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RULES AND REGULATIONS

FOR THE MEDICAL STAFF

OF MEMORIAL HERMANN

MEMORIAL CITY MEDICAL CENTER

MEC approved: April 27, 2017

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RULES AND REGULATIONS FOR THE MEDICAL STAFF OF MEMORIAL HERMANN MEMORIAL CITY MEDICAL CENTER

CONTENTS SECTION 1: CURRENT RULES AND REGULATIONS ................................................................. 1

SECTION 2: ADOPTION/AMENDMENT ........................................................................................ 63

Rules and Regulations for the Medical Staff Memorial Hermann Memorial City Medical Center

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SECTION 1: CURRENT RULES AND REGULATIONS General Conduct of Care If a nurse or allied health professional has any reason to doubt or question the care provided to any patient or believes that appropriate consultation is needed and has not been obtained, he/she shall call this to the attention of the Nurse Manager, Manager of the Service or Shift Supervisor who may refer the matter to the attention of the Department Chairman wherein the physician has clinical privileges. Where circumstances are such as to justify such action, the Department Chairman may himself request a consultation. The Hospital Staff at Memorial Hermann Memorial City Medical Center follows the Center for Disease Control (CDC) Specific Isolation Guidelines as indicated in the Infection Control Manual for each department. Suicide Precautions 1. All suicide precaution patients, including patients who have overdosed or

sustained a self-inflicted wound, will have a psychiatric consult within twelve (12) hours of admission and will remain under the care of the psychiatrist for their hospital stay.

2. Suicide precaution status will be reviewed in the progress notes by the

psychiatrist every 24 hours. 3. Suicide precautions may be discontinued with a written order from the

psychiatrist and/or attending physician after psychiatrist documents in patient’s medical record that patient is no longer suicidal.

Admitting and Discharge of Patients 1. Admitting

All patients admitted to Memorial Hermann Memorial City Medical Center must be under the care and supervision of a member of the Hospital Staff. Physicians admitting patients must provide a provisional diagnosis unless it is a case of emergency and then the provisional diagnosis may be stated as soon as possible after admission.

2. Suspected Infectious Admissions

Admitting physicians will provide the hospital with all necessary information on such patients where they suspect an infection (example: tuberculosis) where measures other than Universal Precautions should be utilized to ensure the protection of other patients and the protection of hospital personnel.


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3. Discharge of Patients

Patients shall be discharged from the hospital only on the order of the attending physician.

4. Direct Admission

Patients who are directly admitted to general nursing unit (not going through ER) after normal admission hours must be seen by a physician within a reasonable amount of time.

5. Timeliness for Physician to See Admitted Patient – Approved by MEC 8/25/2015

(implementation date 6/1/2016)

• Reasonable examination time for ICU patients is upon admission, but no later than 2 hours.

• Reasonable examination time for patients admitted to the floor or observation is upon admission, but no later than 4 hours.

Consultation 1. Physicians are encouraged to speak directly (physician-to-physician) when

soliciting all consults. The physician is responsible for directly contacting a consulting physician for a STAT or Urgent consult. The physician will provide an order to the consulting physician that explains the nature and reason for the consultation. The consulting physician is expected to attend and examine the patient, and enter a report of consultation. Approved by MEC 7/24/2014 & DQC 10/2/2014

Response Time 1. Physicians are required to respond to all calls/pages/texts from any unit in the

hospital within 30 minutes of call/page/text. Failure to respond in 30 minutes will result in escalation per escalation policy. (presented to MEC 10/22/2015)

Formulary 1. A “Closed” Formulary is maintained in the hospital and a copy of this Formulary

is kept in all major treatment areas of the hospital. This Formulary is based on need, effectiveness, risks (safety), and cost of the drug. This Formulary includes both legend and non-legend items. Physicians are encouraged to utilize those drugs listed in the Formulary.

Informed Consent


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1. Memorial Hospital System respects the right of the patient to give informed consent for his/her own medical and surgical treatment. It is the physician’s responsibility to obtain informed consent. A designated hospital employee will verify that the appropriate consent form has been completed and retained in the patient’s medical record prior to the performance of the medical or surgical procedure.

Autopsies 1. Each member of the staff should make an attempt to secure autopsies in all

cases of unusual deaths and of medical, legal, and educational interests. No autopsy shall be performed without legal permit. All autopsies shall be performed by the hospital pathologist or a qualified pathologist approved by the hospital pathologist. Provisional anatomic diagnoses are recorded in the medical record within three days and the complete protocol is made part of the record within 60 days.

2. The following are indications for autopsies performed at the request of a medical

staff member.

a. Deaths in which autopsy may help to allay concerns of the family and/or the public regarding the death and to provide reassurance to them regarding same.

b. Unexpected or unexplained deaths occurring during or following any dental, medical, or surgical diagnostic procedures and/or therapies.

c. Deaths in which the patient sustained or apparently sustain an injury while hospitalized that may have contributed to the patient’s death.

d. All obstetric deaths. e. All neonatal and pediatric deaths. f. Deaths at any age in which organs are donated and it is believed that an

autopsy would disclose a known or suspected illness which may have a bearing on survivors or recipients of the transplant organs.

g. Deaths known or suspected to have resulted from environmental or occupational hazards.

If any of the above indications exist and an autopsy cannot be performed, the reason should be documented in the medical record.

Code Blue Response – Approved by MEC 10/27/2011 & DQC 1/31/2012 1. Attending physician or their designee are responsible for ensuring that the

appropriate physician responds to code blue and if that does not happen, case is to be referred to appropriate peer review committee.

Mandatory Use of Ultrasound When Placing All Central Lines – Approved by MEC 10/27/2011 & DQC 01/31/2012


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1. Use of ultrasound is required when placing all central lines. 2. Ultrasound guidance shall be used in the cardiac catheterization laboratory for

central venous access above the waist when inserting wires for pacemakers and ICD’s. Cardiologists, at their discretion, may use ultrasound or venogram when placing pacemakers. – Revision approved by MEC 7/24/2014 & DQC 102/2014

3. Use of ultrasound guidance will be used for the performance of all thoracentesis procedures, whenever possible. Revision approved by MEC 5/29/2014

Physician Extender Policy - Approved by MEC 04/28/2011 & DQC 06/27/2011 Physician Assistants (PA), Advanced Nurse Practitioner (APN) are members of the allied healthcare medical staff. It is the responsibility of the general medical staff, in order to preserve the standard of care and to support patient safety, to define the scope of practice of PE’s as well as the minimal rules for physician supervision of PEs working under them. For the purposes of this policy the term “practitioner” refers to physicians, surgeons, podiatrists, and dentists/oral surgeons or their covering practitioners who are members of the medical staff.. 1. Patients will be seen by a treating practitioner at least once every twenty-four

(24) hours. 2. PEs will be held minimally to a scope of practice as defined by the Texas Joint

Commission, American Medical Association, CMS, PE professional boards/societies, and regulatory agencies. When there are conflicts between these authorities, the general medical staff will determine the most appropriate standard for its local medical community, and in a manner consistent with the laws of the State of Texas.

3. PEs are always overseen, directly and indirectly, by their designated supervisory practitioner.

4. PEs do not replace the need for a practitioner to adhere to the rules and regulations. a. A practitioner must physically see their patient at least once during their

time on the hospital, including Emergency Department visits. b. A patient must be seen by a treating practitioner daily while hospitalized. c. Notwithstanding the involvement of PEs, the attending practitioner or

other treating practitioners or their covering practitioners must be available for telephone discussion/consultation, responding within the time period required by medical staff policy.

d. If a patient or their agent requests a visit by or direct contact with a treating practitioner, irrespective of the PE’s involvement, the practitioner is to be responsive in a timely manner, appropriate to the clinical situation, and in accordance with existing medical staff policy and rules for professional behavior.


