MEDICAL STAFF, Study notes of Surgical Pathology

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MEDICAL STAFF

RULES AND REGULATIONS

REVISED 2011

i

TABLE OF CONTENTS

MEDICAL STAFF .......................................................................................................................... i

• PART ONE: MEDICAL STAFF FAIR HEARING PLAN RULES AND REGULATIONS i
• 1.0 FAIR HEARING AND APPELLATE REVIEW
  • 1.1. EXCLUSIVE REMEDY
  • 1.2. RIGHT TO REQUEST HEARING
    • AND REQUEST FOR HEARING 1.3. REQUIRED NOTICE OF RECOMMENDATION TRIGGERING HEARING RIGHT
  • 1.4. HEARING NOTICES
  • 1.5. HEARING PANEL AND OFFICERS.............................................................................
  • 1.6. OBJECTIONS TO HEARING PANEL AND OFFICERS
  • 1.7. HEARING RIGHTS
  • 1.8. PRE-HEARING CONFERENCE
  • 1.9. PROVISION OF RELEVANT INFORMATION
  • 1.10. BURDEN OF PROOF
  • 1.11. ADMISSIBILITY
  • 1.12. PRESENCE OF HEARING PANEL MEMBERS
  • 1.13. RECOMMENDATION OF THE HEARING PANEL
  • 1.14. DISPOSITION OF HEARING PANEL REPORT
  • 1.15. NOTICE AND EFFECT OF RESULT
  • 1.16. GROUNDS FOR APPEAL TO THE HHCEB
  • 1.17. TIME FOR APPEAL
  • 1.18. HHCEB APPELLATE REVIEW
• PART TWO: MEDICAL STAFF RULES ii - AND ADMINISTRATIVE RESOURCES......................................................................... 1.0 ALLOCATION OF PATIENT CARE, LABORATORY, EDUCATION, RESEARCH - RECORDS 2.0 ADMISSIONS, TRANSFER AND DISCHARGE OF PATIENTS AND MEDICAL
  • 2.1. PATIENT ADMISSIONS
  • 2.2. ASSIGNMENT OF ADMITTED PATIENTS
  • 2.3. EMERGENCY SERVICE TREATMENT
  • 2.4. PATIENT TRANSFERS................................................................................................
  • 2.5. PATIENT DISCHARGES
  • 2.6. PATIENT DEPARTURE AGAINST MEDICAL ADVICE
  • 2.7. MEDICAL RECORDS
• 3.0 MISCELLANEOUS
  • 3.1. PEER-PROFESSIONAL REVIEW RECORDS
  • 3.2. UMHHC’S POLICIES, PROCEDURES AND GUIDELINES
  • 3.3. PATIENT CONSENT FOR PHOTOGRAPHS
• 4.0 USE OF DRUGS
• 5.0 GENERAL RULES REGARDING PATIENT CARE
  • 5.1. DAILY PATIENT VISITS ADMITTED PATIENTS...................................................
  • 5.2. INFORMED CONSENT................................................................................................
  • 5.3. REPORTS OF SURGICAL PROCEDURES
  • 5.4. TISSUE REMOVAL AND REVIEW
  • 5.5. ATTENDING PHYSICIAN
  • 5.6. ANESTHESIA AND SEDATION.................................................................................
  • 5.7. DENTAL AND ORAL SURGERY PATIENTS
  • 5.8. PHYSICAL EXAMINATIONS
  • 5.9. TRAINEES..................................................................................................................... iii
• 6.0 CONSULTATION REQUESTS
  • 6.1. AUTHORIZED REQUESTOR......................................................................................
  • 6.2. SCOPE OF CONSULTATION
  • 6.3. RESPONSIBILITY OF CONSULTANT
  • 6.4. SUPPORT STAFF REQUESTS FOR PATIENT REFERRAL
• 7.0 MECHANISM FOR PROVIDING EMERGENCY SERVICES
  • 7.1. LEVEL 1 CENTER
  • 7.2. RESPONSIBILITY OF SERVICE
  • 7.3. SERVICE SUPPORT.....................................................................................................
  • 7.4. CODE OF CONDUCT...................................................................................................
    • COMMITTEES PART THREE: COMMITTEE PROTOCOL AND ADDITIONAL STANDING
• 1.0 GENERAL COMMITTEE PROTOCOL
  • 1.1. APPOINTMENT CRITERIA
  • 1.2. REPRESENTATION
  • 1.3. EXECUTIVE SESSION
  • 1.4. ALTERNATIVE PROCEDURES
  • 1.5. ALTERNATIVE MEMBER
• 2.0 ADULT ETHICS COMMITTEE
  • 2.1. COMPOSITION.............................................................................................................
  • 2.2. CHARGE
  • 2.3. MEETINGS AND RECORDS.......................................................................................
• 3.0 CARDIOPULMONARY RESUSCITATION COMMITTEE
  • 3.1. COMPOSITION.............................................................................................................
  • 3.2. CHARGE
  • 3.3. MEETINGS AND RECORDS....................................................................................... iv
• 4.0 CEREBRAL DEATH DETERMINATION COMMITTEE
