METHODIST HEALTH SYSTEM
MEDICAL STAFF POLICY MANUAL
Immediate Prior Version: July 26, 2005
Current Version Approved by:
MDMC Executive Committee: August 9, 2005
MCMC Executive Committee: August 12, 2005
Corporate Medical Board: August 16, 2005
Board of Directors: August 25, 2005
ARTICLE 1 - INTRODUCTION 1
ARTICLE 2 - PURPOSES 1
ARTICLE 3 - DEFINITIONS 1
ARTICLE 4 - MEDICAL STAFF APPOINTMENT 1
4.1 Nature of Medical Staff Appointment 1
4.2 Qualifications for and Terms, Conditions and Responsibilities of Appointment 1
4.2.1 Qualifications for Appointment 1
4.2.2 Professional Liability Insurance 2
4.2.3 Responsibilities of Appointment 2
4.2.4 Authority to Appoint 2
4.2.5 Terms of Appointment 2
4.2.6 Provisional Status 3
4.2.6.1 Applicability 3
4.2.6.2 Continuation, Evaluation and Termination of Provisional Status 3
4.2.6.3 Orientation Process 4
4.2.7 Primary System Hospital Affiliation 4
4.2.8 Applicant’s Obligations 4
4.2.9 Participation in Teaching Programs as Teaching Staff 4
4.2.9.1 Appointment Process 4
4.2.9.2 Degree of Care/Management of Patient by House Staff 5
4.2.10 Compliance with Privacy Regulations 5
4.2.10.1 Adoption of Privacy Notice 5
4.2.10.2 Approval of Restrictions and Limitations 5
4.2.10.3 No Information Patients 5
4.2.10.4 No Effect on Legal Regulations 5
4.3 Ethics and Ethical Relations 6
4.3.1 Conflict of Interest 6
4.3.1.1 Purpose 6
4.3.1.2 Definitions 6
4.3.1.3 Procedures 7
4.4 Scope of Clinical Privileges 8
4.5 Peer Review 8
4.5.1 Purpose 8
4.5.2 Objective 8
4.5.3 Guidelines 8
4.5.4 Privileged Committee Function 9
4.5.5 Definition 9
4.5.6 Process 9
ARTICLE 5 - APPOINTMENT OF INITIAL APPLICANT AND REAPPOINTMENT 11
5.1 Disclosures 11
5.2 Burden of Proof 11
5.3 Application and Initial Appointment 11
5.3.1 Initial Application 11
5.3.2 Corporate Credentials Committee Function 13
5.3.3 Corporate Medical Board Responsibilities 13
5.3.4 Favorable Recommendation by the Corporate Medical Board 14
5.3.5 Deferral of Application 14
5.3.6 Adverse Recommendation by Corporate Medical Board 14
5.3.7 Final Action by Board of Directors 15
5.3.8 Eligibility for Appointment after Adverse Recommendation 15
5.3.9 Expedited Review Process for Initial Applicants 15
5.3.9.1 Purpose and General Requirements 15
5.3.9.2 Expedited Processing Procedure 16
5.3.9.3 Criteria for Applying Process 16
5.3.10 Scheduled Review of Provisional Status for Active Category of Membership 16
5.4 Medical Staff Re-Appointment Process 18
5.4.1 Practitioners' Obligation 18
5.4.2 Reappointment Application Process 18
5.4.3 Department and Corporate Credentials Committee Review 20
5.4.4 Corporate Medical Board Responsibilities 22
5.4.5 Favorable Recommendation by the Corporate Medical Board 22
5.4.6 Deferral of Application 22
5.4.7 Adverse Recommendation by Corporate Medical Board 22
5.4.8 Final Action by Board of Directors 23
5.4.9 Eligibility for Reappointment After Adverse Recommendation 23
5.4.10 Reappointment Criteria 23
5.4.11 Conditional Reappointment 24
5.5 Leave of Absence 24
5.5.1 General Leave of Absence 24
5.5.2 Leave of Absence for Military Service 25
5.5.3 Inactive Status for Illness 25
5.6 Modification of Appointment 25
ARTICLE 6 - CLINICAL PRIVILEGES 26
6.1 Request for Privileges by Initial Applicants and Provisional Appointees 26
6.2 Re-determination of Privileges 26
6.3 Additional Privileges 26
6.4 Privileges Granted to Dentists 26
6.5 Privileges Granted to Podiatrists 26
6.6 Temporary Privileges 27
6.6.1 Temporary Privileges for Initial Applicant 27
6.6.2 Locum Tenens Privileges 27
6.6.3 Temporary Privileges for Specialized Teams 27
6.6.4 Temporary Privileges for the Care of a Specific Patient 27
6.6.5 Special Requirements for Temporary Privileges 27
6.6.6 Termination of Temporary Privileges 28
6.7 Emergency Privileges 28
ARTICLE 7 - CORRECTIVE ACTION 29