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e. Practitioners are to co-sign entries in the medical record of their PEs, no less than every 72 hours.

f. A treating practitioner must personally visit and evaluate any new hospital admission or OBS status patient in accordance with existing medical staff and hospital policy.

g. A treating practitioner must see a patient, irrespective of PE involvement, with any significant clinical deterioration or instability, in accordance with existing medical staff policy, and generally accepted standards of medical care and professionalism.

h. Attending practitioners must round on their patients three times a week or more, as the patient’s clinical condition warrants.

5. Texas Medical Board Rules; Chapter 185: Practitioner Assistants a. Supervision: Overseeing the activities of, and accepting responsibility for,

the medical services rendered by a physician assistant. Supervision does not require the constant physical presence of the supervising practitioner, but includes a situation where a supervising practitioner and the person being supervised are, or can easily be, in contact with one another by radio, telephone, or another telecommunication device.

b. Supervising practitioner- A practitioner licensed by the medical board who has an active and unrestricted license and assumes responsibility and legal liability for the services rendered by the physician assistant, and who has notified the Medical Board of the intent to supervise a specific physician assistant and of termination of such supervision.

c. TMB 185.10: Physician Assistant Scope of Practice: The physician assistant shall provide, within the education, training, and experience of the physician assistant, medical services that are delegated by the supervisory physician. The activities… may be performed in any place authorized by a supervisory physician, including, but not limited to a clinic, hospital, ambulatory surgical center, patient home, nursing home, or other institutional setting.

d. * The AMA recognized these concepts when its 1995 House of Delegates adopted the following Guidelines for Physician/ Physician Assistant Practice:

1) The physician is responsible for managing the health care of patients in all settings.

2) Health care services delivered by physicians and physician assistants must be within the scope of each practitioner’s authorized practice, as defined by state law.

3) The physician is ultimately responsible for coordination and managing the care of patients and, with the appropriate input of the physician assistant, ensuring the quality of health care provided to patients.

4) The physician is responsible for the supervision of the physician assistant in all settings.

5) The role of the physician assistant in the delivering of care should be defined through mutually agreed upon guidelines that are


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developed by the physician and the physician assistant and based on the physician’s delegatory style.

6) The physician must be available for consultation with the physician assistant at all times either in person or through telecommunication systems or other means.

7) The extent of the involvement by the physician assistant in the assessment and implementation of treatment will depend on the complexity and acuity of the patient’s condition and the training, experience and preparation of the physician assistant, as adjudged by the practitioner.

8) Patients should be made clearly aware at all times whether they are being cared for by a practitioner or a physician assistant.

9) The practitioner and physician assistant together should review all delegated patient services on a regular basis, as well as the mutually agreed-upon guidelines for practice.

10) The practitioner is responsible for clarifying and familiarizing the physician assistant with his/her supervising methods and style of delegating patient care.

6. Department/Section Specific Rules a. Medicine/Family Practice/Neurology

1) The attending practitioner will see the patient daily, regardless of the level of care the patient is receiving while hospitalized (inpatient or observation status).

b. Obstetrics/Gynecology 1) Same for Medicine, except,

a) Uncomplicated post-partum – The patient need not be seen by a practitioner daily; a physician extender is sufficient.

b) The patient should always be admitted and discharged by the attending practitioner.

c. Orthopedic Surgery/Surgery 1) The surgeon will see their patients post-op at least once, which

may be day zero. 2) If the surgeon uses physician extenders or medical practitioners to

cover their patients, they will see the patient daily. d. Emergency Department (ED) Physician Staff

1) Extenders will see patients as determined by the policies and procedures of the ED and every medical case will be reviewed and signed off by the supervising ED physician prior to discharge from the ED.

2) Whether a patient needs to be seen physically by a physician will be a matter of clinical judgment of the supervising physician.

*From the American Academy of Physician Assistants MEDICAL RECORDS


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1. Patient's Medical Record

Each attending physician will be responsible for the preparation of a complete and legible medical record for each patient, as required by the Joint Commission on the Accreditation of Healthcare Organizations. Copying and pasting in a patient record without editing that result in inaccurate patient care is unacceptable and; therefore, progress notes shall accurately reflect the current care and status of the patient, at that time, as provided by the practitioner. Approved by MEC June 25, 2015. Providers have two weeks to respond to patient requests for amendment to the Medical Record. Approved by MEC May 28, 2015.

2. Content of the Medical Record

a. The content of the medical record contains sufficient information to identify the patient, support the diagnosis, justify the treatment, document the course and results accurately, and facilitate continuity of care among health care providers.

b. Each medical record shall contain at least the following:

1) The patient's name, address, date of birth, and the name of any legally authorized representative.

2) The patient's legal status for patients receiving mental health services.

3) Emergency care provided to the patient prior to arrival, if any. 4) The record and findings of the patient's assessment. 5) A statement of the conclusions or impressions drawn from the

medical history and physical examination. 6) The diagnosis or diagnostic impression. 7) The reason(s) for admission or treatment. 8) The goals of treatment and the treatment plan. 9) Evidence of known advance directives. 10) Evidence of informed consent for procedures and treatments for

which informed consent is required by organizational policy. 11) Diagnostic and therapeutic orders, if any. 12) All diagnostic and therapeutic procedures and tests performed and

the results. 13) All operative and other invasive procedures performed, using

acceptable disease and operative terminology that includes etiology, as appropriate.

14) Progress notes made by the medical staff and other authorized individuals.

15) All reassessments and any revisions of the treatment plan.


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16) Clinical observations. 17) The patients response to care provided. 18) Consultation reports. 19) Every medication ordered or prescribed for an inpatient. 20) Every dose of medication administered and any adverse drug

reaction. 21) Each medication dispensed to or prescribed for an ambulatory

patient or an inpatient on discharge. 22) All relevant diagnoses established during the course of care. 23) Any referrals/communications made to external or internal care

providers and to community agencies. 24) Conclusions at termination of hospitalization. 25) Discharge instructions to the patient/family. 26) Clinical resume or final progress note.

a) Clinical resume summarizes reason for hospitalization, significant findings, procedures performed and treatment rendered, patient's condition at discharge, and any specific instructions given to the patient and/or family as pertinent.

b) A final progress note may be substituted for the clinical resume on those patients who require less than a 48-hour period of hospitalization and in the case of normal newborn infants and uncomplicated obstetric deliveries. The final/discharge progress note documents the patients condition at discharge, discharge instructions, and follow-up care requirements.

27) Emergency care records - The following additional information is required in the medical record. a) Time and means of arrival. b) The patient's leaving against medical advice. c) Conclusion at termination of treatment, including final

disposition, patient's condition at discharge, and any instructions for follow-up care.

