the:
1. Department chair or departmental executive committee at each System
Hospital,
2. Chair or designee of the corporate credentials committee,
3. Corporate Medical Board**
4. Chief Executive Officer or designee and
5. Two voting members of the governing body on behalf of the Board of
Directors.
At any time during the review process, any of the above referenced individuals
or committees may request that the file be forwarded through the current
usual committee structure for credentialing. At that point, the expedited
approval process would cease.
Although an applicant may be appointed through the expedited process, all
information pertaining to the applicant will be forwarded for affirmation to all
medical staff credentialing committees, the Corporate Medical Board, and the
Board of Directors.
** JCAHO standards do not allow a designee of the Corporate Medical Board
to grant expedited approval – review and approval must be by the Committee
and not a designee.
5.3.9.3
Criteria for Applying Process
The expedited approval process shall only apply to initial applications for
appointment to the Medical Staff that meet the following criteria:
1. New applicant for which there was absolutely no difficulty in verifying
information on the application or obtaining references,
2. No suspicious peer references, and
3. No malpractice claims – or lawsuits, no matter how concluded (favorably,
unfavorably or dismissed)
4. There are no current challenges or previously successful changes
to
licensure or registrations
5. There have been no involuntary terminations of medical staff membership
at another organization
6. The applicant’s privileges have not ever been involuntarily limited,
reduced, or denied
5.3.10 Scheduled Review of Provisional Status for Active Category of Membership
(1)
The following process shall apply for review of those Practitioners on provisional
status except that at the discretion of the corporate credentials committee the
time may vary from the schedule described below to meet the circumstances. The
burden of proof to demonstrate satisfactory qualifications shall remain with the
Practitioner in accordance with Article 5.2 of these Policies.
(2)
12-month provisional performance review by the corporate credentials
committee shall be based upon information concerning the following quality
assurance activities and medical staff peer review which shall include, but not be
limited to: (i) medical record clinical pertinence, blood usage review, surgical case
MHS Medical Staff Policies
Page - 17
review, pharmacy and therapeutic review and drug usage evaluation, (ii) current
professional competency and clinical judgment demonstrated in the treatment of
patients effectively and efficiently, (iii) ethics and conduct, (iv) compliance with
hospital bylaws and medical staff bylaws and rules, (v) attendance at medical staff
departmental and committee meetings and participation in staff affairs, (vi)
compliance with requirements for professional liability coverage, (vii) relations with
other staff members, (viii) cooperation with hospital authorities and personnel, (ix)
utilization of the hospital facilities for his patients, (x) general attitude toward his
patients and practice, the hospital, and the public, (xi) status of licensure or other
registration, (xii) requirements assigned by the department, corporate credentials
committee, or corporate medical board, and (xiii) any other qualifications required
by Article 4.2
(3)
24-month provisional performance review - At least 115 days prior to the
expiration date of the provisional appointment, each Practitioner holding such
appointment shall submit an application for Medical Staff membership on a
prescribed form. The completed application form shall be presented to the Medical
Staff Services department which acts on behalf of the corporate credentials
committee and the Corporate Medical Board. No extensions in the time periods
provided, and no extension of appointment will be granted to a Practitioner to
complete and submit the application form. If the application form is not submitted
by such date, the appointment and all privileges shall terminate and the
Practitioner shall be deemed to have voluntarily allowed the appointment to
terminate. This action shall be reported to the corporate credentials committee,
the Corporate Medical Board, and the Board of Directors. The Practitioner shall
have no right to a hearing or other review of such voluntary termination of
provisional appointment. However, upon the payment of a $500 penalty fee plus
the standard application fee the Practitioner may reapply for Medical Staff
appointment. At the written request of the Practitioner, the $500 penalty fee may
be waived by the chairman of the Corporate Medical Board, upon the advice of the
chairman of the department in question, and a showing that a medical exigency
prevented the Practitioner from completing the application in a timely manner.
(4)
If a complete application as described in Article 5.3.1(4) of the Policies is received,
the chairman of the department shall promptly submit to the corporate credentials
committee his written recommendations regarding the practitioners appointment
to the Medical Staff and the privileges requested. The department chairman may
seek the recommendation of the department credentials committee or the
department’s executive committee sitting as its credentials committee. If subspecialty privileges are requested, the chairman of the department may seek the
recommendation of the appropriate sub-specialty chief.
(5)
The department chairman’s recommendation(s) regarding appointment and clinical
privileges may include terms of supervision, monitoring, probation, admonitions,
and/or other limitations as deemed necessary and appropriate by the department
chairman.
(6)
The corporate credentials committee shall promptly review all pertinent
information on the Practitioner, including the recommendation of the department
chairman and specialty section chief when applicable.
(7)
The review of provisional status by the corporate credentials committee shall be
based upon the information concerning the following and received from the
Practitioner, quality assurance activities, and medical staff peer review, which shall
include, but not be limited to:
MHS Medical Staff Policies
Page - 18
(i)
(ii)
(iii)
(iv)
(v)
(vi)
(vii)
(viii)
(ix)
(x)
(xi)
(xii)
(xiii)
(xiv)
(xv)
(8)
5.4
medical record clinical pertinence, blood usage review, surgical case
review, pharmacy and therapeutic review and drug usage evaluation;
current professional competency and clinical judgment demonstrated in
the treatment of patients effectively and efficiently;
ethics and conduct;
mental and physical status;
compliance with the Bylaws, Policies, Corporate bylaws and other polices,
rules and regulations of the Medical Staff, MHS and the System Hospitals;
attendance at Medical Staff meetings, departmental and committee
meetings and participation in staff affairs;
compliance with requirements for professional liability coverage;
relations with other staff members;
cooperation with System Hospital authorities and personnel;
utilization of the System Hospital facilities for his patients;
general attitude toward his patients and practice, the System Hospital, and
the public;
participation in continuing medical education activities as required by
respective clinical departments;
status of licensure or other registration;
requirements assigned by the department, corporate credentials
committee, or Corporate Medical Board; and
any other qualifications required by the Bylaws and the Policies.
The process to be followed by the corporate credentials committee, Corporate
Medical Board, Board of Directors, and where applicable, the joint conference
committee, shall be similar to that established in Articles 5.3.2 through 5.3.9 of
these Policies, except the recommendation of the Corporate Medical Board to the
Board of Directors shall be, with respect to the twelve (12) months review, either:
termination of appointment or continuation of provisional status for the remainder
of the initial appointment, and, with respect to the twenty-four (24) month review:
(i) appointment to the active staff category with the privileges requested, (ii)
appointment to the active staff category with specified limitations in the
appointment and/or privileges, or (iii) denial of appointment to the Medical Staff,
allowing the provisional appointment and privileges to terminate or expire, as the
case may be.
Medical Staff Re-Appointment Process
5.4.1
Practitioners' Obligation
The Practitioner shall have the burden of proof, as set forth in Article 5.2 of the Bylaws, in
the matters related to reappointment. Each Practitioner considered for reappointment shall
submit a reappointment application on a prescribed form. Such form shall include, but not
be limited to, information on the following:
i.
ii.
iii.
iv.
v.
5.4.2
continuing medical education,
liability insurance,
voluntary or involuntary termination of hospital medical staff membership,
previously successful or currently pending challenges to any licensure or
registration (state or district, Drug Enforcement Administration), and
the voluntary or involuntary relinquishment, denial limitation, reduction, or loss of
such licensure or registration or clinical privileges at another hospital, and any
professional liability claims.
Reappointment Application Process
The following process shall apply to Practitioners applying for reappointment to the Medical
Staff:
MHS Medical Staff Policies
Page - 19
1.
One hundred fifty days (5 months) prior to expiration of appointment, a cover
letter and the reappointment application packet is sent to the Practitioner with
instructions that the completed application shall be returned within 21 days.
2.
If the reappointment application is not received by the Medical Staff services office
within the 21 day period, a certified letter will be sent to the Practitioner
notifying him/her that the reappointment application is delinquent and that within
fourteen (14) days a completed application or a letter of resignation must be
received and that in the absence of a response, the Practitioner will be deemed to
have voluntarily resigned in the face of an adverse recommendation.
The certified letter will state the date the original reappointment application was
mailed to the practitioner and further state the date it should have been returned.
Additionally, the certified letter will state the final date the application must be
returned.
3.
If, after the certified letter has been sent, the application has still not been
received within 7 days by the Medical Staff services office, a phone call will be
made to the Practitioner (not the office staff) by either the Medical Staff
coordinator or department chair.
The individual making the call will:
(a)
reiterate the need for the application
(b)
attempt to find out why the completed application has not been returned
by the practitioner (including any extenuating circumstances)
(c)
advise the Practitioner that failure to return the application within the next
seven (7) days will result in a voluntary resignation and the inability to
reapply for one year.
If the applicant states that he/she does not wish to reapply, it will be presented to
the corporate credentialing committees as a voluntary resignation.
4.
Upon receipt of the application, the Medical Staff office will verify the following
information:
(a)
Current hospital appointments (verified in writing)
(b)
Licensure (verified with the TSBME)
(c)
DEA (Drug Enforcement Administration) License (current copy)
(d)
DPS (Department of Public Safety Narcotics License) (current copy)
(e)
Malpractice insurance claims history (verified in writing)
(f)
Health status (documented on the application)
(g)
Peer reference (at least one written reference must be received)
(h)
Continuing medical education (documented on the application)
(i)
Board certification (verified through the American Board of Medical
Specialties Compendium)
(j)
TB testing within 12 months preceding reappointment (documented on the
application)
Query the national practitioner data bank
Receipt of reappointment dues required per Section 11.1.2
5.
The Medical Staff office also obtains the following information from the System
Hospitals concerning the following:
Quality assurance activities
Medical record clinical pertinence
Blood usage reviews performed
Surgical case reviews performed
Pharmacy and therapeutic reviews performed
MHS Medical Staff Policies
Page - 20
Drug usage evaluation reviews performed
Request information from the hospital legal department regarding litigation
Request hospital-specific clinical activity regarding number of admissions, consults,
and number and type of procedures performed
Check for Medicare/Medicaid sanctions
6.
When the application is complete (meaning all information is in the file) the file will
be sent to the departmental executive committee for review and consideration. If
the clinical department does not have an executive committee, the file will be
reviewed by the department chair. (This process shall be followed for all System
Hospitals)
The departmental executive committee and/or the department chair shall review
the file based on, but not limited to, the following information:
Current professional competency and clinical judgment
Ethics and conduct
Mental/physical status
Compliance with the corporate and Medical Staff bylaws and policies
Attendance at Medical Staff meetings and participation in staff affairs
Relationships with other staff members
Cooperation with hospital authorities and personnel
Utilization of the System Hospital facilities for his/her patients
General attitude toward his/her patients and practice, the System Hospitals, and
the public
Participation in CME activities (as required by the clinical department)
Litigation claims history
Any challenges to any licensure or registration (state or district, DEA), voluntary or
involuntary relinquishment of licensure or registration, voluntary or
involuntary termination of medical staff membership, and voluntary or
involuntary limitation, reduction, or loss of clinical privileges at another
hospital.
5.4.3
7.
Following the review by the departmental executive committee and/or the
department chair, a written recommendation shall be forwarded to the corporate
credentials committee.
8.
After the corporate credentials committee has considered the application and
clinical department recommendation, a recommendation is forwarded to the
system Executive Committees, the Corporate Medical Board and then to the Board
of Directors for final approval in accordance with procedures set forth in these
Policies.
9.
After the Board of Directors considers the application and various committee
recommendations as set forth in these Policies, a letter is sent to the Practitioner
informing him/her of the action taken regarding the reappointment and privileges.
Department and Corporate Credentials Committee Review
(1)
All practitioners, other than those in the departmental affiliate and temporary
affiliate categories, shall submit an application for reappointment on a prescribed
form at least 115 days prior to the expiration of the current appointment.
Departmental affiliates and temporary affiliates shall promptly provide a complete
application on a prescribed form when requested in writing by the department
chairman. The Practitioner shall sign a statement on the approved form that he
agrees to continue to be bound by the terms of the Bylaws, Policies, and other
rules, policies and procedures of MHS, the Medical Staff and the System Hospitals.
The Practitioner has the responsibility to produce a complete application. The
MHS Medical Staff Policies
Page - 21
application form shall be presented to the medical staff services department,
which acts on behalf of the corporate credentials committee and the Corporate
Medical Board. The application will be considered complete when all questions in
the application form have been answered, all requested information and
supporting documentation has been received, and sufficient information to
evaluate the applicant's qualifications has been furnished in the judgment of the
Medical Staff and the Corporation. No extension in the time periods provided, and
no extension of appointment will be granted to a Practitioner to complete and
submit the application form. If the application is not submitted by 115 days prior
to the expiration of the current appointment, the appointment and all privileges
shall terminate and the Practitioner shall be deemed to have voluntarily allowed
the appointment to terminate. This action shall be reported to the corporate
credentials committee, the Corporate Medical Board, and the Board of Directors.
The Practitioner shall have no right to a hearing or other review of such voluntary
termination of appointment. However, upon payment of a $500 penalty fee plus
the standard application fee, the Practitioner may re-apply for medical staff
appointment to provisional status. At the written request of the Practitioner, the
$500 penalty fee may be waived by the Chairman of the Corporate Medical Board
upon the advice of the chairman of the department in question, and a showing
that a medical exigency prevented the Practitioner from completing the application
in a timely manner.
(2)
At least 60 days prior to the expiration of current appointment of each Practitioner,
the chairman of the respective department shall submit in writing to the corporate
credentials committee his recommendations for the reappointment and granting of
privileges for the ensuing period, and for any advancement in staff category. The
department chairman may seek the recommendation of the department
credentials committee or the department’s executive committee sitting as its
credentials committee. If sub-specialty privileges are requested, the chairman of
the department may seek the recommendation of the appropriate sub-specialty
chief. The department chairman may submit a request for an extension of the
Practitioner’s appointment for no greater than sixty (60) days to complete and
submit his recommendation. This request shall be in writing, provide good cause
for the extension, and be submitted to the Chairman of the Corporate Medical
Board. Only those requests that are endorsed by the Chairman, acting on behalf of
the Corporate Medical Board, will be transmitted to the Chief Executive Officer for
approval, and the Board of Directors for ratification. An adverse ruling of a request
for extension shall not be subject to review, appeal, or fair hearing.
(3)
The recommendation(s) regarding reappointment and clinical privileges may
include terms of supervision, monitoring, probation, admonitions, and/or other
limitations as deemed necessary and appropriate by the department chairman.
Where a non-reappointment or a change in appointment or clinical privileges is
recommended, the reasons for such shall be stated and documented.
(4)
The corporate credentials committee shall promptly review all pertinent
information available on the Practitioner for the purpose of determining his
eligibility for reappointment to the Medical Staff, for the granting of clinical
privileges for the ensuing period, and for any change in staff category.
(5)
The corporate credentials committee shall promptly transmit its recommendation
in writing to the Corporate Medical Board and the Executive Committee of each
System Hospital's Medical Staff. Where a non-reappointment, limitation in
appointment or a change in clinical privileges is recommended, the reason for such
recommendation shall be stated and documented.
MHS Medical Staff Policies
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5.4.4
Corporate Medical Board Responsibilities
The Corporate Medical Board, at its next regular meeting after receipt of the application
and the report and recommendations of the corporate credentials committee and the
Executive Committee(s), shall determine whether to recommend that the Practitioner be
reappointed to the Medical Staff or make the determination that the application be
deferred for further consideration or rejected for Medical Staff appointment.
5.4.5
Favorable Recommendation by the Corporate Medical Board
(1)
When the recommendation of the Corporate Medical Board is favorable to the
applicant, the chief executive officer shall promptly forward it, together with all
supporting documentation, to the Board of Directors.
(2)
The Board of Directors or its duly authorized committee, at its next regular
meeting after receipt of the Corporate Medical Board's recommendation, will act
on the application and may reappoint the applicant to the staff, with a delineation
of the clinical privileges which the Practitioner may exercise.
(3)
In the event the Board of Directors' decision is contrary to the recommendation of
the Corporate Medical Board, the Board of Directors shall submit the matter to a
joint conference committee for review and recommendation before taking final
action. If the Practitioner has not been extended the opportunity to have a hearing
pursuant to Article 8 of the Bylaws, the joint conference committee shall defer
making its recommendation until either the Practitioner waives such opportunity or
the committee receives and considers the recommendation of the hearing panel
report after such hearing.
5.4.6
Deferral of Application
If the Corporate Medical Board defers the application for further consideration, it must act
upon the application within two (2) consecutively scheduled meetings with a subsequent
recommendation to either appoint with specified clinical privileges or reject the applicant
for staff appointment.
5.4.7
Adverse Recommendation by Corporate Medical Board
(1)
When the recommendation of the Corporate Medical Board is adverse to the
Practitioner, either in respect to the denial of or limitation to appointment or
clinical privileges requested, the Chief Executive Officer shall notify the Practitioner
(by certified mail, return receipt requested) within ten (10) days after such
decision is made. Not until the Practitioner has been deemed to have waived his
right to a hearing as provided in Article 8 of the Bylaws or has exercised the right
and the Corporate Medical Board has reviewed and considered the report of the
hearing panel or fair hearing committee and reaffirmed the adverse
recommendation, will that recommendation be forwarded to the Board of
Directors.
(2)
After the Corporate Medical Board has considered the report and recommendation
of the hearing panel or fair hearing committee and the hearing record, the
Corporate Medical Board's reconsidered recommendation shall be forwarded with
all pertinent documentation to the Board of Directors.
(3)
The Board of Directors or its duly authorized committee, at its next regular
meeting after receipt of the Corporate Medical Board's recommendation, will act
on the application. The Board of Directors' decisions shall be conclusive, except
that the Board of Directors may refer the matter back to the Corporate Medical
Board for further reconsideration and in so doing shall state the reasons for such
action and shall set a time limit within which a subsequent reconsidered
recommendation to the Board of Directors shall be made. At its next regular
MHS Medical Staff Policies
Page - 23
meeting after receipt of any subsequent reconsidered recommendation and
pertinent information pertaining to the matter, the Board of Directors shall either
reappoint the applicant to the Medical Staff, with a delineation of the clinical
privileges which the Practitioner may exercise, or reject him for Medical Staff
appointment.
(4)
In the event the Board of Directors' decision is contrary to the recommendation of
the Corporate Medical Board, the Board of Directors shall submit the matter to a
joint conference committee for review and recommendation before taking final
action. If the Practitioner has not been extended the opportunity to have a hearing
pursuant to Article 8 of the Bylaws, the joint conference committee shall defer
making its recommendation until either the Practitioner waives such opportunity or
the committee receives and considers the recommendation of the hearing panel
report after such hearing.
5.4.8
Final Action by Board of Directors
When the Board of Directors has taken final action on any application for reappointment to
the Medical Staff, it shall send notice of such decision through the Chief Executive Officer
to the Practitioner and the Corporate Medical Board. If such decision is adverse, the notice
to the Practitioner shall be by certified mail, return receipt requested.
5.4.9
Eligibility for Reappointment After Adverse Recommendation
(1)
A Practitioner may withdraw his application for reappointment or for the privileges
in question as the case may be, by written request any time prior to the meeting
of the hearing panel or fair hearing committee, but in so doing shall not be eligible
to reapply with respect to the subject matter of the adverse recommendation for a
period of (i) in the case of a denial of reappointment to the Medical Staff, one (1)
year, or (ii) in the case of denial of certain requested privileges, six (6) months
except that a Practitioner who withdraws his application for reappointment
following an adverse recommendation related to non-compliance with Medical
Staff, department, and committee meeting attendance requirements may reapply
for appointment to the Medical Staff upon the payment of a $500 penalty fee plus
the standard application fee. Such period shall commence on the date such
application is withdrawn.
(2)
Upon final action of the Board of Directors which is adverse to the Practitioner, the
Practitioner shall not be eligible to reapply with respect to the subject matter of
the adverse action for a period of one (1) year from the date of the action taken
by the Board of Directors.
(3)
Any reapplication submitted after withdrawal pursuant to Article 5.4.10(1) of these
Policies or after final action of the Board of Directors shall be accompanied with
Clear and Convincing Evidence demonstrating that the basis for such previous
adverse recommendation no longer exists.
5.4.10 Reappointment Criteria
The review for reappointment by the corporate credentials committee shall be based on
information concerning the following received from the Practitioner, quality assurance
activities, and Medical Staff peer review, which shall include, but not be limited to:
(i)
medical record clinical pertinence, blood usage review, surgical case review,
pharmacy and therapeutic review and drug usage evaluation;
(ii)
current professional competency and clinical judgment demonstrated in the
treatment of patients effectively and efficiently;
(iii)
ethics and conduct;
(iv)
mental and physical status;
MHS Medical Staff Policies
Page - 24
(v)
(vi)
(vii)
(viii)
(ix)
(x)
(xi)
(xii)
(xiii)
(xiv)
(XV)
compliance with the Bylaws, Policies, Corporate bylaws and other polices, rules
and regulations of the Medical Staff, MHS and the System Hospitals;
attendance at Medical Staff meetings, departmental and committee meetings and
participation in staff affairs;
compliance with requirements for professional liability coverage;
relations with other staff members;
cooperation with System Hospital authorities and personnel;
utilization of the System Hospital facilities for his patients;
general attitude toward his patients and practice, the System Hospital, and the
public;
participation in continuing medical education activities as required by respective
clinical departments;
status of licensure or other registration;
requirements assigned by the department, corporate credentials committee, or
Corporate Medical Board; and
any other qualifications required by the Bylaws and the Policies
5.4.11 Conditional Reappointment
Practitioners in the active staff category, who have not complied with reappointment criteria
(such as meeting attendance, CME, etc.), may be granted conditional reappointment to the
Medical Staff for a one year period. The Practitioner’s compliance with the reappointment
criteria will be monitored during his or her conditional reappointment period.