  • 4.1. COMPOSITION.............................................................................................................
  • 4.2. CHARGE
  • 4.3. MEETINGS AND RECORDS.......................................................................................
• 5.0 CRITICAL CARE STEERING COMMITTEE
  • 5.1. COMPOSITION.............................................................................................................
  • 5.2. CHARGE
  • 5.3. MEETINGS AND RECORDS.......................................................................................
• 6.0 DISASTER COMMITTEE...............................................................................................
  • 6.1. COMPOSITION.............................................................................................................
  • 6.2. CHARGE
  • 6.3. MEETINGS AND RECORDS.......................................................................................
• 7.0 EHR STANDARDS COMMITTEE
  • 7.1. COMPOSITION.............................................................................................................
  • 7.2. CHARGE
  • 7.3. MEETINGS AND RECORDS.......................................................................................
• 8.0 INFECTION CONTROL COMMITTEE
  • 8.1. COMPOSITION.............................................................................................................
  • 8.2. CHARGE
  • 8.3. MEETINGS AND RECORDS.......................................................................................
• 9.0 NOMINATING AND BYLAWS COMMITTEE
  • 9.1. COMPOSITION.............................................................................................................
  • 9.2. CHARGE
  • 9.3. MEETINGS AND RECORDS.......................................................................................
• 10.0 OPERATING ROOM POLICY COMMITTEE............................................................... v
  • 10.1. COMPOSITION.............................................................................................................
  • 10.2. CHARGE
  • 10.3. MEETINGS AND RECORDS.......................................................................................
• 11.0 PAIN COMMITTEE
  • 11.1. COMPOSITION.............................................................................................................
  • 11.2. CHARGE
  • 11.3. MEETING AND RECORDS
• 12.0 PATIENT SAFETY COMMITTEE
  • 12.1. COMPOSITION.............................................................................................................
  • 12.2. CHARGE
  • 12.3. MEETINGS AND RECORDS.......................................................................................
• 13.0 PEDIATRIC ETHICS COMMITTEE
  • 13.1. COMPOSITION.............................................................................................................
  • 13.2. CHARGE
  • 13.3. MEETINGS AND RECORDS.......................................................................................
• 14.0 PHARMACY AND THERAPEUTICS COMMITTEE
  • 14.1. COMPOSITION.............................................................................................................
  • 14.2. CHARGE
  • 14.3. MEETINGS AND RECORDS.......................................................................................
• 15.0 PRACTITIONER WELLNESS
  • 15.1. COMPOSITION.............................................................................................................
  • 15.2. CHARGE
  • 15.3. MEETINGS AND RECORDS.......................................................................................
• 16.0 SEDATION ANALGESIA COMMITTEE vi
  • 16.1. COMPOSITION.............................................................................................................
  • 16.2. CHARGE
  • 16.3. MEETINGS AND RECORDS.......................................................................................
• 17.0 TRANSFUSION COMMITTEE
  • 17.1. COMPOSITION.............................................................................................................
  • 17.2. CHARGE
  • 17.3. MEETINGS AND RECORDS.......................................................................................