3. Delinquent Medical Records (Executive Committee Approved 6/18/98)

All physicians are responsible for completing their medical records within 30 days of a patient’s discharge. Failure to complete incomplete records by the suspension date will result in the record becoming delinquent and the physician will be suspended of any and all privileges including admitting, emergency room, consults, etc. Physicians with five (5) suspensions within a twelve (12) month period shall result in forfeiture of membership on the Medical Staff and the individual shall be required to submit a new application for privileges along with the required application fee. (Approved by MEC 4/27/2017)


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4. History and Physical

A complete history and physical examination shall be recorded within 24 hours after admission by a qualified physician (or qualified oral surgeon member in the case of dental patients without medical problems). This report should include all pertinent findings resulting from an assessment of all the systems of the body. If there are no pertinent findings by assessment or history, then the physician will document no findings applicable to address. If a complete history and physical has been completed within thirty (30) days prior to admission, a durable, legible copy of this report may be used in the patient's hospital medical record AND there must be a H&P updated medical record entry documenting an examination for any changes in the patient’s condition or documentation of no changes to the H&P within 24 hours after admission. For surgical patients, the update must be documented prior to surgery. Elements to be included in the H&P are to include chief complaint, details of the present illness, past, social and family history, inventory for body systems to include all conditions present on admission, relevant physical examination, conclusions, impressions, and a plan of treatment. Dentists are responsible for the part of their patient’s history and physical examination that relates to dentistry and podiatrists are responsible for the part of their patient’s history and physical examination that relates to podiatry. (approved by MEC May, 2008) Surgery (defined to include Cath Lab, Endoscopy, and Interventional Radiology) is performed only after a history, physical examination, any indicated diagnostic tests, and the preoperative diagnosis have been completed and recorded in the patient's medical record. In emergency situations in which there is not adequate time to record the history and physical examination before surgery, a brief note, including the preoperative diagnosis, is recorded before surgery. All history and physicals shall be authenticated by the responsible staff member.

5. Consultation Reports

Consultations shall show evidence of a review of the patient's record by the consultant, pertinent findings on examinations of the patient, and the consultant's opinion and recommendations. This report shall be made a part of the patient's record. A limited statement such as "I concur" does not constitute an acceptable report of consultation. When operative procedures are involved, the consultation note shall, except in emergency situations so verified by the record, be recorded prior to the operation.

6. Operative Reports

Operative reports shall be dictated or written in the medical record immediately after surgery, and shall contain a description of the findings, the technical procedures used, estimated blood loss, the specimens removed, the


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preoperative and postoperative diagnoses, the name of the primary surgeon and any assistants. The complete operative report is filed in the medical record and authenticated by the surgeon as soon as possible after surgery. See Progress Notes section for the required operative note. (approved by Executive Committee 5/08)

7. Discharge Summaries

A discharge summary (clinical resume) shall be written or dictated on all medical records of patients hospitalized over 48 hours. The summary concisely recapitulates the reason for hospitalization, the significant findings, the procedures performed and treatment rendered, the condition of the patient on discharge and information provided to the patient and family, as appropriate. The final diagnosis may be recorded in the body of the medical record or the discharge summary. A final progress note may be substituted for the resume in the case of uncomplicated obstetrical deliveries, normal newborn infants, and patients with problems of a minor nature requiring less than a 48-hour period of hospitalization. The final progress note should include condition at discharge and information provided to the patient and family, as appropriate. All summaries shall be authenticated by the responsible staff member. (approved by Executive Committee 5/08)

8. Obstetrical Record

The current obstetrical record shall include a complete prenatal record. The prenatal record may be a copy of the attending practitioner's office record, transferred to the hospital before admission, but an interval admission note must be written that includes pertinent additions to the history and any subsequent changes in the physical findings.

9. Progress Notes

a. An admission progress note, handwritten by the admitting physician is required within 24 hours of admission and should contain sufficient information to justify admission and guide the nursing personnel and other physicians in caring for the patient until the complete, dictated history and physical is available on the chart.

b. Progress notes must be written daily by either the attending or consulting

physician to provide a chronological record of the patient's progress. Progress notes shall be written at the time of observation, and shall be dated and signed by the physician at the time the note is entered. The progress notes shall be entered in chronological order.

c. Progress notes shall be written describing new symptoms arising,

changes in the condition of the patient, complicating factors in the course


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of the disease, indications for continued hospitalization, and reactions to medications or procedures.

d. Each time a new or revised diagnosis is made, it shall be recorded into

the progress notes as soon as possible. e. A complete detailed progress note on all special procedures, such as

spinal puncture, thoracentesis, biopsies, etc., shall be written immediately after the procedure is completed. Pertinent laboratory and radiological findings and results of any specific examination shall be recorded.

f. An operative or other high-risk procedure progress note is entered in the

medical record immediately after surgery/procedure if the full operative or other high-risk procedure report cannot be entered into the record immediately after the operation or procedure. (approved by the Executive committee 5/08)

g. Progress notes describing the postoperative course of the patient shall

include removal or replacement of drains or packs, removal of sutures or clips, change of dressings, and condition of the wound, as well as the general course of the patient.

h. Any employee or individual who treats, counsels, educates, tests,

evaluates or ministers to a patient may document in the patient's medical record as delineated in their job description. Documentation shall be in accordance with generally accepted professional standards of documentation and as required by the Medical Staff Rules and Regulations, hospital policies and regulatory and accrediting bodies.

i. In the event of a death in the Hospital, the deceased shall be pronounced

dead by the attending physician or their designee within two (2) hours. The date, time and circumstances of death must be recorded by the physician or registered nurse pronouncing the death.

An RN may confirm the death of a patient on DNR/Without Exclusions Orders after determining absence of a pulse (by ausculating the heart) and absence of a manual blood pressure. This will be documented in the nursing notes. A registered nurse may determine death for “Do Not Resuscitate” patients when there is a physician’s order for the nurse to pronounce the patient. The body shall not be released until an entry has been made and signed in the medical record of the deceased by a member of the Medical Staff. Exceptions shall be made in those instances of incontrovertible and irreversible terminal disease wherein the patient’s course has been


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adequately documented to within a few hours of death. Policies with respect to release of dead bodies shall conform to state and local law. Medical Examiner cases statutorily require death pronouncement by a licensed physician. Approved by MEC 11/30/2010 & DQC 1/20/2011

10. Orders

a. Preprinted Orders

A member of the Medical Staff may utilize preprinted orders or electronic orders on admissions or treatment of patients. Nursing Services will follow preprinted orders after the orders are completed to reflect specific patient needs. These orders must be signed by the attending physician. All preprinted orders shall be reviewed annually by each physician.

b. Verbal Orders

All orders for inpatients and outpatients shall be documented. All orders shall be in writing or entered into the EMR, dated and timed. Orders shall be considered documented, if identified by the name of the person receiving the order and the name of the practitioner giving the order. (approved by Executive Committee 5/08) Orders dictated over the telephone and verbal orders can be taken by specialty licensed, registered or certified personnel in the area of their specialty only. Orders for medications may only be taken by an RN, LVN, RPh or a graduate nurse (with demonstrated competence to take dictated or verbal orders), and specialty licensed, registered or certified personnel under the direct supervision of a physician (i.e., radiology technologist). Verbal orders shall not be taken for chemotherapeutic agents. Verbal orders must be authenticated in accordance with state and federal law. Verbal orders must be signed by the prescribing practitioner within 48 hours. The attending physician may authenticate the verbal or telephone order for his/her covering physician. A signed order for outpatient tests and procedures is required. The scheduling of an outpatient test or procedure is not considered an order. All verbal or telephone orders shall be entered by authorized persons to whom they are given and forwarded to the physician giving the order for signature in his/her inbox. (approved by Executive Committee 5/08) Provider giving the verbal or telephone order must give their full name and


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MSO/dictation number to the person taking the verbal or telephone order. (presented to MEC 10/22/2015) Verbal orders for restraints/seclusion and advance directives/DNR are permitted but they must be signed as per hospital policy.

c. Automatic Stop Order

There shall be an automatic stop order on all narcotics, antibiotics, steroids, anticoagulants, barbiturates, and tranquilizers after 120 hours unless the exact number of doses or treatment have been clearly specified by the physician.

d. All oxygen therapy, including oxygen tents, oxygen mist, oxygen cannula,

oxygen masks, etc. be automatically discontinued after four days from the day ordered unless reordered by the physician.

e. Oxytocin will be stopped automatically at 24 hours. f. There shall be an automatic release after 48 hours for blood ordered on a

standby basis unless the attending physician requests an extension of time.

