MEDICAL STAFF RULES AND REGULATIONS DEPARTMENT OF SURGERY

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MEDICAL STAFF RULES AND REGULATIONS

1. Membership and clinical privileges in the following sections shall be limited to practitioners who have satisfactorily completed all training requirements to qualify for certification by their respective specialty boards. Applicants must maintain eligibility to sit for the qualifying examination, be in the examination process, or be board certified to be recommended for privileges in the Department of Surgery and proof must be

available at the time of application. (added 9/88 and amended 6/93) DEPARTMENT OF SURGERY

I. NAME

The name of this organization shall be the Department of Surgery of the Medical Staff of Providence Holy Cross Medical Center, Mission Hills. The Department is organized as provided in the Bylaws of Providence Holy Cross Medical Center [PHCMC] Medical Staff.

II. PURPOSE

It shall be the purpose of the Department of Surgery to concern itself with the surgical care performed in the hospital. This shall include preoperative, operative, and postoperative care; the maintenance of high professional standards; methods to assure professional competence of members, basing delineation of privileges on training, experience, demonstrated ability, and integrity; the continuing education in the surgical sciences of all department members; the selection of equipment; and the development of appropriate procedures for the department.

III. MEMBERSHIP

A. All surgeons in good standing on the Medical Staff shall be members of the Department of Surgery.

B. The Department of Surgery shall consist of the following sections:

Anesthesiology; Cardiovascular Surgery (added 6/93); Cardiovascular Anesthesia (added 2/97); Dentistry; General Surgery; Neurosurgery; Ophthalmology; Oral Surgery; Orthopedic Surgery; Otolaryngology; Pathology; Plastic surgery; Podiatry; Radiation Therapy (added 1/90);Thoracic Surgery; Urology; Vascular Surgery; and any others to be designated in the future.

C. All practitioners with application to the Medical Staff of PHCMC, Department of Surgery, must have a satisfactory ethical standing in the profession and a satisfactory moral status in the community. Documentation of clinical skills by program directors must be provided.

D. Membership criteria and clinical privileges in the Department of Surgery shall be delineated by the appropriate section of the Department, subject to the approval of the Department of Surgery, and shall reflect at least the following general requirements:

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Cardiovascular Anesthesiology (amended 2/97)

Pathology Cardiovascular Surgery (amended 2/97) Plastic Surgery

General Surgery Podiatry

Neurosurgery Radiation Therapy

Ophthalmology Thoracic Surgery

Oral Surgery Urology

Orthopedic Surgery Vascular Surgery Otolaryngology

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“Qualified specialist” or “qualified surgical specialist” or “qualified non-surgical specialist” means:

a. A physician licensed in California who is board certified in a specialty by the merican Board of Osteopathic Specialties, a Canadian Board or other appropriate foreign specialty board as determined by the American Board of Medical Specialties for that specialty.

b. A non-board certified physician may be recognized as a “qualified specialty” by the local EMS agency upon substantiation of need by a trauma center if:

1) The physician can demonstrate to the appropriate hospital body and the hospital is able to document that he/she has met requirements which are equivalent to those of the Accreditation Council for Graduate Medical Education (“ACGME”) or the Royal College of Physicians and Surgeons of Canada;

2) The physician can clearly demonstrate to the appropriate hospital body that he/she has substantial education, training, and experience in treating and managing trauma patient which shall be tracked by the trauma quality improvement program; and

3) The physician has successfully completed a residency program

2. In the section of Anesthesiology, membership and clinical privileges shall be limited to physicians who have completed all training requirements to qualify for certification by their respective specialty boards. Applicants must maintain eligibility to sit for the qualifying examination, be in the examination process, be Board Certified, or, if no longer eligible to sit for the qualifying exam, demonstrate competence in the appropriate field by proof of activity and expertise to be recommended for privileges in the

Department of Surgery, and proof must be available at the time of application (added 6/93). The underlined section above applies only to existing staff members.

The term "board certification/eligibility" used anywhere within these rules & regulations refers to the American Board of Medical Specialties or American Osteopathic Board.

E. Physicians who are not board certified or board eligible but who have one or more years of surgical training, two or more years of surgical practice or surgical assisting, or other special qualifications acceptable to the department of surgery, are eligible to apply for membership in the department of surgery for assisting privileges only. These practitioners are not eligible to apply for primary surgical privileges unless they meet all membership and privilege requirements in the department of surgery.

F. All surgeons with unsupervised peripheral vascular surgery privileges shall be required to participate on the E.R. Vascular Surgery Panel as a condition of holding peripheral vascular surgery privileges within the Department of Surgery.