7.1 Corrective Action 29
7.2 Summary Suspension 29
7.3 Automatic Suspension or Revocation 29
7.4 Precautionary Administrative Suspension 29
7.5 MHS Practitioner Conduct Policy 29
7.5.1 Policy 29
7.5.2 Definitions 29
7.5.3 Procedure for Reporting and Handling Apparent Violations 31
7.5.3.1 Reporting the Incident 31
7.5.3.2 Documentation of the Incident 31
7.5.3.3 Investigation of the Incident 31
7.5.3.4 Review with the Practitioner 31
7.5.3.5 Conduct of a Level I Review 32
7.5.3.6 Conduct of a Level II Review 33
7.5.3.7 Conduct of a Level III Review 33
7.5.3.8 Conduct of a Level IV Review 33
7.5.3.9 Letters of Admonishment and Conditional Conduct Letters 34
7.5.3.10 Practitioner Advocate 34
7.5.3.11 Documentation of the Meeting with the Practitioner 34
7.5.3.12 Outline of Formal Disciplinary Measures 34
7.5.3.13 Exoneration of Practitioner 34
7.5.3.14 Exclusion of Practitioner from the Hospital Facilities 35
7.5.3.15 Responsibility for Sponsored and/or Employed Individuals 35
7.5.3.16 Presence of Counsel at Reviews 35
7.5.3.17 Confidentiality and Protection from Discovery 35
7.5.3.18 Order of Review 36
7.5.3.19 Retention of Records 36
7.5.3.20 The Corporate Credentials Committee Responsibility 36
7.5.3.21 Time of the Essence 36
ARTICLE 8 - FAIR HEARING PROCEDURE 36
ARTICLE 9 - MEDICAL STAFF CATEGORIES 37
9.1 Types of Categories 37
9.2 Active Membership 37
9.2.1 Category Description; Qualifications; Rights; and Responsibilities 37
9.2.2 Senior Active Status 37
9.3 Affiliate Category 37
9.3.1 Consulting Affiliate 37
9.3.2 Sponsored Attending Affiliate 37
9.3.3 Honorary Affiliate 38
9.3.4 Departmental Affiliate 38
9.3.5 Temporary Affiliate 38
9.3.6 Courtesy Affiliate 38
9.4 Administrative and Medical Staff Functions 38
9.5 House Staff 38
ARTICLE 10 - ALLIED HEALTH PROFESSIONALS 39
10.1 Relationship to Medical Staff 39
10.2 Categories, Qualifications, Application Process, Monitoring, and Identification 39
10.2.1 Categories 39
10.2.1.1 Allied Health Associates 39
10.2.1.2 Allied Health Assistants 39
10.2.2 Qualifications 39
10.2.3 Application Process 39
10.2.4 Monitoring of Approved Applicants 40
10.2.5 Identification 40
10.2.6 Suspension and Exclusion of Allied Health Professionals 40
10.2.7 Sponsoring Practitioner’s Responsibilities 40
ARTICLE 11 - MEDICAL STAFF ORGANIZATION AND OFFICERS 42
11.1 Officers of the Medical Staff 42
11.1.1 Annual Stipend 42
11.1.2 Source of Funds 42
11.1.3 Control of Funds 42
ARTICLE 12 - CORPORATE MEDICAL STAFF COMMITTEES 43
12.1 Composition and Appointment 43
12.2 Authority to Delegate 43
12.2.1 Special Committees 43
12.2.2 Standing Special Committees 43
12.3 Corporate Medical Board 43
12.4 Corporate Graduate Medical Education Committee 43
12.5 Other Corporate Medical Staff Committees 43
12.5.1 Corporate Bylaws and Policies Committee: 43
12.5.2 Corporate Credentials Committee 44
12.5.3 Medical Staff Health Subcommittee 44
12.5.3.1 Creation 44
12.5.3.2 MHS Practitioner Health Policy 45
12.5.4 Corporate Clinical Ethics Committee 49
12.5.4.1 System Hospital Clinical Ethics Sub-committee 50
12.5.5 MHS Medical Staff Policy and Guidelines Committee 51
12.5.6 Corporate Health Information Management Committee 52
ARTICLE 13 - SYSTEM HOSPITAL MEDICAL STAFF COMMITTEES 53
13.1 Composition and Appointment 53
13.2 Authority to Delegate 53
13.2.1 Special Committees 53
13.2.2 Standing Special Committees 53
13.3 Executive Committee 53
13.4 Succession & Leadership Committee 53
13.5 Other System Hospital Medical Staff Committees 53
13.5.1 Professional Care Audit/Review Committee 53
13.5.2 Utilization Management Committee 55
13.5.3 Medical Staff Quality Council 56
ARTICLE 14 - MEDICAL STAFF CLINICAL DEPARTMENTS AND SECTIONS 57
14.1 Organization 57
14.2 Other Matters Related to Medical Staff Clinical Departments 57