11. Symbols and Abbreviations

Symbols and abbreviations shall have only one meaning. Symbols and abbreviations may be used in the body of the medical record and may be used only when they have been approved by the Medical Record Committee. Final diagnosis shall be recorded without the use of symbols or abbreviations.

12. Final Diagnoses

Principal and Secondary Diagnosis and Procedures: The principal and secondary diagnoses and procedures (including complications and co-morbidities), must be recorded at the time of discharge, without the use of symbols or abbreviations, preferably with the discharge order. This must be dated and signed by the attending practitioner or assigned house staff at the time of patient’s discharge. (approved by Executive Committee on 2/15/01)

13. Release of Medical Information

All medical records are the property of the hospital, and shall be removed from the hospital's jurisdiction and safekeeping only in accordance with a court order, subpoena, or statute. Unauthorized removal of charts from the hospital is


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grounds for suspension of the practitioner for a period to be determined by the Executive committee.

14. Readmissions

In the case of readmission of a patient, all previous records shall be available for use by the attending practitioner, whether or not he was the original practitioner.

16. The medical records of those physicians who cannot complete their records due to death or relocation shall be retired only upon action of the Executive Committee of the Hospital Staff and shall result in the forfeiture of that physician's privileges. Privileges may be reinstated only upon completion of those records and reapplication to the staff.

Approved Executive Committee December, 1998 Revised Executive Committee September, 1999 Revised Executive Committee April, 2000 15. Clinical Staging It is the attending physician’s responsibility to add the staging into the patient’s

Medical Record. This must be done within thirty (30) days after the patient has been discharged. Approved by MEC 05/27/2010 & DQC 07/15/2010

CARDIOVASCULAR LABORATORY A. General Rules

1. The establishment of policies and rules of the Cardiovascular Laboratory (Cath Lab) is the responsibility of the Cardiology Department subject to the approval of the Executive Committee. The department will directly supervise the medical care provided in the Lab.

2. The supervisor and designee for the Cath Lab will be responsible for the

day-to-day adherence to the policies. 3. All cases to be performed in the Lab will be scheduled with the name of

the physician intending to perform the procedure. 4. The use of the Cath Lab is restricted to those physicians who are

recommended by the Cardiology Department and subsequently approved by the Credentials and Executive Committees.

5. Patient candidates for cardiac catheterization will have the following

diagnostic tests as ordered by physician prior to their catheterization:

a. hemogram


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b. Chem 4 or chem7 c. PT.PTT d. CXR e. EKG f. additional lab as ordered by physicians

6. All patients will have history and physicals dictated and documented in the

record prior to catheterization or the case must be postponed. 7. Requests for performance of special procedures requiring radiological

interpretation shall include presumptive diagnosis stipulated by the requesting physician.

8. It is the responsibility of the physician conducting the procedure to ensure

that informed consent is given, understood and acknowledged by the patient. The signed and witnessed acknowledgment will appear on the medical record prior to the initiation of any procedure. In the case of an emergency, the next of kin may consent for the procedure.

9. The physician conducting the procedure must identify the patient prior to

the initiation of any procedure. The physician will remain in attendance for the duration of the procedure.

10. An intravenous line must be established for the duration of the procedure. 11. Patients undergoing cardiac catheterization will be monitored by EKG,

B/P, O2SAT. 12. Cardiac catheterizations will not be conducted during the unavailability of

any of the following in the Laboratory: a. pressure and EKG monitor b. defibrillator c. pacemaker d. x-ray equipment

13. Procedures must be scheduled with the Cath Lab personnel. The Administrative Coordinator will schedule additional cases after hours. Every effort should be made to post cases at least 24 hours prior to the preferred time for the procedure. Do not change times on the schedule, these are scheduled time slots.

14. Physicians must be in the Lab and ready to begin at the time the

procedure is scheduled to start. The procedure may be placed in the next available time slot on the schedule if the delay is in excess of thirty minutes and other procedures are scheduled to follow.


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15. The Lab will be available for routine procedures Monday through Friday,

7:30 a.m. to 3:30 p. m. Only emergency cardiac catheterization will be done on a 24-hour basis with the assistance of the staff ON CALL. Emergency special procedures that become necessary after normal working hours will be conducted in the Cath Lab with the assistance of the staff ON CALL.

16. Emergency procedures that require elective cases to be bumped will

require the physician scheduling the emergency case to contact the physician whose case is being bumped. If for some reason, the physician does not agree to have his case bumped, an involved party may contact the chairman of the Cardiology Department who has the authority to resolve the issue in an appropriate manner. (Executive motion approved on 3/90)

17. The Lab personnel will initiate in-house transportation procedures to

ensure the presence of the patient at the assigned time. 18. In those cases where anesthetic is required, the Cath Lab nurse will make

arrangements with surgery for the presence of an anesthesiologist in the Lab. Anesthesia will be administered in accordance with policies established by the Department of Anesthesia.

19. Physicians will document fully the procedure performed. Cardiac

catheterizations and PTCA procedures must be documented with a diagram for the medical record chart. Failure to provide documentation in a 24 hour time frame will be referred to the Medical Records Committee

20. The following procedures may be performed in the Cath Lab:

A. right and left heart catheterizations B. coronary arteriography C. ventricular and atrial angiography D. aortic root angiography/abdominal aortagram E. cardiac output F. O2 saturations G. transvenous pacemaker placement H. HISS bundle recordings, atrial recordings, ventricular recordings I. intravascular thrombolysis J. intraortic balloon insertion K. endomyocardial biopsy L. percutaneous transluminal angioplasty

1) coronary 2) peripheral 3) renal 4) AV grafts


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M. pulmonary arteriography N. cerebral arteriography O. general visceral angiography P. special percutaneous procedures (cholangiography, needle

biopsies) Q. percutaneous nephrostomy R. extremity angiography S. catheter placement for chemotherapy infusion T. electrophysiology study U. automatic implantable cardioverter defibrilator V. coronary and peripheral rotoblator W. cardioversions X. IVC filter placement Y. coil embolization Z. tilt table AA. permanent transvenous pacemakers BB. coronary stent CC. peripheral stent DD. renal stent EE. RF ablations FF. intravascular ultrasound – coronary & peripheral

21. PTCA’s requiring surgical standby precautions will be scheduled in the

operating room by the Surgeon. The surgical team and the surgeon must be available prior to the initiation of the PTCA, except for emergency PTCA's. The Cardiac Cath Lab personnel will notify surgeons and the operating room of case starting time.

