BAYSHORE COMMUNITY HOSPITAL
DEPARTMENT OF OPHTHALMOLOGY
RULES AND REGULATIONS
1.
DEFINITION:
The Department of Ophthalmology will be composed of all ophthalmologists.
Chair
The Chair of the Department must hold the rank of Full Attending or Senior
Attending and be Board Certified in the appropriate specialty and will be elected
for a two (2) year term at a departmental meeting held in September. This term
of office will commence on January 1. A Chair may be re-elected for another
two (2) year term and then must remain out of office for a period of one term.
Vice Chair
The Vice Chair of the Department of Ophthalmology shall be chosen by the
Department Chair.
2.
APPOINTMENTS:
Appointment to the Ophthalmology Service is accomplished by application to the Staff,
recommendation by the Department Chair and approval by the Credentials Committee,
Executive Committee, and Board of Trustees. At the time of approval by the Credentials
Committee, the Chair of the Department will recommend the rank of the incoming
ophthalmologist based on several requirements. All new applicants will be evaluated by
the Department Chair prior to appearance at the Credentials Committee. At that time,
the Chair will ascertain whether or not the ophthalmologist intends to become a fully
functioning member of the Hospital and Medical Staff and would be primarily utilizing
Bayshore Hospital. The Chair and the applicant will decide whether he/she should be
placed on the Active or Regional (Active) Staff. Very infrequently would a new member
be admitted at the Associate Attending or Full Attending level. If an ophthalmologist
has six (6) or more admissions or provides services to twenty-five (25) or more hospitalbased patients, he/she will be asked to assume the responsibilities of an Assistant
Attending.
All initial appointments to the Ophthalmology Staff shall be Provisional/probationary
appointments. Provisional appointments shall be for a period of twelve (12) months
which may be extended once for an additional twelve (12) months. The practitioner
shall be notified, in writing, by the Chair of Ophthalmology when the Provisional period
is to be extended. If, after the extension of the Provisional period has expired, a
practitioner is not appointed to the Staff, the Staff appointment shall be deemed to be
terminated.
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Department of Ophthalmology - Rules and Regulations
3.
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RANKS:
Ranks will be recommended by the Chair of the Department of Ophthalmology who will
utilize the procedures outlined in the Medical Staff Bylaws to have these
recommendations confirmed.
a) Assistant Attending
Assistant Attending is the usual entering rank for full-time Department of
Ophthalmology physicians and Carries with it the responsibilities of being
present in the hospital or providing equivalent coverage for any hours assigned.
Assistant Attendings are expected to attend all Department meetings and to
participate in hospital functions related to patient care.
b) Associate Attending
The rank of Associate Attending is available for those physicians who have
served as Assistant Attending for a minimum of at least one year. This rank will
be considered for those who have demonstrated excellence in emergency care
performance. The rank is not automatic and attitude will be considered by the
Chair when promoting a physician to this rank.
c) Full Attending
In order to achieve Full attending status, the physician must be Board Certified
in the appropriate specialty and filed in the medical staff office, and must have
served a minimum of one year as an Associate Attending. The Physician must
fulfill all of the requirements and obligations and show more than an active
interest in the hospital.
4.
PRIVILEGES:
Requests for initial levels of privileges require a list of operations performed during the
last five (5) years or other period as appropriate by the Department Chair.
When new privileges for procedures are requested, the ophthalmologist must present
documentation indicating attendance at courses, where and how long the courses were
and the name of the sponsoring organization. After approval by the Chair of
Ophthalmology, the request will be presented to the Credentials Committee, Executive
Committee, and the Board of Trustees with recommendations for performance of the
procedure with or without supervision.
The Chair of Ophthalmology will review the documents presented by the applicant to
include specifically training and experience in each area of ophthalmology for which the
applicant intends to ask for privileges. These documents should be specific insofar as
experience in the given area is concerned, whether by number of cases or length of time
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spent on a particular service, recommendations from the Directors of the Services, and
if possible, total number of cases as operating surgeon or assistant.