14.2.1 Qualifications, Selection, and Tenure of Department Chairmen 57
14.2.1.1 Qualifications 57
14.2.1.2 Term of Office 57
14.2.1.3 Method of Election 57
14.2.1.4 Removal of Departmental Officers 57
14.2.1.5 Department Officers with Contractual Relationship 57
14.2.2 Duties of Department Chairmen 58
14.2.3 Functions of Departments 59
14.2.4 Assignment to Departments 60
14.2.5 Department of Family Practice 60
14.2.6 Department of Emergency Medicine 60
14.2.7 Trauma Service, Administrative Section of the Department of Surgery 60
ARTICLE 15 - MEDICAL STAFF MEETINGS 61
15.1 Regular Meetings 61
15.2 Annual Meeting 61
15.3 Special Meetings 61
15.4 Attendance at Medical Staff Meetings 61
15.4.1 Requirements 61
15.4.2 Exclusion from Attendance Requirement 61
15.5 Notification, Quorum and Agenda 61
15.5.1 Notification 61
15.5.2 Quorum 61
15.5.3 Agenda 62
15.5.3.1 Regular Meeting Agenda 62
15.5.3.2 Special Meeting Agenda 62
ARTICLE 16 - DEPARTMENTAL AND COMMITTEE MEETINGS 63
16.1 Regular Meetings 63
16.1.1 Frequency of Meetings 63
16.1.2 Purpose and Record Requirements 63
16.1.2.1 Purpose of Meetings 63
16.1.2.2 Record of Meetings 63
16.2 Special Meetings 63
16.3 Attendance Requirements – Department and Committee Meetings 63
16.4 Other Matters Related to Department and Committee Meetings 64
16.4.1 Notification 64
16.4.2 Quorum 64
16.4.3 Committee and Departmental Manner of Action 64
16.4.4 Rights of Ex-Officio Members 64
16.4.5 Departmental and Committee Reports 64
ARTICLE 17 - RULES OF ORDER 64
ARTICLE 18 - IMMUNITY FROM LIABILITY 64
ARTICLE 19 - AMENDMENTS TO BYLAWS, POLICIES AND DEPARTMENT RULES 65
19.1 Medical Staff Bylaws 65
19.2 Policies 65
19.2.1 Process to Amend Policies 65
19.2.1.1 Requests for Amendments, Modifications and Repeal 65
19.2.1.2 Action of Medical Staff Bylaw and Policies Committee 65
19.2.1.3 Action of Executive Committee 65
19.2.1.4 Action of the Corporate Medical Board 65
19.2.1.5 Action of the Board of Directors 65
19.2.2 Notification to the Medical Staff 66
19.3 Department Rules 66
ARTICLE 20 - GENERAL PROVISIONS 66
ARTICLE 21 - ADMISSION AND DISCHARGE OF PATIENTS 67
21.1 Patient Admission 67
21.2 Types of Cases Admitted 67
21.3 Infectious Patients 67
21.4 Admission Priorities 67
21.5 Assignments by Patient Care Unit and Patient Transfers 67
21.6 General Consent to Treatment Form 68
21.7 Informed Consent 68
21.8 Utilization Review 68
21.9 Discharge of Patient 68
21.10 Pronouncement of Death 68
21.11 Autopsies 68
ARTICLE 22 - MEDICAL RECORDS 69
22.1 Responsibility for Medical Record 69
22.2 History and Physical Examination Report 69
22.3 Records by House Staff and Teaching Physician 69
22.4 Progress Notes 69
22.5 Reports 70
22.6 Consultation Content 70
22.7 Symbols and Abbreviations 70
22.8 Discharge Summary 70
22.9 Completion of the Medical Record 70
22.10 Authentication of Routine Order 71
22.11 Release of Patient Information 71
22.12 Medical Records are Property of the Hospital 71
22.13 Availability of Medical Records 71
22.14 Filing of Medical Record 71
22.15 Medical Record in the Emergency Room 72
ARTICLE 23 - GENERAL CONDUCT OF CARE 73
23.1 Consultations 73
23.2 Clarification 73
23.3 Orders for Treatment Shall be in Writing 73
23.4 Prescriptions During the Patient's Hospitalization 73
23.5 Laboratory Work 74
23.6 Patients Admitted for Dental Services 74
23.7 Patients Admitted for Podiatric Services 74
ARTICLE 24 - EMERGENCY SERVICES 75
24.1 Call Schedule 75
24.1.1 On-Call Practitioner Must Come To the ED When Called 75
24.1.2 Disputes Over Need to Respond 75
24.1.3 Assistance in Screening and/or Stabilization 75
24.1.4 Ability to Pay Not To Be Considered 75
24.1.5 Timely Response 75
24.1.6 Justification for Delay 76
24.1.7 Follow-Up Care 76
24.1.8 Disciplinary Actions 76
24.1.9 Definitions 76
24.2 Disaster Plans 77