22. A surgeon does not have to be on standby when a peripheral angioplasty

is being performed. Executive motion approved: 10/88. B. Sterile Technique

1. Sterile technique will be observed when appropriate. Cardiac catheterizations and arterial puncture arteriograms will require all personnel and physicians to wear caps, masks, gowns and gloves. Protective eye wear will be worn when appropriate. If contamination occurs, positive corrective action will be taken, i.e., glove change, drape change, etc. Individuals with long hair should take special precautions to ensure the hair is properly covered.

2. Cath Lab personnel or physicians should not scrub on a case if they have

a cut or wound on their hand. 3. Personnel or physicians with upper respiratory infections should spend as

little time as possible in direct patient contact. They should wear a mask


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at all times while in the Cath Lab suites and change their mask every hour.

4. Infections: Personnel with active infections should not be permitted to

scrub. They may do other jobs, but should have as little direct contact with the Cath Lab suite as possible. Physicians and the assistants who have infections are requested to delay elective procedures until their infections are controlled.

C. Dress Code

1. Dress Code: Only the scrub suits shall be worn in the Cardiovascular Lab suites. These clothes should be changed after a known contaminated case or after soiling by blood and body fluids. A buttoned lab coat should be worn over scrub clothes when leaving the department. All personnel and physicians must wear proper attire in enter Cardiovascular Laboratory rooms. Shoe Covers are not routinely required.

Approved Executive Committee December, 1998 EMERGENCY ROOM 1. Emergency physicians will staff the Emergency Department.

A specific physician shall be designated as the Medical Director of the Emergency Department. He/she shall organize a group of physicians to provide 24 hours per day Emergency Department coverage. Emergency physicians shall be in the hospital 24 hours per day. No physician shall be appointed or assigned to the Emergency Department without the explicit approval of the director of the Emergency Department. All appointments shall be subject to approval by the Emergency Services Committee and Hospital administration. The Emergency Department Director shall have authority to suspend any Emergency Physician at any time subject to the approval of the Emergency Services Committee.

2. Each service or subspecialty represented on the medical staff, as approved by

the Hospital Executive Committee, shall submit a schedule of specialists available for referral for patient admission, Emergency Department evaluation, or outpatient office follow-up. The on-call specialist shall be obligated to respond to requests of the Emergency Department. Return of phone pages shall occur within 30 minutes. Response directly to the Emergency Department shall be within a time appropriate to the patient’s condition. If a request is made by the Emergency physician to the on-call physician to respond to the Emergency Department, the physician on-call or his/her designee is obligated to do so.


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3. If it is the first violation of the ED response policy within the past two (2) rolling years, the Chief of Staff will at his/her discretion write (email or letter) or (Approved by SQC 2/27/2014) call the physician and review the Medical Staff Policy with the physician and discuss the imperative to respond to the Emergency Department within 30 minutes. This conversation will be documented and placed in the physician’s Medical Staff file. The physician will have an opportunity to sign this document and make additional comments. Approved by MEC 2/25/2010 & DQC 4/29/2010

4. If it is the second violation of the ED Response policy within the past two (2) rolling years, the Chief of Staff will call the physician, review the Medical Staff Policy, and inform the physician that if a third violation were to occur, the violation will be referred to the MEC. This conversation will be documented and placed in the physician’s Medical Staff file. Approved by MEC 2/25/2010 & DQC 4/29/2010

5. If it is the third violation of the ED Response policy within the past two (2) rolling years, the physician will be sent a letter from the Chief of Staff – on behalf of the MEC – describing the violation. Depending upon the severity of the infractions, the MEC always has the authority and accountability to escalate the consequences for the physician if the violation negatively impacted patient care. The MEC will review a list of physicians who violation the ED Response Policy at its monthly meetings. Approved by MEC 2/25/2010 & DQC 4/29/2010

6. It is the responsibility of a physician who is in line for calls from the hospital regarding actual or prospective patients to notify his/her answering service or to otherwise provide notice to the medical community needing access to him/her when he/she will be inaccessible, such as in area of compromised telecommunications or beeper functionality, or to otherwise arrange back-up coverage for his/her services. Approved by MEC 3/25/2010 & DQC 4/29/2010

7. All patients who are admitted to the Emergency Department shall be seen by the Emergency Physician or Emergency Department Mid-Level Provider (Nurse Practitioner or Physician Assistant) unless the patient’s attending physician will see the patient within thirty (30) minutes of arrival to the Emergency Department. If the patient’s condition dictates, the emergency physician will see the patient immediately. No patient will be referred to the Emergency Department, receive treatment, and be discharged or admitted without being seen by a physician or Emergency Department Mid-Level Provider. Approved by MEC 01/27/2011 & DQC 04/14/2011

8. All patients who are admitted to the Hospital will be admitted to an attending

physician with privileges at Memorial Hermann Memorial City Medical Center. The attending physician will be notified of the patient’s admission. The Emergency physician, as a courtesy, may write admission orders. These orders will expire within 12 hours or less and the attending will be responsible for further


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care. Once the patient leaves the Emergency Department for hospital admission, it becomes the attending physician’s medical and legal responsibility to assume care for the patient and for ongoing care while the patient is hospitalized. All patients must be seen, per Hospital Bylaws, within a reasonable amount of time for floor admissions and within 12 hours for CCU admissions.

9. Once a patient has been admitted and is held in the Emergency Department awaiting a bed, the attending physician will be called for orders. If the attending physician feels uncomfortable giving verbal orders, there will be a physician to physician consult before the orders are given. Patient should not be treated different in the Emergency Department than on hospital floors. Approved by MEC 2/25/2010 & DQC 4/29/2010

10. On-call physicians are obligated to provide follow-up for emergency patients

referred to their offices. If problems arise in this referral pattern, the case will be forwarded to hospital administration.

11. Any new unassigned patients admitted to the Hospital from the ER, all sub-

specialists on call are to be available to provide their services for 24 hours (defined to be the 24 hours that corresponds to the ER call schedule). Approved by the Executive committee on November 17, 2004. Amended by the Executive Committee on January 26, 2005 as follows: The sub-specialists on call are to be contacted directly by the referring physician. If the physician refuses/fail to consult, the matter will be referred to the Department Chair or Chief of Staff for resolution.

12. If there is a disagreement between the Emergency physician and the attending

physician regarding patient discharge, the attending physician must come to the Emergency Department, evaluate the patient, and determine an appropriate disposition.

13. If the Emergency Department is unable to obtain a response from an on-call

attending, the issue will be immediately directed toward the Section Chair of that Section, administration, and the Director of the Emergency Department for resolution.

14. Attending physicians cannot sign their private patients out to the Emergency

physician. 15. The Emergency physician may be required to respond to the hospital units in the

case of Medical Emergency Team Activation (MET). This will only occur in the event of a life-threatening emergency. His/her primary responsibility is the Emergency Department.

16. The Emergency Department will not accept standing orders for narcotics or call-

in orders for scheduled drugs.


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17. Obstetrical Patients:

a. Patients >20 weeks gestation experiencing obstetrical problems will be triaged directly to L&D. the patient’s obstetrician or the on-call obstetrician shall be responsible for patient care.

b. Patients > 20 weeks gestation with non-OB problems will be treated in the Emergency Department by the Emergency Department attending.

c. Pregnant multiple trauma patients will be initially evaluated and resuscitated by the Emergency physician. If the patient develops obstetrical problems during the process, the obstetrician will be emergently consulted to respond to the emergency department. Patients who are hemodynamically stable may be referred to OB for prolonged fetal monitoring and will become the responsibility of the on-call obstetrician or the patient’s obstetrician whichever is appropriate.

d. Patients presenting at less than 20 weeks gestation will be seen by the Emergency Department attending and referred to OB as appropriate. The OB/GYN attending may elect to see the patient in the Emergency Department. He/she has the decision to perform any required procedures in the most appropriate environment which optimizes patient care.

