Bylaws

ARTICLE X - COMMITTEES

10.1         DESIGNATION

Medical staff committees shall include but not be limited to, the medical staff meeting as a committee of the whole, meetings of departments and divisions, meetings of committees established under Section X, and meetings of special or ad hoc committees created by the MEC (pursuant to this Section) or by departments (pursuant to Sections 9.4(i) and (l). The committees described in this Article shall be the standing committees of the medical staff. Special or ad hoc committees may be created by the Medical Executive Committee to perform specified tasks. Unless otherwise specified, the chair and members of all committees shall be appointed by and may be removed by the Chief of Staff, subject to consultation with and approval by the Medical Executive Committee. Medical staff committees shall be responsible to the Medical Executive Committee.

10.2         GENERAL PROVISIONS

10.2-1 TERMS OF COMMITTEE MEMBERS

Unless otherwise specified, committee members shall be appointed for a term of one year, and shall serve until the end of this period or until the member's successor is appointed, unless the member shall sooner resign or be removed from the committee.

10.2-2 REMOVAL

If a member of a committee ceases to be a member in good standing of the medical staff, or loses employment or a contract relationship with the hospital, suffers a loss or significant limitation of practice privileges, or if any other good cause exists, that member may be removed by the Medical Executive Committee.

10.2-3 VACANCIES

Unless otherwise specifically provided, vacancies on any committee shall be filled in the same manner in which an original appointment to such committee is made; provided however, that if an individual who obtains membership by virtue of these bylaws is removed for cause, a successor may be selected by the Medical Executive Committee.

10.3         MEDICAL EXECUTIVE COMMITTEE

10.3-1 COMPOSITION

The Medical Executive Committee shall consist of the following persons:

(a)               the officers of the medical staff;

(b)               the department chairs and chair-elects;

(c)               Chairman of the Board or his designee, Administrator, or his designee, Vice president of Patient Care Services, or her designee, as ex-officio, non-voting members;

10.3-2 DUTIES

The duties of the Medical Executive Committee shall include, but not be limited to:

(a)               representing and acting on behalf of the medical staff in the intervals between medical staff meetings, subject to such limitations as may be imposed by these bylaws;

(b)               coordinating and implementing the professional and organizational activities and policies of the medical staff;

(c)               receiving and acting upon reports and recommendations from medical staff departments, divisions, committees, and assigned activity groups;

(d)               recommending actions to the Board of Directors on matters of a medical-administrative nature;

(e)               establishing the structure of the medical staff, the mechanism to review credentials and delineate individual privileges, the organization of quality assurance activities and mechanisms of the medical staff, termination of medical staff membership and fair hearing procedures, as well as other matters relevant to the operation of an organized medical staff;

(f)                 evaluating the medical care rendered to patients in the hospital;

(g)               participating in the development of all medical staff and hospital policy, practice, and planning;

(h)               reviewing the qualifications, credentials, performance and professional competence, and character of applicants and staff members, and making recommendations to the Board of Directors regarding staff appointments and reappointments, assignments to departments, privileges, and corrective action;

(i)                 taking reasonable steps to promote ethical conduct and competent clinical performance on the part of all members including the initiation of and participation in medical staff corrective or review measures when warranted;

(j)                  taking reasonable steps to develop continuing education activities and programs for the medical staff;

(k)               designating such committees as may be appropriate or necessary to assist in carrying out the duties and responsibilities of the medical staff and approving or rejecting appointments to those committees by the chief of staff;

(l)                  reporting to the medical staff at each regular staff meeting;

(m)             assisting in the obtaining and maintenance of accreditation;

(n)               developing and maintenance of methods for the protection and care of patients and others in the event of internal or external disaster;

(o)               appointing such special or ad hoc committees as may seem necessary or appropriate to assist the Medical Executive Committee in carrying out its functions and those of the medical staff;

(p)               reviewing the quality and appropriateness of services provided by contract physicians;

(q)               reviewing and approving the designation of the hospital's authorized representative for National Practitioner Data Bank purposes; and

(r)                 establishing a mechanism for dispute resolution between medical staff members (including limited license practitioners) involving the care of a patient.

(s)               overseeing the collaboration and participation of the medical staff in the hospital-wide performance improvement program.

10.3-3 MEETINGS

The Executive Committee shall meet as often as necessary, but at least a minimum of ten times per year and shall maintain a record of its proceedings and actions.