Because the end of the one year conditional reappointment period is too late to learn that
the Practitioner has not complied, the corporate credentialing committee shall adopt the
following procedure for one year conditional reappointments:
5.5
1.
The Practitioner shall receive a certified letter from the departmental executive
committee and/or corporate credentials committee notifying the individual of the
need for improvement. The letter shall clearly state that cooperation and efforts to
comply fully must be evident throughout the year and that progress will be
evaluated periodically during the year (no less than semi-annually). The letter shall
also state that termination may occur at any time during the year if progress is not
sufficient.
2.
Semi-annual reports of progress or failure to progress shall be submitted to the
corporate credentials committee by the departmental executive committees or the
chair of the clinical department.
3.
A copy of the semi-annual report shall also be forwarded to the Practitioner
specifically addressing the status of compliance or non-compliance.
Leave of Absence
5.5.1
General Leave of Absence
Any member of the Medical Staff may request, in writing to the department chair, a leave
of absence for a period of time not to exceed his current term of appointment. If his
absence exceeds his allotted leave, he shall apply, through the appropriate department
chairman, for reappointment to the Medical Staff, to be considered in a manner similar to
the reappointment procedure as specified in Article 5.4 of these Policies. Upon applying for
reappointment to the Medical Staff after the period of absence has exceeded the allotted
leave, the Practitioner shall be required to submit a written report and other pertinent
documentation regarding his professional and other activities during his absence including,
but not limited to, and as applicable, documentation evidencing that the cause of the
absence will not affect the Practitioner’s ability to meet all requirements for appointment
and the exercise of the Practitioner’s clinical privileges.
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5.6
5.5.2
Leave of Absence for Military Service
Any Practitioner who goes on active duty in the armed forces of the United States shall
retain his appointment and privileges on the Medical Staff while so serving and shall not be
required to attend meetings or be liable for any assessments. Upon release from active
duty, the member shall submit to the Corporate Medical Board, through the Chief
Executive Officer, evidence of an honorable discharge and a summary of his medical duties
while in the armed forces, to include specifically a report of any limitation of clinical
privileges imposed by military credentials authorities.
5.5.3
Inactive Status for Illness
A Practitioner who has a prolonged illness may be placed on inactive status. When his
condition improves and he desires to resume active practice, he shall apply for
reinstatement. This action shall be recommended to the corporate credentials committee
by the respective department chairman. The Practitioner submitting the request shall have
the burden of providing documentation establishing that the illness necessitating the leave
no longer affects the Practitioner’s clinical competence or his ability to meet the
qualifications for appointment to the Medical Staff set forth in the Bylaws and the Policies.
Modification of Appointment
A Practitioner desiring to transfer from one department to another or to change staff category or
to change designation of his primary System Hospital, shall submit a written request to the
corporate credentials committee. This request shall be processed in a manner following that
procedure provided in Article 5.4 of the Policies.
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ARTICLE 6 - CLINICAL PRIVILEGES
6.1
Request for Privileges by Initial Applicants and Provisional Appointees
The request for clinical privileges desired by an initial applicant shall be specified with the initial
application for staff appointment. The determination of clinical privileges to be granted to an
applicant approved for appointment shall be based upon the applicant’s education, training,
experience, current competence, licensure, health status, references, and other relevant
information, including an appraisal by the clinical specialty chief in which such privileges are
sought. The initial applicant shall have the burden of establishing his qualifications and competency
in the clinical privileges he requests and subsequently demonstrate his proficiency and judgment as
defined by the departmental proctoring program.
6.2
Re-determination of Privileges
The re-determination of clinical privileges and the maintenance, increase, or curtailment of same
shall be based upon the direct observation of care provided, subsequent training and experience
from the time the privileges were granted, current competence, licensure, health status, review of
the records of patients treated in a System Hospital or other hospitals, and review of the records of
the Medical Staff quality assurance activities which document the evaluation of the Practitioner's
participation in the delivery of medical care.
In the event that there is a lack of information concerning the Practitioner’s provision of medical
care in a System Hospital because the Practitioner’s practice is primarily office-based, the
Practitioner may be granted privileges based upon other information confirming professional
competency, but subject to the requirements for supervision and/or monitoring developed by the
applicable clinical department.
6.3
Requests for New or Additional Privileges
6.3.1
Purpose
The purpose of this policy is to describe the mechanisms used by the Medical Staff to
assure that appropriate, comprehensive criteria are developed and implemented which will
help assure that privileges will be granted to those practitioners who can demonstrate
current clinical competence for new procedures not currently listed on the delineation of
privilege form.
Criteria for clinical privileges are the mechanism used by the Medical Staff to define, in
advance of requests for clinical privileges, how to measure current clinical
competency in order to make recommendations to the Board of Directors.
The process set out in this policy will apply to all medical staff members and will be
administered in a manner to assist the Medical Staff in its attempt to establish, as feasible,
one standard of care across Methodist Health System.
6.3.2
Policy
(1) In accordance with Section 4.4 and Article 6 of the Medical Staff Bylaws, it is the policy
of the Medical Staff that no Practitioner shall perform any procedure that is not within
the scope of privileges granted to such Practitioner and shall only practice at a System
Hospital within the scope of privileges granted in accordance with the Bylaws and
Policies.
(2) It is the policy of the Medical Staff that to the extent a Practitioner is requesting New
Privileges (defined below), it is the Practitioner’s responsibility to request such
privileges in accordance with the requirements of the Bylaws and Policies.
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(3) It is the policy of the Medical Staff, that no request for New Privileges will be approved
unless the following are met: (a) the approval is based upon the review conducted by
and the recommendations of the Medical Staff; (b) to the extent the New Privileges
involve New Technology or a new service/procedure, MHS has determined that the
New Technology or new service/procedure will be offered at a System Hospital; (c)
that criteria for the specific New Privilege have been developed by the medical staff
and approved by the Corporate Medical Board; and (d) that the Practitioner applying
for such New Privileges meets such criteria. All requests for privileges that are not
listed on the approved delineation of privilege form are subject to this policy before
the applicant's request is processed or accepted.
(4) It is the policy of the Medical Staff and MHS that all criteria that are developed for any
New Privilege are reviewed by the Corporate Credentials Committee, the Medical
Executive Committee of each System Hospital, and the Corporate Medical Board and
that all privileging recommendations submitted to the Board of Directors by the
Corporate Medical Board are based upon, at a minimum, such criteria. If more than
one specialty is involved in the procedure, the Corporate Credentials Committee shall
seek consensus by the medical staff departments involved and to the extent a
consensus cannot be reached may appoint an ad hoc committee to review the request.
(5) It is the policy of the Medical Staff and MHS that no temporary privileges will be
granted in order to perform or exercise a New Privilege.
(6) The burden is on the applicant to provide all review bodies with information regarding
the new procedure to support his/her request.
(7) The potential applicant is provided with the specific criteria developed for the clinical
privilege he or she is requesting.
6.3.3
Definitions
6.3.3.1
General Procedure
6.3.3.2
New Privilege
6.3.3.3
New Technology
Those treatments/procedures routinely taught in an approved residency training
program.
Permission to perform a procedure or clinical task for which the Practitioner
has not been previously granted privileges including, but not limited to: (i)
those not listed on the Practitioner’s approved privilege form; (ii) those listed
on a Practitioner’s core privilege list but for which the Practitioner does not
have privileges to perform; (iii) those involving New Technology and (iv) those
meeting the definition of a Special Procedure.
New device or technology that has not previously been used or performed at a
System Hospital.
6.3.3.4
6.3.4
Special Procedure
Treatments or procedures that are considered new or are otherwise not
considered part of a routine training program.
Procedure
(1) If a Practitioner requests a New Privilege, the request is processed utilizing the form
attached to this policy. This form will be forwarded to the appropriate department
chairman to determine whether the New Privilege involves a procedure or clinical task
MHS Medical Staff Policies
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that is a General Procedure, a Special Procedure, or New Technology with the
following outcome:
a.
If it is determined that the procedure is New Technology the practitioner must
provide written confirmation that the New Technology was approved through the
MHS New Technology approval process. In addition to, and while obtaining
confirmation, the request will be handled as a Special Procedure.
b.
If it is determined that the New Privilege is a General Procedure and
experience is obtained through residency training, the Department Chair may
recommend the addition of the procedure to the privilege form without outlining
specific criteria.
The Practitioner would be required to furnish any necessary documentation that is
not already in the credentials file. The request for the New Privilege will be
presented to the Corporate Credentials Committee, Medical Executive Committee
of each System Hospital, and the Corporate Medical Board for their review and
recommendation. The recommendation of the Corporate Medical Board will then
be submitted to the Board of Directors for its review and decision. The Practitioner
will be notified whether the privilege has been granted, and the practitioner can
then exercise the privilege.
c.
If it is determined that the New Privilege is a Special Procedure, the following
must be defined by the Department Chair:
i.
ii.
iii.
iv.
v.
vi.
vii.
viii.
ix.
x.
xi.
The type of basic education required to perform the procedure (MD, DO,
DDS, DPM);
Postgraduate training required to perform the procedure (completion of an
accredited residency program or fellowship and letter from training
director attesting to training and competency);
Completion of a specific training course(s);
Work experience - documented evidence of successful completion of a
certain number of the procedures, attestation of competency from the
department chair where the procedure was performed, and documentation
of the number of procedures performed and types of complications;
Whether board certification is required;
Whether prerequisite privileges are required;
Minimum competency requirements for reappointment if applicable;
Whether proctoring is required (concurrent or retrospective with the
minimum number of cases proctored and by whom);
An outline of the Special Procedure including:

Indications for use of the procedure with expected results

Potential complications and anticipated complication rates

Other pertinent information reported in medical literature as
appropriate;
Consideration for monitoring for procedures with significant risks including
a requirement for evaluating the results through a focused review which
should be performed and reported to the Medical Staff Quality Council;
As appropriate, consider management of the patient pre and post
procedure.
(2) The proposed criteria should be sent to the Medical Staff Services Office for forwarding
to the Corporate Credentials Committee.
(3) The Corporate Credentials Committee will forward the proposed criteria to the Medical
Executive Committee and the Corporate Medical Board for approval.
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(4) Once criteria are approved, they are added to the privilege form maintained in the
Medical Staff Services Department.
(5) The Practitioner applying for the New Privilege will be notified of the criteria and must
provide information and documentation demonstrating his or her qualifications. Once
this information is obtained the request for the New Privilege will be forwarded to the
Department Chairman, Corporate Credentials Committee, Medical Executive Committee
and Corporate Medical Board for a decision on what recommendation to submit to the
Board of Directors for its consideration. From time to time, multi-specialty committees
may be established by the Corporate Medical Board or the Corporate Credentials
Committee to assist with issues crossing over two or more different medical
specialties. In the event a multi-specialty committee exists and the New Privilege being
requested is within the area of interest for that multi-specialty committee, either the
Corporate Medical Board or the Corporate Credentials Committee may require such
committee's review and input before making a recommendation on the request for the
New Privilege.
(6) The Practitioner applying for the New Privilege will be notified of the final
recommendation regarding his or her request for the New Privilege after the meeting
of the Board of Directors.
(7) If the Practitioner applying for the New Privilege does not supply the required
information or documentation, the request will be considered incomplete and will not
be processed.
(8) Privilege systems will be updated by the Medical Staff Services Department.
6.4
Privileges Granted to Dentists
Privileges granted to Dentists shall be based on their training, experience, and current competence
and judgment. The scope and extent of surgical procedures that each Dentist may perform shall be
specifically delineated and granted in the same manner as all other surgical privileges. Surgical
procedures performed by Dentists shall be under the overall supervision of the chairman of the
department of surgery. All dental patients shall receive the same basic medical appraisal as
patients admitted to other surgical services. A Physician member of the Medical Staff shall be
responsible for performing the admission history and physical examination and for the care of any
medical problem that may be present at the time of admission or that may arise during
hospitalization.
6.5
Privileges Granted to Podiatrists
Privileges granted to Podiatrists shall be based on their training, experience, and current
competence and judgment. The scope and extent of surgical procedures that each Podiatrist may
perform shall be specifically delineated and granted in the same manner as all other surgical
privileges. Surgical procedures performed by Podiatrists shall be under the overall supervision of
the chairman of the department of surgery. All podiatric patients shall receive the same basic
medical appraisal as patients admitted to other surgical services. A Physician member of the
Medical Staff shall be responsible for performing the admission history and physical examination
and for the care of any medical problem that may be present at the time of admission or that may
arise during hospitalization.
6.6
Temporary Privileges
6.6.1
Temporary Privileges for Initial Applicant
In accord with this Article, temporary privileges may be granted in the designated primary
System Hospital upon (i) the approval of the chairman of the appropriate department or
his designee, and (ii) for Methodist Dallas Medical Center and Methodist Charlton Medical
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Center, the approval of the Executive Vice President of Clinical Operations for MHS or his
designee or for any other System Hospital the primary administrative officer of that System
Hospital who is employed by MHS or his designee. If sub-specialty privileges are
requested, the chairman of the department may seek the recommendation of the
appropriate sub-specialty chief.
Temporary privileges may be granted for an initial applicant, who is appropriately licensed,
only if the application for appointment is complete and no issues have been discovered
during the verification process. A personal interview may be required with the chairman of
the respective department or his designee. Upon the chairman’s recommendation or in the
chairman’s absence the recommendation of the president of the System Hospital medical
staff, the Executive Vice President of Clinical Operations or the Executive Vice President of
Corporate Services at MHS may grant for Methodist Dallas Medical Center and/or Methodist
Charlton Medical Center temporary admitting and clinical privileges to the applicant for a
period not to exceed three (3) months (the same shall apply for any other System Hospital
except the authority for granting such temporary admitting and clinical privileges shall lie
with the primary administrative officer of that System Hospital who is employed by MHS or
such primary administrative officer’s designee). In exercising such privileges, the applicant
shall act under the supervision of the chairman of the department to which he is assigned
or his designee.
6.6.2
Locum Tenens Privileges
For Methodist Dallas Medical Center and/or Methodist Charlton Medical Center, either the
Executive Vice President of Clinical Operations or the Executive Vice President of Corporate
Services for MHS may permit an appropriately licensed Physician, Dentist or Podiatrist
serving as a temporary affiliate for a member of the Medical Staff to attend patients in
Methodist Dallas Medical Center and/or Methodist Charlton Medical Center, provided his
application and credentials first have been approved in writing by the department
chairman concerned (the same shall apply for any other System Hospital except the
authority for permitting such activity to occur at the System Hospital in question shall lie
with the primary administrative officer of that System Hospital who is employed by MHS or
such primary administrative officer’s designee). Unless an extension is granted, these
privileges shall be for a period not to exceed sixty (60) days.
6.6.3
Temporary Privileges for Specialized Teams
For Methodist Dallas Medical Center and/or Methodist Charlton Medical Center, temporary
privileges may be granted by either the Executive Vice President of Clinical Operations or
the Executive Vice President of Corporate Services for MHS to members of a specialized
team who work under the direction and responsibility of a member of the active staff (the
same shall apply for any other System Hospital except the authority for granting such
privileges shall lie with the primary administrative officer of that System Hospital who is
employed by MHS or such primary administrative officer’s designee). These privileges may
be requested by written application on the appropriate form.
6.6.4
Temporary Privileges for the Care of a Specific Patient
For Methodist Dallas Medical Center and/or Methodist Charlton Medical Center, temporary
privileges may be granted by either the Executive Vice President of Clinical Operations or
the Executive Vice President of Corporate Services for MHS based on the recommendation
of the respective department chairman for the care of a specific patient to an appropriately
licensed Physician, Dentist or Podiatrist who is not an applicant for membership (the same
shall apply for any other System Hospital except the authority for granting such privileges
shall lie with the primary administrative officer of that System Hospital who is employed by
MHS or such primary administrative officer’s designee).
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6.6.5
6.6.6
Special Requirements for Temporary Privileges
The department chairman shall have the authority to impose special requirements of
supervision and reporting on any applicant granted temporary privileges. Upon notice of
failure to comply with such special conditions, the following individuals shall have the
authority to immediately terminate temporary privileges:
(1)
For Methodist Dallas Medical Center and Methodist Charlton Medical Center, either
the Executive Vice President of Clinical Operations or the Executive Vice President
of Corporate Services for MHS; and
(2)
For any other System Hospital, the authority shall lie with the primary
administrative officer of that System Hospital who is employed by MHS or such
primary administrative officer’s designee.
Termination of Temporary Privileges
Upon the recommendation of the chairman of either the Executive Committee of a System
Hospital or the department, the following individuals may, at any time, terminate a
Physician’s, Dentist’s or Podiatrist’s temporary privileges effective as of the discharge from
the hospital of the patient(s) that are under his care in the hospital:
(1)
For Methodist Dallas Medical Center and Methodist Charlton Medical Center, either
the Executive Vice President of Clinical Operations or the Executive Vice President
of Corporate Services for MHS; and
(2)
For any other System Hospital, the authority shall lie with the primary
administrative officer of that System Hospital who is employed by MHS or such
primary administrative officer’s designee.
However, where it is determined that the life or health of any such patient would be
endangered by continued treatment by the Physician, Dentist or Podiatrist the termination
may be imposed by any person entitled to impose a summary suspension as stated in
Article 7.2 of the Bylaws. This summary suspension shall be immediately effective and the
appropriate department chairman or, in his absence, the chairman of the Executive
Committee, shall assign a member of the Medical Staff to assume responsibility for the
care of the suspended individual's patient(s) until discharged from the hospital. Where
feasible, the wishes of the patient(s) shall be considered in the selection of a substitute
Medical Staff Practitioner.
6.7
Emergency Privileges
In the case of an emergency (a condition in which serious permanent harm would result to the
patient or in which the life of a patient is in immediate danger and any delay in administering
treatment would add to that danger), any practitioner on the medical staff, to the degree
permitted by his license and regardless of service or staff status or lack of it, shall be permitted to
do all in his power to save the life of the patient, including the calling of such consultation as may
be available and the using of every facility of the hospital. When the emergency situation no longer
exists, the practitioner must request the privileges necessary to continue to treat the patient. In
the event such privileges are denied or he does not desire to request privileges, the patient shall
be assigned to a practitioner on the medical staff with appropriate privileges after consultation with
the chief of the appropriate service.
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ARTICLE 7 - CORRECTIVE ACTION
7.1
Corrective Action
Provisions dealing with corrective action are set forth in the Bylaws.
7.2
Summary Suspension
Provisions dealing with summary suspension are set forth in the Bylaws.
7.3
Automatic Suspension or Revocation
Provisions dealing with automatic suspension are set forth in the Bylaws.
7.4
Precautionary Administrative Suspension
Provisions dealing with automatic suspension are set forth in the Bylaws.
7.5
MHS Practitioner Conduct Policy
Pursuant to Article 7.5 of the Bylaws, this Article 7.5 of the Policies constitutes the process,
procedures and guidelines related to the MHS Practitioner Conduct Policy.
7.5.1
Policy
It is the intent of MHS that all individuals within its facilities will treat others with respect,
courtesy, and dignity and conduct themselves in a professional and cooperative manner.
This Medical Staff policy addresses conduct that does not meet the above standard. In
dealing with incidents that may represent inappropriate conduct, the protection of patients,
employees, Practitioners, and others in the hospital and the orderly operation of the
System Hospitals are paramount concerns.
Although this Policy and the interventional steps outlined herein apply to inappropriate
behavior exhibited by a Practitioner toward another Practitioner, MHS employee, patient,
or visitor, the initial step encouraged is for the individuals affected by the disruptive
behavior to attempt to resolve the issue(s) through direct communication and interaction.
The interventions outlined in this Policy should be used in the event such direct
communication and interaction is not appropriate, not practicable, will not alleviate the
issue(s), or individuals involved do not feel comfortable with such direct intervention.
Employees of MHS who engage in inappropriate conduct will be managed by MHS
administration in accordance with policies established by MHS’s Human Resources
Department. Practitioners who engage in disruptive conduct will be managed in
accordance with the policies and procedures set forth herein as well as the processes and
procedures set forth in the Bylaws.
Conduct that suggests Practitioner impairment shall be addressed pursuant to the MHS
Practitioner Health Policy (see Article 12.5.3.2 of the Policies) under the auspices of the
Medical Staff Health Sub-committee. Conduct resulting from possible impairment may also
be separately addressed under this policy as appropriate.
7.5.2
Definitions
Council of Presidents or Council: There shall be a Council of Presidents at each System
Hospital. The Council of Presidents shall be composed of the president of the medical staff,
the immediate past president, and the president-elect of the medical staff. In the event a
member of the Council of Presidents is the subject of a claim of misconduct, the other
members of the Council may appoint any past president of the medical staff to the Council.
At new System Hospitals, the Council of Presidents shall be the medical staff executive
committee at such new System Hospital until such time that the three medical staff officer
positions referenced in this Section 7.5.2 are filled at such new System Hospital.
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Disruptive Practitioner: A Practitioner whose conduct: (i) disrupts the operation of the
hospital, (ii) affects the ability of others to get their jobs done, (iii) creates a “hostile work
environment” for hospital employees or other Practitioners on the medical staff, (iv) begins
to interfere with the Practitioner’s own ability to practice competently, or (v) adversely
affects the care of his/her or others’ patients.