G. All surgeons with general surgery privileges shall be required to participate on the E.R. General Surgery Panel as a condition of holding general surgery privileges within the Department of Surgery. Exception: Specialists who are currently serving on another mandatory specialty ER panel at PHCMC.

H. If the orthopedic surgery panel is not covered in any given month, there will be a mandatory back-up system in which all members withorthopedic surgery privileges will be required to cover alphabetically on a 1 night each basis until the coverage is complete. Those who have limited privileges are required to participate in the panel call within the privileges held.

I. All Otolaryngologists shall be required to participate on the E.R. ENT Panel as a condition of holding Otolaryngology privileges within the Department of Surgery, regardless of his or her staff status.

J. Any physician who cannot cover the panel on the days assigned will be responsible for arranging appropriate coverage.

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K. ER Panel call is optional for surgeons age 70 or older.

ER Panel is optional for orthopedic surgeons age 55 or older. (Added 5/2009)

If the orthopedic surgery panel is not covered in any given month, there will be a mandatory back-up system in which all members with orthopedic surgery privileges will be required to cover alphabetically on a 1 night each basis until the coverage is complete. Those who have limited privileges are required to participate in the panel call within the privileges held [Section III.H] (Added 5/2009)

L. RESIGNATIONS FROM THE EMERGENCY CALL PANEL/MEDICAL STAFF

Upon resignation from the medical staff, resignations from emergency call panel responsibilities shall require 3 working days notice before physicians will be officially released from any already-assigned panel rotations, unless the physician has secured a qualified alternate to fulfill his/her call panel obligations. Resignations should be provided in writing so that a replacement can be found to fulfill panel call obligations for the remainder of the panel call cycle. Failure without good cause to provide 3 working days notice of such resignation, shall result in a written letter of reprimand to the physician which will be incorporated into the physician's credentials file so that if may be referenced if/when any outside inquiry is received from a third party regarding the physician's tenure on this hospital's staff. It may also be taken into consideration should the physician request privileges at this facility in the future.

M. RESPONSIBILITY OF PANEL PHYSICIANS

The surgeon on call at the time of diagnosis or the day of need is responsible for responding to the patient. Responsibility does not revert to the surgeon who was covering the ER call panel on the date that the patient was admitted.

IV. ORGANIZATION

A. MEETING FREQUENCY

The Department of Surgery shall meet every other month, at least six (6) times per year, in accordance with the Medical Staff Bylaws. The Chairman and Vice-Chairman of the Department shall be elected as defined in the Medical Staff Bylaws.

B. QUORUM

The presence of 10 voting members of the Department of Surgery shall constitute a quorum. (added 10/90)

V. DUTIES OF THE DEPARTMENT

A. To be responsible for the administration of the policies and procedures of the surgical staff. B. To establish and alter operating policies dealing with the basic care of the surgical patients as

seems required in the best interests of the patient and hospital.

C. To coordinate with the Continuing Medical Education Department educational programs for the surgical staff.

D. Credentials – In conjunction with the Credentials Committee, evaluate for staff membership and clinical privileges, the credentials of practitioners requesting new or renewal of privileges to practice within the scope of the Department, and submit a recommendation to the Medical Executive Committee (revised 4/91)

E. To monitor the quality of the surgical care as judged by a review of the medical records of surgical cases; to investigate, on the recommendations of other standing committees, all cases which have been referred for such investigation.

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F. To recommend corrective or disciplinary action regarding its members for infractions to the Medical Executive Committee in accordance with the Medical Staff Bylaws.

G. To be responsible for the initial and ongoing evaluation of Surgical Physician Assistants' qualifications, clinical privileges, prerogatives, and responsibilities as outlined in the Medical Staff General Rules & Regulations. (added 8/93)

VI. ORGANIZATION OF DIVISIONS, COMMITTEES DIVISIONS

Upon approval of the Medical Executive Committee, a clinical department may be divided, as appropriate, into divisions as described in the Medical Staff Bylaws.

STANDING COMMITTEES

Surgery Peer Review Committee: (amended 9/96)

The Chairman of the Department shall appoint a Surgery Peer Review Committee Chairman at the beginning of each calendar year. The Committee Chairman may succeed himself indefinitely at the discretion of the Department Chairman. The Committee Chairman may then select the remainder of the membership in consultation with the Department Chairman. Meetings will be held every other month or as needed, but at least five (5) times per year to perform patient care review activities and other

functions as requested by the Chief of Surgery. Supervisory Committee: (amended 9/96)

In accordance with the Medical Staff Bylaws, the Department Chairman shall appoint a Supervisory Committee which shall be available to assist him in ensuring that functions described in the Medical Staff Bylaws are performed. The Chairman of the Department will act as the Chairman of this committee; the remainder of the committee shall consist of not less than 2 Active Staff members. Meetings will be activated when deemed necessary by the Chairman.