When an ophthalmologist who already has privileges in one area requests privileges in
either another area of ophthalmology or in a new technique of ophthalmology, that
ophthalmologist must present to the Chair of Ophthalmology, for forwarding to the
Executive Committee, Credentials Committee, and the Board of Trustees, evidence of
attendance at a continuing medical education function such as a course or a group of
courses. The ophthalmologist must present written evidence of attendance and, if
possible, a graduation type certificate from the institutions where he/she received
training. With this new addition to the ophthalmologist’s privileges delineation, a
supervisory period will be designated on each occasion. When these new privileges
have been approved, the Medical Staff Manager will send written notification to the
Operating Room.
In the biennial reapplication and redelineation of privileges of all ophthalmologists,
appraisal of the ophthalmologist’s competency in performing certain procedures will be
carried out. Consideration will be given to the recency of performance of the
procedure, postgraduate courses, continuing medical education, and other educational
material which may have a bearing on the competency of the ophthalmologist’s
performance. It is conceivable that an ophthalmologist who has not performed a
procedure for some time may be asked to demonstrate his/her competency in that
particular procedure or procedures, either by proof of further study or practice or by
supervision.
Operating Room privileges will be extended to all members of the Department of
Ophthalmology in accordance with their recognized skills, training, established
precedence and according to delineation of privileges.
If one or more members of the Medical Staff desire privileges that differ significantly
from the scope of practice implied by the privileges already granted to that (or those)
individuals, such individuals should make application to the Chair of his/her
Department, for such privileges, in writing. The Chair of the Department will then (with
the aid of an ad hoc committee which he/she will appoint if he/she so desires):
a) for new procedures or expanded scope of care at this institution,
make a recommendation to the Credentials Committee regarding
the advisability of granting the privileges and, where indicated, the
cost efficiency of such care.
b) provide the Credentials Committee with proposed criteria for the
granting of privileges for the new procedure or expanded scope of care.
c) make an individual recommendation to the Credentials Committee
regarding the practitioner requesting the privileges.
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d) propose a mechanism to the Credentials Committee for enhanced
monitoring and evaluation of clinical performance and outcomes.
The Credentials Committee will then act upon the aforementioned matters and refer its
recommendations to the Executive Committee and then to the Board of Trustees of the
Hospital for final action.
If the privileges “cross over” departmental or service lines, the application will be
reviewed by the Chair of each of the involved departments. If the Chair of the
Department fails to make any recommendations within sixty (60) days, the application
may be referred by the individual practitioner to the Medical Executive Committee.
Should the decision by the Executive Committee be unfavorable to the requesting
practitioner, he/she may appeal the decision through the usual due process described in
the Bylaws.
When the privileges requested have been approved by the Executive Committee, the
new privileges will be recorded in the practitioner’s privilege record and distributed in
the usual manner.
Members of the Department of Ophthalmology may appeal and oppose changes of
status of their privileges by the mechanisms established in the Bylaws of the Medical
Staff of Bayshore Community Hospital.
A Delineation of Privileges form will be kept in each doctor’s file in the Medical Staff
Office as well as in the Operating Room. On the Reapplication form, it must be stated
that the privileges which are being requested are adequate and fully covered by
appropriate malpractice insurance.
Renewal of privileges within the Department of Ophthalmology will be based on
consideration of the following:
a) Basic medical knowledge
b) Professional judgment
c) Sense of responsibility
d) Ethical conduct
e) Competence and skill
f) Cooperativeness, ability to work with others
g) Reasonable use of hospital facilities (admission of patients to the
Hospital not generated by E.D. call)
h) Appearance
i) History and physical exam taking
j) Record keeping
k) Case presentations
l) Patient management
m) Physician-patient relationship
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n) Ability to understand/speak English
o) Participation in Medical Staff affairs
p) Physical and mental capabilities
q) Continuous professional education
r) Prompt and timely completion of medical records
s) Attendance at Quarterly Staff, department/section and committee meetings
t) Reasonable use of Hospital facilities
Additionally, renewal of privileges will be affected by being cited by:
a)
b)
c)
d)
e)
Utilization Review
Multi-Disciplinary Peer Review Committee
Infection Control Committee
Credentials Committee
Executive Committee
Without adequate exposure in the O.R., E.D., and the floors, no one, including the Chair,
can determine whether or not the applicant should be removed from Provisional Status.