Disruptive conduct includes but is not limited to:
 Threatening or abusive language, action, gesture (e.g. belittling, berating, or
threatening another individual);
 Degrading or demeaning comments regarding a person or the hospital
 Profanity or similarly offensive language;
 Physical contact with another individual that is unwelcome, threatening or intimidating;
 Non-legitimate derogatory comments about the quality of care being provided;
 Intentionally false complaints about other Practitioners;
 Refusal to respond to and address the disruptive conduct of individuals employed or
sponsored by the Practitioner; or
 Medical record entries that could be considered inappropriate by a disinterested body
of medical staff members.
 Harassment (including conduct that constitutes discrimination or sexual harassment
pursuant to the relevant MHS policy).
Neither the term “Disruptive” nor this policy as a whole should be interpreted as intending
to stifle legitimate complaints that are made through appropriate procedures in a
professional manner.
Harassment: MHS expects all employees and others affiliated with MHS (e.g. contractors,
medical staff members) to accomplish their work in a respectful, business-like manner, and
with concern for the privacy and well being of their co-workers. Harassment of employees
by co-workers is not permitted; this includes harassment of a sexual, racial, ethnic, age,
disability, or religious nature. Such harassment includes physical contact, gestures or
jokes, unsolicited remarks, or display or circulation of written materials or pictures, any of
which are likely to offend any gender, racial, ethnic, age, disability or religious group.
Sexual harassment includes unwelcome sexual advances, requests for sexual favors, and
unwelcome verbal or physical contact of a sexual nature. An incident will be regarded as a
violation of policy when:
 submission to such conduct is made a condition of the working relationship;
 submission to or rejection of such conduct is used as a factor in employment-related
decisions such as promotion, performance evaluations, pay adjustments, discipline,
work assignment, or any other condition of the working relationship or career
development;
 such conduct has the purpose or effect of unreasonably interfering with an individual’s
work performance, or
 such conduct creates an intimidating, hostile or offensive working environment
Depending on the specific circumstances, persons accused of sexual harassment may also
be subject to civil lawsuits and criminal prosecution.
Practitioner: Practitioner is a member of the MHS Medical Staff or a physician, dentist, or
podiatrist privileged to provide health care services at a System Hospital.
7.5.3
Procedure for Reporting and Handling Apparent Violations
7.5.3.1
Reporting the Incident
Employees of the hospital who observe, or are subjected to conduct of a
Disruptive Practitioner shall immediately notify their supervisor, Human
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Resources, Medical Staff Office, or their respective Vice President about the
incident. Any Practitioner who observes such behavior shall notify the
President of the Medical Staff or another Medical Staff Officer directly. Upon
learning of the incident the supervisor/hospital administrator/Medical Staff
President/Medical Staff Officer shall:
(1) Attempt to resolve the issue between the parties by either face to face
communication or with the help of a supervisor or officer of the medical
staff. (If resolved at this level, a record of the incident will be placed in the
practitioner’s file for monitoring purposes but will not invoke the collegial
review process, summary report, etc.;
(2) If unable to resolve through communication, request that the individual
reporting the incident document it in writing by completing the Medical
Staff Incident Report (hereinafter “Incident Report” – form attached as
Appendix 1). The importance of confidentiality will be emphasized to the
complainant at this time. Document must be signed by complainant.
7.5.3.2
Documentation of the Incident
7.5.3.3
Investigation of the Incident
The Incident Report documenting an incident of apparent inappropriate
behavior shall include at a minimum the following:
(1) the date and time of the incident and the date of the Incident Report;
(2) factual description of incident;
(3) the name of any patient or patient’s family member who was involved in
the incident, including any patient or family member who witnessed the
incident;
(4) the circumstances which precipitated the incident;
(5) the names of other witnesses to the incident as well as the names of
anyone else the complainant told about the incident;
(6) consequences, if any, of the incident as it relates to patient care,
personnel, or hospital operations;
(7) action taken at the time of the incident to intervene in, or remedy, the
incident; and
(8) name and signature of the complainant.
The Incident Report will be hand delivered to the Medical Staff Office, which
shall notify the President of the System Hospital medical staff or his designee
who in turn will notify the department chair and the Executive Vice Presidents.
The president will review the Incident Report and select an appropriate
investigator. For most cases the investigator will be another Medical Staff
officer, usually a section chief or department chair who will also conduct the
collegial review. For more serious cases or those to be reviewed by the Council
of Presidents at a System Hospital, the president may investigate the case
personally. To the extent the complaint is initiated by a Methodist employee,
Human Resources will also be informed of the complaint and will receive a
copy of the incident report.
The person conducting the investigation will discuss the complaint with the
individual that initiated the complaint. As appropriate, the investigator will
interview other relevant persons that may have pertinent information. To the
extent that the person filing the complaint is an employee of Methodist, the
person investigating the complaint must contact Human Resources and involve
the designated representative in any interviews with employees that result
from the investigation.
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7.5.3.4
Review with the Practitioner
After receipt of the Incident Report and as part of the investigation, a meeting
is scheduled with the Practitioner to review the incident. This meeting may be
conducted at one of four levels of review, which are summarized below and
more fully detailed in subsequent paragraphs. The investigation at one level
may uncover circumstances that require a higher level of review. The identity
of the complainant is disclosed in the Incident Report and only in extraordinary
circumstances may the identity be withheld.
(1) Collegial Intervention: This is the lowest level of review and is
conducted informally. It is reserved for either the first complaint against a
Practitioner or for dealing with issues that are felt to be minor but cannot
be ignored. Designed to educate and where necessary provide nonthreatening correction, it is usually conducted by a colleague such as a
section chief or chairman, and in some cases by the president of the
System Hospital medical staff.
(2) Council of Presidents: A review at this level may be the result of a single
serious complaint or follow multiple complaints that suggest the possibility
of a pattern of inappropriate conduct. This level of review is designed to
educate and provide more substantial collegial correction than that given by
section chiefs or department chairmen. This body may also recommend to
the Corporate Medical Board disciplinary measures be taken.
(3) System Hospital Executive Committee: Reviews that rise to this level
are generally either very serious in nature, repetitive with little evidence of
control at lower levels, or repetitive with escalating gravity. This body may
invoke various interventions and disciplinary options, refer the matter to
the Corporate Medical Board, and may recommend corrective action in
accordance with the Bylaws.
(4) Corporate Medical Board: Reviews that achieve this highest level of
interest do so either because of the seriousness of the complaint and lack
of response to other measures or because the nature of the issues to be
dealt with can be handled more effectively in this venue. The Corporate
Medical Board has all interventions and disciplinary options available to it
and may initiate corrective action in accordance with the Bylaws.
7.5.3.5
Conduct of a Level I Review
The Medical Staff officer shall schedule a meeting with the Practitioner. This
meeting is usually one-on-one and shall be informal and collegial. The
Practitioner is advised of the nature of the incident as detailed in the Incident
Report and is given ample opportunity to provide his/her response. The
Practitioner will be advised that any retaliation against person who initiated
the Incident Report would be grounds for immediate and serious disciplinary
action including summary suspension. After hearing the Practitioner’s
explanation, the Medical Staff officer must decide if the behavior was
appropriate or inappropriate. If the behavior was inappropriate, then the
standards of behavior expected at this Hospital will be reviewed with the
Practitioner. The meeting can also be used to educate the Practitioner about
administrative channels for registering complaints or concerns about quality of
services, to identify other sources of support or counseling for the Practitioner,
and to advise the Practitioner about the consequences of any future violation
of this policy. The Medical Staff officer may also determine that the behavior
was not inappropriate. After the meeting the Medical Staff officer documents
the substance of the meeting by preparing a Review Summary (form attached
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as Appendix 2 to these Policies). The Practitioner has the right to read the
Review Summary and may prepare a written rebuttal. The Incident Report,
review summary, and rebuttal are reviewed by the System Hospital president
for approval and then retained in the confidential Practitioner’s quality file.
7.5.3.6
Conduct of a Level II Review
7.5.3.7
Conduct of a Level III Review
7.5.3.8
Conduct of a Level IV Review
The Council of Presidents (hereinafter referred to as Council) will schedule a
meeting with the Practitioner. In some cases either or both of the Executive
Vice Presidents and the Practitioner’s section chief or department chair may
also attend. During this meeting the Practitioner will be informed of the nature
of the incident as detailed in the Incident Report and shall be allowed to
respond. If the Council determines that the Practitioner’s conduct was
inappropriate, it will review the standards of behavior expected at this
hospital. The Council may also recommend additional disciplinary actions (See
Article 7.5.3.12) that must be reviewed and approved by the Executive
Committee of the System Hospital, or it may refer the entire case to the
Corporate Medical Board for Level IV Review (see below). If the Council
determines that the Practitioner’s conduct was not inappropriate, the
Practitioner may be exonerated (see Paragraph 13). At the conclusion of the
meeting, the Council documents the substance of the meeting by preparing a
review summary. The Practitioner has the right to read the review summary
and may prepare a written Rebuttal. The Incident Report, review summary,
and rebuttal are retained in the confidential Practitioner’s quality file.
After investigating an incident the Council may choose to refer single events of
egregious behavior or those which suggest a pattern of repeated or escalating
severity of episodes to the System Hospital Executive Committee for
investigation and action. The Council will meet with the Practitioner and
prepare a review summary describing the current episode of inappropriate
conduct, any previous episodes of misconduct, and disciplinary action(s) that
have been taken in the past. The president of the System Hospital medical
staff will present this summary to the System Hospital Executive Committee at
the next regularly scheduled meeting, or if urgent, at an emergency meeting
at which a quorum is in attendance. The System Hospital Executive Committee
will review the Review Summary, modify it as necessary, and may or may not
schedule an interview with the Practitioner. If interviewed, the Practitioner will
be given a copy of the Review Summary during the interview. If the
Practitioner is not interviewed by the Executive Committee, the Practitioner will
be given a copy of the Review Summary after it has been reviewed by the
Executive Committee. The Practitioner has the right to read the Review
Summary and may prepare a written rebuttal. If the System Hospital Executive
Committee determines that this policy has been violated it may initiate a
collegial intervention by a member or members of the Board of Directors,
impose disciplinary measures as outlined in this Policy, or recommend
corrective action in accordance with the Medical Staff Bylaws.
Practitioners reach this level of review when the incident is referred to the
Corporate Medical Board by a System Hospital Executive Committee or the
Council of Presidents. The President will present a review summary of the
issues and previous actions to the Corporate Medical Board. The Corporate
Medical Board has the ability, at its option, to meet with the Practitioner, to
conduct investigations, request hearings, impose sanctions, and initiate
corrective action. Although not required, in some cases it may be appropriate
for the Practitioner to meet with a member(s) of the Board of Directors
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because a layperson may have a better chance to gain the attention and
acceptance of the Practitioner.
7.5.3.9
Letters of Admonishment and Conditional Conduct Letters
7.5.3.10
Practitioner Advocate
7.5.3.11
Documentation of the Meeting with the Practitioner
7.5.3.12
Outline of Formal Disciplinary Measures
At the conclusion of a review at any level, a Practitioner may be sent, at the
discretion of the person or body conducting the review, a letter of
admonishment. In addition, a conditional conduct letter may be issued in
connection with a review that reaches the Executive Committee or Corporate
Medical Board level.
At any time during any of the review levels, Practitioner may be accompanied
by a single member of the medical staff. Officers of the Medical Staff
(President, President-Elect and Immediate Past President) and the Chair of the
complainant’s Department or Section Chief may not serve as a practitioner
advocate.
After meeting with a Practitioner a review summary of the meeting and
conclusions will be prepared by the reviewing body and the Practitioner is
invited to review this document in the Medical Staff office where it is kept in
the Practitioner’s quality file. The Practitioner then has the right to prepare a
written rebuttal. The review summary prepared by the medical staff and any
rebuttal shall be retained in the confidential Practitioner’s quality file. The
Medical Staff credentials committee will review this confidential file at the time
the Practitioner reapplies for privileges at the hospital.
A variety of measures may be used to discipline a Practitioner.
(1) Council of Presidents:
 letter of admonishment;
 refer to the Executive Committee or the Corporate Medical Board
(2) Executive Committee:
 letter of admonishment;,
 recommend suspension of clinical privileges for a period of 14 days or
less and refer the matter to the Corporate Medical Board (pursuant to
the Medical Staff Bylaws, only the chairman of a System Hospital
Executive Committee, the chairman of the respective clinical
department, or either Executive Vice President shall have the authority
to suspend the clinical privileges of a Practitioner)
(3) Corporate Medical Board:
 any measures listed above;
 require letter of apology to the appropriate individual;
 require completion of a course of professional counseling focused on
behavior modification;
 issue Conditional Conduct Letter (Example per Appendix 3 attached to
these policies);
 initiate formal investigation (departmental ad hoc investigation
committee, to be conducted pursuant to the Bylaws)
 refer to the Board of Directors
 additional measures unique to the board.
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7.5.3.13
Exoneration of Practitioner
7.5.3.14
Exclusion of Practitioner from the Hospital Facilities
7.5.3.15
Responsibility for Sponsored and/or Employed Individuals
If review of a Practitioner’s questionable behavior at any level results in a
conclusion that there is no basis for the complaint, the Practitioner may be
exonerated and the exoneration is documented in the review summary.
Although this document is maintained in the Practitioner’s confidential file, it is
NOT counted against the Practitioner should there be any additional
complaints of inappropriate behavior. Furthermore, if it appears to the
reviewing body that the complainant may not have acted in good faith in
reporting inappropriate behavior, then the reviewing body may recommend
investigation of the complainant. If the complainant is a hospital employee, a
copy of the review summary is submitted to the Chief Executive Officer with a
recommendation to initiate an evaluation of the employees’ actions. If the
complainant is a Practitioner, the Council or Executive Committee may initiate
a review of the complaining Practitioner’s actions as per the procedures
established in this document.
In rare situations it may be appropriate to exclude the Practitioner from the
System Hospital’s facilities pending the formal investigation process pursuant
to the Bylaws and any related hearing and appeal that may result. Such
exclusion is not a suspension of clinical privileges, even though the effect is
the same. Rather, the action is taken to protect patients, employees,
physicians, and others on the System Hospital’s premises from inappropriate
conduct. In addition, it is to emphasize to the Practitioner the serious nature of
the problem created by such conduct. Before such exclusion, the Practitioner
shall be notified of the event or events precipitating the exclusion that shall
only be imposed by the Chief Executive Officer or his designee with
advice/input from the President of the System Hospital medical staff.
Individuals sponsored or employed by Practitioners (including Practitioner’s
office staff and allied health professionals sponsored and/or employed by a
Practitioner) often times have occasion to interact with patients, hospital
personnel and other Practitioners in a System Hospital. Because of these
interactions, Practitioners shall be required to take appropriate action to
ensure that those individuals who are sponsored or employed by the
Practitioner conduct themselves in the same manner that is required of
Practitioners under this policy. A Practitioner’s failure or refusal to take
appropriate action shall be considered disruptive conduct itself and subject to
the procedures outlined in this policy. All Practitioners who are members of a
group shall each be responsible for the individuals employed and/or sponsored
by the group.
7.5.3.16
Presence of Counsel at Reviews
In order to effectuate the objectives of this policy, and except as otherwise
may be determined by the Chief Executive Officer and the President, counsel
shall not attend any of the meetings described above. This does not deny
the right to have counsel available for formal hearings as provided for in the
Bylaws as a part of due process.
7.5.3.17
Confidentiality and Protection from Discovery
All of the activities conducted within this procedure will be treated as
confidential in an effort to obtain the greatest protection from discovery
allowed by law. So long as Medical Staff officers involved in reviews follow the
policies and procedures set forth herein and in the Bylaws and act responsibly
and in Good Faith, they should be protected by federal law and indemnified by
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the System Hospital. All documents related to these proceedings should be
prepared by the Medical Staff office, marked “Confidential-Peer Review
Document” and maintained in confidential files in that office.
7.5.3.18
Order of Review
7.5.3.19
Retention of Records
7.5.3.20
The Corporate Credentials Committee Responsibility
7.5.3.21
Time of the Essence
While the order in which a Practitioner’s conduct is reviewed is generally as
outlined above, each case is unique and should be handled as such. In some
situations the serious nature of the incident may require that review should be
conducted from the first at one of the higher levels. Nothing in this outline of
procedures prevents skipping one or more levels of review should the
circumstances warrant.
Records of investigations and violations of this policy are maintained in the
Practitioner’s confidential quality file and are examined by those authorized in
these procedures during the course of an investigation/review, and by the
corporate credentials committee during the normal course of evaluation for
reapplication for privileges. After an adverse Level I review, if no further
episodes of inappropriate behavior are documented during the reappointment
period and the reappointment is successful, this portion of the quality file is
made inactive. Once inactivated, this portion of the file is not examined again
unless new episodes of violations of this policy are reported. If an adverse
finding is made at a Level II or higher review, then this information remains in
the quality file for two successive reappointment periods that have been
concluded without further incidents. At that time the portion of the quality file
dealing with conduct is inactivated and is not examined again unless there is a
new investigation into a violation of this policy.
The corporate credentials committee reviews the Practitioner’s confidential
quality file at the time of reappointment. If during this review the committee
detects a pattern of behavior that it believes may be inappropriate, the
committee may request a personal interview with the Practitioner or request a
review of the Practitioner’s behavior by the Executive Committee prior to
acting on the reapplication. The corporate credentials committee does not
recommend disciplinary action.
In evaluating violations of this policy, the Medical Staff members involved will
be mindful that the processes set forth in this MHS Practitioner Conduct Policy
should be conducted in a timely manner. In that regard, a good faith effort will
be made to handle each episode expeditiously.
ARTICLE 8 - FAIR HEARING PROCEDURE
Provisions dealing with the fair hearing procedure are set forth in the Bylaws.
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ARTICLE 9 - MEDICAL STAFF CATEGORIES
9.1
Types of Categories
The list of medical staff categories is set forth in the Bylaws.
9.2
Active Membership
9.2.1 Category Description; Qualifications; Rights; & Responsibilities Active Status I
Practitioners who regularly admit patients to or regularly manage the care of patients in a
System Hospital (minimum of five (5) patient contacts per year or 10 patient contacts in
two years) and who meet all qualifications for and assume all of the functions and
responsibilities of membership on the Medical Staff, including but not limited to committee
assignments, emergency call rotation as required by the clinical department, attendance at
departmental and Medical Staff meetings, and consultation assignments, shall be
appointed to the active membership as a Status I Active Member.
Status I Active Members have the right to vote, to hold Medical Staff office, and to serve
on department or Medical Staff standing committees. A Practitioner who is currently a
Status I Active Member who fails to admit or manage the care of a sufficient number of
patients to continue as a Status I Active Member may be granted a one time (one year)
provisional appointment period by the Board of Directors within which to meet the patient
admittance or management requirement.
9.2.2
Active Status II (Without Privileges)
Practitioners who do not meet the criteria for Status I Active Membership but who are
associated with the hospital in the community or who demonstrate by way of other
substantial involvement in the activities of the Medical Staff of a System Hospital a genuine
concern and interest in a System Hospital are considered eligible for appointment as a
Status II Active Member of the Medical Staff.
Practitioners choosing this category will have no clinical privileges but may visit and review
the medical record of their patients in the hospital. Status II Active Members may also may
make rounds on their patients who are admitted to a System Hospital but may not give
orders either written or verbal, may not comment upon or direct the care of any patient in
a System Hospital in any manner and may not note anything in the medical record of a
patient in a System Hospital other than factual observations and/or the fact that he/she
visited the patient. They shall have full access to all outpatient services.
Practitioners in this category will have the right to vote, hold office, and serve on medical
staff committees Practitioners in this category will be required to pay appointment and
reappointment fees and must meet the attendance requirements for general medical staff
meetings. Practitioner in this category cannot provide emergency call coverage,
Practitioners in this category will be assigned to a Medical Staff department that covers
their specialty, are not required to attend Department meetings but may elect to attend
and participate in such meetings.
9.2.3
Senior Active Status
The senior active medical staff shall consist of senior members of the Medical Staff who
qualify to be in Active Status I or Status II Membership, attain the age of sixty-five (65),
and request change in appointment. Members of the medical staff in this category desiring
to actively treat patients must meet the qualifications for Status I Active Membership.
Senior active members shall have the rights and privileges corresponding to their Status I
or Status II designation. In addition to being excused from attending general medical staff
meetings, members in the Senior Active category: (i) are excused from paying
reappointment fees; and (ii) may be exempted from serving on the emergency call list as
recommended by their respective departments and approved by the Executive Committee
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for the respective System Hospital. Guidelines for exemptions shall be listed in the
respective departmental rules.
9.3
Affiliate Category
A listing of the sub-categories of the affiliate category are set forth in the Bylaws.
Practitioners who (i) admit or are involved in the care of patients in a System Hospital on an
occasional basis and (ii) qualify for one of the affiliate sub-categories, may be appointed to the
affiliate category of the Medical Staff. Affiliates have no rights to vote, to hold Medical Staff office,
or to serve on department or System Hospital standing committees. Affiliates must provide
evidence of clinical performance in such form as to allow an appropriate judgment to be made with
respect to their ability to exercise the clinical privileges requested.
9.3.1
Consulting Affiliate
Practitioners whose practice in a System Hospital is largely limited to consultation or
teaching shall be appointed to the consulting affiliate category. Consulting affiliates shall
respond to consultation requests made by any Practitioner on the Medical Staff. They shall
have no assigned duties or attendance requirements. Appointment to this category shall be
by departmental recommendation, specifying the need for or the benefits from such
appointment. Appointment may not exceed twenty-four (24) months.
