Medical Staff Bylaws - Arkansas Children's Hospital

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REVISIONS TO MEDICAL STAFF BYLAWSADDITION OF ADULT SERVICE12.1 Organization of Services12.1.1 There shall be services of Anesthesiology, Cardiovascular Surgery, Dentistry,Neurosurgery, Ophthalmology, Orthopaedic Surgery, Otolaryngology, Pathology, Pediatric Medicine,Psychiatry, Radiology, Surgery, Urology, and Adult Medicine.12.1.2 Each Service shall be headed by a Chief of Service and shall function under the directionof the MSEC. Each service will also have a Vice-Chief, when possible.12.2 Assignment to Services12.2.1 The MSEC will, after consideration of the recommendations of the clinical services,recommend initial service assignments for all Medical Staff members and for all other approvedPractitioners with clinical privileges.12.2.2 Physicians assigned to the Adult Medicine Service are limited to adultspecialists/subspecialists who take call for the Burn Unit or are asked to treat adult patients who havebeen granted a treatment exception (over 21) by the Medical Director. Adult Medicine physicians mustfollow the requirements for admitting adult patients as specified in Paragraphs 1.1.2 & 1.1.3.Approved by Medical Staff Executive Committee: June 12, 2012Approved by Medical Staff General Committee: July 26, 2012Approved by Board of Directors: August 29, 2012REVISIONS TO MEDICAL STAFF BYLAWSDESCRIPTION OF STANDING COMMITTEES13.9.6 Patient Care Committee1. Composition: The Patient Care Committee will consist of at least the following:the Chief Medical Officer, the Chief Quality Officer, the Chief Operating Officer, the Chief of Staff, TheChief Nursing Officer, the Chief Medical Information Officer, the Chief Nursing Information Officer,the Vice Chair for Clinical Services for Pediatrics, ACH General Counsel, the Chairs of the SurgicalAffairs Committee, the Ethics Advisory Committee, the Outpatient Care Committee, the Traumacommittee, the Pharmacy & Therapeutics Committee, the Medical/Surgical (Inpatient) Committee, theInfection Control Committee, and the Intensive Care Committee. The ACH General Counsel will be anon-voting member of this committee.83
2. Function: The Committee is chartered by the Medical Staff Executive Committeeto oversee on its behalf the delivery of patient care throughout the ACH system.• Oversee and align the decision-making activities of the professionalpartnership committees with the ACH mission and service standards• Review of activities of professional partnership committees andrecommend approval of minutes to MSEC• Review and recommend approval of new programs that impact thedelivery of care in the ACH system• Periodic review of existing patient care activities and programs• Review metrics of clinical activities of patient care service lines• Recommend and refer performance improvement initiatives to the Qualityand Patient Safety committeeand/or revision• Review selected clinical policies and make recommendations for update3. Meetings: The Patient Care Committee will meet at least 10 times per year.Approved by Medical Staff Executive Committee: July 10, 2012Approved by Medical Staff General Committee: July 26, 2012Approved by Board of Directors: August 29, 201213.9.7 Risk Management/Peer Review Committee1. Composition: The Risk Management/Peer Review Committee will consist of atleast the following: the Chief Quality Officer, the Medical Director, the Chief Operating Officer, theChief of Staff, The Chief Nursing Officer, the Chief Finance Officer, the Vice Chief of Staff, theImmediate Past Chief of Staff, the Surgeon-in-Chief, The Pediatrician-in-Chief, a General Pediatricsrepresentative, a Pediatric Chief Resident, a Vice-President Patient Care Services, a Pharmacyrepresentative, the Vice President of Medical Administration, Safety, and Improvement, the ClinicalRisk Management Director, the Medical Staff Administration Director, a Quality ImprovementCoordinator, and a representative of the Office of General Counsel as a non-voting member (for advisoryonly) The Chief Quality Officer, or designee, will serve as chairperson. Department Chairs/Directors ofaffected service(s) or section(s) or others requested by the committee will attend meetings without vote,as requested by the committee chair.2. Function: The Risk Management/Peer Review Committee is chartered by theBoard Services and Quality Committee to oversee the peer review and clinical risk management84
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Approved: August 2011
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10.13 Release .....................
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PREAMBLEWHEREAS, Arkansas Children'
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3.1 Nature of Medical Staff Members
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ARTICLE 4: CATEGORIES OF THE MEDICA
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4.2.6.4 If the H&P has been written
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ARTICLE 5. HOUSE STAFF AND MEDICAL
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ARTICLE 6: AFFILIATED HEALTH PROFES
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7.1 General ConditionsARTICLE 7: AP
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A. To abide by the Bylaws, Rules an
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7.4 Reapplication After Adverse Dec
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and for the granting of clinical pr
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ARTICLE 8: CLINICAL PRIVILEGES8.1 C
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date such action becomes effective
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E. Ability to perform the privilege
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A. if no other physician currently
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B. A current license to practice.C.
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9.2.2.1 In conducting such evaluati
Page 41 and 42: 9.3.2 Whenever the corrective actio
Page 43 and 44: 9.4.3 A summary suspension becomes
Page 45 and 46: 9.6 Temporary Suspension9.6.1 A tem
Page 47 and 48: D. automatic suspensions;E. a suspe
Page 49 and 50: B. A hearing occasioned by an adver
Page 51 and 52: 10.6.6 Utilization of Attorneys. At
Page 53 and 54: D. Upon conclusion of the affected
Page 55 and 56: 10.5.3(a) involving actions other t
Page 57 and 58: C. Whether or not the hearing commi
Page 59 and 60: 10.14 Exceptions To Hearing And App
Page 61 and 62: ARTICLE 11: OFFICERS11.1 Officers o
Page 63 and 64: 11.6.1.8 Receive and interpret the
Page 65 and 66: ARTICLE 12: SERVICES12.1 Organizati
Page 67 and 68: D. Determining the qualifications a
Page 69 and 70: 13.3 Notice of Meetings13.3.1 Writt
Page 71 and 72: written notification of any further
Page 73 and 74: K. Make recommendations regarding t
Page 75 and 76: G. Provide for development of medic
Page 77 and 78: 13.9.5.1 Composition: The Patient C
Page 80 and 81: ACH commitment to patient care qual
Page 82 and 83: 14.5 Removal of Delegated Authority
Page 84 and 85: 16.1 Confidentiality of Information
Page 86 and 87: ARTICLE 17: RULES AND REGULATIONS17
Page 88 and 89: ARTICLE 19: POLICIESWhen the MSEC a
Page 90 and 91: DEFINITIONSAdmitting Physician - Th
Page 94 and 95: functions of the ACH clinical enter
Page 96 and 97: per year.3. Meetings: The Quality a
Page 98: 6.5 Violations of AppointmentAny vi
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Medical Staff Bylaws - Arkansas Children's Hospital

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