24.3 Disaster Privileges 77
24.3.1 Purpose 77
24.3.2 Policy 77
24.3.3 Procedure 77
ARTICLE 25 - GENERAL 79
25.1 Confidentiality of Medical Staff Files 79
25.2 Assessment for Medical Staff Members 79
25.3 Hospital Orientation 79
Methodist Health System Medical Staff Practitioners Notice of Privacy Practices 80
MHS Medical Staff Policies
Page - iv
MEDICAL STAFF POLICIES
ARTICLE 1 - INTRODUCTION
Pursuant to Article 19.2 of the Bylaws, the Medical Staff through the Corporate Medical Board has established certain policies and procedures to carry out further and in more detail describe the general provisions, concepts, policies, principles and obligations set out in the Bylaws. This Policy manual contains those more detailed policies and procedures, and the provisions set forth in this Medical Staff Policy Manual are the “Policies” as that term is used in the Bylaws.
ARTICLE 2 - PURPOSES
The purposes of the medical staff organization are as expressly stated in the Bylaws.
ARTICLE 3 - DEFINITIONS
Unless expressly stated otherwise, capitalized terms contained in this Policy Manual shall have the same meaning as given in the Bylaws.
ARTICLE 4 - MEDICAL STAFF APPOINTMENT
4.1 Nature of Medical Staff Appointment
The Nature of Medical Staff Appointment is as set forth in the Bylaws. Additional requirements, policies and rules related to initial application, appointment and reappoint including the process for initial application, appointment and reappointment are set forth in Article 5 of these Policies.
4.2 Qualifications for and Terms, Conditions and Responsibilities of Appointment
4.2.1 Qualifications for Appointment
In order to qualify for appointment on the Medical Staff, a Physician, Dentist, or Podiatrist must:
1. Be licensed to practice in the State of Texas;
2. Provide documentation establishing his or her:
(i) background, including satisfactory experience and training,
(ii) demonstrated competence,
(iii) mental and physical status,
(iv) compliance with the Bylaws, the Policies, Medical Staff rules, and MHS and System Hospital policies, and bylaws,
(v) good character and reputation,
(vi) adherence to the ethics of his profession, and
(vii) ability to work with others.
The documentation must be of sufficient adequacy to assure the Medical Staff and the Board of Directors that he or she will be effective Medical Staff members and will provide a high quality of medical care in an efficient manner to any patient admitted or treated by them.
3. As appropriate, participate in Federal and State health care programs;
4. Possess and maintain current registrations for prescribing medications with the Drug Enforcement Agency (DEA) and Department of Public Safety (DPS) as applicable
5. Have, at all times, professional liability insurance in amounts as specified in the Policies,
6. Furnish proof of the insurance required,
7. As applicable, meet the Citizenship requirements of the Medical Staff, and
8. Provide immediate written notice to the Chief Executive Officer and the medical staff services department of any failure to renew, cancellation, reduction, denial of coverage, or other changes resulting in less coverage than is required for medical staff appointment.
No Physician, Dentist, or Podiatrist shall be entitled to appointment to the Medical Staff or to the exercise of particular clinical privileges in a System Hospital merely by virtue of the fact that he is duly licensed to practice medicine, dentistry, or podiatry in the State of Texas or any other state, or that he is a member of any professional organization, or that he has had in the past, or presently has such privileges at another hospital. Sex, race, creed, and/or national origin are not used in making decisions regarding the granting or denying of medical staff membership or clinical privileges.