9.3.2
Sponsored Attending Affiliate
Practitioners who are sponsored by a member of the active staff in order to provide
coverage or access to an otherwise unavailable or limited service shall be appointed to the
sponsored attending affiliate category. A department, or a sponsor, who has similar
privileges, must attest to the need for the appointment. The sponsoring medical staff
member must be a member of the System Hospital staff at which the practitioner seeks
primary System Hospital affiliation. The sponsored attending affiliate shall have no
assigned duties or attendance requirements. Appointments may not exceed twenty-four
(24) months.
9.3.3
Honorary Affiliate
Practitioners who have provided long-standing service to MHS and the Medical Staff or
who have outstanding professional attainments shall be appointed to the honorary affiliate
category. These Practitioners need not reside in the community. They shall not be granted
clinical privileges nor shall they have any assigned duties or responsibilities. They shall be
allowed to attend all departmental and Medical Staff meetings and to utilize the Medical
Staff educational resources. Appointment may not exceed five (5) years.
9.3.4
Departmental Affiliate
Practitioners who provide departmental medical coverage for a department at the request
of the department shall be appointed to the departmental affiliate category. They shall
have no assigned duties or attendance requirements. Appointment may not exceed six (6)
months.
9.3.5
Temporary Affiliate
Practitioners who provide medical services on behalf of an active member while the
member is absent for a limited time period shall be appointed to the temporary affiliate
category. They shall have no assigned duties or attendance requirements. Appointment
may not exceed sixty (60) days.
9.3.6
Courtesy Affiliate
Practitioners whose principal hospital is not one of the System Hospitals, but who desire
occasionally to admit patients or remain involved in the care of patients in a System
Hospital, shall be appointed to the courtesy affiliate category. Only Practitioners who are
currently on active staff status shall be eligible for this category. Such Practitioners must
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demonstrate active participation in the active or associate staff at another hospital that
requires quality review activities of a substance and character similar to those of MHS.
Practitioners in this category shall have “on-call” responsibilities commensurate with
Practitioners on the active staff; shall have no attendance requirements and are limited to
24 admissions, consults, and/or procedures (inpatient and outpatient) in a two-year
reappointment period. Appointments shall not exceed twenty-four (24) months.
Membership in this staff category shall be limited in size and duration.
9.4
Administrative and Medical Staff Functions
If a Practitioner on the Medical Staff performs administrative functions with respect to the
Corporation or any System Hospital in addition to medical functions, then with respect to
administrative functions, such Practitioner shall be subject to the administrative rules and
procedures of the Corporation in the same manner and to the same extent as other individuals of
equal rank and responsibility; and with respect to medical functions, such Practitioner shall be
subject to these Bylaws, the Policies and other policies, rules and regulations of the Medical Staff.
The termination of a Practitioner's administrative functions shall not terminate his appointment to
the Medical Staff, but the termination of such Practitioner's appointment to the Medical Staff shall
terminate his administrative functions, unless in either case the written agreement between such
Practitioner and the Corporation provides otherwise.
9.5
House Staff
House Staff shall not be considered Medical Staff members nor shall the term House Staff be
considered a category of Medical Staff membership. Such physicians shall be subject to these
Bylaws, the Policies, departmental rules and regulations, the policies and procedures of MHS and
the System Hospitals, and any other policies and procedures applicable to the medical education
program while providing medical care in a System Hospital. The House Staff will attend meetings
of the staff and the department for which he is assigned and participate in Medical Staff
committees to which he may be appointed. Since they are not members of the Medical Staff, the
House Staff shall not be entitled to any procedural rights afforded by these Bylaws or the Policies
including, without limitation, any due process rights.
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ARTICLE 10 - ALLIED HEALTH PROFESSIONALS
10.1
Relationship to Medical Staff
The provisions concerning allied health professionals relationship to the Medical Staff are set forth
in the Bylaws.
10.2
Categories, Qualifications, Application Process, Monitoring, and Identification
10.2.1 Categories
Allied Health Professionals fall into two categories:
10.2.1.1
Allied Health Associates
10.2.1.2
Allied Health Assistants
This category includes persons who are licensed, certified or registered in the
State of Texas to exercise independent judgment within the scope of their
licensure, certification, or registration. Allied health associates may only
participate in the management of patients at a System Hospital under the
direction of a sponsoring Practitioner who is a Physician. This category shall
include, but not be limited to, clinical psychologists, physician assistants,
surgical assistants, and advanced nurse practitioners. Physician assistants may
be included in this category if they have successfully completed a PA Program
approved by the AMA Council or have been certified by NCCPA.
This category includes persons who are not licensed, certified or registered in
the State of Texas and must, at all times, function under the direct supervision
and presence of their sponsoring Practitioner who is a Physician. Allied health
assistants do not exercise any degree of independent judgment in the
management of patients. In addition, individuals who have state licensure,
certification or registration but do not qualify for the allied health associate
category and/or are excluded by hospital policy may be considered for this
category.
10.2.2 Qualifications
The specific qualifications required of each applicant for allied health professional status
shall be determined by the appropriate clinical department within the general framework of
the allied health professional categories set forth in Section 10.2 of these Policies. The
Corporation, through the medical staff services office (as a peer review process), will verify
information related to an allied health professional’s qualifications; however, allied health
professionals are not credentialed. Allied health professionals function as employees of a
System Hospital or as employees of or as being sponsored and supervised by a Practitioner
who is a Physician.
10.2.3 Application Process
10.2.3.1
All applications by allied health professionals shall be in writing, shall be
signed by the applicant and sponsoring Practitioner, or in the case of an
applicant who is engaged by or under contract with a System Hospital,
signed by the Executive Vice President of Clinical Operations for MHS, or
his designee, and shall be submitted on a prescribed form.
10.2.3.2
A statement signed by the sponsoring Practitioner shall accompany the
application. Such statement shall attest to the sponsoring Practitioner
assuming ultimate responsibility for the actions of the applicant when
working within the confines of a System Hospital. The sponsoring
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Practitioner must execute an indemnification agreement acceptable to the
Corporation.
10.2.3.3
The sponsoring Practitioner shall submit, in conjunction with the
application, a clearly defined summation of the scope of activity of the
applicant being requested. Such scope of activity must fall within the
criteria established by the appropriate clinical department (criteria will be
approved by the corporate credentials committee).
10.2.3.4
Evidence of liability coverage must be provided by all allied health
professionals at coverage limits that are at least the same as what
Practitioners are required to have pursuant to the Bylaws and the Policies.
See requirement for professional liability insurance Article 4.2.2 of the
Policies.
10.2.3.5
Allied health associates must have three (3) recommendations from
Physicians (excluding the sponsoring Practitioner). At least two
recommendations must be from Practitioners assigned to the clinical
department where the allied health professional will practice. Peer
recommendations must support the applicant's professional ethics and
competence.
10.2.3.6
Allied health professionals must be sponsored by a member of the active
staff in the appropriate clinical department.
Allied health applications will not be processed through the Medical Staff credentialing
system. The completed application with the aforementioned attachments shall be
submitted to the appropriate Medical Staff clinical department for review and
recommendation. The recommendation is then forwarded to the Executive Vice
President for Clinical Operations for MHS for acceptance, rejection, or other
appropriate disposition.
10.2.4 Monitoring of Approved Applicants
Allied health professionals will be reviewed concurrent with the review of their sponsoring
Practitioner’s reappointment to the Medical Staff to determine the continued need for their
services and their level of competence.
10.2.5 Identification
All allied health professionals shall wear proper identification in accord with applicable
governing regulations and professional standards.
10.2.6 Suspension and Exclusion of Allied Health Professionals
All allied health professionals shall adhere to the Bylaws, the Policies and the standards,
policies, guidelines, rules and regulations of the Medical Staff, the Corporation and the
System Hospitals. The failure or refusal to adhere to the aforementioned may, in the
Corporation’s sole discretion, result in immediate suspension or exclusion from the System
Hospitals.
10.2.7 Sponsoring Practitioner’s Responsibilities
10.2.7.1
Practitioner’s who sponsor an allied health professional at a System
Hospital shall:
(i)
supervise the activities of all allied health professionals he
sponsors,
(ii)
be responsible for the actions of the allied health professionals he
sponsors,
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(iii)
(iv)
10.2.7.2
assist the Corporation in suspending or excluding an allied health
professional from practicing in the System Hospitals,
provide the documentation required of sponsoring Practitioners
including, but not limited to, the summation of the allied health
professional’s scope of activity, the attestation whereby he
assumes responsibility for the allied health professional in
question, and the agreement to indemnify the Corporation.
Practitioners who sponsor an allied health professional and who do not
fulfill their sponsoring responsibilities as set forth the Bylaws or these
Policies shall be subject to disciplinary action.
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ARTICLE 11 - MEDICAL STAFF ORGANIZATION AND OFFICERS
The provisions related to the organizational structure and officers of the Medical Staff are set forth in the
Bylaws.
11.1
Officers of the Medical Staff
11.1.1 Annual Stipend
In recognition of the time commitment required of the Physician elected to the position of
President of each System Hospital Medical Staff, the Physician elected to such position
shall receive an annual stipend of twenty four thousand dollars ($24,000.00) in accordance
with these Policies. In order to receive such stipend, the Physician shall be required to sign
an agreement with Methodist Health System. Such agreement shall set out the services to
be provided (consistent with the duties of President as outlined in the Bylaws) and that
such Physician is providing such services on behalf of the Medical Staff as independent
contractor.
11.1.2 Source of Funds
One half of the stipend paid to the President of each System Hospital Medical Staff shall be
paid from dues collected from the Medical Staff in accord with this Section 11.1.2. The
other half of such stipend shall be paid by MHS. The portion of the stipend to be paid by
the Medical Staff shall be funded through collection of dues from the Medical Staff
(“Medical Staff Dues”). The Medical Staff Dues are non-refundable and shall be set at
$10.00 per month which is to be paid prior to the member’s reappointment to the Medical
Staff. All members of the active and affiliate Medical Staff shall pay Medical Staff Dues
except the following:
A. Senior active members of the Medical Staff
B. Practitioners granted a special exception by the Corporate Medical Board.
The payment of Medical Staff Dues shall be considered a Citizenship Requirement, and the
payment of such in accordance with these Policies shall be a condition to reappointment
on the Medical Staff.
11.1.3 Control of Funds
The Medical Staff Dues collected in accord with Section 11.1.2 shall be held by MHS in a
separate account and used to pay the Medical Staff’s portion of the President’s stipend.
Any funds remaining after payment of the Medical Staff’s portion of the President’s stipend
will be available for Medical Staff use (solely in its relationship to MHS) as determined by
the Corporate Medical Board. As requested by the Corporate Medical Board, MHS will from
time to time provide the Corporate Medical Board with an accounting report of dues
collected and funds used.
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ARTICLE 12 - CORPORATE MEDICAL STAFF COMMITTEES
12.1
Composition and Appointment
Provisions related to composition and appointment of Medical Staff committees are set forth in the
Bylaws.
12.2
Authority to Delegate
Pursuant to Section 12.2 of the Bylaws, the committees established thereby may, in accordance
with Section 12.2, delegate their responsibilities to sub-committees. The sub-committees to which
such responsibilities may be delegated may be Standing Committees or Special Committees.
12.2.1 Special Committees
Special committees of the corporate Medical Staff shall be created by motion of an existing
committee of the Corporate Medical Staff as required to properly carry out the duties of
the Medical Staff when the work of the committees can be accomplished within the
medical staff year. A special committee shall have only the authority and power of action
specifically granted by the motion which created the committee. The composition of a
special committee shall be determined by its purpose, and a special committee shall
confine its work to the purpose for which it is appointed. The members of a special
committee shall be appointed by the chairman of the committee creating it and the special
committee shall not continue beyond the term of the chairman of the committee creating it
unless extended by the succeeding chairman.
12.2.2 Standing Special Committees
Standing special committees of the corporate Medical Staff shall be created by motion of
an existing committee of the Corporate Medical Staff as required to properly carry out the
duties of the medical staff when the work of the committee is of an ongoing nature. A
standing special committee shall have only the authority and power of action specifically
granted by the motion which created the committee. The composition of a standing special
committee shall be determined by its purpose, and such a committee shall confine its work
to the purpose for which it is appointed. Standing special committees may have an
unlimited duration, but the members of the standing special committees shall be appointed
annually by the chairman of committee creating it.
12.3
Corporate Medical Board
Provisions related to the Corporate Medical Board are set forth in the Bylaws.
12.4
Corporate Graduate Medical Education Committee
Provisions related to the Corporate Graduate Medical Education Committee are set forth in the
Bylaws.
12.5
Other Corporate Medical Staff Committees
12.5.1 Corporate Bylaws and Policies Committee:
(1)
Composition: The corporate bylaws and policies committee shall be composed of a
minimum of eight (8) members appointed by the chairman of the Corporate
Medical Board in consultation with the president of each System Hospital medical
staff to include the following:
Two past medical staff presidents from each System Hospital
A physician representative of each System Hospital
Chairman of corporate credentials committee
Chairman of Corporate Medical Board
Non-voting members shall include the following:
The Executive Vice Presidents or their designees
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(2)
Chairman: The chairman of the corporate bylaws and policies committee shall be a
Practitioner who is a physician and appointed by the chairman of the Corporate
Medical Board.
(3)
Functions and Responsibilities: The corporate bylaws committee shall be
responsible for reviewing all proposed amendments to the Bylaws and Policies of
the Medical Staff and, as appropriate, recommending proposed amendments to
the Corporate Medical Board. The corporate bylaws committee shall also be
responsible for conducting an annual review of the Bylaws and Policies to
determine their appropriateness and propose amendments as needed.
(4)
Meetings: The corporate bylaws committee shall meet as often as required to
transact its business and maintain a permanent record of its proceedings, and
submit all recommendations to the Corporate Medical Board.
12.5.2 Corporate Credentials Committee
(1)
Composition: The corporate credentials committee shall be composed of at least
five (5) members of the active staff who are either former presidents or
department chairs or section chiefs.
The Chair of the Corporate Medical Board will appoint the Chair and other
members. Members will be appointed for three (3) year terms with the initial
terms staggered such that approximately one third of the members will be
appointed each year. The Chair will be appointed for a three (3) year term. The
Chair and members may be reappointed for additional terms without limit. Any
member of the corporate credentials committee, including the Chair, may be
relieved of his/her committee membership by a two-thirds (2/3) vote of the
Corporate Medical Board. Service on this committee shall be considered as the
primary medical staff obligation of each member of the committee and other
medical staff duties shall not interfere. The credentials committee may also invite
ex-officio members such as representatives from hospital administration and the
Board.
(2)
Meetings: The credentials committee shall meet monthly.
(3)
Responsibilities:
To review and recommend action on all applications and reapplications for
membership and status on the MHS medical staff;
To review and recommend action on all requests for privileges for practitioners
granted privileges for MHS;
To recommend criteria for the granting of medical staff membership and clinical
privileges for MHS;
To develop, recommend, and consistently implement policy and procedures for all
credentialing activities at MHS;
To perform such other functions as requested by the Corporate Medical Board.
(4)
Confidentiality: This committee shall function as
consistent with federal and state law. All members
committee shall, consistent with the medical staff
policies, keep in strict confidence all papers, reports,
virtue of membership on the committee.
a peer review committee
of the corporate credentials
and hospital confidentiality
and information obtained by
12.5.3 Medical Staff Health Subcommittee
12.5.3.1
Creation
The Medical Staff Health Subcommittee shall be a standing committee of the
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corporate credentials committee, with its members being appointed by the
chairman of the Corporate Medical Board. It shall function as an authorized
peer review committee of the Medical Staff with respect to matters related to
the impairment of practitioners on the Medical Staff or applicants for
appointment to the Medical Staff. It shall be governed by and follow the
procedures set forth in the MHS Practitioner Health Policy (Article 12.5.3.2 of
the Policies).
12.5.3.2
MHS Practitioner Health Policy
A. Policy: Whenever a practitioner who is on the medical staff or applying for
membership is under psychological or behavioral counseling, the Medical
Staff Health Subcommittee, if requested by the Corporate Medical Board
or the Corporate Credentials Committee, will monitor the counseling being
provided to the Practitioner and report to the Corporate Medical Board
and/or Corporate Credentials Committee a summary of the monitoring
activities and/or reports received from any counselor. All Practitioners will
fully cooperate with monitoring and reporting activities of the Medical Staff
Health Subcommittee.
B. Purpose of the Medical Staff Health Subcommittee: The purpose of the
MSHS is to respond to reports of prior or possible current Practitioner
Impairment in order to ensure that all Practitioners on the Medical Staff are
performing professional services satisfactorily. The MSHS seeks to
accomplish this purpose primarily through assisting Practitioners in
confronting and overcoming their Impairment once identified. In keeping
with this purpose, the MSHS should only recommend corrective action as a
last resort or only in cases when patient safety is at issue.
C. Composition and Function of Medical Staff Health Subcommittee: The MSHS
shall consist of a Chairman and at least four other members, plus two
alternates (who will be non-voting unless activated to serve in the manner
set out below), appointed by the Chairman of the Corporate Medical Board
with the input of the MSHS. Terms of appointment shall be at the discretion
of the Chairman of the Corporate Medical Board. Its membership shall be
reviewed and appointed annually. For consistency purposes, members may
serve recurring terms. Its members shall include representatives from each
System Hospital. It shall cooperate with and as deemed appropriate by the
MSHS, seek assistance from other appropriate bodies and individuals, such
as the Dallas County Medical Society Impaired Physicians Committee. It
shall advise department chairmen and the corporate credentials committee,
when requested, concerning applications for privileges by Practitioners who
may have an Impairment. A quorum shall consist of at least one-half of the
committee’s voting membership plus one member present. If circumstances
arise where a quorum cannot be reached because of the absence of a
voting MSHS member, the Chairman of the MSHS may request one or more
of the alternates to serve on the MSHS.
D. Definitions: Unless otherwise specified herein, terms used in this policy shall
have the same meaning as set forth in the Practitioner Conduct Policy (see
Article 7.5 of these Policies).
Impairment: For purposes of this policy, an Impairment shall exist when the
activities or professional conduct of any Practitioner are noted to be a
deviation from his/her usual behavior, or if it is noted that a Practitioner is
unable to practice medicine with reasonable skill and safety to patients
because of impaired judgment due to physical or mental illness, including
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deterioration through the aging process, loss of motor skill, psychological
dysfunction, or use or abuse of drugs, chemicals or alcohol.
E. Records: A written record of the proceedings of the MSHS shall be
prepared at the direction of the chairman of the MSHS. All records of the
MSHS shall be kept in confidential files in the custody of the Medical Staff
Services Office.
F. Confidentiality: Throughout the process, all information, including the
name of the person making the report, will be kept confidential and any
discussions will be among the involved parties and committee members
only. The Corporate Medical Board will be informed about any member of
the Staff who has been evaluated through this process, but the
practitioner's identity will be kept confidential by referring to the
practitioner by a code number instead of by name.
G. Self-Reporting: Any member of the Medical Staff of Allied health
Professional Staff may self-report to the Medical Staff Health
Subcommittee and obtain the same referrals, encouragement and support
from the Committee by contacting any member of the Committee and
requesting a meeting to discuss his/her health concerns. The Committee
will enforce the same requirements and reporting responsibilities in the
event impairment is suspected and the practitioner does not comply with
the committee's recommendations.
H. Reporting of Impairment: Any Practitioner who suffers or has suffered from
Impairment or is undergoing or has undergone any type of treatment
and/or counseling for Impairment is required as a condition of appointment
or continued appointment/reappointment on the Medical Staff to report the
details of such Impairment to the MSHS and report such other information
as requested by the MSHS pertaining to such Impairment.
Any Practitioner who has knowledge of another Practitioner who suffers
from Impairment or who is undergoing any type of treatment and/or
counseling for Impairment is obligated to report such Impairment to the
MSHS.
Any Practitioner returning from a leave of absence which was based in
whole or part on any health related reason that raises concerns of
Impairment, must receive a recommendation from the MSHS prior to
returning to practice at any System Hospital. The MSHS may require the
Practitioner to provide documentation (including documentation from the
Practitioner’s treating physician) evidencing such Practitioner’s ability to
return to practice. The MSHS may recommend conditions on such
Practitioner’s return to practice at a System Hospital. The MSHS’s
recommendation shall be forwarded to the corporate credentials committee
and appropriate departmental executive committee.
I.
Applicants for Appointment and Reappointment: Prior to initial appointment
or granting of temporary privileges, an applicant with a history of
impairment shall be interviewed by the MSHS. The Practitioner should
provide information satisfactory to the MSHS concerning any denial,
suspension, revocation, voluntary/involuntary surrender, or modification of
any staff membership or privileges, licensure, of DEA/DPS registration
arising from and/or related to an Impairment.
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J.
Processing of Reports of Impairment
1. Reports of alleged impaired behavior by a member of the Medical Staff
of MHS should be presented to the Chairman of the MSHS or one of the
following:
(a) The chairman of the Practitioner's department
(b) Chairman of the corporate credentials committee
(c) President of the System Hospital Medical Staff
(d) An Executive Vice President
(e) President of MHS (or Assistant to the President responsible for
Medical staff Affairs)
2. Upon presentation, such a report shall be referred to the MSHS.
3. Whether or not a summary suspension is indicated or has taken place,
on receipt of the initial referral, the Chairman of the MSHS shall contact
the individual Practitioner to arrange a meeting between him or her and
the MSHS. Whenever action has taken place or must be taken to
summarily suspend a Practitioner because of an issue of Impairment, a
meeting of the MSHS should be held within 72 hours if the suspension
occurs during a weekday or within 96 hours if it occurs on a holiday or
weekend. In cases of summary suspension, the MSHS should report to
the Corporate Medical Board as soon as practicable after meeting with
the suspended Practitioner and conducting whatever additional
investigation the MSHS deems necessary. In all cases of summary
suspension, the procedures to be followed for imposition of such
suspension and what occurs after imposition are set forth in the Bylaws.