10.4         JOINT CONFERENCE COMMITTEE

10.4-1 COMPOSITION

The Joint Conference Committee shall be composed of an equal number of members of the Board of Directors and of the Medical Executive Committee, but the medical staff members shall at least include the Chief of Staff, the Chief of Staff-elect, and the Immediate Past Chief of Staff. The administrator shall be a non-voting ex-officio member. The chairship of the committee shall alternate yearly between the Board of Directors and the Medical Staff.

10.4-2 DUTIES

The Joint Conference Committee shall constitute a forum for the discussion of matters of hospital and medical staff policy, practice, and planning, and a forum for interaction between the Board of Directors and the medical staff on such matters as may be referred by the Medical Executive Committee or the Board of Directors. The Joint Conference Committee shall exercise other responsibilities set forth in these bylaws.

10.4-3 MEETINGS

The Joint Conference Committee shall meet on the call by the Medical Executive Committee or the Board of Directors, and shall transmit written reports of its activities to the Executive Committee and to the Board of Directors.

10.5         UTILIZATION REVIEW COMMITTEE

10.5-1 COMPOSITION

The Utilization Review Committee shall consist of sufficient members to afford, insofar as feasible, representation from the major specialty departments. Subcommittees may be appointed by the committee for departments or divisions, as the committee may deem appropriate.

10.5-2 DUTIES

The duties of the utilization review committee shall include:

(a)               conducting utilization review studies designed to evaluate the appropriateness of admissions to the hospital, lengths of stay, discharge practices, use of medical and hospital services and related factors which may contribute to the effective utilization of services. The committee shall communicate the results of its studies and other pertinent data to the Medical Executive Committee and shall make recommendations for the utilization of resources and facilities commensurate with quality patient care and safety;

(b)               establishing a utilization review plan which shall be approved by the Medical Executive Committee; and

(c)               obtaining, reviewing, and evaluating information and raw statistical data obtained or generated by the hospital's case management system.

10.5-3 MEETINGS

The Utilization Review Committee shall meet as often as necessary at the call of its chair, but a minimum of ten. It shall maintain a record of its findings, proceedings and actions, and shall make a monthly report of its activities and recommendations to the Medical Executive Committee.

10.6         PHARMACY AND THERAPEUTICS COMMITTEE

10.6-1 COMPOSITION

The Pharmacy and Therapeutics Committee shall consist of at least five representatives from the medical staff, a voting representative from the pharmaceutical service, and a non-voting representative from the nursing service and hospital administration.

10.6-2 DUTIES

The duties of the Pharmacy and Therapeutics Committee shall include:

(a)               assisting in the formulation of professional practices and policies regarding the evaluation, appraisal, selection, procurement, storage, distribution, use, safety procedures, and all other matters relating to drugs in the hospital, including antibiotic usage;

(b)               advising the medical staff and the pharmaceutical service on matters pertaining to the choice of available drugs;

(c)               making recommendations concerning drugs to be stocked on the nursing unit floors and by other services;

(d)               periodically developing and reviewing a formulary or drug list for use in the hospital;

(e)               evaluating clinical data concerning new drugs or preparations requested for use in the hospital;

(f)                 establishing standards concerning the use and control of investigational drugs and of research in the use of recognized drugs;

(g)               maintaining a record of all activities relating to pharmacy and therapeutics functions and submitting periodic reports and recommendations to the Medical Executive Committee concerning those activities;

(h)               reviewing untoward drug reactions.

10.6-3 MEETINGS

The committee shall meet as often as necessary at the call of its chair but at least quarterly. it shall maintain a record of its proceedings and shall report its activities and recommendations to the Medical Executive Committee.

10.7         INFECTION CONTROL COMMITTEE

10.7-1 COMPOSITION

The Infection Control Committee shall consist of at least three (3) voting members from the Medical Staff and the Infection Control Practitioner. Other voting members, may include representatives from the departments of medicine, surgery, obstetrics/gynecology, pediatrics, pathology, nursing service, administration, and an individual employed in a surveillance or epidemiological capacity. it may include non-voting consultants in microbiology and non-voting representatives from relevant hospital services.