The applicant should be aware that Provisional status expires at the end of twenty-four
(24) months and if he/she is not recommended for full privileges at that time, the Staff
Appointment shall be deemed to be terminated.
5.
SUPERVISION:
Every new ophthalmologist who comes into the Ophthalmology Service will have a
period of supervision, the duration of which will vary. The supervision consists of having
any Assistant, Associate, or Full Attending, in the same specialty, on the Ophthalmology
Service review the chart preoperatively to include the necessity for surgery, the type of
surgery to be done, and to actually operate with the ophthalmologist in the Operating
Room, and then to check the follow-up care of the patient during the hospital stay,
including postoperative orders.
Each time an operative case is performed, the supervising surgeon must complete a
Surgical Proctor’s Report which will be sent by the Supervisor of the Operating Room to
the Medical Staff Coordinator for inclusion in the ophthalmologist’s file. No definite
number of required cases is listed as far as being removed from supervision is
concerned. A minimum of six (6) major cases would be suggested before consideration
is given for removal from supervision. An ophthalmologist is removed from supervision
by the Chair of Ophthalmology on the advice of the surgeons who have participated in
the supervisory period. This notification will be in writing by the Chair to the
Ophthalmologist, to the Operating Room Supervisor, and to the Medical Staff Manager
who will make the other departments of the Hospital aware of this removal from
supervision. Minor cases defined as short, uncomplicated, requiring local anesthesia
and regarded by the Ophthalmology Staff as minor surgery do not require supervision.
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Department of Ophthalmology - Rules and Regulations
6.
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CONSULTATIONS:
If there should be an occurrence where an ophthalmologist refuses to give permission
to another doctor to examine, render an opinion, or take over a case, the Chair of
Ophthalmology first, the President of the Medical Staff second, and the President of the
Hospital third should be approached to help obtain that permission. If there is an
urgent or emergency situation, any one of these three officials could be contacted by
telephone to arbitrate the situation and to help make a decision.
7.
ELECTION FOR DEPARTMENT CHAIR:
VOTING PRIVILEGES
Voting privileges for Medical Staff elections shall be granted in accordance with the
Bylaws, Rules and Regulations of the Medical Staff of Bayshore Community Hospital.
All interested members interested in running for Chair will be screened. Only
ophthalmologists who are Full Attending and who are qualified to vote and not on
suspension will be considered. No nominations will be obtained from the floor at the
September Ophthalmology Staff meeting.
All members present at the meeting have the right to vote.
8.
MEETINGS/ATTENDANCE:
Departmental meetings will be held on a quarterly basis. Permanent records of these
meetings will be kept.
Rotation with mortality conferences and presentation of selected cases will be
maintained throughout the year. Quality Improvement reports and a review of the
work of the Department will be carried out at these meetings.
If a member of the Department of Ophthalmology has not attended the required
number of departmental meetings, Quarterly Staff Meetings, and committee meetings
from January 1st to December 31st of the previous year such that the Member maintains
active status as defined by the Medical Staff Bylaws, he/she will be ineligible to vote for
the Chair of the Department of Ophthalmology at the September meeting and for the
officers of the Medical Staff and members-at-large of the Executive Committee at the
December Quarterly Staff Meeting.
9.