Although not required to do so, the Corporate Medical Board may
appoint the MSHS as the ad hoc investigation committee in cases of
summary suspension involving Impairment issues.
4. Upon referral, the MSHS shall have authority to receive reports, initiate
investigations and interventions, and plan and monitor treatment, if
deemed necessary.
5. After initial review of available evidence by the MSHS, the affected
Practitioner shall be required to meet with the MSHS before a formal
recommendation is made to the Corporate Medical Board. The MSHS
shall also inform the Practitioner that privileges at MHS may be
immediately suspended in accordance with the Bylaws and that these
staff privileges may be reinstated only by Medical Staff action pursuant
to the Bylaws, and shall provide the Practitioner with a copy of these
procedures.
6. Depending upon the severity of the problem and the nature of the
impairment, the MSHS has the following options:
(a) Make recommendations to the Practitioner;
(b) Continue to monitor the situation;
(c) Recommend that the Practitioner be required to undertake a
rehabilitation program as a condition of continued appointment and
clinical privileges or forbearance in seeking corrective action;
(d) Recommend immediate suspension of all or part of the
Practitioner's privileges; or
(e) Without suspending privileges, recommend to the Corporate
Medical Board or other appropriate Medical Staff committee or
officer that other action be taken.
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7. If an allegedly impaired Practitioner agrees with the MSHS's
recommendation for treatment and/or limitation of privileges the
Practitioner shall sign a written agreement acknowledging a
commitment to a stipulated treatment or recovery program as a
condition of maintaining or reinstating medical staff membership and/or
clinical privileges.
The written agreement will reflect the plan of treatment and/or
limitation of privileges. Such an agreement shall not be subject to
appeal by the Practitioner, but will be reported to the corporate
credentials committee, the Corporate Medical Board, and the Board of
Directors for review and approval. If any of these bodies directs any
action not agreed to by the Practitioner, and it is grounds for a hearing
under Article 8.2.2.2 of the Bylaws, the Practitioner may request a
hearing under Article 8 of the Bylaws.
8. The MSHS shall seek the advice of hospital counsel to determine
whether any conduct must be reported to law enforcement authorities
or other governmental agencies, and what further steps must be taken.
9. Records of actions under this procedure shall be maintained in the files
of the MSHS. Records of actions taken with respect to appointment and
privileges shall be placed in the Practitioner's medical staff peer review
file.
10. The Chairman of the department or Chairman of the MSHS shall inform
the individual who filed the initial report that follow-up action was taken.
11. All parties shall avoid speculation, gossip, and any discussions of this
matter with anyone not directly concerned with the investigation,
treatment, or decision-making as outlined in this policy.
K. Reinstatement
1. After a Practitioner completes a rehabilitation program, privileges shall
not be reinstated until it is established, to the satisfaction of the MSHS
that (i) the Practitioner has successfully completed a program in which
the MSHS has confidence, (ii) that the Practitioner is in stable recovery,
and (iii) that patient safety will not be compromised. All determinations
and recommendations of the MSHS are subject to the review and
approval of the corporate credentials committee, the Corporate Medical
Board, and the Board of Directors.
2. In determining whether a Practitioner's appointment and privileges may
be reinstated, the MSHS shall obtain a letter from the director of the
rehabilitation program where the Practitioner was treated. As a precondition to reinstatement the Practitioner must authorize the release of
this information. That letter must state:
(a) whether the Practitioner is participating in the program;
(b) whether the Practitioner is in compliance with all of the terms of the
program;
(c) whether the Practitioner attends AA/NA meetings regularly (if
applicable)
(d) to what extent the Practitioner's behavior and conduct are
monitored;
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(e) whether, in the opinion of the director, the Practitioner is in stable
recovery
(f) whether an aftercare program has been recommended to the
Practitioner and, if so, a description of the aftercare program; and
(g) whether, in the director's opinion, the Practitioner is capable of
resuming medical practice and providing continuous, competent
care to patients so that patient safety will not be compromised if
the Practitioner is reinstated.
3. The Practitioner must inform the MSHS of the name and address of the
physician primarily responsible for monitoring his/her recovery program.
The chairman of the MSHS has the right to require an opinion from
other physician consultants of his/her choice.
4. The MSHS has the right to know from the physician primarily
responsible for monitoring the recovery program, the precise nature of
the Practitioner's condition, and the course of treatment as well as the
physician's opinions regarding progress and prognosis.
5. The Practitioner shall be required to obtain periodic reports for MHS
from his or her primary monitoring physician -- for a period of time
specified by the MSHS Chairman -- stating that the Practitioner's ability
to treat and care for patients in the hospital is not impaired. An annual
meeting between the MSHS and the Practitioner shall be held to discuss
progress unless otherwise specified by the MSHS.
6. The Practitioner's exercise of clinical privileges in a System Hospital shall
be monitored by the department chairman or by a Practitioner
appointed by the department chairman. The nature of that monitoring
shall be determined by the MSHS after its review of all the
circumstances.
7. The Practitioner must agree to submit to random alcohol or drug
screening tests on a random basis (if appropriate to the Impairment) as
directed by the Chairman of the MSHS. Refusal to respond immediately
to a request for a screening specimen will be considered as equivalent
to a positive test and will result in automatic termination of appointment
and privileges without appeal.
L.
Appeal Rights: If an allegedly impaired Practitioner disagrees with any
actions or recommendations of the MSHS, the Subcommittee will refer the
matter to the Corporate Medical Board for decision or corrective action
under Article 7 of the Bylaws. The Practitioner will have the same rights of
hearing and appeal as in other cases where corrective action is proposed.
M. Education: It is important to provide education to the Medical Staff and
Hospital Staff about impairment and recognition of possible health
concerns. Relevant lectures, CME programs and/or printed materials and
articles will be provided for members of the Medical, Allied Health, and
Hospital staffs at least annually.
12.5.4 Corporate Clinical Ethics Committee
(a)
Functions and Responsibilities. The Corporate Clinical Ethics Committee shall be a
special standing committee of the Medical Staff charged with the responsibility of
overseeing the clinical ethics consultation process at the System Hospitals by
performing the following:
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(1)
(2)
(3)
(4)
(5)
(b)
Receiving regular reports of the System Hospital clinical ethics subcommittees;
Addressing issues and questions which arise from the clinical ethics
consults performed by the System Hospital clinical ethics sub-committees;
Promoting consistency in handling clinical ethics issues and, as needed
and to address issues of consistency, establishing processes to be followed
by the System Hospital clinical ethics sub-committees;
Educating the Medical Staff on the mechanism to resolve clinical ethics
issues; and
Performing such other functions related to clinical ethics as may be
requested by the Corporate Medical Board.
Composition. The Corporate Clinical Ethics Committee shall be composed of four
members from each System Hospital clinical ethics sub-committee (two of the four
members selected from each sub-committee shall be Practitioners) and one person
from each of the following categories:
(1)
(2)
(3)
One member of the Board of Directors;
One member from the Corporation’s pastoral care department; and
An attorney from the Corporation’s Legal Affairs Department.
The Practitioners serving on the Corporate Clinical Ethics Committee shall be
selected by the Chairman of the Corporate Medical Board. The non-practitioners
serving on the Corporate Clinical Ethics Committee shall be selected by the
Chairman of the Corporate Medical Board with approval from the CEO.
(c)
Chairman: The chairman of the Corporate Clinical Ethics Committee shall be
appointed by the Chairman of the Corporate Medical Board. The Chairman of the
Corporate Clinical Ethics Committee, by virtue of his position, shall be a member of
the Corporate Medical Board.
(d)
Meetings. The Corporate Clinical Ethics Committee shall meet as often as
necessary to transact its business and at least quarterly. The committee shall
maintain a permanent record of its proceedings, and submit quarterly reports to
the Corporate Medical Board of its activities and actions.
12.5.4.1
System Hospital Clinical Ethics Consult Teams
(a) Functions and Responsibilities. The System Hospital clinical ethics consult
teams shall be a special standing committee of each System Hospital
medical staff charged with the responsibility of performing clinical ethics
consults at the consult team's respective System Hospital. It shall report
directly to the Corporate Clinical Ethics Committee and follow directives
given
by
the
Corporate
Clinical
Ethics
Committee.
(b) Composition. The System Hospital clinical ethics consult teams shall be
composed of at least five Practitioners from the System Hospital medical
staff and one person from each of the following categories:
(1)One
(2)One
(3)One
(4)One
member
member
member
member
from
from
from
from
the
the
the
the
System
System
System
System
Hospital’s
Hospital’s
Hospital’s
Hospital’s
administrative staff;
pastoral care department;
nursing administration;
social work department; and
The Practitioners serving on the System Hospital clinical ethics consult
team shall be selected by the President of the System Hospital medical
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staff. The non-practitioners serving on the System Hospital clinical ethics
consult team shall be selected by the Executive Vice President of Clinical
Operations for MHS. The consult team, at its discretion, may seek
assistance from any other clinical or administrative source available at the
System Hospital or Corporation.
(c) Team Leader: The team leader of the System Hospital clinical ethics consult
team shall be a Practitioner selected by the President of the System Hospital
medical staff.
(d) Meetings. The System Hospital clinical ethics consult team will not be required
to meet as a group. The consult team members will continue to submit
quarterly reports to the Corporate Clinical Ethics Committee of its activities and
actions.
12.5.5 MHS Medical Staff Policy and Guidelines Committee
(a)
Functions and Responsibilities: The MHS Medical Staff Policy and Guidelines
Committee shall be a special standing committee of the Medical Staff charged with
the responsibility of reading and reviewing all policies, guidelines, pathways, and
order sets developed to assure all meet the same standard of care at all system
hospitals by performing the following:
(1)
(2)
(3)
(4)
(5)
Provide medical staff direction that shall include but not be limited to the
policies, guidelines, pathways, and order sets used in the care of patients
or in the support of patient care;
Provide medical staff review of evidence based practices for
implementation;
Provide medical staff review of standards of care (nursing, respiratory
therapy, etc.);
Provide medical staff review of forms for patient care documentation; and
Perform all of the above functions to support the promulgation of the
JCAHO standards.
The Committee shall report its activities to each System Hospital Medical Executive
Committee for advice and input and submit all recommendations to the Corporate
Medical Board for approval.
(b)
Chairman: The chairman of the MHS Medical Staff Policies and Guidelines
Committee shall be appointed by the chairman of the Corporate Medical Board
form the Presidents-elect of each System Hospital.
(c)
Composition: The MHS Medical Staff Policies and Guidelines Committee shall be
composed of representatives from each system hospital, appointed by the
President of the System Hospital Medical Staff as follows:
(3) Surgery Department (1 representative from each System Hospital)
(3) Medicine Department (1 representative from each System Hospital)
(3) OB/Gyn Department (1 representative from each System Hospital)
(2) Methodist Dallas Medical Center at-large representatives
(2) Methodist Charlton Medical Center at-large representatives
(1) At-large representative from any new System Hospital
(1) Chief Nursing Officer – MDMC
(1) Chief Nursing Officer – MCMC
(1) Chief Nursing Officer from any new System Hospital
Executive Vice President or designee
Non-Voting:
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(1) Representative from MHS Risk Manager
(d)
Meetings: The MHS Medical Staff Policies and Guidelines Committee shall meet as
often as required to transact business in a timely manner and at least quarterly.
12.5.6 Corporate Health Information Management Committee
(a)
Functions and Responsibilities: The health information management committee is
charged with the responsibility of monitoring and evaluating the quality of the
medical record as follows:
(i)
(ii)
(iii)
(iv)
(v)
(vi)
(vii)
(viii)
(ix)
Reviewing medical records for their timely completion, clinical pertinence,
adequacy, and completeness;
Conducting reviews to assure that records properly describe the condition
and progress of the patient, the therapy provided, the identification of
responsibility for all actions taken, and that they are sufficiently complete
at all times, so that safe transfer of responsibility is assured if such
becomes necessary;
Strive to see that the standards promulgated by the Joint Commission on
Accreditation of Healthcare Organizations pertaining to the medical record
are adhered to by the System Hospital medical staff;
Periodically review the rules pertaining to the prescribed content of
medical records, as well as the provisions for assuring prompt and
effective completion of medical records;
Review any medical record form which will become part of the medical
record;
Act in an advisory capacity to the director of health information
management;
Make recommendations to the Corporate Medical Board on matters
pertaining to the medical record;
Evaluate and make recommendations on any medical record problems
brought before the committee by the director of medical records; and
Monitor the performance of Practitioners on the medical staff regarding
delinquent medical records.
The Committee shall report its activities to each System Hospital
Medical
Executive Committee for advice and input and submit all recommendations to the
Corporate Medical Board for approval.
(b)
Composition: The Corporate Health Information Management
consist of:
(i)
(ii)
Committee
shall
the chair who shall be appointed by the Chair of the Corporate Medical
Board, and
at least two (2) physician representatives from each System Hospital also
appointed by the Chair of the Corporate Medical
Board
based
on
recommendations from the President of each System Hospital Medical
Staff.
Non-voting members shall include the following:
(i)
The Vice President responsible for Health Information Management and
(ii)
The Director of each System Hospital Health Information Management
Department.
(c)
Meetings: The Corporate Health Information Management Committee shall meet
as often as required to transact its business and at least quarterly, and maintain a
permanent record of its proceedings.
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ARTICLE 13 - SYSTEM HOSPITAL MEDICAL STAFF COMMITTEES
13.1
Composition and Appointment
Provisions related to composition and appointment of Medical Staff committees are set forth in the
Bylaws.
13.2
Authority to Delegate
Pursuant to Section 13.2 of the Bylaws, the committees established thereby may, in accordance
with Section 13.2, delegate their responsibilities to sub-committees. The sub-committees to which
such responsibilities may be delegated may be Standing Committees or Special Committees.
13.2.1 Special Committees
Special committees of the System Hospital medical staff shall be created by motion of an
existing committee of a System Hospital medical staff as required to properly carry out the
duties of the System Hospital medical staff when the work of the committees can be
accomplished within the medical staff year. A special committee shall have only the
authority and power of action specifically granted by the motion which created the
committee. The composition of a special committee shall be determined by its purpose,
and a special committee shall confine its work to the purpose for which it is appointed. The
members of a special committee shall be appointed by chairman of the committee creating
it, and the special committee shall not continue beyond the term of the chairman of the
committee creating it unless extended by the succeeding chairman.
13.2.2 Standing Special Committees
Standing special committees of the System Hospital medical staff shall be created by
motion of an existing committee of a System Hospital medical staff as required to properly
carry out the duties of the System Hospital medical staff when the work of the committee
is of an ongoing nature. A standing special committee shall have only the authority and
power of action specifically granted by the motion which created the committee. The
composition of a standing special committee shall be determined by its purpose, and such
a committee shall confine its work to the purpose for which it is appointed. Standing
special committees may have an unlimited duration, but the members of the standing
special committees shall be appointed annually by the chairman of the committee creating
it.
13.3
Executive Committee
Provisions related to the Executive Committee of each System Hospital are set forth in the Bylaws.
13.4
Succession & Leadership Committee
Provisions related to the nominating committee of each System Hospital are set forth in the
Bylaws.
13.5
Other System Hospital Medical Staff Committees
13.5.1 Professional Care Audit/Review Committee
(1) Functions and Responsibilities: The purpose of the professional care audit and review
committee (“PCAR Committee”) for each System Hospital is to evaluate the quality of
medical and healthcare services by reviewing drug usage, pharmacy and therapeutics
functions, blood usage.
Drug Usage Evaluation: The principal goal of medication usage evaluation is to
improve the processes involved in medication prescribing, preparation and dispensing,
administration, and monitoring.
This function is performed by the System Hospital medical staff in cooperation with as
required, the pharmaceutical department/service, the nursing department/service,
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management and quality assurance department and other departments/services and
individuals.
A provision for communicating to members of the relevant System Hospital clinical
department/services the findings, conclusions, and recommendations resulting from
such review activities and actions taken is delineated in the Hospital Quality Review
Plan. Results of drug usage evaluation shall be reported to each clinical department
and the PCAR Committee.
Blood Usage Evaluation: The System Hospital medical staff performs blood usage
review at least quarterly to continuously improve the appropriateness and
effectiveness with which blood and blood components are used. The scope of blood
usage review shall include the use, administration, distribution, and handling of blood,
blood components, and blood derivatives.
This function is performed in accord with the Hospital Quality Review Plan. Results of
blood usage evaluation shall be reported at least quarterly to each clinical department
and the PCAR Committee.
Pharmacy and Therapeutics: The pharmacy and therapeutics function is performed, at
least quarterly, by the System Hospital medical staff, in cooperation with the
pharmaceutical department/service, the nursing department/service, management and
administrative services, and, as required other departments/services and individuals.
The pharmacy and therapeutics monitoring function includes at least the following:
(i)
The development or approval of policies and procedures relating to the
selection, distribution, handling, use, and administration of drugs and
diagnostic testing materials;
(ii)
The development and maintenance of a drug formulary or drug list; and
(iii)
The definition and review of all significant untoward drug reactions in accord
with the Hospital Quality Review Plan.
A report of this function shall be submitted, at least quarterly, to the PCAR Committee.
(2) Composition: The PCAR Committee shall be a multidisciplinary committee to include at
least the following, all appointed by the president of the medical staff of each System
Hospital based on recommendation of the clinical department/service chairman:
(i)
Representative of each major clinical department/service (medicine, ob/gyn,
surgery and pathology)
(ii)
Pharmacist (Voting privileges on pharmaceutical matters only).
Non-voting members shall include the following:
(i)
The Executive Vice President of Clinical Operations for MHS or designee
(ii)
Nursing representative
Other members of the medical staff may be requested to attend the committee
meetings at the discretion of the chairman for consultation in special areas. When
possible, one-third of the committee membership of the previous year will be
reappointed for purposes of continuity.
(3) Chairman: The chairman of the PCAR Committee shall be appointed by the president
of the System Hospital medical staff.
(4) Meetings: The PCAR Committee shall meet as often as required to transact its business
and at least quarterly, maintain a permanent record of its proceedings, and submit a
report of findings, conclusions, recommendations, actions taken, and effectiveness of
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actions taken to the Executive Committee of its respective System Hospital medical
staff.
(5) New System Hospitals: Until such time as the Executive Committee of a new System
Hospital deems it appropriate to create a PCAR Committee at a new System Hospital,
all functions of the PCAR Committee at a new System Hospital shall be carried out by
the Executive Committee at the new System Hospital.
13.5.2 Utilization Management Committee
(1) The principal goal of utilization management is to monitor and evaluate the over
utilization, under utilization and inefficient scheduling of resources at each System
Hospital.
(2) Functions and Responsibilities:
(i)
To ensure the maintenance of high quality patient care;
(ii)
To assist the Executive Committee of the System Hospital Medical Staff in
establishing admitting policies;
(iii)
To conduct utilization review studies designed to evaluate the appropriateness
of admissions to the System Hospital, lengths of stay, discharge practices, use
of medical and hospital services, and all related factors which may contribute
to more effective and efficient utilization of System Hospital and physician
services;
(iv)
To appraise the medical necessity of continued hospitalization and services,
where appropriate, by examining the patient's record;
(v)
To report to the Executive Committee of the System Hospital Medical Staff,
ways of providing more efficient utilization of beds;
(vi)
To report to the Executive Committee of the System Hospital Medical Staff
violations of the Bylaws and the Policies of the Medical Staff pertaining to
admission and utilization of System Hospital facilities;
(vii)
To review at intervals the System Hospital's discharge planning program; and
(viii)
To formulate, and periodically re-evaluate, a written utilization review plan for
the System Hospital.
(3) Composition: The Utilization Management Committee shall be a standing committee of
each System Hospital Medical Staff and shall be a multidisciplinary committee
composed of active staff members to include a representative of each major clinical
department/service (medicine, ob/gyn, surgery), all appointed by the president of the
System Hospital Medical Staff based on the recommendation of the clinical
department/service chairman.
Non-voting members shall include the following:
(i)
The Executive Vice President of Clinical Operations for MHS or designee
(ii)
Director of health information management
(iii)
Utilization review coordinator
(iv)
Representative of nursing service
(v)
Representative of social service
When possible, one-third of the committee membership of the previous year will be
reappointed for purposes of continuity.
Other members of the System Hospital medical staff may be requested to attend the
committee meetings at the discretion of the chairman for consultation in special areas.
(4) Chairman: The chairman of the Utilization Management Committee shall be appointed
by the president of the System Hospital Medical Staff.
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(5) Meetings: The Utilization Management Committee shall meet as often as required to
transact its business and at least quarterly, maintain a permanent record of its
proceedings, and submit all recommendations for action to the Executive Committee of
its respective System Hospital medical staff.
(6) New System Hospitals: Until such time as the Executive Committee of a new System
Hospital deems it appropriate to create a Utilization Management Committee at a new
System Hospital, all functions of the Utilization Management Committee at a new
System Hospital shall be carried out by the Executive Committee at the new System
Hospital.
13.5.3 Medical Staff Quality Council
(1) Purpose: To develop processes and the infrastructure to support medical staff quality
management and performance improvement and shall be a standing committee of the
Medical Staff.
(2) Functions and Responsibilities: To provide educational opportunities for medical staff
leadership regarding performance improvement, quality and peer review, and
integration with credentialing; provide a mechanism for prioritizing cross-department
or inter-disciplinary performance improvement initiatives; provide a forum to review
the quality management and performance improvement initiatives of each medical
staff department; review the consistent application of MHS quality management and
performance improvement principles (rates, rules, event review, peer review, etc.);
integrate, where possible, cross-departmental performance improvement initiatives;
and identify, prioritize, and delegate clinical quality issues for review and improvement.