VII. PRIVILEGES

A. Membership and privileges within the Department of Surgery includes the privilege to: 1. Admit to inpatient services

2. Perform Medical Histories & Physicals 3. Provide surgical consultation.

4. Coordinate and direct management of patients' medical conditions.

This applies to all members of the Department of Surgery, including Anesthesiologists, with the following EXCEPTIONS: (added 1/93)

Podiatrists and General Dentists

Podiatrists and General Dentists shall have the privilege to admit to inpatient services.

However, no podiatrist or General Dentist may admit or treat patients without having a medical staff member who is a MD or DO (who has privileges to admit patients) record a H&P within 24 hours after admission and assume responsibility for the care of such patient's medical problems which are not specifically within a podiatrist's or dentist's scope of practice. Podiatrists or dentists may not perform medical H&Ps, provide surgical consultation beyond his or her scope of practice, or coordinate/direct management of patients' medical conditions.

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Oralmaxillofacial Surgeons

1. Oralmaxillofacial surgeons shall have the privilege to admit to inpatient services. 2. Privileges to perform medical H&Ps (on patients admitted only for Oralmaxillofacial

surgery) will be considered based upon the individual Oralmaxillofacial surgeons documented education, experience, and current competency.

3. Oralmaxillofacial surgeons granted privileges to do histories & physical examinations (on patients admitted only for Oralmaxillofacial surgery) shall have no requirements for either co-admission, H&P by a MD or DO, or responsibility of a MD or DO for the care of his patient's medical problems unless the oralmaxillofacial surgeon seeks consultation. 4. Oralmaxillofacial surgeons who are not granted privileges to do (Oralmaxillofacial

surgery) history & physical examinations shall arrange for a H&P within 24 hours after admission for each patient he admits, to be performed by a doctor of medicine or osteopathy who is a medical staff member and who has privileges to admit patients. That MD or DO shall be responsible for the care of any medical problems that may be present at the time of the patient's admission or that may arise during the course of the patient's hospitalization and which are outside the scope of practice of a dentist.

Oralmaxillofacial surgeons may not provide consultation beyond his or her scope of practice, nor coordinate/direct management of patients' medical conditions beyond his or her scope of service or licensure.

B. OPERATING ROOM PRIVILEGES FOR GENERAL DENTISTS (added 9/93)

Operating room privileges for General Dentists will be considered if the applicant provides evidence of completion of a hospital based graduate dental internship or residency with operating room experience, or documentation of operating room experience.

C. PRIVILEGE CONTROL CARD

Each Privilege Control Card is considered to be an addendum to these Rules & Regulations; therefore, any amendment to the Privilege Control Card shall be approved by the Department of Surgery and MEC.

VIII. FREQUENCY OF PATIENT VISITS

Patients admitted by members of the Department of Surgery must be seen at least daily by the surgeon or his designee, or more frequently as medically required by the patient's condition. (amended 7/92) IX. CONSULTATION POLICY

The hospital-wide Consultation Policy, contained in the General Medical Staff Rules and Regulations shall be observed by all members of the Department.

X. POLICIES AND PROCEDURES

As hospital interests and services expand, the Department of Surgery may develop policies and procedures as appropriate to maintain quality and standards of care. Once approved within the framework of the Medical Staff, such policies and procedures shall be a part of these Rules and Regulations.

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XI. PREOPERATIVE HISTORY AND PHYSICAL EXAMINATIONS

A. Pre-operative History & Physical Reports shall be required as outlined in the General Medical Staff Rules and Regulations.

B. In order to observe this policy in the best interests of all concerned, patients shall be detained in the surgical "holding area" until this requirement is met. In all cases where this requirements is not met, the surgery is subject to cancellation by the Surgical Service Supervisor as authorized by the Department of Surgery and Medical Executive Committee and supported by

Administration.

C. Preoperative history and physical examinations assessments may be performed by non-staff physicians with the condition that the staff surgeon sign the report and accept legal responsibility for the assessment. (approved 8/24/87 amended 5/8/97)

XII. ASSISTANTS IN SURGERY

Any licensed practitioner (i.e. MD, DO, DPM, Oralmaxillofacial Surgeon), who is a member of the Medical Staff with clinical privileges, may assist in surgery without applying for surgical assisting privileges.