PART ONE: MEDICAL STAFF FAIR HEARING PLAN

This Part One may be referred to as the “Fair Hearing Plan” or “Plan”

1.0 FAIR HEARING AND APPELLATE REVIEW

1.1. EXCLUSIVE REMEDY

If an adverse ruling is made with respect to a Medical Staff Membership, Staff status or clinical privileges at any time, regardless of whether the individual is an Applicant or a Member, the individual shall follow and abide by the remedies afforded by the Bylaws and this Fair Hearing Plan before resorting to a formal legal action.

1.2. RIGHT TO REQUEST HEARING

1.2-1 Right to Request Hearing

A Member or Applicant may request a hearing upon one or more of the following actions or recommended actions relating to professional competence or professional conduct in the care of patients:

(a) Denial of initial appointment or reappointment, termination or revocation of any appointment.

(b) Denial of requested clinical privileges, suspension of clinical privileges for more than fifteen (15) days (other than precautionary suspension) or revocation of privileges.

(c) Denial of reinstatement from a leave of absence if the reason is related to professional competence or conduct.

(d) Any other professional review action that must be reported to the Michigan Department of Community Health under MCLA § 333.20175(5) and/or to the Data Bank under the federal Health Care Quality Improvement Act, 42 USC § 11101 et seq. and implementing regulations.

1.2-2 A Member or Applicant who is not entitled to a hearing or appeal may dispute an ECCA finding or determination by requesting that a written rebuttal be attached to his or her file and by submitting the rebuttal within thirty (30) days of ECCA’s action.

1.3. REQUIRED NOTICE OF RECOMMENDATION TRIGGERING HEARING RIGHT AND REQUEST FOR HEARING

1.3-1 The COS must promptly give Special Notice of a recommendation or action that entitles a Member or Applicant to request a hearing. This

1.5. HEARING PANEL AND OFFICERS

1.5-1 The CEO, after consulting with the COS, will appoint a Hearing Panel consistent with the following guidelines:

(a) The Hearing Panel will consist of at least three (3) Active Members, one of whom shall be designated as the chair.

(b) The Hearing Panel may include any combination of one or more Member(s) and/or physicians or laypersons unaffiliated with the UMHHC. Knowledge of the underlying professional review matter, in and of itself, does not preclude an individual from serving on the Hearing Panel; nor does employment by, or other contractual arrangement with, UMHS or any of its affiliates.

(c) As determined by the CEO, the Hearing Panel may not include any individual who:

(i) Is in direct economic competition with the Member or Applicant.

(ii) Is demonstrated to have an actual bias, prejudice or conflict of interest that would prevent him or her from fairly and impartially considering the matter.

1.5-2 Presiding Officer

The chair of the Hearing Panel shall serve as the Presiding Officer, unless the CEO appoints a Hearing Officer. The Hearing or Presiding Officer shall:

(a) Provide the Member or Applicant with a reasonable opportunity to be heard and to present evidence, subject to reasonable limits on the number of witnesses and duration of direct and cross- examination.

(b) Prohibit conduct or presentation of evidence that is cumulative, excessive, irrelevant or abusive, or that causes undue delay.

(c) Maintain decorum throughout the hearing.

(d) Determine the order of the proceeding.

(e) Rule on all matters of procedure and the admissibility of evidence.

(f) Conduct argument by counsel on procedural points outside the presence of the Hearing Panel unless the Hearing Panel by a majority vote requests to be present.

The Presiding Officer and the Hearing Panel may be advised by internal or external UMHS legal counsel with regard to the hearing procedure. He or she may participate in the private deliberations of the Hearing Panel and serve as a legal advisor to the Hearing Panels.

1.5-3 Hearing Officer

The CEO, after consulting with the COS, may appoint a Hearing Officer. Where a Hearing Officer is used in conjunction with a Hearing Panel, the Hearing Officer shall not act as an advocate for either side at the hearing, and will conduct the hearing, maintain decorum and rule on all evidentiary and witness matters. A Hearing Officer will be an attorney at law experienced in conducting such hearings. The Hearing Officer may not be, or represent clients, in direct economic competition with the Member or Applicant.

