Bylaws

ARTICLE IX - CLINICAL DEPARTMENTS AND DIVISIONS

9.1             ORGANIZATION OF CLINICAL DEPARTMENTS AND DIVISIONS

The medical staff shall be divided into clinical departments. Each department shall be organized as a separate component of the medical staff and shall have a chair selected and entrusted with the authority, duties, and responsibilities specified in Section 9.6. A department may be further divided, as appropriate, into divisions which shall be directly responsible to the department within which it functions, and which shall have a division chief selected and entrusted with the authority, duties and responsibilities specified in Section 9.7. When appropriate, the Medical Executive Committee may recommend to the medical staff the creation, elimination, modification, or combination of departments or divisions.

9.2             CURRENT DEPARTMENTS AND DIVISIONS

The current departments and divisions are:

a.      Department of Emergency Medicine

b.      Department of Surgery
-    Ortho/Podiatry Committee
-         Cardiovascular

c.      Department of Obstetrics & Gynecology
-         Perinatal Advisory Committee

d.      Department of Pediatrics
-         Perinatal Advisory Committee
-         Neonatal Intensive Care Unit (NICU)

e.      Department of Family Practice

f.        Department of Internal Medicine
-         Cardiology
-         Gastroenterology
-         Physical Medicine & Rehabilitation

g.      Department of Anesthesiology

h.      Department of Pathology

i.        Department of Radiological Health Sciences

j.         Department of Psychiatry

9.3             ASSIGNMENT TO DEPARTMENTS AND DIVISIONS

Each member shall be assigned membership in at least one department, and to a division, if any, within such department, but may also be granted membership and/or privileges in other departments or decisions consistent with practice privileges granted.

9.4             FUNCTIONS OF DEPARTMENTS

The general functions of each department shall include:

(a)               conducting patient care reviews for the purpose of analyzing and evaluating the quality and appropriateness of care and treatment provided to patients within the department. The number of such reviews to be conducted during the year shall be as determined by the Medical Executive Committee in consultation with other appropriate committees. The department shall routinely collect information about important aspects of patient care provided in the department, periodically assess this information, and develop objective criteria for use in evaluating patient care. Patient care reviews shall include all clinical work performed under the jurisdiction of the department, regardless of whether the member whose work is subject to such review is a member of that department;

(b)               recommending to the Medical Executive Committee guidelines for the granting of privileges and the performance of specified services within the department;

(c)               evaluating and making appropriate recommendations regarding the qualifications of applicants seeking appointment or reappointment and privileges within that department;

(d)               conducting, participating and making recommendations regarding continuing education programs pertinent to departmental clinical practice;

(e)               reviewing and evaluating departmental adherence to: (1) medical staff policies and procedures and (2) sound principles of clinical practice;

(f)                 coordinating patient care provided by the department's members with nursing and ancillary patient care services;

(g)               submitting written reports to the Medical Executive Committee concerning: (1) the department's review and evaluation activities, actions taken thereon, and the results of such action; and (2) recommendations for maintaining and improving the quality of care provided in the department and the hospital;

(h)               meeting at least quarterly for the purpose of considering patient care review findings and the results of the department's other review and evaluation activities, as well as reports on other department and staff functions;

(i)                 establishing such committees or other mechanisms as are necessary and desirable to perform properly the functions assigned to it, including proctoring protocols;

(j)                  taking appropriate action when important problems in patient care and clinical performance or opportunities to improve care are identified;

(k)               accounting to the Medical Executive Committee for all professional and medical staff administrative activities within the department;

(l)                  appointing such committees as may be necessary or appropriate to conduct department functions; and

(m)             formulating recommendations for departmental rules and regulations reasonably necessary for the proper discharge of its responsibilities subject to the approval by the Medical Executive Committee and the medical staff.

9.5             FUNCTIONS OF DIVISIONS

Subject to approval of the Medical Executive Committee, each division shall perform the functions assigned to it by the department chair. Such functions may include, without limitation retrospective patient care reviews, evaluation of patient care practices, credentials review and privileges delineation, and continuing education programs. The division shall transmit regular reports to the department chair on the conduct of its assigned functions.