18. The Emergency physician and/or the sponsoring physician (Emergency

Department Director or his/her designee) shall oversee physician extenders. Qualifications and scope of practice are defined in the attached Delegation Protocol for Fast Track. Physician extenders may perform the required medical screening exam in a selected population of patients defined by the delegation protocol.

19. All patient transfers will be accomplished through the hospital’s transfer policy

with completion of all appropriate documentation. 20. The Emergency Department will accept call-in orders from the medical staff. All

patients, however, must be seen by a physician prior to disposition. OBSTETRICS/GYNECOLOGY I. OBSTETRICS

A. Consultation is required when delivery is to be performed by physicians who are not specialists in OB/GYN.

B. Laboratory Tests


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1. CBC, serologic test for syphilis, Rh Factor (D and Du) and HIV will be drawn upon admission. HbsAg will be drawn upon admission if not available through the prenatal record. If time does not permit obtaining specimens before delivery, they will be secured on the postpartum floor. On all Rh (D and Du) negative women, a Rhogam work-up will be done. A vaginal Group Beta Strep specimen will be obtained on all admissions for labor. GBS testing is optional if patient tested positive before hospital admission (8/93) All lab will be done ASAP unless specified as STAT.

2. HIV Testing

HIV tests will be done on all patients at the time of admission. A blood sample from the mother or from the umbilical cord of the infant will be submitted to the laboratory for HIV testing, providing the patient consents. If the patient does not consent, the patient will be referred to an anonymous testing facility and this will be documented in the medical record. (reference House Bill 1345 approved 6/16/95) A partner of a patient with HIV infection shall be notified by the Health Department Partner Notification Program regardless of whether the person with HIV consents to the notification. (reference House Bill 1345 approved 6/16/95)

3. A voided or catheterized urine specimen will be obtained on admission to the Maternity Center and checked for sugar and protein, blood, WBC's, and ketones. Physician will be notified of any abnormal results.

4. Placentas and cords will be sent to Pathology for gross

examination. If abnormalities are found, a complete examination will be done by Pathology. (5/93)

C. Patients in their first trimester should be evaluated for admission to the

proper unit (L&D, OB special Care, or Gyn). In accordance with hospital guidelines septic patients or patients with infections will be placed in appropriate isolation when warranted. All patients within three weeks postpartum will be considered for readmission to L&D, gyn, or post-partum services at the discretion of the admitting physician and dependent on availability of beds and nursing staff on the units.

D. Patients may be examined vaginally by the nurses unless contraindicated

(e.g. known or suspected placenta previa).


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E. All patients in active labor will have intravenous access with an infusion or IPVAD with an 18 gauge needle or larger. A continuous intravenous line may be initiated by a nurse as indicated by patient’s condition. The IV solution of D5LR should be utilized.

F. Intravenous MgSO4 and intravenous tocolytic agents must be

administered in Labor and Delivery or OB Special Care. G. Anesthesia personnel are available for obstetrical patients 24-hours/day. H. It is the duty of the nurse in the Labor and Delivery area to keep the

attending physician informed of the patient's condition. In cases of complications, should the attending physician take no action in regard to the patient, it shall be the duty of the nurse to notify the Chairman of the Department of OB/GYN.

I. Pediatric or neonatology consultation is suggested, but not limited to the

following situations:

1. Thick meconium stained fluid 2. Maternal amnionitis 3. Abruptio placenta or placenta previa 4. Post term infant greater than 42 weeks gestation 5. Fetal distress 6. Low or intermediate lung maturity studies. 7. Intrauterine growth retardation 8. Toxemia or hypertensive disorders with known or suspected fetal

compromise. 9. Diabetes beyond Class A 10. Some mothers with antepartum fever of undetermined etiology 11 Multiple fetal gestation 12. Under 30 weeks gestation.

The above categories will be used as guidelines for the nursing staff to exercise the prerogative to notify the pediatrician and/or neonatologist with the obstetrician's consent for an impending delivery. This motion does not negate the previous recommendation that pediatrician consultation by the obstetrician for the above categories be accomplished as early as indicated.

J. Physician/Nurse Attendance at Delivery

1. A pediatrician or neonatologist will be notified for all general anesthetic deliveries (C-section or vaginal). Executive motion approved: 6/89.


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2. A nurse will be in attendance at all Cesarean sections and designated strictly for the care of the baby. Executive motion approved: 6/89.

K. Support persons may be present during delivery at the discretion of the

attending physician.

L. Every effort will be made to obtain cord blood at all deliveries. Laboratory personnel will obtain additional blood by heel stick when cord blood is unobtainable.

On all Rh (D and Du) negative mothers, regardless of the Rh of the baby, every effort will be made to do a direct Coombs test immediately on cord blood. If the Coombs test is positive on cord blood, or if cord blood is not available, it will be verified by a Coombs test on blood from a heel stick. If the latter is also positive, Hb, Hct and total and direct bilirubin will be determined on cord blood. If the oxalated tube of cord blood is clotted, Hb and Hct will be done on blood from a heel stick. On Rh (D and Du) positive mothers, a direct Coombs test will be done as soon as possible, if cord blood is available. If the Coombs test is positive on cord blood, it can be verified by a Coombs test on blood from a heel stick. If the latter is also positive, Hb and Hct will be determined as soon as possible. Total bilirubin will be determined from cord blood as soon as possible.

M. PACU services will be provided twenty-four hours per day.

1. All surgical obstetrical patients will be admitted to the obstetrical PACU (excludes vaginal deliveries unless followed by a BTL delivery). Patients who are considered contaminated or infectious, i.e., patients with purulent drainage, hepatitis, tuberculosis, or patients exhibiting temperatures of 100.4 degrees or higher will be recovered in the room in which they delivered or in the LDR in which they labored.

2. All patients should stay in the PACU until stabilized before being

transferred to the postpartum unit. If complications arise during this time, the attending physician or anesthesiologist must write an order before the patient is transferred. All patients must meet PACU discharge criteria before transfer. (1/94)

N. Medical Induction or Augmentation of Labor

Induction or augmentation of labor with oxytocin should be initiated only after the attending physician has determined that it is required for the


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benefit of the mother or fetus. When labor is to be augmented, the obstetrician should review the course of labor, examine the patient and establish the indication and plan of action. The patient must be examined prior to starting the infusion. Examination of the patient may be delegated by the patient’s obstetrician. Personnel familiar with the effects of oxytocin agents and able to identify both maternal and fetal complications should be in attendance while oxytoxic agents are being administered. The obstetrician should be readily available, and be able to be in Labor and Delivery within a reasonable time for the management of any complication that may arise. (8/97) Oxytocin should be administered intravenously only, using a mechanical device that permits precise control of the flow rate. In the case of intravenous oxytoxic agents prior to the third stage of labor, the initial dosage should not exceed a concentration of ten units per 1000cc of dilutant. Intravenous oxytocins given prior to the third stage of labor will be started only by IV piggyback method. Subcutaneous, sublingual and intradermal pitocin will not be used. Intravenous oxytoxic agents used for delivery purposes must be administered in the Maternity Center. If a rate of 32 mu/min or greater is required, the obstetrician must be notified of patient status. Oxytocin infusions are initiated and rate increased by physician order only. An electronic fetal monitor will be used to record fetal heart rate and uterine contractions continuously when oxytocin is administered. If this equipment is not available, the fetal heart rate, frequency and character of contraction, rate of oxytocin flow and maternal pulse should be recorded at the same intervals as for continuous monitoring. The intervals of the monitroing will be in compliance with current ACOG recommendations as noted in the guidelines for perinatal care. Maternal blood pressure should be recorded every 30 minutes and more frequently if indicated.