OPERATING ROOM:
a) Consent for Surgery
No patient may be operated on without proper consent, signed by the
patient or legal representative, except in an emergency life and death
situation. This consent will consist of the prescribed Bayshore Community
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Hospital form, and, in addition, the operating ophthalmologist must
document, in writing, on the chart, over his/her signature, that the surgery
has been explained to the patient or legal representative and consent
obtained.
b) Supervision
Every ophthalmologist, when entering the Operating Room to perform a
surgical procedure or assist in a surgical procedure, is under the direct
supervision, observation, and control of the Chair of the Department of
Ophthalmology. This specifically applies, not only to ophthalmologists,
surgeons and oral surgeons, but also to the occasional internist, such as a
gastroenterologist or medical pulmonary specialist who requests the use of
the Operating Room to provide proper care to a patient.
10.
EMERGENCY ROOM ASSIGNMENT:
Everyone on the Ophthalmology Service is expected to rotate on Emergency
Department call within his/her specialty. Regional Staff members and Senior Attending
members do not rotate although they may be required to take E.D. call at the discretion
of the Chair based on Hospital need. Assistant, Associate, and Full Attending members
normally take their turn at Emergency Department call. Some ophthalmologists who
have offices and practices which are primarily in another area may request not to be
placed on Emergency Department call, and consideration will be given to their request.
Assignment to E.D. call is completed by the Chair of Ophthalmology each Fall for the
coming year. Since E.D. call in Ophthalmology at Bayshore Community Hospital is a
privilege rather than a duty, assignment will be based on the following:
a) Basic medical knowledge
b) Professional judgment
c) Sense of responsibility
d) Ethical conduct
e) Competence and skill
f) Cooperativeness, ability to work with others
g) Reasonable use of Hospital facilities (admission of patients to
the Hospital not generated by E.D. call)
h) Appearance
i) History and physical exam taking
j) Record keeping
k) Case presentations
l) Patient management
m) Physician-Patient relationship
n) Ability to understand/speak English
o) Participation in Medical Staff affairs
p) Physical and mental capabilities
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Department of Ophthalmology - Rules and Regulations
q) Continuous professional education
r) Prompt and timely completion of medical records
s) Attendance at Quarterly Staff, department/section and committee
meetings
t) Location of office with obvious little chance of admitting patients
to the Hospital through that office practice
In addition, assignment will be affected by citation by:
a)
b)
c)
d)
11.
Utilization Review
Multi-Disciplinary Peer Review Committee
Infection Control Committee
Executive Committee
PEER REVIEW AND QUALITY MONITORING:
The Department will perform regular quality monitoring. This quality monitoring will
include Ongoing Professional Practice Evaluation (OPPE) and Focused Professional
Practice Evaluation (FPPE) as outlined in Section III of the Medical Staff Rules and
Regulations.
Focused Professional Practice Evaluation (FPPE)
A FPPE will be conducted in the following situations:
1. For all new department members. The FPPE occurs during the period in
which the new practitioner is on supervision.
2. When a practitioner requests a new privilege.
3. When any other below triggers are met:
 A single event that resulted in a mortality or caused significant harm;
 A single event that may/can cause significant harm if repeated;
 An identified pattern that has negatively impacted on the health of the
patient;
 An identified pattern that has the potential to adversely impact on the
health of the patient;
 Complaints by patients, family members or designated legal
representatives of a patient regarding care/treatment.
 Deviation from an expected range of values resulting from PI data
collection.
 Adverse or negative performance trend over six consecutive months of
Ongoing Professional Practice Evaluation (OPPE).
 Repeated failure to follow hospital or medical staff policy.
 Notice from any regulatory or peer review agency
4. When conducting a review, any or all of the following aspects may be
considered
 Through patient care, medical/clinical knowledge
 Practice based learning and improvement
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 Interpersonal communication skills
 Professionalism
 Systems based practice
 Patient safety
 Medical management
 Medication use
 Patient outcomes data
5. Resources to utilize –
Data may be gathered from:
 Chart review
 Direct observations
 Statistical reviews
 Proctoring
 Peer references
 Interviews
Reviews will be conducted in-house unless it is determined that for reasons of conflict or
insufficient expertise that an outside reviewer is required. This decision may be made by
the departmental chair, the chairperson of the Multi-Disciplinary Peer Review
committee, or the chairperson of the committee.