A. PROCEDURES REQUIRING AN ASSISTANT:

Selection of an appropriate assistant shall be at the surgeon's discretion, except as noted in Article XII.B.

B. PROCEDURES REQUIRING A SURGEON TO ASSIST (added 1/93, revised 8/93. 9/97) Only a (*)SURGEON may act as FIRST assistant on the following surgeries:

MAJOR VASCULAR – Heart and Great Vessel Operations, above the diaphragm.

(*) Definition of a surgeon: A physician who has satisfactorily completed all training requirements to qualify for certification by his/her surgical specialty board and who has surgical privileges at PHCMC or another accredited hospital.

XIII. SPECIAL SURGICAL PRIVILEGES

Supplemental documentation requirements for special surgical privileges are described on the Department of Surgery Clinical Privilege Card.

XIV. PROCTORING PROTOCOL

A. POLICY

In addition to routine quality improvement activities, all new staff members shall be concurrently proctored. This will also apply to all existing staff members requesting additional privileges, depending upon the type of privileges requested, as recommended by the Department Chairman.

Former staff members re-applying to the medical staff may be required to undergo proctoring upon individual consideration and/or depending on the quality improvement outcome data and demonstrated competency. (Added 5/2009)

Certain divisions/specialties within the Department of Surgery, include more than one category of cases, (i.e., such as endovascular intervention procedures within vascular surgery and total ankle replacement procedures within podiatry). (Added 3/2009)

During the reapplication process, staff members must demonstrate continued competence in their specialty based on volume and variety of procedures done at Providence Holy Cross Medical Center. In accordance with the Medical Staff Bylaws, whenever a staff member, who

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shall have been granted additional clinical privileges and/or are granted privileges with specific proctoring requirements, fails to complete the proctoring requirement(s), within such a twenty-four (24) month period, it shall be recommended that such additional clinical privileges and/or privileges with specific proctoring requirements will not be renewed. (Added 3/2009)

If the proctoring requirement for basic proctoring is not completed within two years, the member shall be deemed a voluntary resignation. Waiver of proctoring can be granted on special occasions and in accordance with the rules stipulated in these rules. (Added 3/2009) B. METHODS OF PROCTORING

1. During the period of Provisional staff membership, a sufficient number of cases shall be proctored to determine the individual's qualifications. A minimum of six cases must be proctored. Special/supplemental proctoring requirements for specific procedures, if any, are described on the Proctoring Evaluation and/or Clinical Privilege Card.

2. The cases proctored shall be of varied pathology and sufficient difficulty so as to provide a comprehensive view of the physician's ability to handle such cases.

3. The individual proctor shall prepare a written report of each case, which must be reviewed and accepted by the Department of Surgery. These reports shall be included in the physician's credential file and such reports shall be absolutely privileged for purposes of damage actions.

4. Proctoring includes evaluation of all aspects of the management of an individual case by direct observation of surgical skills.

5. No single proctor shall account for more than 50% of the proctoring done for any individual, except under unusual circumstances as by which the chairman can override this rule. (Added 3/2009)

C. PROCTOR QUALIFICATIONS

1. A proctor shall be a member of the Department of Surgery who has unrestricted privileges for the procedure(s) s/he is proctoring.

2. Under special circumstances a staff member who is fully credentialed, who has not yet completed his/her own proctoring, but who has one satisfactory proctoring report on file, may be eligible to act as a proctor.

3. Associates shall not be eligible to proctor each other, except in special circumstances which will be considered by the Department of Surgery. (amended 9/96)

An “Associate” is defined as practitioners with vested or apparent interest in the surgeon. A family relative cannot serve as the proctor for the same reason. Exception to this rule will be applied only to closed hospital services, including but not limited to Anesthesia, Pathology, Radiation Oncology. (Added 3/2009)

4. Physicians who serve as proctors and act as assistant surgeons, but who do not render a fee for service, shall be covered by the hospital's malpractice insurance policy. 5. In a situation where no staff member is deemed qualified to supervise the work of an

applicant, the Medical Staff may consult external sources for assistance. D. NEW STAFF MEMBER'S RESPONSIBILITIES

1. The practitioner being proctored shall be responsible for obtaining an appropriate proctor.

2. The practitioner being proctored must provide the proctor's name to the Operating Room [O.R.] at the time the procedure is scheduled. The O.R. shall not place any case on the O.R. schedule until the name of the proctor has been provided.