O. Patients Presenting to the ER

1. All pregnant patients presenting to the ER will be triaged for OB or non-OB problems. Those patients with non-OB emergent conditions will be treated in the ER. Those patients 20 weeks or greater with OB problems will be sent to L&D or OB Special Care. Patients 20 weeks or less will be seen in the ER.

2. For those patients 20 weeks or less seen in the ER: The on-call

OB physician will be notified at the discretion of the ER physician if the patient does not have an attending physician. Those patients with an attending OB physician may be sent to L&D or OB Special Care at the discretion of the OB physician.


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3. Patients 20 weeks or greater that are experiencing OB problems will be sent directly to L&D or OB Special Care. If the patient does not have an attending OB physician, the on-call physician will be notified.

4. All private patients who are instructed to go to L&D or OB Special

Care by their attending physician will go directly to the unit.

P. The hospital will be provided with results of prenatal screenings by the physicians’ offices. If no records are available the appropriate tests will be ordered as noted under Section 1 B. If mother’s hepatitis status is positive or if mother’s hepatitis status is still unknown 12 hours post delivery, the infant will receive the Hepatitis B Immune Globulin (HBIG) and Hepatitis B vaccine.

Q. Rhogam should be administered within 6 to 8 hours after delivery if

possible, but should be given within 72 hours after delivery. R. The disposal of remains of fetuses will follow the law of the State of Texas

Bureau of Vital Statistics (included on following page). S. Patients admitted to the hospital with active genital herpes will be cared

for with the following precautions to prevent the spread of the virus:

1. Patient will be admitted to a private room and contact isolation procedures will be used.

2. Nursery and postpartum units will be notified of admission. 3. Isolation is required for newborns of mothers who have had a

positive culture within two weeks of delivery. INTERPRETATION OF STATE AND FEDERAL LAWS REGARDING VITAL STATISTICS AS THEY APPLY TO FETUSES LIVE BIRTH: A child showing any evidence of life (action of heart, breathing or movement of voluntary muscle) after complete birth should be registered as a live birth. Birth is considered complete when the child is altogether (head, trunk and limbs) outside the body of the mother, even if the cord is uncut and the placenta still attached. Note that this is irrespective of gestational period, weight, length, etc. of fetuses. All live births require the filing of a birth certificate.


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STILLBIRTH: A fetus showing no evidence of life after complete birth (no action of heart, breathing or movement of voluntary muscle) if the 20th week of gestation has been reached, should be registered as a stillbirth. IMPORTANT: If the child shows any evidence of life after complete birth, even though it be only momentary, the birth should be registered as a live birth and a death certificate should also be filed. Note that the law governing reportable stillbirths is definite so far as gestation is concerned. Moreover, it does not allow the subtraction of a period of time which a patient carried a dead fetus. If the gestational period is unknown or is inaccurate, birth weight of the fetus may be used. This is, however, less accurate than the crown-heel (standing) height of the fetus due to soft tissue absorption following fetal death in utero. Whenever weight and length do not supply corresponding estimates of gestational period, the one indicating the greater period is to be used. CONVERSION TABLE

Gestation C-H length Weight Weight in weeks in Cm Grams Lbs. Oz. 4 1.0 - - - 8 4.0 - - - 12 9.0 14 - - 16 16.0 108 0 4 18 20.5 198 0 7 19 22.75 253 0 9* 20 25.0 316 0 11 21 26.25 385 0 13 2/3 22 27.5 460 1 ¼ 24 30.0 630 1 6 1/3 28 35.0 1045 2 5 32 40.0 1680 3 131/4 36 45.0 2478 5 8 40 50.0 3400 7 8

* Any measurement or weights below this line is a stillborn; above it is an abortion. II. GYNECOLOGY

A. Sterilization Procedures:

1. Sterilization may be done on any adult female requesting such in writing.

2. Sterilization of minors shall require consultation with the Chairman

of the Department, one other member of the OB/GYN staff, and written consent of the parents.


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3. If a patient has a working epidural, sterilization can be performed

immediately after delivery. If the patient does not have a working epidural, then a period of six hours must pass before administering anesthetic for sterilization.

B. All invasive carcinoma of the cervix must be clinically staged prior to

radiation, radium or definitive surgery. C. Cryosurgery or electroconizations shall not be done unless preceded by a

Papanicolaou smear or biopsy negative for malignancy. D. All patients for hysterectomy, except in an emergency, shall have had at

least a Pap smear and/or a biopsy of the cervix without evidence suggestive of invasive carcinoma in the last twelve months except in those cases where the hysterectomy is part of the treatment of known uterine malignancy.

E. Only medically indicated pregnancy terminations are permitted at

Memorial Hermann Memorial City Hospital.

1. Up to twelve weeks gestation (end of first trimester) no consultation is needed.

2. After twelve weeks, proof of gestational age by ultrasonography

shall be required. Ultrasound findings with interpretation shall become part of the hospital record prior to termination of pregnancy.

3. Clear documentation of medical need must be evident in the

Medical Record prior to the procedure. 4. Pregnancy termination will not be performed after twenty weeks

gestation. Exceptional circumstances must be approved by the Chairman of the Department.

5. In accordance with Senate Bill 30, parental notification must be made before an abortion can be performed on a minor. Two exceptions to this are: a. when an emergency exists b. when the minor has received an order from a statutory court

granting permission to the minor for an abortion without parental notification.


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Physicians who perform emergency abortions on minors must report the procedure to the Texas Department of Health on the form approved by the TDH.

6. In addition, in accordance with Senate Bill 30, similar reporting is

also required for third trimester abortions regardless of age and should be reported to TDH within 30 days of the abortion.

F. ER Back-Up Coverage

1. All unassigned OB/GYN patients presenting through the ER will be

assigned to the pre-arranged contracted OB/GYN call group. Approved Executive Committee December, 1998 Revised Executive Committee February, 2000 PEDIATRIC DEPARTMENT 1. All Departments will chart on the same progress notes. 2. A history and physical examination will be on the chart or dictated within 24

hours after admission. If dictated, written admission note must be completed. 3. All pediatric patients under two years of age must have a pediatric consultation,

with the exception of healthy newborns admitted to the Newborn Nursery by a Family Practitioner.

4. All patients 14 years of age or younger must have a pediatric consult if hospital stay is greater than 48 hours. All pediatric patients that require critical care will be transferred to Memorial Hermann Children’s Hospital or Texas Children’s Hospital. 5. Pediatric patients 14 days of age or younger who require surgery will require a

neonatology consultation. 6. Admission Procedure: All medical and surgical patients 14 years of age or

younger will be admitted to the Pediatric Unit. The Pediatric Inpatient Unit may take patients up to 18 years of age if requested and followed by a pediatrician or hospitalist and if bed is available.

a. All pediatric patients will go directly from admitting or the Emergency

Room to the Pediatric floor. They will go directly to x-ray only if ordered by physician.

b. The following shall be obtained and charted: 1) Weight 2) Height


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3) Allergies 4) T.P.R. 5) B.P. c. Children less than two (2) years old need an FOC. 7. Unless specifically ordered otherwise, the pulse, respiration and temperature will

be taken on all patients every four hours round the clock, and blood pressures will be checked upon admission and one time per shift. Intake and output will be recorded on all children under one year of age and all patients with IV’s. Daily weights will be recorded routinely on all children under six months of age, and patients with diarrhea, vomiting, pyelonephritis/UTI or dehydration.