The System Hospital Medical Staff Quality Council shall report to the System Hospital
Medical Executive Committee.
(3) Composition: The Chair of the Medical Staff Quality Council shall be the President of
the System Hospital Medical Staff. Other members of the Committee shall consist of
the Chair or service chief of:
Anesthesiology
Emergency Medicine
Medicine
OB/Gyn
Pathology
Radiology
Surgery
In addition, the Immediate Past President and President-Elect of the System Hospital
Medical Staff shall also be voting members of the Committee.
Ex-Officio Members shall be:
Vice President of Quality Management
Director of Clinical Outcomes
(5) Meetings: The Committee shall meet as often as necessary to transact business and at
least quarterly.
(6) New System Hospitals: Until such time as the Executive Committee of a new System
Hospital deems it appropriate to create a Medical Staff Quality Council at a new
System Hospital, all functions of the Medical Staff Quality Council at a new System
Hospital shall be carried out by the Executive Committee at the new System Hospital.
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ARTICLE 14 - MEDICAL STAFF CLINICAL DEPARTMENTS AND SECTIONS
14.1
Organization
Provisions related to clinical department organization are set forth in the Bylaws.
14.2
Other Matters Related to Medical Staff Clinical Departments
14.2.1 Qualifications, Selection, and Tenure of Department Chairmen
14.2.1.1
Qualifications
Each chairman shall be a member of the active medical staff and qualified by
board certification, training, experience, and demonstrated ability for the
position (at new System Hospitals the requirement that department chairman
be an active member of the medical staff is waived for the first three years
from the date the new System Hospital opens).
If the selected chairman is not board certified, the following criteria must be
met:
1. Outstanding professional attainments; or
2. Demonstrated leadership abilities and knowledge of medical staff affairs
gained through medical staff committee chairmanship or medical
directorship of a special unit, etc.
14.2.1.2
Term of Office
14.2.1.3
Method of Election
Each department chairman shall be elected for the term specified by the
clinical department rules (which shall provide for a term of at least one year
and not more than two), subject to approval of the executive committee and
the MHS executive officer with administrative responsibility for clinical
operations at the System Hospital in question. Department chairman may
serve recurring terms, subject to the annual approval of the Executive
Committee and the MHS executive officer with administrative responsibility for
clinical operations for the System Hospital.
Except for appointments at a new System Hospital, the method for electing
department chairs, section chiefs and other designated department officers
shall be as follows:
The chairman of each department shall appoint a nominating committee two
months prior to the annual meeting. This committee shall nominate candidates
for department chairman, for chiefs of each section, and for other designated
officers within the department. The slate of candidates shall be presented and
voted on at the annual meeting. The names of the newly elected department
chairmen and section chiefs shall be transmitted to the Executive Committee
and the MHS executive officer with administrative responsibility for clinical
operations for the System Hospital, within seven (7) days from the date of
election, for approval. Procedures for election shall be outlined in each
department's rules. In the case where department chairmen and section chiefs
are not elected at the designated department meeting, the president of the
System Hospital medical staff shall appoint a chairman and/or chief with
Executive Committee approval.
For appointments at a new System Hospital, the department chairs, section
chiefs and other department officers shall be appointed by the President of
new System Hospital medical staff, subject to the approval of the MHS
executive officer with administrative responsibility for clinical operations at the
new System Hospital. This process of electing such chairs, chiefs and other
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department officers at a new System Hospital shall continue until such time as
the Executive Committee at the new System Hospital and the MHS executive
officer with administrative responsibility for clinical operations at the new
System Hospital in question mutually agree that the process otherwise set
forth in this sub-section 14.2.1.3 should apply.
14.2.1.4
Removal of Departmental Officers
14.2.1.5
Department Officers with Contractual Relationship
Removal of a departmental officer during his term of office may be
accomplished by a two-thirds majority vote of all active staff members of the
department, but no such removal shall be effective unless and until it has
been ratified by the Executive Committee and the MHS executive officer with
responsibility for clinical operations for the System Hospital in question.
Departmental officers may also be removed in the same manner and for the
same grounds as set forth in Article 11.3.4 (1) and (2) of the Bylaws.
In departments with full-time or part-time section chiefs or department
chairmen (such as department of pathology and clinical laboratory,
department of emergency medicine, cardiology section of the department of
medicine, pulmonary disease section of the department of medicine), where a
contractual relationship exists between the Corporation and the department or
section involved, appointments shall be on a continuing basis subject to the
terms of the contract between the department chairman or section chief and
Methodist Health System. The chairman or chief with such a contractual
relationship shall be appointed to such position as a result of the contractual
relationship which relationship shall be entered into after advice from the
Medical Staff. The responsibility of the chairman or chief will be of a dual
nature, professionally to the Medical Staff and administratively to the Chief
Executive Officer.
14.2.2 Duties of Department Chairmen
Each chairman shall:
(1)
Be accountable for all professional and administrative activities within his
department;
(2)
Be a member of the Executive Committee, giving guidance on the overall medical
policies of the System Hospital in question and making specific recommendations
and suggestions, regarding his own department in order to assure quality patient
care;
(3)
Maintain continuing review of the professional performance of all members with
clinical privileges in his department and report annually or as requested thereon to
the Executive Committee;
(4)
Be responsible for recommending to the medical staff the criteria for clinical
privileges that are relevant to the care provided in the department;
(5)
Be responsible for assessing and recommending to the relevant hospital authority
off-site sources for needed patient care, treatment, and services not provided by
the department or the organization;
(6)
Be responsible for the integration of the department or service into the primary
functions of the organization;
(7)
Be responsible for the coordination and integration of interdepartmental and
intradepartmental services;
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(8)
Be responsible for the development and implementation of policies and procedures
that guide and support the provision of care, treatment, and services;
(9)
Be responsible for submitting recommendations for a sufficient number of qualified
and competent persons to provide care, treatment and service;
(10)
Be responsible for making the determination of the qualifications and competence
of department or service personnel who are not licensed independent practitioners
and who provide patient care, treatment, and services;
(11)
Be responsible for the maintenance of quality control programs, as appropriate;
(12)
Be responsible for the orientation and continuing education of all persons in the
department or service;
(13)
Be responsible for the recommendations for space and other resources needed by
the department or service;
(14)
Be responsible for assuring departmental medical care evaluation mechanisms for
patient care review;
(15)
Be responsible for enforcement of the Corporation bylaws, these Bylaws, the
Policies, and the rules within the department;
(16)
Be responsible for implementation within his department of actions taken by the
Executive Committee;
(17)
Be responsible for the proper documentation of the departmental activities and
medical care evaluation;
(18)
Transmit to the Executive Committee and corporate credentials committee his
department's recommendations concerning appointments, reappointments and the
delineation of clinical privileges for all Practitioners in his department; and
(19)
Assist in the preparation of annual reports pertaining to his department as may be
requested.
Note:
Duties of the department chairmen also apply to the chief of service of a nondepartmentalized medical staff.
14.2.3 Functions of Departments
Each department shall:
(1)
Develop written rules, consistent with the Bylaws and the Policies and the policies
of the Corporation, for establishing its own criteria for the granting of clinical
privileges, for the holding of office in the department, and for assisting the
chairman of the department in pursuit of his duties. The rules of the departments
shall be reviewed as needed and any amendments shall be approved by the
System Hospital Executive Committee, the Corporate Medical Board and the MHS
executive officer with administrative responsibility for clinical operations at the
System Hospital in question;
(2)
Conduct a planned and systematic review to assess the quality and
appropriateness of patient care delivered by Practitioners in the department. A
mechanism shall be established for conducting a review relating to patient care for
the purpose of discussion at the departmental meetings that will contribute to the
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continuing education of every Practitioner and to the process of developing criteria
to assure optimal patient care. Business and ethical matters pertaining to the
department should also be handled at these departmental meetings;
(3)
Meet as often as required to transact its business as determined by the clinical
department. Departmental meetings shall not release the members from their
obligation to attend general meetings of the Medical Staff as designated in Article
15 of the Bylaws;
(4)
Document the departmental committee activities, meetings, and medical care
evaluation proceedings, and forward these minutes to the appropriate Executive
Committee;
(5)
With regard to matters which require consideration and/or resolution under the
auspices of the department but which are common to other departments, refer
such matters to the other respective departments in order that mutual agreement
can be reached; and
(6)
Develop rules so that Practitioner coverage is available (twenty-four hours a day)
at the System Hospitals for the specialty or specialties represented in the
department.
14.2.4 Assignment to Departments
The Corporate Medical Board shall, after consideration of the recommendations of the
clinical departments as transmitted through the corporate credentials committee,
recommend initial departmental assignments for all Practitioners.
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ARTICLE 15 - MEDICAL STAFF MEETINGS
15.1
Regular Meetings
Provisions related to regular meetings are set forth in the Bylaws.
15.2
Annual Meeting
Provisions related to the annual meeting of the Medical Staff are set forth in the Bylaws.
15.3
Special Meetings
Provisions related to special meetings are set forth in the Bylaws.
15.4
Attendance at Medical Staff Meetings
15.4.1 Requirements
The Bylaws set forth the attendance requirements for Medical Staff meetings. Unless
otherwise excused for cause by the Executive Committee, the failure to meet the
meeting/attendance requirements set forth in Article 15.4.1 of the Bylaws shall be grounds
for conditional reappointment or termination of appointment as follows:
(1)
Provisional Appointee: Failure to meet attendance requirements in either the first
or second twelve (12) months of the provisional appointment shall be cause for
automatic termination of the appointment and privileges consistent with Article
4.2.6.2(3) of these Policies. The terminated provisional appointee shall not be
eligible to reapply for Medical Staff appointment for a period of one (1) year.
(2)
Non-Provisional Active Members: Failure to meet attendance requirements on the
first occasion shall cause the Practitioner to be reappointed on a conditional basis
for one year; continued non-compliance with attendance requirements for a
second consecutive year shall cause automatic termination of appointment and
privileges. In the latter event, the Practitioner may reapply for appointment to the
Medical Staff upon the payment of a $500 penalty and standard application fee.
Such application shall be processed in the same manner as applications for initial
appointment. Thereafter, if a Practitioner fails to meet attendance requirements
for a third consecutive year, termination shall be final and reapplication shall not
be subject to further consideration. Additional departmental attendance
requirements are set forth in Articles 16.3 of the Bylaws.
15.4.2 Exclusion from Attendance Requirement
Provisions related to exclusion from Medical Staff meeting attendance requirements are set
forth in the Bylaws.
15.5
Notification, Quorum and Agenda
15.5.1 Notification
Written notice stating the purpose, place, day, and hour of any special meeting of the
corporate or System Hospital medical staff shall be given to each member of the active
staff in question. The notice shall be given not less than seven days before the date of
such meeting by posting same in the appropriate System Hospital(s). No business shall be
transacted at any special meeting except that stated in the notice calling the meeting.
15.5.2 Quorum
The presence of fifty percent (50%) of the total membership of the active medical staff in
question at any regular or special meeting shall constitute a quorum for purposes of the
Medical Staff taking action, including action required to amend the Bylaws.
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15.5.3 Agenda
15.5.3.1
Regular Meeting Agenda
15.5.3.2
Special Meeting Agenda
The agenda at any regular medical staff meeting shall include when
applicable:
(1) Call to Order
(2) Approval of minutes
(3) Report from management
(4) Reports from committees
(5) Reports from departments
(6) Unfinished business
(7) New business
(8) Announcements
(9) Program
(10)Adjournment
The agenda at special meetings shall include when applicable:
(1) Call to order
(2) Reading of the notice calling the meeting
(3) Transaction of business for which the meeting was called
(4) Adjournment
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ARTICLE 16 - DEPARTMENTAL AND COMMITTEE MEETINGS
16.1
Regular Meetings
16.1.1 Frequency of Meetings
Provisions related to frequency of meetings are set forth in the Bylaws.
16.1.2 Purpose and Record Requirements
16.1.2.1
Purpose of Meetings
16.1.2.2
Record of Meetings
Departmental committees shall meet to fulfill their responsibilities set forth in
the Bylaws or the special purpose for which they were appointed. Each clinical
department and major clinical service (or the medical staff as a whole, if nondepartmentalized) shall meet as often as necessary and at least quarterly to
consider findings from the ongoing monitoring and evaluation of the quality
and appropriateness of the care and treatment provided to patients through a
planned and systematic review of quality and appropriateness of care
rendered by Practitioners in the department. A critical assessment of patient
care shall be accomplished by reviewing and evaluating the clinical work of
Practitioners with privileges in the department. This review should include a
consideration of selected deaths, morbidity and mortality analysis, particularly
interesting cases, infections, unimproved hospitalized patients, complications,
errors in diagnosis, results of treatment, and such reports which are relative to
patient care within the hospital. The departmental meetings should continually
attempt to improve the knowledge and skills of Practitioners in the department
through educational programs. Business and ethical matters pertaining to the
department also should be handled at these meetings.
A record of each department and committee meeting, that includes the
resultant conclusions, recommendations, and actions taken, shall be
maintained.
16.2
Special Meetings
Provisions related to special meetings of departments and committees are set forth in the Bylaws.
16.3
Attendance Requirements – Department and Committee Meetings
The Bylaws set forth the attendance requirements for department and committee meetings. Failure
to meet the attendance requirements may result in conditional reappointment or termination of
reappointment as follows:
(1) Provisional Appointees: Failure to meet annual attendance requirements in either the first or
second twelve (12) months of the provisional appointment shall be cause for automatic
termination of the appointment and privileges consistent with Article 4.2.6.2(3) of the Policies.
The terminated provisional appointee shall not be eligible to reapply for medical staff
appointment for a period of one (1) year.
(2) Non-Provisional Active Members: Failure to meet attendance requirements on the first occasion
shall cause the Practitioner to be reappointed on a conditional basis for one year; continued
non-compliance with annual attendance requirements for a second consecutive year shall
cause automatic termination of appointment and privileges. In the latter event, the Practitioner
may reapply for appointment to the Medical Staff upon the payment of a $500 penalty and
standard application fee. Such application shall be processed in the same manner as
applications for initial appointment. Thereafter, if a staff member’s appointment is terminated
for a third consecutive year, termination shall be final and reapplication shall not be subject to
further consideration. Additional medical staff attendance requirements are set forth in Article
15.4.1 of the Bylaws.
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16.4
Other Matters Related to Department and Committee Meetings
16.4.1 Notification
Written notice stating the purpose, place, day, and hour of any special meeting or of any
regular meeting not held pursuant to resolution shall be given to each member of the
department or committee not less than seven (7) days before the date of such meeting.
16.4.2 Quorum
A quorum for purposes of all department and committee meetings shall consist of those
department or committee members present at the meeting in question except for the
following committees: The Corporate Medical Board, System Hospital Executive
Committees, Corporate Credentials Committee, and the Corporate Clinical Ethics
Committee. For the committees listed, the quorum requirements shall be fifty (50%) of the
voting medical staff members of the committee in question.
16.4.3 Committee and Departmental Manner of Action
The action of a majority of the members present at a meeting at which a quorum is
present shall constitute proper authorization powers of the committee or department.
16.4.4 Rights of Ex-Officio Members
Ex-officio members of a committee shall not be counted in determining the existence of a
quorum nor shall these individuals have a voting right except where their voting power is
delineated in the description of the committee as set forth in the Bylaws or is formally
authorized at the time of appointment.
16.4.5 Departmental and Committee Reports
(1)
Minutes: Minutes of each regular and special meeting of a committee or
department shall be prepared and shall include a record of attendance and the
vote taken on each matter. The minutes shall be approved by the department or
committee chairman and forwarded to the designated committee. Each committee
and department shall maintain a permanent file of the minutes of each meeting.
(2)
Annual Report: Thirty days prior to the end of the medical staff year, the
committee and department chairmen shall be responsible for the preparation of a
brief annual report, if so requested.
ARTICLE 17 - RULES OF ORDER
The rules of order conducting affairs at any meeting are as set forth in the Bylaws.
ARTICLE 18 - IMMUNITY FROM LIABILITY
Provisions related to immunity from liability are set forth in the Bylaws.
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ARTICLE 19 - AMENDMENTS TO BYLAWS, POLICIES AND DEPARTMENT RULES
19.1
Medical Staff Bylaws
Provisions related to the process to amend the Bylaws are set forth in the Bylaws.
19.2
Policies
19.2.1 Process to Amend Policies
19.2.1.1
Requests for Amendments, Modifications and Repeal
19.2.1.2
Action of Medical Staff Bylaw and Policies Committee
19.2.1.3
Action of Executive Committee
19.2.1.4
Action of the Corporate Medical Board
19.2.1.5
Action of the Board of Directors
Proposed amendments, modifications and repeals of the Policies may be
requested by any Practitioner, the Chief Executive Officer, any Executive Vice
President, the MHS executive with administrative responsibility for a System
Hospital, or any department or committee of the Medical Staff.
All requests to amend, modify or repeal any section of these Policies shall be
submitted to the Medical Staff Bylaws and Policies Committee for initial review
and recommendation. The Medical Staff Bylaws and Policies Committee shall,
in accordance with the procedure set forth in Article 19.2.2 of these Policies
notify the Medical Staff of its recommendations to amend, modify or repeal
these Policies. The recommendations of the Medical Staff Bylaws and Policies
Committee shall be submitted to the Corporate Medical Board and each
System Hospital Executive Committee for review, recommendation and/or
approval.
At its next meeting following the expiration of the notice period set forth in
Article 19.2.2, each System Hospital Executive Committee shall review the
recommendations of the Medical Staff Bylaws and Policies Committee and vote
to approve, reject or approve with modifications the recommendations of the
Medical Staff Bylaws and Policies Committee. The action of the Executive
Committee must be by at least a two-thirds vote. The Executive Committee
will submit its recommendation(s) to the Corporate Medical Board.
The Corporate Medical Board shall review the recommendations of the Medical
Staff Bylaws and Policies Committee and each System Executive Committee. If
the Medical Staff Bylaws and Policies Committee and each System Hospital
Executive Committee recommend to approve the same amendment,
modification or repeal, the Corporate Medical Board shall vote to approve or
reject the recommendations. If the Medical Staff Bylaws and Policies
Committee and each System Hospital Executive Committee do not recommend
to approve the same amendment, modification or repeal, the Corporate
Medical Board may vote to reject the proposed amendment, modification or
repeal or to submit the matter back to the Medical Staff Bylaws and Policies
Committee for further consideration in which case the process set forth in this
Article 19.2 shall begin anew. The action of the Corporate Medical Board must
be by at least a two-thirds vote. The Corporate Medical Board shall report its
actions to the Board of Directors.
Upon submission of the recommendation of the Corporate Medical Board, the
Board of Directors may vote to approve, reject or propose a modification to
the recommendation. In the event that the Board of Directors votes to reject
or modify the recommendation of the Board of Directors, its decision shall be
submitted to the Medical Staff Bylaws and Policies Committee for review and
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further consideration at which point the process set forth in this Article 19.2
shall begin anew.
19.2.2 Notification to the Medical Staff
At least thirty (30) days prior to submitting to each System Hospital Executive Committee
any recommendations to amend, modify or repeal these Policies, the Medical Staff Bylaws
and Policies Committee shall notify the Medical Staff of any such recommendations by
posting its recommendations in the medical staff office (or at the discretion of the Medical
Staff Bylaws and Policies Committee some other similar location) of each System Hospital.
Practitioners may direct any comments concerning any proposed recommendation to a
member of the System Hospital Executive Committee for consideration by the Executive
Committee prior to its vote.
19.3
Department Rules
Provisions related to department rules are set forth in the Bylaws.
ARTICLE 20 - GENERAL PROVISIONS
Matters related to construction of terms and headings, Board of Directors actions and designees of Chief
Executive Officer and Executive Vice Presidents are set forth in the Bylaws.
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ARTICLE 21 - ADMISSION AND DISCHARGE OF PATIENTS
21.1
Patient Admission
A patient may be admitted to a System Hospital only by a member of the Medical Staff who has
admitting privileges. All Medical Staff members shall be governed by the official admitting policy of
the System Hospital in question. In addition, patients admitted to the clinic service and followed by
the House Staff will be the responsibility of the directors of the training programs of the respective
clinic service. Except in an emergency, no patient shall be admitted to a System Hospital until a
provisional diagnosis has been stated. In case of emergency, the provisional diagnosis shall be
stated as soon after admission as possible.
Practitioners admitting patients shall be held responsible for giving such information as may be
necessary to assure protection of the patient from self harm and to assure the protection of other
patients from those who are a source of danger from any cause whatever.
21.2
Types of Cases Admitted
The System Hospitals shall accept patients suffering from all types of diseases usually admitted to
a general, acute hospital, except known communicable diseases for which no facilities for care are
available. Patients who might do harm to themselves, hospital personnel, or others may be
admitted to a System Hospital if the patient is attended by family members or private duty nurses
24 hours a day, except where the attending physician indicates, in writing, that special attendants
are not necessary. Patients with contagious diseases, when admitted, will be handled in
accordance with the established isolation procedures.
21.3
Infectious Patients
At the time of a room reservation, or in the case or an emergency, the admitting physician shall
inform the admitting office of the presence or suspected presence of any infection so that proper
isolation measures or room assignments may be made.
21.4
Admission Priorities
The reservation officer shall admit patients on the basis of the following order of priorities:
a.
Emergency Admissions: Physicians admitting emergency cases shall be prepared to justify
such admissions to the appropriate department chairman. Evidence of willful or continual
misuse of this category of admission by a physician shall be brought to the attention of the
appropriate department chairman for proper action.