At the conclusion of the investigative process the appropriate medical staff PI
committee will assign an alpha identifier to each event as follows:
A
B
C
D
E
Routine/Acceptable Care
Non-Routine/Acceptable Care
Routine or Non-Routine/Questionable Care/Questionable variation from
evidence based medical care
Non-Acceptable Care/Variation from evidence based medical care
Inadequate Documentation
Corrective action plans are required whenever a variance from the standard of care has
resulted in an adverse patient event and/or demonstrated a pattern of sustained non
compliance has occurred.
The corrective action plan shall be developed with the guidance of the VP for Medical
Affairs, the Multi-Disciplinary Peer Review Committee and the appropriate chair of
service.
The Corrective action plan shall be specific for the event, contain achievable actions,
goals, and a timeframe for compliance and reporting of progress to the appropriate
committee/subcommittees as designated. See Medical Staff Bylaws, Article IX,
Corrective Action.
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Ongoing Professional Practice Evaluation (OPPE) - Periodic performance reviews of all
current medical and affiliated staff will be conducted. This also will include physician
assistants and nurse practitioners. OPPE data will be collected and placed in the
physician’s file for review by the departmental Chair or his designee. Available data will
be reviewed every six months and may come from various sources and reports. Not all
reports will be required to be reviewed simultaneously.
The following data may be reviewed:
 Information acquired through periodic chart review
 Direct observation
 Monitoring of diagnostic or treatment techniques
 Discussion with other individuals involved in the care of the patient
including consulting physicians, nursing and administrative personnel
 Reports compiled medical records, obtained by extraction from the EMR
or data collection agency, or other hospital departments.
 Other sources as deemed appropriate.
Aspects of OPPE to be considered may include, but should not be limited to, any of the
items below:
 Medical assessment and treatment of patient
 Adverse privileging decision
 Use of medications.
 Use of blood and blood components
 Appropriateness and outcome of operative and other procedures.
 Appropriateness and clinical practice patterns including length of stay,
denials, avoidable days.
 Significant departures from established patterns of clinical practice,
department specific indicators, meeting criteria for autopsies.
 Sentinel event data, patient safety data including Do Not Use
abbreviations. Accurate, timely and legible completion of medical records
including time and quality of H&P’s and operative notes. Number of
unsigned telephone orders. Patient complaints, coordination of care
treatment and services with other practitioners and hospital personnel.
 Mobidity and Mortality data.
 Use of consultants.
 Other relevant criteria as determined by the medical staff, returns to the
OR, returns to the ED, return of infections including surgical site
infections, central line infections, ventilator acquired pneumonia.
 Hand washing.
 Critical events.
 Core measures compliance.
Information derived from OPPE may be used to determine whether:
 To Continue
 To limit
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

11
To revoke any existing privileges
To initiate a problem specific focused professional practice review (FPPE).
Actions may be taken when deficiencies in OPPE become apparent and need not wait
until the bi-annual reappointment process. Data from each 6 month evaluation should
be considered in aggregate when reviewing data for reappointment. All practitioners are
subject to review.
12.
INABILITY TO BOOK 7:30 A.M. CASES DUE TO LACK OF HISTORYAND PHYSICAL
REPORTS ON CHARTS:
Any surgeon whose 7:30 a.m. case is delayed 3 times because a History and Physical
report is not on the chart will not be allowed to book a 7:30 a.m. case for 6 months.
These Rules and Regulations are specifically directed to the members of the Department
of Ophthalmology; however, they do not supersede the Medical Staff Bylaws.
These Rules and Regulations are specifically directed to members of the Department
of Ophthalmology and are in conformance with the published Bylaws and Rules and
Regulations of the Medical Staff and must be reviewed and approved annually.
Approved by the Executive Committee 10/19/99
Amended: October 2000
Amended: April 2001
Amended: July 2005
Amended: 04/03/08
Amended: 4/30/08
Amended: July 2014