10.7-2 DUTIES

The duties of the Infection Control Committee shall include:

(a)               developing a hospital-wide infection control program and maintaining surveillance over the program;

(b)               developing a system for reporting, identifying and analyzing the incidence and cause of nosocomial infections, including assignment of responsibility for the ongoing collection and analytic review of such data, and follow-up activities;

(c)               developing and implementing a preventive and corrective program designed to minimize infection hazards, including establishing, reviewing and evaluating aseptic, isolation and sanitation techniques;

(d)               developing written policies defining special indications for isolation requirements;

(e)               coordinating action on findings from the medical staff's review of the clinical use of antibiotics;

(f)                 acting upon recommendations related to infection control received from the chief of staff, the Medical Executive Committee, departments and other committees; and

(g)               reviewing sensitivities of organism specific to the facility.

10.7-3 MEETINGS

The Infection Control Committee shall meet as often as necessary at the call of its chair but at least once every two months. It shall maintain a record of its proceedings and shall submit reports of its activities and recommendations to the Medical Executive Committee.

10.8         BYLAWS COMMITTEE

10.8-1 COMPOSITION

The Bylaws Committee shall consist of at least five members of the medical staff, including at least the Chief of Staff-elect and Immediate Past Chief of Staff.

10.8-2 DUTIES

The duties of the Bylaws Committee shall include:

(a)               conducting an annual review of the medical staff bylaws, as well as the rules and regulations and forms promulgated by the medical staff, its departments and divisions;

(b)               submitting recommendations to the Medical Executive Committee for changes in these documents as necessary to reflect current medical staff practices; and

(c)               receiving and evaluating for recommendation to the Medical Executive Committee suggestions for modification of the items specified in subdivision (a).

10.8-3 MEETINGS

The Bylaws Committee shall meet as often as necessary at the call of its chair but at least annually. It shall maintain a record of its proceedings and shall report its activities and recommendations to the Medical Executive Committee.

10.9         PERFORMANCE IMPROVEMENT COMMITTEE

The Performance Improvement Committee shall consist of such members as may be designated by the Medical Executive Committee including, insofar as possible, at least one representative from each clinical department, from the nursing service and from administration.

10.9-2 DUTIES

The Performance Improvement Committee shall perform the following duties:

(a)               recommend for approval of the Medical Executive Committee plans for maintaining quality patient care within the hospital. These may include mechanisms to:

(1)               establish systems to identify potential issues in patient care;

(2)               set priorities for action on patient care issues;

(3)               refer priority problems for assessment and corrective action to appropriate departments or committees;

(4)               monitor the results of quality assurance activities throughout the hospital; and

(5)               coordinate quality assurance activities.

(b)               submit regular confidential reports to the Medical Executive Committee on the quality of medical care provided and on quality review activities conducted.

10.9-3 MEETINGS

The committee shall meet as often as necessary at the call of its chair, but at least a minimum of ten. it shall maintain a record of its proceedings and report its activities and recommendations to the Medical Executive Committee and Board of Directors, except that routine reports to the board shall not include peer evaluations related to individual members.

10.10    PHYSICIANS' ADVISORY COMMITTEE

The Physicians' Advisory Committee shall be implemented, as required by these bylaws and Title 22.

10.10-1 COMPOSITION

In order to improve the quality of care and promote the competence of the medical staff, the Medical Executive Committee shall establish a Physicians' Advisory Committee comprised of no less than three active members of the medical staff, a majority of which, including the chair, shall be physicians. Except for initial appointments, each member shall serve a term of two years with reappointment, and the terms shall be staggered as deemed appropriate by the Executive Committee to achieve continuity. Insofar as possible, members of this committee shall not serve as active participants on other peer review or quality assurance committees while serving on this committee.

10.10-2 DUTIES

The Physicians' Advisory Committee may receive reports related to the health, well being, or impairment of medical staff members and, as it deems appropriate, may investigate such reports. With respect to matters involving individual medical staff members, the committee may, on a voluntary basis, provide such advice, counseling, or referrals as may seem appropriate. Such activities shall be confidential; however, in the event information received by the committee clearly demonstrates that the health or known impairment of a medical staff member poses an unreasonable risk of harm to patients, that information may be referred for corrective action. The committee shall also consider general matters related to the health and well being of the medical staff and, with the approval of the Executive Committee, develop educational programs or related activities.

10.10-3 MEETINGS

The committee shall meet as often as necessary, but at least quarterly. It shall maintain only such record of its proceedings as it deems advisable, but shall report on its activities on a routine basis to the Medical Executive Committee.