21.5
b.
Urgent Admissions: Physicians admitting urgent cases shall be prepared to justify such
admissions to the appropriate department chairman. Evidence of willful or continual
misuse of this category of admission by a physician shall be brought to the attention of the
appropriate department chairman for proper action.
c.
Preoperative Admissions: This category of admission includes all patients already
scheduled for surgery.
d.
Routine Admissions: This category of admission includes all elective admissions involving
all services and shall be handled on a first-come, first-serve basis.
Assignments by Patient Care Unit and Patient Transfers
Patients shall be assigned whenever possible to the appropriate unit according to their diagnosis.
When deviations are made from assigned areas, the reservations officer will correct these
assignments at the earliest possible moment in keeping with transfer priorities.
a.
From emergency room to appropriate patient bed;
b.
From obstetric unit to general care area when medically indicated;
c.
From intensive care unit to general care area;
d.
From coronary care unit to general care area; or
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e.
From temporary placement in an inappropriate geographic or a clinical service area to the
appropriate area for the patient.
No patient shall be transferred without such transfer being approved by the responsible physician.
21.6
General Consent to Treatment Form
A general consent form shall be obtained at the time of admission in accordance with the
admission policy.
The admitting officer shall notify the attending Medical Staff member whenever such consent has
not been obtained and, when so notified, it shall (except in emergency situations) be the
attendant’s obligation to obtain proper consent before the patient is treated in the hospital.
21.7
Informed Consent
Written attestation of a discussion concerning informed consent between a patient (or when
appropriate by a patient representative) and physician, using MHS Form 03745, should be obtained
by the Medical Staff member performing any special diagnostic procedures and operative
procedures prior to the procedure, except in those situations where in the patient's life is in
jeopardy and suitable signatures cannot be obtained due to the condition of the patient.
Both the patient or patient's representative and the physician performing the procedure will sign
the form where indicated after discussion about the procedure. If an anesthetic is to be
administered by someone other than the physician performing the procedure, the person providing
such anesthetic will also sign the form where indicated after discussion about the proposed
anesthetic with the patient or the patient's representative. The patient's signature may be
witnessed by a nurse.
The physician should also note the details of the informed consent discussion in the patient's
history and physical note or in the progress note section of the medical record.
21.8
Utilization Review
The attending Medical Staff member shall be required to document the need for continued
hospitalization in accordance with the guidelines specified in the hospital's utilization review plan.
Upon request of the Medical Records/Utilization Review Committee, the attending shall provide
written justification of the necessity for continued hospitalization for a patient in question.
21.9
Discharge of Patient
Patients shall be discharged by 11:00 a.m. on an order of the attending Medical Staff member.
Patients awaiting special diagnostic reports shall be discharged by 1:00 p.m.
21.10 Pronouncement of Death
Pronouncement of death for hospital patients shall be made by a licensed physician within a
reasonable time and an entry made and signed in the medical record of the deceased. The release
of bodies shall be in accordance with hospital policy pertinent to this matter.
21.11 Autopsies
All Medical Staff members are encouraged to secure permission for autopsies whenever possible.
All autopsies shall be performed by the hospital pathologist or by a physician delegated this
responsibility only after a signed written consent has been obtained. Provisional anatomic
diagnoses shall be recorded on the medical record within 72 hours and the complete protocol shall
be made a part of the record within three months.
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ARTICLE 22 - MEDICAL RECORDS
22.1
Responsibility for Medical Record
The attending Medical Staff member shall be responsible for the preparation of a complete and
legible medical record for each patient. This record shall include:
a.
Identification data
b.
present illness
c.
personal history
d.
family history
e.
physical examination and provisional diagnosis
f.
special reports (consultations, clinical laboratory and radiology reports)
g.
medical or surgical treatment
h.
operative report
i.
pathological findings
j.
progress notes
k.
discharge note
l.
final diagnosis
m.
condition on discharge
n.
autopsy report (when applicable)
22.2
History and Physical Examination Report
A complete admission history and physical examination should be recorded within 24 hours of
admission and prior to performing any special diagnostic procedures and operative
procedures except in an emergency. This report should include the chief complaint and details
of the present illness, relevant past, social and family histories, an inventory of body systems, a
comprehensive physical assessment and provisional assessment encompassing the need for
hospitalization
In the event the history and physical examination has been dictated and is not available on the
record prior to the procedure, the physician must document in the progress notes, the reason for
the procedure, physical assessment and provisional assessment encompassing the need for
hospitalization and the procedure to be performed. In addition, the previously dictated history and
physical examination must be included in the medical record within 24 hours of admission.
A history and physical examination, written within the last 30 days may be accepted. However, it
must contain an updated medical record entry documenting an examination for any changes in the
patient's current condition prior to the procedure (taken from proposed hospital policy - MHS 385).
A short term admission history and physical will be acceptable when a patient is admitted for a
period not to exceed 24 hours. The physician must document in the progress notes the reason for
hospital admission. A hospital stay exceeding 24 hours will require a complete history and physical.
22.3
Records by House Staff and Teaching Physician
The attending physician shall sign the history and physical, operative report and discharge
summary of his private patients, when they have been dictated by a member of the House Staff. A
countersignature, by the supervising teaching physician, shall be required on the diagnosis sheet
on clinic/teaching cases. Dictated reports will be signed by House Staff. There shall be evidence in
the medical record that the teaching physician has been involved in the management of a patient
treated by a member of the House Staff.
22.4
Progress Notes
Pertinent progress notes should be recorded at the time of observation, sufficient to permit
continuity of care and transferability. Wherever possible, each of the patient's clinical problems
should be clearly identified in the progress notes and correlated with specific orders as well as
results of tests and treatment. Medical Staff members who fail to respond within 48 hours to a
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request from utilization review physicians for medical record documentation, shall be barred from
scheduling elective admissions as well as admitting previously scheduled elective admissions.
An admission note should be written within 24 hours of admission for all patients. It should contain
the chief complaint, review of present illness, pertinent findings of the physical examination, and
should conclude with an assessment of the patient's problems, reasons for hospitalization, and
plan of care.
Progress notes shall be written by the attending or designee daily on all general nursing care and
critical care units (except the Transitional Care Unit). Progress notes shall include documentation of
pertinent changes and reflect the need for continued stay.
22.5
Reports
Immediately following surgery or a medical invasive procedure (defined as a procedure performed
by a physician, dentist, or podiatrist in which the body is entered by a needle, tube, device, or
scope), an operative progress note shall be written to include the name of the primary practitioner
and assistants, findings, technical procedures used, specimens removed, and post-operative
diagnosis as well as estimated blood loss.
A detailed report of the surgery or medical invasive procedure should be dictated or written in the
medical record immediately after the procedure and should contain a description of the findings,
details of the surgical or medical invasive procedure, specimens removed, postoperative diagnosis
and the name of the primary practitioner and any assistants. The report should be promptly signed
by the practitioner and made a part of the patient's medical record.
22.6
Consultation Content
Consultations shall show evidence of a review of the patient's record by the consultant, pertinent
findings on examination of the patient, the consultant's opinion and recommendations. This report
shall be made a part of the patient's record. A limited statement such as "I concur" does not
constitute an acceptable report of consultation. When operative procedures are involved, the
consultation note shall, except in emergency situations so verified on the record, be recorded prior
to the operation.
The request for a consultation should be documented in the physician orders and the request
should be specific as to the reason for consult. In addition, the request should be made personally,
physician to physician. The results of the consultation should be documented in the record and in
addition should be communicated directly with the physician requesting the consult.
22.7
Symbols and Abbreviations
Symbols and abbreviations may be used only when they have been approved by the Medical Staff.
An official record of approved abbreviations shall be on file in the record room.
22.8
Discharge Summary
A discharge summary shall be written or dictated on all inpatients and observation patients’
medical records except for normal obstetrical deliveries, normal newborn infants, and day surgeries
and shall be authenticated by the responsible Medical Staff member. The discharge summary
should contain the following information: 1) the reason for hospitalization, 2) significant findings
(diagnoses), 3) procedures performed and treatment rendered, 4) the patient’s condition at
discharge, and 5) instructions to the patient and family, if any.
For normal newborns with uncomplicated deliveries and day surgeries, a progress note may
substitute for the discharge summary. The progress note documents the patient’s condition at
discharge, discharge instructions and follow-up care required.
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22.9
Completion of the Medical Record
The Medical Staff of MHS underscores the importance of an accurate, timely and complete medical
record. The goal of this policy is to encourage practitioners to complete the record on the hospital
units, during the patient stay.
Medical records will be audited for completeness when they reach the Health Information
Management Department. Incomplete records will be placed in the “equal access - common area”
to allow the attending and other involved medical staff members to complete the record. Every day
a record is not completed will be tracked.
A record becomes delinquent and begins to accrue “delinquent days”:
1.
After 7 days in equal access, if it lacks a history and physical examination and/or
operative/medical invasive procedure report.
2.
After 14 days in equal access, if it lacks a discharge summary report or a signature.
One delinquent day is attributed to a practitioner for each day that he/she has one or more
delinquent charts in the common area. A count of cumulative delinquent days will be tracked.
Practitioners will receive regular notification of the status of their medical records, and of their
“cumulative delinquent day” count. Practitioners, who accumulate 28 delinquent days, will be
notified of their status by letter from the Health Information Management department. Those who
accumulate 56 delinquent days will receive such notice and will meet with their Department Chair.
Those accumulating 84 delinquent days will be asked to meet with the Executive Committee of the
System Hospital.
Practitioners who accumulate a total of 100 delinquent days in a calendar year will be
automatically terminated from the Medical Staff. The practitioner will be eligible to reapply after
paying a $500 penalty fee, plus the $300 application fee, completion of an application for medical
staff membership and privileges, and will be considered a provisional appointee (losing all active
staff rights).
Practitioners who accumulate a total of 100 delinquent days in a calendar year two years in a row
will be terminated from the Medical Staff and will not be eligible to reapply for one year.
22.10 Authentication of Routine Order
A Medical Staff members' routine orders, when applicable to a given patient, shall be reproduced in
detail on the order sheet of the patient's record, dated, and signed by the staff member.
22.11 Release of Patient Information
Written consent of the patient is required for release of medical information to persons not
otherwise authorized to receive this information.
22.12 Medical Records are Property of the Hospital
All records (including any films, x-rays or other diagnostic record) are the property of the System
Hospital in question and may be removed from the hospital's jurisdiction and safekeeping only in
accordance with a court order, subpoena, or statute. In case of readmission of a patient, all
previous records shall be available for the use of the attending Medical Staff member. This shall
apply whether the patient is attended by the same staff member or by another. Unauthorized
removal of charts from the hospital is grounds for suspension of the Medical Staff member for a
period to be determined by the appropriate Executive Committee.
22.13 Availability of Medical Records
Access to all medical records of all patients shall be afforded to members of the Medical Staff for
bona fide study and research purposes consistent with applicable state and federal law and with
preserving the confidentiality of personal information concerning the individual patients. Subject to
the discretion of the Chief Executive Officer, former members of the Medical Staff shall be, in
accordance with applicable state and federal law, permitted access to information from the medical
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records of their patients covering all periods during which they attended such patients in the
hospital.
22.14 Filing of Medical Record
A medical record shall not be permanently filed until it is completed by the responsible Medical
Staff member or it is ordered filed by the medical records committee.
22.15 Medical Record in the Emergency Room
An appropriate medical record shall be kept for every patient receiving emergency medical care
and shall be incorporated in the patient's hospital record if such exists. The record shall include:
a.
adequate patient identification;
b.
information concerning the time of the patient's arrival, and by whom transported;
c.
pertinent history of the injury or illness including data relative to first aid or emergency
care given the patient prior to his arrival at the hospital;
d.
description of significant clinical, laboratory, and roentgenologic findings;
e.
diagnosis;
f.
treatment given;
g.
condition of the patient on discharge or transfer; and
h.
final disposition, including instructions given to the patient and/or his family, relative to
necessary follow-up care.
Each patient's medical record shall be signed by the physician in attendance that is responsible for
its clinical accuracy.
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ARTICLE 23 - GENERAL CONDUCT OF CARE
23.1
Definitions of Physician Roles in the Hospital
The following definitions describe the role and responsibilities physicians have in regard to a
hospitalized patient. Except for the primary care physician all other physicians described must have
privileges in the hospital appropriate to their role. The purpose of these descriptions is to assist in
the clarification of roles for the various physicians who may provide care to a patient in order to
assist with good communication between a patient’s physician care givers to provide optimum care
during hospitalization.
23.1.1 Attending Physician
The physician who is responsible for caring for the patient during an admission to the
hospital (including the physician who accepts the transfer of a patient) and ensuring the
record contains a history and physical, discharge summary, instructions listing all
medications and dosage. This physician is:
(1) Responsible for all treatment including medications and procedures and all diagnostic
tests and procedures that this physician orders, provides, directs or arranges. It is the
responsibility of the Attending Physician and Consulting Physician(s) or Covering
Physician(s) to discuss and approve in general planned testing and therapeutic
processes or procedures before they are done by the Consulting or Covering
Physician(s). However, the Attending Physician is not required to approve details of
those specific procedures, tests and items provided, ordered or arranged for by a
Consulting Physician or a Covering Physician while they are in process when such
procedure, test or items are within the realm of services for which the physician was
asked to consult or provide coverage.
(2) Responsible for coordinating all consults.
(3) Responsible for communicating with the primary care physician during hospitalization
to exchange information.
(4) Responsible for providing a written summary of the hospitalization to the primary care
physician and Consulting Physician(s) on discharge of the patient.
The medical record should clearly indicate the name of the attending physician. In order to
change the attending physician at any point during admission, the current attending
physician (or physician accepting the transfer of a patient) must obtain the consent of the
physician who will be the new attending physician and the consent and identity of the new
attending physician must be documented in the progress note and thereafter an order
written in the medical record to complete the documentation needed to properly indicate
that change of the attending physician.
23.1.2 Referring Physician
The physician who requests a consultation in the form of (a) evaluation alone or (b)
evaluation and treatment from another provider:
(1) The referring physician may be the same as the attending physician.
(2) If the referring physician is not the attending physician then he/she is responsible or
gaining approval from the attending physician before obtaining consultation. A referral
for consultation requires physician to physician communication.
23.1.3 Primary Care Physician
The physician who provides overall care for the patient outside the hospital. May be the
same as the attending physician or the referring physician.
23.1.4 Admitting Physician
The physician who admits a patient to the hospital, either directly or through the ER. May
be the same as the attending physician, the referring physician or the primary care
physician.
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23.1.5 Consulting Physician
A physician who is requested by direct communication with the referring physician either
(a) to evaluate or (b) to evaluate and treat a patient:
(1) The consulting physician is responsible for understanding the request (a or b) and for
informing the patient’s attending physician and referring physician about proposed
treatment and for receiving approval for same before proceeding.
23.1.6 Covering Physician
A physician who temporarily assumes care responsibilities for the patient on behalf of the
attending physician, a referring physician, primary care physician or consulting physician:
(1) This physician may be an associate
(2) Should have the same or similar privileges in the hospital.
(3) Two-way communication is essential as responsibilities are shifted both to the covering
physician and back to the attending physician.
23.2
Consultations
a.
It is the duty of the Medical Staff through its departmental chairmen to see that members
of the staff do not fail in the matter of calling consultants as needed. Judgment as to the
necessity for consultation rests with the attending Medical Staff member. Except when
consultation is precluded by emergency circumstances or is otherwise not indicated, the
attending Practitioner shall consult with another qualified Medical Staff member when a
patient requires a procedure or care that is not within the scope of the attending
physician's practice or when otherwise required by the Medical Staff or Hospital policies.
It shall be the obligation of the physician who desires a consult to personally contact the
consultant.
The request for a consultation should be documented in the physician orders and the
request should be specific as to the reason for the consult. The results of the consultation
should be documented in the record and in addition should be communicated directly with
the physician requesting the consult.
b.
23.3
Individuals acting as consultants must be appropriately credentialed in accord with the
Bylaws prior to providing consultation.
Clarification
a.
Clarification of Orders by Nursing Service: Both MHS and the Medical Staff organization
encourage nurses to seek clarification or assurances when they have questions or concerns
about the appropriateness of a physician's order, treatment methods, or delay in
treatment, or some other condition where the patient's health or safety might be at stake.
MHS and its medical staff organization ask that physicians and nurses communicate freely
and respectfully and that physicians handle questions from nurses responsibly and
sensitively and accept responsibility for resolving these questions satisfactorily (refer to
MHS Chain of Command Policy MHS 354 for specified procedure to be followed when a
nurse or other healthcare worker wishes to seek clarification or assurances from a
physician).
b.
Clarification of Orders by House Staff: If a member of the House Staff has any reason to
doubt or question the care provided to any patient or believes that appropriate
consultation is needed and has not been obtained, this individual shall call this to the
attention of the director of medical education. The director of medical education may bring
the matter to the attention of the appropriate department chairman and, when justified,
the department chairman may himself request a consultation.
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23.4
Orders for Treatment Shall be in Writing
All orders for treatment shall be in writing. An order shall be considered to be in writing if dictated
to an employee of the hospital whose a licensed nurse or a licensed, registered, or certified
professional acting within the scope of his or her licensure, registration, or certification (to include
registered dietitians, respiratory therapists, physical therapists, and pharmacists), and signed by
the person to whom dictated with the name of the Medical Staff member per his or her own name.
The ordering or attending Practitioner shall authenticate the orders in the time frame ordinarily
required for completion of the medical record, unless otherwise provided by hospital or medical
staff policies or guidelines.
Standing order forms will be acceptable if authenticated by the ordering or attending Practitioner.
23.5
Prescriptions During the Patient's Hospitalization
When possible, only drugs on the hospital drug list shall be prescribed. When other drugs are
ordered by the attending Medical Staff member for private patients, they will be secured by the
pharmacy. On order of the attending, this order specifying medication by name or by prescription
number and the name of the pharmacy, medications may be brought into the hospital for use
during the patient's stay.
23.6
Laboratory Work
a.
Laboratory service shall be provided by a System Hospital to assure as complete a service
as possible. Examinations which cannot be made in the hospital shall be referred to an
outside, approved laboratory and, in the case of a paying patient, shall be charged to the
patient.
b.
23.7
Each clinical department may require certain laboratory studies to be ordered on selected
patients who, because of their clinical diagnosis, have special needs. The department will
be required to review and update such requirements per departmental rules.
Patients Admitted for Dental Services
A patient admitted for dental care is a dual responsibility involving the Dentist and a Physician
member (a doctor of medicine or a doctor of osteopathy) of the Medical Staff.
a.
Dentist's responsibilities:
1.
a detailed dental history justifying hospital admission;
2.
a detailed description of the examination of the oral cavity and a pre-operative
diagnosis;
3.
a complete operative report, describing the finding and the technique. In case of
extraction of teeth, the dentist shall clearly state the number of teeth and
fragments removed. All tissue, including teeth and fragments, shall be sent to the
hospital pathologist for examination;
4.
progress notes as are pertinent to the oral condition;
5.
clinical resume; and
6.
responsibility to obtain coverage by an anesthesiologist.
b.
Physician's responsibilities:
1.
medical history pertinent to the patient's general health;
2.
a physical examination to determine the patient's condition prior to anesthesia;
and
3.
supervision of the patient's general health status while hospitalized, if indicated.
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23.8
Patients Admitted for Podiatric Services
a.
Podiatrist's responsibilities:
1.
a detailed podiatric history justifying hospital admission;
2.
a detailed description of the examination of the foot and a pre-operative diagnosis;
3.
a complete operative report, describing the finding and technique. All tissue shall
be sent to the hospital pathologist for examination;
4.
progress notes as are pertinent to the podiatric medical condition;
5.
clinical resume;
6.
responsibility to obtain coverage by an anesthesiologist
b.
Physician's responsibilities:
1.
medical history pertinent to the patient's general health;
2.
a physical examination to determine the patient's condition prior to anesthesia;
and
3.
supervision of the patient's general health status while hospitalized, if indicated.
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24.1
ARTICLE 24 - EMERGENCY SERVICES
Call Schedule
Each clinical department or service shall provide the emergency room with a current call list for
emergency room patients who do not request a specific member of the Medical Staff to care for
them.
Cases of non-compliance with departmental call schedules shall be referred to the appropriate
department.
It is the policy of Methodist Health System (MHS) hospitals to comply with the Emergency Medical
Treatment and Active Labor Act (EMTALA). EMTALA requires that any patient who presents at the
Emergency Department (ED) must receive an appropriate medical screening examination to
determine if that patient has an emergency medical condition. If so and except as authorized
under EMTALA, the patient’s condition must be stabilized prior to Transfer.
The provisions of EMTALA apply not only to the hospital but also to the practitioners who provide
on-call coverage. Failure to comply with EMTALA can result in fines to both the hospital and
practitioner of up to $50,000 per incident, civil lawsuits for damages, and exclusion from Medicare,
Medicaid, and other government funded health programs.
The purpose of this policy is to assist in compliance with EMTALA by explaining the obligations of
on-call practitioners under the law and under the policies of the MHS Medical Staff.
24.1.1 On-Call Practitioner Must Come To the ED When Called
The on-call practitioner must come to the ED when requested by the ED physician, another
physician, a nurse, or any hospital worker making the request on behalf of a practitioner or
nurse who is not available to call the on-call practitioner directly. Seeing the patient at the
on-call practitioner’s office or clinic is not an option until the patient is determined to be
“stable” or not to have an “emergency medical condition,” as those terms are defined in
the Definitions section below.