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E. RECIPROCAL PROCTORING ARRANGEMENTS

1. The practitioner may provide proctoring reports from local institutions to supplement the actual observation (may not exceed 50% of the proctored cases) on the premises if: a. The proctor is someone who is eligible to serve as proctor at PHCMC.

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b. The same range and level of privileges must have been requested by the applicant at both institutions.

F. WAIVER OF PROCTORING (amended 6/96)

A waiver of proctoring may be considered by the Department if the applicant provides the following:

1. Evidence that s/he is actively practicing in the community. AND

2. Letter from the Chairman of the Department of Surgery, or the Chairman of the Surgery Peer Review committee of another local accredited Hospital where the applicant holds privileges, specifically vouching for the applicant's clinical competence and

recommending a waiver of proctoring. AND

3. Letters from two active or courtesy staff surgeons who are surgically active at PHCMC and who have had direct experience in surgery with the new doctor. At least one of these surgeons must be within the same specialty as the applicant. These letters must address the applicant's clinical competence and specifically recommend a waiver of proctoring.

XVII. O.R. SCHEDULING:

In the event a surgeon will be late for surgery: Surgeons are expected to be on time for surgery for the efficiency of the operating room and for the comfort of all of the patients on the schedule. There might be occasions when a surgeon will unexpectedly delayed. Unless the surgeon calls ahead to report that he will be late, or if he fails to respond to a call from the O.R., within 30 minutes of his start time, the schedule will not be held up and his case will be fitted into the schedule as determined appropriate by the charge nurse. Any dispute about the schedule will be decided upon by the first call anesthesiologist and charge nurse.

XVIII. PREOPERATIVE TESTING GUIDELINES

Appropriate screening tests are based on the needs of the patient. Clinical judgment is required in applying this guideline in the best interest of this need.

ADMISSION LABS FOR SURGERY

1. Children under nine (9) years of age having surgery with minimal anticipated blood loss do not require lab work.

2. Children under nine (9) year of age having surgery - T&A: CBC within seven (7) days. 3. Healthy (ASA Class I & II) patient on no medications: CBC within three (3) months. 4. Cataract patients not on digoxin, diuretics, diabetic medications, anticoagulants or

antiarrhythmics: CBC within three (3) months.

5. Patients on digoxin, diuretics, diabetic medications, anticoagulants or antiarrhythmics: CBC and a Basic Metabolic Panel within one (1) week, and an EKG within three (3) months.

6. Patients with cardiac disease (angina, arrhythmias or CHF) or patients with pulmonary disease or smoking history: CBC, a Basic Metabolic Panel within one (1) week, and an EKG within one (1) year.

7. Patients having a Craniotomy: CBC, a Basic Metabolic Panel within one (1) week, and an EKG within one (1) year.

8. Patients with renal disease: CBC, a Basic Metabolic Panel within one (1) week, and an EKG within one (1) year.

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9. Patients with renal disease (on dialysis): CBC within one (1) week, a Basic Metabolic Panel on the day of surgery, and an EKG within one (1) year.

10. Patients with hepatic disease: CBC, Minor Coag, a Basic and Comprehensive Metabolic Panel within one (1) week, and an EKG within one (1) year.

11. Patients with bleeding disorders: CBC, Minor Coag, a Basic Metabolic Panel within one (1) week, and an EKG within one (1) year.

12. Patients on anticoagulants: CBC, Minor Coag, a Basic Metabolic Panel within one (1) week, and an EKG within one (1) year. Patients on Coumadin within two (2) weeks: Minor Coag within forty-eight (48) hours. Repeat if abnormal.

BASELINE TESTS FOR

1. Patients over age forty (40): EKG within a year.

2. Pre-menopausal patients having D&C, Hysterectomy or Hysteroscopy: pregnancy test within seventy-two (72) hours.

3. Healthy (ASA Class I & II) Non Obstetrical patients having epidural or spinal anesthesia: CBC and Minor Coag panel within three (3) months.

4. Obstetrical patients: minimum of CBC and type and screen on admission.

5. Any patient who is typed and cross-matched for surgery: a minimum of a CBC within one (1) week.

XIX. APPROVALS

As evidenced by the following signatures, these Rules and Regulations have been adopted by the Department of OB/GYN, with acceptance by the Medical Executive Committee, and approval by the Hospital's Board of Trustees.

Approval Dates SURG: 01/13/2011

MEC: 04/02/2009; 06/01/2009; 03/07/2011 MAC: 03/21/2011

CMB: 04/14/2011

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