1.6. OBJECTIONS TO HEARING PANEL AND OFFICERS

Any objections to any member of the Hearing Panel, or the Hearing Officer or Presiding Officer, shall be made in writing, within ten (10) days of receipt of notice, to the CEO. A copy of such written objections must be provided to the COS and must include the basis for the objections. The COS shall be given a reasonable opportunity to comment. The CEO shall rule on the objections and give notice to the parties. The CEO may request that the Hearing Officer make a recommendation as to the validity of the objections.

1.7. HEARING RIGHTS

1.7-1 In the hearing the Member or Applicant has the following rights:

(a) To representation by an attorney or other person of the requestor’s choice.

(b) To have a record made of the proceedings. The Hearing Officer or Presiding Officer shall determine the nature of the record including whether the hearing will be transcribed. Copies of the record may be obtained by the Member or Applicant upon payment of any reasonable charges associated with the preparation thereof.

(c) To call and question witnesses.

(d) To present evidence determined to be relevant by the Hearing Officer regardless of its admissibility in a court of law.

1.10-2 In all other hearings, the committee or body that proposed the recommendation or action that is the subject of the hearing will have the duty to produce evidence in support of the recommendation or action, but the Member or Applicant will have the ultimate burden of proving, by clear and convincing evidence, that the recommendation or action is arbitrary, unreasonable or has no basis in fact.

1.11. ADMISSIBILITY

The hearing will not be conducted according to rules of evidence. There shall be no right of discovery. Any relevant evidence will be admitted if it is the sort of evidence on which responsible persons are accustomed to rely in the conduct of serious affairs, regardless of the admissibility of the evidence in a court of law.

1.12. PRESENCE OF HEARING PANEL MEMBERS

A majority of the Hearing Panel shall be present throughout the hearing. In unusual circumstances, when a Hearing Panel member must be absent from any part of the hearing, he or she shall read the entire record of the portion of the hearing from which he or she was absent.

1.13. RECOMMENDATION OF THE HEARING PANEL

1.13-1 Within twenty (20) days after final adjournment of the hearing (which may be designated as the time the Hearing Panel receives the hearing record or transcript or any post-hearing statements, whichever is later), the Hearing Panel shall render a recommendation, accompanied by a written report stating the basis for the recommendation, to the CEO and HHCEB which shall contain a concise statement of the basis for its recommendation.

1.13-2 The Member or Applicant shall be provided a copy of the Hearing Panel recommendation and report. Within fifteen (15) days after the delivery of the copy of the Hearing Panel recommendation and report to the Member or Applicant, the Member or Applicant may submit a written statement specifying the recommendations to which the Member or Applicant disagrees and the reasons for such disagreement.

1.14. DISPOSITION OF HEARING PANEL REPORT

The Hearing Panel shall deliver its report and recommendation, and a copy of the Member or Applicant’s written statement, if any, to the CEO who shall forward it, along with all supporting documentation, to the ECCA and the HHCEB for further action. The COS shall send to the Member or Applicant a copy of these materials by Special Notice.

Within thirty (30) days after receipt (or finalization, if a committee of the whole was involved) of the report of the Hearing Panel, the ECCA or the HHCEB, as the

case may be, shall consider the same and affirm, modify or reverse the prior recommendation or action in the matter. It shall transmit the result, together with the hearing record, the report of the Hearing Panel and all other documentation considered, to the COS and CEO.

1.15. NOTICE AND EFFECT OF RESULT

1.15-1 Effect of Favorable Result Adopted by ECCA. If the ECCA recommendation is favorable to the Member or Applicant, the COS shall promptly forward it, together with all supporting documentation, to the HHCEB for its final action. The HHCEB shall take action thereon by adopting or rejecting the ECCA result in whole or in part, or by referring the matter back to the ECCA for further reconsideration.

1.15-2 Effect of an Adverse Result Adopted by ECCA. If the result of the ECCA determination continues to be adverse to the Member or Applicant, the COS shall send a Special Notice informing the Member or Applicant of the decision and the right to request appellate review by the HHCEB as provided below.