24.1.2 Disputes Over Need to Respond
If the on-call practitioner disagrees about the need to come to the ED, the on-call
practitioner must come to the hospital and render care irrespective of the disagreement.
The on-call practitioner may address the disagreement with the appropriate individual at
the hospital at a later time.
24.1.3 Assistance in Screening and/or Stabilization
If requested, the on-call practitioner shall be physically present in the ED to assist in
providing an appropriate medical screening examination, as well as in the ongoing
stabilization and treatment of an ED patient prior to Transfer. The on-call practitioner shall
remain in the ED until released by the ED physician. (See “Definitions” section below for a
definition of “stabilize.”)
24.1.4 Ability to Pay Not To Be Considered
The on-call practitioner shall not consider the patient’s financial circumstances or the
patient’s insurance or means of payment in the decision to respond to, treat, or Transfer
the patient.
24.1.5 Timely Response
The on-call practitioner must verbally respond to the ED physician’s call within 30 minutes
and be physically present in the ED within one hour if requested. Response time runs from
when the ED physician, nurse, or other hospital worker places the call.
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24.1.6 Justification for Delay
a)
The on-call practitioner is not required to interrupt any critical care services he/she
is providing at the time he/she receives a call to a specific patient (that is, care
that requires his or her personal management).
b)
Immediately after the practitioner finishes caring for the specific patient, he or she
will contact the requesting unit, respond if requested, and give an estimated time
of arrival.
24.1.7 Follow-Up Care
Unless other arrangements are made, the on-call practitioner shall provide follow-up
patient care throughout the episode of illness.
24.1.8 Disciplinary Actions
a)
Any violation of this policy by an on-call practitioner will be reported to the
Department Chair. The Department Chair will notify the President of the Medical
Staff.
b)
Except in the case of a flagrant violation, for the first incident, the on-call
practitioner will receive counseling, a rebuke, and/or an official warning.
c)
If the on-call practitioner commits a second violation, he or she will be reported to
the Department Chair, who may recommend to the President of the Medical Staff
any action he/she deems appropriate. The Department Chair shall also provide a
written report to the President of the Medical Staff at the System Hospital in
question who shall report the matter to the System Hospital Medical Staff
Executive Committee.
d)
The Medical Staff Executive Committee may recommend any type of corrective
action available under the Medical Staff Bylaws.
e)
Any violation if this policy may be reported to and if the violation is flagrant shall
be reported to the Chief Executive Officer and Board of Directors.
f)
In determining whether a violation is flagrant, the System Hospital Medical Staff
Executive Committee shall consider the total circumstances, including, but not
limited to, whether the violation was deliberate, the seriousness of the patient’s
condition, and how disruptive the violation was to hospital operations.
24.1.9 Definitions
Emergency Medical Condition means:
a)
A medical condition manifesting itself by acute symptoms of sufficient severity
(including severe pain) such that the absence of immediate medical attention
could reasonably be expected to result in:
(i)
Placing the health of the individual (or, with respect to a pregnant woman,
the health of the woman or her unborn child) in serious jeopardy,
(ii)
Serious impairment to bodily functions, or
(iii)
Serious dysfunction of any bodily organ or part, or
b)
With respect to a pregnant woman who is having contractions:
(i)
That there is inadequate time to effect a safe Transfer to another hospital
before delivery, or
(ii)
The Transfer may pose a threat to the health or safety of the woman or
the unborn child
Stabilize means: with respect to an Emergency Medical Condition, to provide such medical
treatment of the condition as may be necessary to assure within reasonable medical
probability, that no material deterioration of the condition is likely to result from or occur
during the Transfer of the individual from a facility, or, with respect to an Emergency
Medical Condition involving a pregnant woman, that the woman has delivered (including
the placenta).
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Transfer means: the movement (including the discharge) of an individual outside of a
System Hospital’s facilities at the direction of any person employed by (or affiliated or
associated, directly or indirectly, with) the System Hospital, but does not include such a
movement of an individual who has been declared dead or leaves the facility without the
permission of any such person.
24.2
Disaster Plans
a.
There shall be a plan for the care of mass casualties at the time of any major disaster,
based upon the System Hospital's capabilities in conjunction with other emergency
facilities in the community. It shall be developed by a disaster planning committee which
includes at least two members of the Medical Staff, the director of nursing services or
designee, and a representative from the System Hospital administration.
b.
24.3
A Medical Staff member shall fulfill his duties and responsibilities under the disaster plan of
the System Hospital, reporting to the hospital upon notification, and functioning as
assigned by the medical officer in charge. The medical officer in charge and the Chief
Executive Officer shall coordinate activities and directions, including, if necessary,
evaluation of evacuation from hospital premises. The plan for mass casualties shall be
rehearsed at least twice a year.
Disaster Privileges
24.3.1 Purpose
To provide guidelines for the privileging of practitioners who are not members of the
medical staff or do not possess medical staff privileges at Methodist Health System during
an “Emergency” (defined as any officially declared emergency, whether it is local, state, or
national).
24.3.2 Policy
Any practitioner providing patient care must be granted privileges prior to providing patient
care, even in an Emergency. During an Emergency, practitioners who do not have
privileges to practice at a System Hospital may be granted privileges in accordance with
the guidelines set out in this policy.
24.3.3 Procedure
These guidelines only apply if an Emergency exists. The Disaster Control Officer (as
defined under the Methodist Health System Disaster Plan or the principal administrative
officer of the hospital coordinating the response to the disaster in accordance with such
plan) shall have the authority to determine if an Emergency exists for purposes of
activating this policy. The following information must be provided and, if possible, verified
in order for a practitioner without privileges to be granted privileges when an Emergency
exists:
1.
2.
3.
4.
Valid professional license to practice in Texas
Valid picture ID issued by a state, federal, or regulatory agency
List of current hospital affiliations where the practitioner holds active staff
privileges
National Practitioner Data Bank and OIG query
Verification of the above information should be completed as soon as possible by the
medical staff office or as soon as feasible. A record of this information should be retained.
It is recommended that the practitioner act under the supervision of a medical staff
member.
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Privileges may be granted in accordance with this policy by the Disaster Control Officer,
the Chief Executive Officer or an Executive Vice President of Methodist Health System or
by the designee of any such officer, conditioned upon the receipt of a favorable
recommendation (written or oral) by the president, president-elect or immediate pastpresident of the medical staff for either System Hospital, the chair person of the Corporate
Medical Board, or the chair person of the Corporate Credentials Committee (the medical
staff officer making the recommendation must be on the active staff of the Medical Staff at
the time he/she makes the recommendation).
When the Emergency no longer exists, all privileges granted pursuant to this policy
terminate automatically.
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ARTICLE 25 - GENERAL
25.1
Confidentiality of Medical Staff Files
The confidentiality of all files pertaining to a Medical Staff member or an individual applying for
Medical Staff membership shall be preserved. All minutes of Medical Staff departmental,
committee, and general staff meetings, all credentials files, and all correspondence, reports,
documents and files generated by or for the Medical Staff are considered privileged. Medical Staff
files may be reviewed only at the discretion of the president of the System Hospital medical staff,
the respective departmental chairmen, or committee chairmen and/ with the approval of the Chief
Executive Officer or an Executive Vice President.
All Medical Staff files, minutes, credentials, and other related documents are maintained in the
Medical Staff Services Department. All records are held in strict confidence and safeguard.
25.2
Assessment for Medical Staff Members
Medical Staff members may be assessed an amount to be determined by the Executive Committee
each year for the medical education fund.
25.3
Hospital Orientation
Basic orientation sessions with hospital department such as Medical Staff Services, Medical
Records, Utilization Review, Operating Room, Emergency Room, and Admitting area arranged for
new members of the Medical Staff by the Medical Staff coordinator.
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Methodist Health System Medical Staff Practitioners
Notice of Privacy Practices
Effective Date: April 14, 2003
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.
If you have any questions about this Notice please contact: HIPAA Privacy Officer at 214-947-4472.
This Notice describes how physicians, dentist, podiatrists and independent allied health professionals
engaged in the private practice of medicine who have been granted privileges to provide health care at
Methodist Health System (“MHS”) facilities (collectively all such physicians, dentists, podiatrists and allied
health professionals are referred to as “Practitioners”) may use and disclose your protected health
information for purposes of treatment, payment or health care operations and for other purposes that are
permitted or required by law. “Protected health information” is information about you, including
demographic information, that may identify you and that relates to your past, present or future physical or
mental health or condition and related health care services. It also describes your rights to access and
control your protected health information.
A record of care and services is created in order to manage the care you receive and to comply with
certain legal requirements. The Practitioners understand that medical information about you is personal.
The Practitioners are committed to protecting medical information about you and are required by law to:
 maintain the privacy of your protected health information;
 provide you with this notice summarizing the Practitioners legal duties and practices related to the use
and disclosure of medical information;
 abide by the terms of the notice currently in effect.
The Practitioners reserve the right to change this notice. The new notice will be effective for all protected
health information that the Practitioners possess at that time and that the Practitioners receive in the
future. The current notice will be available upon request, at Methodist Health System facilities and on the
web page www.MHS.com.
1. Uses and Disclosures of Protected Health Information
The following categories describe the types of uses and disclosures of your protected health care
information that the Practitioners, their office staff and their agents may make once you have
acknowledged receipt of this notice. For each category of uses or disclosure this notice will explain what is
meant and provide some examples. These categories and examples are not meant to be exhaustive, but to
describe the types of uses and disclosures that may be made as allowed under the law.
Treatment: The Practitioners will use and disclose your protected health information to provide,
coordinate, or manage your health care and any related services. This includes the coordination or
management of your health care with a third party that has already obtained your permission to have
access to your protected health information. For example the Practitioners would disclose your protected
health information, as necessary, to a home health agency that provides care to you. The Practitioners will
also disclose protected health information to other physicians who may be treating you when you have
given the necessary permission to disclose your protected health information. For example, your protected
health information may be provided to a physician to whom you have been referred to ensure that the
physician has the necessary information to diagnose or treat you. In addition, the Practitioners may
disclose your protected health information from time-to-time to another physician or health care provider
(e.g., a specialist or laboratory) who, becomes involved in your care by providing assistance with your
health care diagnosis or treatment.
Payment: The Practitioners may use and disclose medical information about you so that the treatment
and services you receive or are provided on your behalf by the Practitioners covered by this Notice at the
hospital may be billed to and payment may be collected from you, an insurance company or a third party.
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For example, the Practitioners may need to give your health plan information about surgery you received
at the hospital so your health plan will pay the involved Practitioners or reimburse you for the surgery. The
Practitioners may also tell your health plan about a treatment you are going to receive to obtain prior
approval or to determine whether your plan will cover the treatment
Healthcare Operations. The Practitioners may use or disclose, as-needed, your protected health
information in order to support the business activities of their practices. These activities include, but are
not limited to, quality assessment activities, employee review activities, training of medical students,
licensing, and conducting or arranging for other business activities. For example, the Practitioners may
disclose your protected health information to their office staff to coordinate your care and records. In
addition, the Practitioners may use a sign-in sheet at the registration desk where you will be asked to sign
your name and indicate your physician. The Practitioners may also call you by name in the waiting room
when your physician is ready to see you.
Appointment Reminders. The Practitioners may use or disclose your protected health information, as
necessary, to contact you to remind you of your appointment.
Treatment Alternatives and Health-Related Benefits and Services. The Practitioner may use or
disclose your protected health information, as necessary, to provide you with information about treatment
alternatives or other health-related benefits and services that may be of interest to you. You may contact
your Practitioner’s office from where you received such material to request, in writing, that these materials
not be sent to you.
Fundraising Activities. A Practitioner may use or disclose your demographic information and the dates
that you received treatment from your Practitioner, as necessary, in order to contact you for fundraising
activities supported by our office. If you do not want to receive these materials, please contact your
Practitioner’s office, in writing, and request that these fundraising materials not be sent to you.
Facility Directories: Unless you sign a document to become a No Information Patient, the Practitioners
may use and disclose in a directory your name, the location at which you are receiving care, your condition
(in general terms), and your religious affiliation. All of this information, except religious affiliation, will be
disclosed to people that ask for you by name. Members of the clergy will be told your religious affiliation.
Individuals Involved in Your Care or Payment for Your Care. The Practitioners may release medical
information about you to a friend or family member who is involved in your medical care. The Practitioners
may also give information to someone who helps pay for your care. The Practitioners may also tell your
family or friends your condition and that you are in the hospital. In addition, the Practitioners may disclose
medical information about you to an entity assisting in a disaster relief effort so that your family can be
notified about your condition, status and location.
Emergencies. The Practitioners may use or disclose your protected health information in an emergency
treatment situation without your acknowledgment of this Notice. If this happens, an attempt will be made
to try and obtain your acknowledgement as soon as reasonably practicable after the delivery of treatment.
If a Practitioner is required by law to treat you and the Practitioner has attempted to obtain your
acknowledgment but is unable to obtain your acknowledgment, he or she may still use or disclose your
protected health information for treatment, payment and operation purposes.
Research. The Practitioner may use or disclose information about you for purposes of research projects
approved by an institutional review board that has reviewed the research proposal and established
protocols to ensure the privacy of your health information. The Practitioner will almost always ask for your
specific permission if they will have access to your name, address or other information that reveals who
you are, or will be involved in your care at the hospital.
Food and Drug Administration. The Practitioner may disclose your protected health information to a
person or company required by the Food and Drug Administration to report adverse events, product
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defects or problems, biologic product deviations; to track products; to enable product recalls; to make
repairs or replacements, or to conduct post marketing surveillance, as required
As Required By Law. The Practitioners will disclose medical information about you when required to do
so by federal, state or local law.
To Avert a Serious Threat to Health or Safety. The Practitioners may use and disclose medical
information about you when necessary to prevent a serious threat to your health and safety or the health
and safety of the public or another person. Any disclosure, however, would only be to someone able to
help prevent the threat.
Organ and Tissue Donation. If you are an organ donor the Practitioners may release medical
information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an
organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
Military and Veterans. If you are a member of the armed forces, the Practitioners may release medical
information about you as required by military command authorities. The Practitioners may also release
medical information about foreign military personnel to the appropriate foreign military authority.
Workers' Compensation The Practitioners may release medical information about you for workers'
compensation or similar programs. These programs provide benefits for work-related injuries or illness.
Public Health Risks. The Practitioners may disclose medical information about you for public health
activities. These activities generally include the following:
 to prevent or control disease, injury or disability;
 to report births and deaths;
 to report child abuse or neglect;
 to report reactions to medications or problems with products;
 to notify people of recalls of products they may be using;
 to notify a person who may have been exposed to a disease or may be at risk for contracting or
spreading a disease or condition;
 to notify the appropriate government authority if we believe a patient has been the victim of abuse,
neglect or domestic violence. We will only make this disclosure if you agree or when required or
authorized by law.
Health Oversight Activities. The Practitioners may disclose medical information to a health oversight
agency for activities authorized by law. These oversight activities include, for example, audits,
investigations, inspections, and licensure. These activities are necessary for the government to monitor the
health care system, government programs, and compliance with civil rights laws.
Lawsuits and Disputes. If you are involved in a lawsuit or a dispute the Practitioners may disclose
medical information about you in response to a court or administrative order. The Practitioners may also
disclose medical information about you in response to a subpoena, discovery request, or other lawful
process by someone else involved in the dispute, but only if efforts have been made to tell you about the
request or to obtain an order protecting the information requested.
Law Enforcement. The Practitioners may release medical information if asked to do so by a law
enforcement official:
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In response to a court order, subpoena, warrant, summons or similar process;
To identify or locate a suspect, fugitive, material witness, or missing person;
About the victim of a crime if, under certain limited circumstances, we are unable to obtain the
person's agreement;
About a death we believe may be the result of criminal conduct;
About criminal conduct at the hospital; and
In emergency circumstances to report a crime; the location of the crime or victims; or the identity,
description or location of the person who committed the crime.
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Coroners, Medical Examiners and Funeral Directors. The Practitioners may release medical
information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased
person or determine the cause of death. The Practitioners may also release medical information about
patients of the hospital to funeral directors as necessary to carry out their duties.
National Security and Intelligence Activities. The Practitioners may release medical information
about you to authorized federal officials for intelligence, counterintelligence, and other national security
activities authorized by law.
Protective Services for the President and Others. The Practitioners may disclose medical information
about you to authorized federal officials so they may provide protection to the President, other authorized
persons or foreign heads of state or conduct special investigations.
Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement
official, the Practitioners may release medical information about you to the correctional institution or law
enforcement official. This release would be necessary (1) for the institution to provide you with health
care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and
security of the correctional institution.
Required Uses and Disclosures: Under the law, the Practitioners must make disclosures to you and
when required by the Secretary of the Department of Health and Human Services to investigate or
determine our compliance with the requirements of Section 164.500 et. seq.
Uses and Disclosures of Protected Health Information Based upon Your Written Authorization.
Other uses and disclosures of your protected health information will be made only with your written
authorization, unless otherwise permitted or required by law as described below. You may revoke your
authorization, at any time, in writing, except to the extent that a Practitioner or his or her practice has
taken an action in reliance on the use or disclosure indicated in the authorization.
2. Your Rights
The following is a statement of your rights with respect to your protected health information and a brief
description of how you may exercise these rights.
Right to inspect and copy your protected health information. You have the right to inspect and
copy your medical information, as provided by law, usually this includes medical and billing records but
does not include psychotherapy notes. You must submit your request to inspect and copy in writing to the
Health Information Management Department of the MHS facility at which you were treated. Your request
to inspect or copy may be denied in certain circumstances and in case of such denial, you may have the
right to have this decision reviewed by a health care professional of the Practitioner’s choosing. For
purposes of this Notice of Privacy Practices, the right expressed in this provision applies only to the health
information maintained by the MHS facility at which the Practitioner provided you care. For health
information maintained by the specific Practitioner in question (or the specific Practitioner’s office), please
contact the Practitioner or the Practitioner’s office.
Right to have your physician amend your protected health information. If you feel medical
information the Practitioner have about you is incorrect or incomplete, you may request that the
information be amended. You must submit a request for amendment to the Health Information
Management Department of the MHS facility at which you were treated with a reason supporting your
request to amend. The request may be denied if the request is;
 Not in writing
 not supported by a reason
 asks to amend information that is accurate or complete
 for parts of the information you are not permitted to inspect or copy, by law
 part of the record which was not created by the Practitioner
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For purposes of this Notice of Privacy Practices, the right expressed in this provision applies only to the
health information maintained by the MHS facility at which the Practitioner provided you care. For health
information maintained by the specific Practitioner in question (or the specific Practitioner’s office), please
contact the Practitioner or the Practitioner’s office.
Right to request a restriction of your protected health information. You may ask a Practitioner not
to use or disclose any part of your protected health information for the purposes of treatment, payment or
healthcare operations. You may also request that any part of your protected health information not be
disclosed to family members or friends who may be involved in your care, unless provided for by law. The
Practitioners are not required by law to agree to a restriction that you may request. You may request a
restriction by completing a Request for Restrictions form and present it to admitting or registration
representative at the MHS hospital at which you were treated for acceptance or denial. For purposes of this
Notice of Privacy Practices, the right expressed in this provision applies only to the health information
maintained by the MHS facility at which the Practitioner provided you care. For health information
maintained by the specific Practitioner in question (or the specific Practitioner’s office), please contact the
Practitioner or the Practitioner’s office.
Right to request confidential communications. You have the right to request that the Practitioner
communicate with you about medical matters in a certain way or at a certain location. For example, you
can ask that you only be contacted at work or by mail. Please make this request in writing to an admitting
or registration representative at the MHS hospital at which you were treated. You will not be asked the
reason for your request, and reasonable requests will be accommodated. Your request may also be
conditioned on you providing information as to how payment will be handled or specification of an
alternative address or other method of contact. For purposes of this Notice of Privacy Practices, the right
expressed in this provision applies only to communications of or with the MHS facility at which the
Practitioner provided you care. For communications of or with the specific Practitioner in question (or the
specific Practitioner’s office), please contact the Practitioner or the Practitioner’s office.
Right to an accounting of disclosures, if any, of your protected health information. This right
applies to disclosures for purposes other than treatment, payment or healthcare operations or other
allowed disclosures including those to family members or friends involved in your care, as described in this
Notice of Privacy Practices. It may also exclude disclosures made based upon a written authorization from
you. You have the right to a list of disclosures for time periods no longer than six years and not before
April 14, 2003. The first list you request within a 12 month period will be free. For additional lists you may
be charged a fee which you will be asked for prior to compiling the list. Please make any requests for a list
of disclosures covered by this Notice to the Health Information Management Department of the MHS
facility where you were treated. For purposes of this Notice of Privacy Practices, the right expressed in this
provision applies only to disclosures made by the MHS facility at which the Practitioner provided you care.
For disclosures made by the specific Practitioner in question (or the specific Practitioner’s office), please
contact the Practitioner or the Practitioner’s office.
Right to obtain a paper copy of this notice . Upon your request, the Practitioner office will provide you
with a paper copy of this notice, even if you have agreed to accept this notice electronically.
3. Complaints
You may complain to a Practitioner, to the MHS facility were the Practitioner provided you care, or to the
Secretary of Health and Human Services if you believe your privacy rights have been violated by the
Practitioner. You may file a complaint with the Practitioner by notifying your Practitioner or with the MHS
facility by notifying Methodist Health System, Corporate Offices – HIPAA Privacy Officer, 1441 N. Beckley,
Dallas Texas 75203, of your complaint. All complaints must be in writing, and you will not be retaliated
against for filing a complaint.
You may contact our Privacy Contact at (214) 947-4472.
This notice was published and becomes effective on April 14, 2003.
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