9.6             DEPARTMENT HEADS

9.6-1 QUALIFICATIONS

Each department shall have a chair and chairman elect who shall be members of the active medical staff and shall be qualified by training, experience and demonstrated ability in at least one of the clinical areas covered by the department. Department chairs must be certified by an appropriate specialty board or must demonstrate comparable competence.

9.6-2 SELECTION

Department chairs and chairman elect shall be elected every one year by those members of the department who are eligible to vote for general officers of the medical staff, subject to the rules & regulations of each department. Election of department chairs and chairman elect shall be subject to ratification by the Medical Executive Committee. Vacancies due to any reason shall be filled for the unexpired term through special election by the respective department with such mechanisms as that department may adopt.

9.6-3 TERM OF OFFICE

Each department chair and chairman elect shall serve a one year term which coincides with the medical staff year or until their successors are chosen, unless they shall sooner resign, be removed from office, or lose their medical staff membership or privileges in that department. Department officers shall be eligible to succeed themselves.

9.6-4 REMOVAL

After election and ratification, removal of department chairs and chairs elect from office may occur for cause by a two-thirds vote of the Medical Executive Committee or two-thirds vote of the department members eligible to vote on departmental matters who cast votes.

9.6-5 DUTIES

Each chair shall have the following authority, duties and responsibilities, and the chair elect, in the absence of the chair, shall assume all of them and shall otherwise perform such duties as may be assigned:

(a)               act as presiding officer at departmental meetings;

(b)               report to the Medical Executive Committee and to the Chief of Staff regarding all professional and administrative activities within the department;

(c)               generally monitor the quality of patient care and professional performance rendered by members with privileges in the department through a planned and systematic process; oversee the effective conduct of the patient care, evaluation, and monitoring functions delegated to the department by the Medical Executive Committee;

(d)               develop and implement departmental programs for retrospective patient care review, on-going monitoring of practice, credentials review and privilege delineation, medical education, utilization review, and quality assurance;

(e)               be a member of the Medical Executive Committee, and give guidance on the overall medical policies of the medical staff and hospital and make specific recommendations and suggestions regarding the department;

(f)                 transmit to the Medical Executive Committee the department's recommendations concerning practitioner appointment and classification, reappointment, criteria for privileges, monitoring of specified services, and corrective action with respect to persons with privileges in the department;

(g)               endeavor to enforce the medical staff bylaws, rules, policies and regulations within the department;

(h)               implement within the department appropriate actions taken by the Medical Executive Committee;

(i)                 participate in every phase of administration of the department, including cooperation with the nursing service and the hospital administration in matters such as personnel, supplies, special regulations, standing orders and techniques;

(j)                  assist in the preparation of such annual reports, including budgetary planning, pertaining to the department as may be required by the Medical Staff Executive Committee;

(k)               recommend delineated privileges for each member of the department; and

(l)                  perform such other duties commensurate with the office as may from time to time be reasonably requested by the Chief of Staff or the Medical Executive Committee.

9.7             DIVISION CHIEFS

9.7-1      QUALIFICATIONS

Each division shall have a chief who shall be a member of the active medical staff and a member of the division, and shall be qualified by training, experience, and demonstrated current ability in the clinical area covered by the division.

9.7-2      SELECTION

Each division chief shall be selected or elected with such mechanism as the department may adopt. Vacancies due to any reason shall be filled for the unexpired term by the department chair.

9.7-3      TERM OF OFFICE

Each division chief shall serve a one-year term which coincides with the medical staff year or until a successor is chosen, unless the division chief shall sooner resign or be removed from office or lose medical staff membership or privileges in that department. Division chiefs shall be eligible to succeed themselves.

9.7-4      REMOVAL

After appointment and ratification, a division chief may be removed by the department chair and the Medical Executive Committee.

9.7-5      DUTIES

Each division chief shall:

(a)               act as presiding officer at division meetings;

(b)               assist in the development and implementation, in cooperation with the department chair, of programs to carry out the quality review, and evaluation and monitoring functions assigned to the division;

(c)               evaluate the clinical work performed in the division;

(d)               conduct investigations and submit reports and recommendations to the department chair regarding the privileges to be exercised within the division by members of or applicants to the medical staff; and

(e)               perform such other duties commensurate with the office as may from time to time be reasonably requested by the department chair, the Chief of Staff, or the Medical Executive Committee.