1.15-3 Effect of a Favorable Action by the HHCEB. Favorable action taken by the HHCEB is the final decision.

1.15-4 Effect of Adverse Result by HHCEB. If, based on a favorable recommendation by the ECCA, the HHCEB rejects the recommendation and renders a decision adverse to the Member or Applicant, the COS shall send a Special Notice informing the Member or Applicant of the decision and right to request appellate review by the HHCEB as provided below.

1.16. GROUNDS FOR APPEAL TO THE HHCEB

The grounds for appeal are limited to the following:

1.16-1 There was substantial failure to comply with this Fair Hearing Plan and/or the Bylaws of the Medical Staff during or prior to the hearing, so as to deny a fair hearing.

1.16-2 The recommendations of ECCA were made arbitrarily or capriciously.

1.17. TIME FOR APPEAL

Within ten (10) days after the Member’s or Applicant’s receipt of the Special Notice under Section 1.15 above, the Member or Applicant may request an appeal. The request shall be in writing, delivered to the CEO either in person or by certified mail, return receipt requested, and shall include a statement of the reasons for appeal and the specific facts or circumstances which justify further

PART TWO: MEDICAL STAFF RULES

1.0 ALLOCATION OF PATIENT CARE, LABORATORY, EDUCATION, RESEARCH

AND ADMINISTRATIVE RESOURCES

Allocation and reallocation in UMHHC of physical resources in patient care, in laboratory services, in education, in research and in administration shall be made by the CEO. Requests for such allocation and reallocation may be recommended to the appropriate committee by a Service Chief or by a Member in consultation with the Department Chair.

2.0 ADMISSIONS, TRANSFER AND DISCHARGE OF PATIENTS AND MEDICAL RECORDS

2.1. PATIENT ADMISSIONS

2.1-1 Admission Priority Categories

The admission of patients to UMHHC hospital facilities through the ABCC will be on the basis of medical necessity as determined by ABCC protocol and OCA.

2.1-2 Admission Requests and Diagnosis

Patients may be admitted to UMHHC hospital only at the request of a Medical Staff Member with admitting privileges, or designee. Except in an emergency, no patient shall be admitted to UMHHC hospital facilities until after a provisional diagnosis has been provided to the ABCC. In cases of emergency, the provisional diagnosis shall be stated as soon after admission as possible.

2.1-3 Non-Discrimination

Admission shall not be denied because of the patient’s race, sex (includes gender identity and gender expression), color, religion, creed, national origin or ancestry, age, marital status, sexual orientation, disability, special disabled veteran and Vietnam-era veteran status, height or weight and source of payment or any other basis which is legally impermissible.

2.1-4 Member Responsibilities Generally

A qualified Physician Member shall be responsible for the medical care and treatment of the patient, for the prompt completeness and accuracy of the medical record, for necessary special instructions and for transmitting reports of the condition of the patient to relatives of the patient and other concerned parties who are entitled to such information.

For patients admitted to the Oral-Maxillofacial Surgery Service, an appropriately qualified Oral Surgeon may be responsible and carry out these patient care duties if granted privileges to do so.

2.1-5 Performance of Admission History and Physical Examination

A complete admission history and physical examination shall be recorded no more than thirty (30) days before or twenty-four (24) hours after admission, but prior to surgery or a procedure requiring anesthesia services, as applicable, in accordance with this Part. If the circumstances are such that a delay is necessary, a brief admission note may be reported pending completion of the history and physical examination. Either a history and physical examination or an admission note should be recorded before surgery or any other procedure requiring anesthesia services is performed or treatment is instituted, in accordance with this Part, except in cases of bona fide emergency. Such emergency shall be documented in the medical record. Minimally, the admission history and physical should include relevant medical and surgical history (co- existing disease, review of systems, current medications, and allergies/reactions) and a focused physical examination (vital signs, pulmonary/cardiovascular).

2.1-6 Admission Information

An admitting Member shall provide the following information in the patient’s medical record, when such information is available to the admitting Member:

(a) Provisional diagnosis.