10.11    ETHICS COMMITTEE

1011-1 COMPOSITION

The Ethics Committee shall consist of physicians and such other staff members, as the Medical Executive Committee may deem appropriate. It may include nurses, lay representatives, social workers, clergy, ethicists, attorneys, administrators and representatives from the Board of Directors, although a majority shall be physician members of the medical staff.

10.11-2 DUTIES

The Ethics Committee may participate in development of guidelines for consideration of cases having ethical implications; development and implementation of procedures for the review of such cases; development and/or review of institutional policies regarding care and treatment of such cases; retrospective review of cases for the evaluation of ethical policies; consultation with concerned parties to facilitate communication and aid conflict resolution; and education of the hospital staff on ethical matters. This committee is strictly of advisory nature.

10.11-3 MEETINGS

The committee shall meet quarterly and as often as necessary at the call of its chair. It shall maintain a record of its activities and report to the Medical Executive Committee.

10.12    COMMITTEE ON INTERDISCIPLINARY PRACTICE

10.12-1 COMPOSITION

The Committee on Interdisciplinary Practice (CIDP) shall consist of, at a minimum, the Vice president of Patient Care Services, the administrator or designee, and an equal number of physicians appointed by the Medical Executive Committee and registered nurses appointed by the Vice President of Patient Care Services. Licensed or certified health professionals other than registered nurses who perform functions requiring standardized procedures shall be included in the committee. The chair of the committee shall be a physician member of the active medical staff appointed by the Medical Executive Committee.

10.12-2 DUTIES

The CIDP shall perform functions consistent with the requirements of law and regulation. The CIDP shall routinely report to the Board of Directors through the Medical Executive Committee and, in addition, shall submit an annual report directly to the Board of Directors and the Medical Executive Committee.

10.12-3 MEETINGS

The CIDP shall meet at the call of the chair at such intervals as the chair or the Medical Executive Committee may deem appropriate.

10.13    CANCER COMMITTEE

10.13-1 COMPOSITION

The Cancer Committee shall include representatives from Oncology, Surgery, Radiology, Urology, Pediatrics, Gynecology, Hematology-Oncology, Pathology, Family Practice, Nursing, Social Services, Administration, Rehabilitation (Physical Medicine), Hospice, Pharmacy, Nutrition, and the Cancer Registry.

10.13-2 DUTIES

The Cancer Committee shall establish procedures and reporting mechanisms that ensure:

(1)   Access for patients to consultative services in all disciplines;

(2)   Coverage of the entire spectrum of cancer by educational programs, conferences, and other clinical activities;

(3)   Ongoing review of patient care;

(4)   Accurate maintenance of the cancer database and proper operation of the Tumor Registry.

10.13-3 MEETINGS

The Cancer Committee shall meet as often as necessary but not less than quarterly and shall report its recommendations and findings to the Medical Executive Committee.

10.14    CONTINUING MEDICAL EDUCATION COMMITTEE

10.14-1 COMPOSITION

The medical staff shall be committed to the formation of a committee, which deals with continuing medical education. This committee shall be composed of physician members and other health professionals of the medical staff whose number shall be appropriate to the size of the hospital and amount of program activities produced annually. The composition shall be a chairperson, who shall serve for at least two years, and committee members who shall serve staggered terms in order to assure continuity. If the hospital has a Director of Medical Education, that individual should be at least an ex-officio member of the committee.

10.l14-2 DUTIES

The Continuing Medical Education Committee shall perform the following duties:

(a)               plan, implement, coordinate and promote ongoing special clinical and scientific programs for the medical staff. This includes:

(1)               identifying the educational needs of the medical staff;

(2)               formulating clear statements of objectives for each program;

(3)               assessing the effectiveness of each program;

(4)               choosing appropriate teaching methods and knowledgeable faculty for each program; and

(5)               documenting staff attendance at each program.

(b)               assist in developing processes to assure optimal patient care and contribute to the continuing education of each practitioner.

(c)               establish liaison with the quality assurance program of each hospital in order to be apprised of problem areas in patient care, which may be addressed by a specific continuing medical education activity.

(d)               maintain close liaison with other hospital medical staff and department committees concerned with patient care.

(e)               make recommendations to the Executive Committee regarding library needs of the medical staff.

(f)                 advise administration of the financial needs of the continuing medical education program.

10.14-3 MEETINGS

The Committee shall meet as often as necessary, but at least quarterly. It shall maintain minutes of the program planning discussions and report to the Medical Executive Committee.