SUTTER MEDICAL CENTER, SACRAMENTO DEPARTMENT OF MEDICINE RULES AND REGULATIONS - NEPHROLOGY SECTION I PURPOSE: The Nephrology Section is an organized component of the Department of Medicine

providing an opportunity for physicians in Nephrology to confer for the purpose of education, quality improvement and to address administrative problems of their medical practice in the hospital setting.

II ORGANIZATION: A. Membership Criteria for Nephrology Section 1. Must be a member of the Department of Medicine. 2. Must be Board certified or admissible in the subspecialty of Nephrology. 3. If unable to meet criteria (2) and physician’s practice includes a substantial

amount of time in the subspecialty of Nephrology, the physician may be admitted to the section by majority vote of the section.

4. Member may not currently be a member of another specialty section of the

Department of Medicine at Sutter Medical Center, Sacramento. 5. The Nephrology Section will recommend the training and experience

criteria for membership in the Nephrology Section to the Administrative Committee of the Department of Medicine.

B. Privileges 1. Nephrology privileges may be granted to Section Members and other

physicians who: a. Are Board certified or Board Admissible in Nephrology; or b. Have completed one year of full-time clinical Nephrology

fellowship; or c. Document satisfactory completion of previous 2 years of practice

in a JCAHO-accredited hospital where he/she exercised Nephrology privileges comparable to those being requested at this facility.

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d. Document current clinical competence as set out in any existing guidelines for privileges.

C. Criteria for Continued Section Membership and Privileges 1. Continued membership in the section requires: a. Continued authority to exercise clinical privileges in the

Nephrology Section. b. Continued satisfactory performance of Medical Staff

responsibilities and continued good standing on the Medical Staff. 2. Continued exercise of clinical privileges in the Nephrology Section

requires satisfactory results in any proctoring, audit or review conducted by any section, Department or Medical Staff committee concerned with quality of care, or satisfactory correction of any problems noted in any such review.

D. Meetings 1. The Nephrology Section will meet as needed. 2. Meetings may be called by the Chairperson of the Section. 3. Meetings of the Section will have meeting notice sent to the members 10

days before the scheduled meeting. 4. Emergency meetings may be held with less than two weeks notice with the

business confined only to the emergency item. 5. Should parliamentary procedures be necessary, Sturgis Rules of Order

shall govern. E. Voting 1. Elections of Section officers shall be by mail, secret ballot. 2. Other matters may be decided by the majority of vote of those present at

any properly called meeting of the Section. 3. Proxy voting is permissible at meetings, with written proxy given to the

Section Chairperson in advance of, or at the time of, the meeting, signed by the absent member designating who shall cast the member's vote.

4. Active staff members are eligible to vote. Z:\Department Medicine\Rules & Regulations\MED - Nephrology Section Rules.2013.doc

Nephrology Section Rules and Regulations - Page Three F. Officers 1. Chairperson of the Nephrology Section a. Section head shall be known as Section Chairperson. b. Section Chairperson shall have been a member of the Department

of Medicine in good standing for two years. c. The Chairperson is elected by majority vote. d. Term of office is for two years. e. There is no limit to the number of terms except the individual may

not serve more than two terms consecutively. f. The chairperson of the Nephrology Section shall be elected in

even-numbered years for a term beginning January 1 of the odd-numbered year.

2. Duties of the Chairperson a. Duties of the Chairperson shall be in accordance with Department

of Medicine Rules and Regulations, Section III-K. 3. Vice-Chairperson The Nephrology section may elect a Vice-Chairperson to perform in the

absence of the Chairperson if the Section feels its size and volume of business so requires.

III SECTION RESPONSIBILITY AND AUTHORITY: A. The Section derives authority from the Department of Medicine. B. Section policy requires the approval of the Department of Medicine

Administrative Committee as well as the Medical Executive Committee and the Board.

C. Section rules are subservient to the Department of Medicine Rules and Regulations, which are in turn subservient to the Medical Staff Bylaws.

D. Section rules are intended to be read in concert with the Department of Medicine Rules and Regulations.

E. Assisting in quality improvement is a responsibility of the Section, under the direction of the Department of Medicine Quality Improvement Audit Committee.

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IV AMENDMENTS TO RULES: A. Rules of the Nephrology Section may be changed by majority vote taken by

written ballot or at any regular meeting of the Section. Proposed changes shall be submitted to members allowing at least four weeks for consideration prior to voting. Any additional amendments to the proposed changes raised during this four week period or at the meeting may be incorporated into the proposed changes prior to voting.

B. Amendments to rules are subject to approval by the Department of Medicine

Administrative Committee, the Medical Executive Committee and the Board. APPROVED: Nephrology Section October 2, 2012 Medicine Administrative Committee October 2, 2012 Medical Executive Committee October 23, 2012 Medical Policy Committee November 1, 2012 Board of Directors November 5, 2012 Developed: 3/84 Revised: 8/95, 10/12 Review w/o revision: 1/88; 4/89; 7/91; 10/08

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