(b) A valid reason for admitting the patient, including information to support the medical necessity and the appropriateness of the admission.

(c) Information needed to properly care for the patient being admitted.

(d) Information needed to protect the patient from himself/herself.

(e) Information needed to protect UMHHC personnel and others from potential problems or dangers presented by the patient.

2.1-7 Admission of Potentially Suicidal or Dangerous Patients

If an admitting Member or designee reasonably believes a patient admitted for other purposes is potentially suicidal or dangerous to himself/herself or others, the admitting Member or designee shall promptly obtain a consultation from a suitable mental health

2.5. PATIENT DISCHARGES

2.5-1 Practitioner Order

Except as provided in Section 2.5-3, patients shall be discharged only on the documented order of a Physician, Oral Surgeon, or other authorized individual.

2.5-2 Notice of Planned Discharge

It shall be the responsibility of the attending Member, or other authorized individual, to give notice of planned discharges as soon as discharge is determined to be appropriate.

2.5-3 Exceptions to Discharge by a Physician or Oral Surgeon

No discharge order by a Physician or Oral Surgeon is required in the following circumstances:

(a) When a patient is removed pursuant to a disaster plan.

(b) When a patient leaves a UMHHC facility against advice.

(c) When there is a question of a patient being removed from UMHHC hospitals or being dismissed because the patient’s presence is interfering with proper care of other patients. In such a case, the attending Member and the Administrator-on-Call shall be notified.

2.5-4 Pronunciation of Death

In the event of a death at a UMHHC facility, the deceased shall be pronounced dead by a Physician, physician assistant, nurse practitioner, or certified nurse midwife. Policies with respect to autopsies and release of bodies shall conform to Michigan laws.

2.5-5 Autopsies

Every Physician Member practicing at UMHHC facilities is expected to actively seek performance of autopsies. No autopsy shall be performed without recorded consent of the legally authorized agent. This consent shall include exceptions and/or limitations to the autopsy. All autopsies shall be performed by members of the Pathology Service. Physicians seeking consent for autopsies from the next of kin of deceased patients shall explain adequately what constitutes a routine autopsy, and the extent of the consent shall not be violated. The Pathology Service shall review the consent, including any exceptions in or limitations of autopsy consent or procedures requested.

2.5-6 Unclaimed Bodies

When applicable, the official who has been designated by the CEO to have control of unclaimed bodies shall notify the Anatomy Committee of the Medical School seventy-two (72) hours after death (excluding Sundays and holidays), that an unclaimed body is available for use by the Anatomy Committee. An unclaimed body means a dead human body for which the deceased has not provided for a disposition, an estate or assets to defray costs of burial do not exist, and the body is not claimed for burial by any person, relative or court appointed fiduciary who has the right to control the disposition of the body.

2.5-7 Organ Donation Request

In appropriate cases, requests shall be made to next of kin for donation of organs, as required by state law and UMHHC organ donation policy.

2.6. PATIENT DEPARTURE AGAINST MEDICAL ADVICE

2.6-1 Notification in Reporting

If a patient threatens to leave or leaves a UMHHC facility against advice of a Member or without usual discharge, a notation of the event shall be made in the patient’s medical record and a report shall be submitted to the Administrator-on-Call. If the attending Member(s) is (are) not directly involved, the attending Member(s) shall also be notified as soon as practical of the patient’s anticipated or actual leaving of the facility.

2.6-2 Release Form

A patient leaving a UMHHC facility against medical advice of a Member shall be requested to sign the proper release form, which will be placed in the patient’s medical record. A patient’s failure or refusal to sign the proper release form shall also be recorded in the patient’s medical record. A discharge note shall then be properly prepared by the Member on site with the patient at the facility.

2.6-3 Limitation on Patient’s Right to Discharge Against Medical Advice

A competent patient generally has the right to leave a facility against the advice of the patient’s attending Member. However, a facility has a right, in its discretion, to disallow a patient’s departure under certain circumstances for safety reasons, including, but not limited to:

(a) A patient is mentally incompetent and without assistance of a legal representative or other support person.