8. All children admitted with recorded diagnoses of vomiting, diarrhea,

UTI/Pyelonephritis or dehydration will have strict intake and output recorded. 9. All IV's, site and volume infused will be checked hourly and an infusion device

must control the drip rate. 10. All children who are eighteen months of age or younger will be placed in cribs or

isolettes as indicated. 11. Parents are encouraged to stay with the child and sleep in the room. 12. Pediatric patients with non-communicable disease may be visited by siblings

regardless of age in accordance with hospital visitation hours. 13. All pediatric patients under 50 pounds are to receive injections in the thigh

regardless of age. 14. IV insertion will be done by the nursing staff. If a third attempt produces an

unsuccessful result, the nurse must request assistance from another qualified person. The physician will be notified of IV insertion difficulty after six (6) failed attempts.

15. Admitted critically ill children should be through the Emergency Room. 16. Dosages for emergency medications are to be calculated via computer on

admission and should be placed in front of the chart and in the crash cart code sheet binder. (see Code Sheet)

17. Written or telephone orders must be received by the nurses within one hour after

a new patient arrives to the floor. 18. All medication orders on pediatric patients must have the dosage specified. A

medication ordered "for age" is not acceptable. Medications should be calculated by mg/kg dose.


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19. Pre-op Fasting Orders for Pediatric Patients: a. Children should not have liquids for at least 2 hours before anesthesia.

b. Breast feeding infants should not be fed for at least 3 hours before anesthesia.

c. Formula fed infants should not be fed for at least 4 hours before anesthesia.

20. All ER admits to Pediatrics must be seen by the physician within 12 hours of

admission to the unit. 21. All direct admits must have the attending or consult physician see the patient

within 4 hours of admission to the unit or 4 hours prior to admit. 22. All patients on pediatrics must have a physician see them every 24 hours with

written progress notes. 23. All pediatricians with 24 admission (defined to include newborns, consultations,

admitted inpatients, or doctor visits to patients in the ER) will be required to serve on the Emergency Room back-up call schedule. (revised 8/20/98)

24. All patients must be seen by the attending physician on the day of discharge.

(added 9/3/08) Approved Executive Committee 1/22/09 PEDIATRIC DEPARTMENT NURSERY I. GENERAL

A. All infants admitted to the Newborn Nursery will be examined and have the newborn examination form completed by the attending physician or consult neonatology within 24 hours after birth. If examination is not completed within 24 hours, the Chief of Pediatrics will be notified.

B. All practitioners or neonatologists seeing newborns will exam the

newborns at least once a day until discharge. C. Infants will be placed under a radiant warmer in the Admitting Nursery and

vital signs monitored every 30 minutes until the infants condition has remained stable for two hours and has no identifiable problems. The infant will be given an initial bath when the temperature reaches 98.0


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degrees F axillary and condition is stable. The heat will be discontinued and infant placed in an open crib when the temperature again reaches 98.0 degrees F axillary or above.

D. Cord blood - routine blood type, and Rh will be done on all patients.

Coombs will be done on all Rh negative and O+ mothers. A positive Coombs will be reported immediately and the following lab work drawn: Bilirubin total and direct, hemoglobin/hematocrit, and reticulocyte count. All initial Bilirubins will be total/direct then subsequent Bilirubins will be total only unless ordered otherwise.

E. Vitamin K 0.5 mg IM will be administered to each newborn on admission. F. Ophthalmic antibiotic ointment will be placed in the eyes of each newborn

on admission to the nursery. G. One Touch Policy

A One Touch is a heel stick blood test drawn to determine an estimation of blood glucose. It will be done on all LGA, SGA, IDM, Infants less than 2500 grams, infants greater than 4000 grams, and all symptomatic infants, and a follow-up heel-stick glucose will be done before second feeding if initial glucose is normal.

1. If the one touch glucose value is less than 40 mg/dl feed D5W and

repeat in 30 minutes. If followup glucose is <40, draw stat serum glucose and notify physician.

H. Maternal Temperature

Labor and delivery shall notify the Nursery of any maternal temperature of 101.0 degrees F (38.4 degrees C) (10/94) or greater noted 24 hours prior to delivery, during labor or up to 24 hours after delivery, and any related treatment. Obstetrics shall notify the Nursery of any maternal temperature of 101.0 degrees F (38.4 degrees C) or greater during the mother's postpartum stay, and any related treatment and diagnosis, such as chorioamnionitis. The Nursery shall notify the baby's attending physician and/or neonatology consultant if the mother's temperature elevation occurs before delivery or in the first 24 hours after delivery. The Nursery will try to obtain any information available concerning source of maternal infection, treatment, and obstetrical diagnosis.


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I. All infants who appears unstable or in distress will be admitted to the NICU. The infant must be examined by the attending physician or designated neonatologist within one hour of admission. The neonatal nurse may request the attending physician or neonatologist to see the infant sooner if deemed necessary.

J. Infants weighing less than 2000 grams will be admitted to the NICU. K. Oxygen may be given in emergency situations to neonates by the nursery

staff to maintain pulse oxymetry <90%. The attending physician will then be notified.

L. All infants admitted to the NICU must be 28 days of age or less. Infants

older than 28 days requiring admission must have neonatology approval. M. Circumcisions may be performed only after the infant has had an initial

examination by a physician. The procedure may be done 1 1/2 to 2 hours after a feeding. If performed on the day of discharge, the infant will be observed for two hours in the Nursery prior to discharge. If infant has not voided prior to circumcision, hold circumcision and notify pediatrician. A discharge does not need to be delayed if infant doesn't void after the circumcision.

N. All surgical patients 14 days of age or younger must have a neonatology

consult O. Personnel Policy – Personnel floated in Nursery from outside the perinatal

units must wear clean scrub clothing. II. NICU

A. Consultations

1. The pediatrician or primary care physician of choice may be notified upon the infants admission to NBN/NICU. Upon acceptance of the patient, the pediatrician or primary care physician becomes the physician of record for newborn and, therefore, bears primary responsibility for its care.

2. If circumstances arise by virtue of known maternal factors or by

findings which become apparent during the course of labor that require a physician in attendance in the delivery room to care for the infant, the obstetrician/ L&D nurse will notify the neonatologist.

3. Neonatology is available for consultation for infants in the nursery

who develop problems. The staff neonatologist will make


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recommendations to the attending pediatrician. If at the time of consultation, the patient's condition requires emergency measures, then the neonatologist will undertake all necessary measures to care for the patient and then inform the pediatrician as soon as possible.

4. Neonatology is basically a consultation service. A neonatologist

may be the primary physician.

B. Coverage

1. A neonatologist will be available as necessary. 2. A monthly schedule listing person on call, telephone number, and

pager number will be posted in the Maternity Center, NBN, and the Neonatal Intensive Care Unit.

C. Admissions

Until the neonate may be examined by the pediatrician, the following criteria will be considered for direct admits to the Intensive Care Unit from the Maternity Center.

1. Weight 2000 grams or less 2. Infants 34 weeks gestation or less (for transition). 3. Apgar under 7 at 5 minutes (for transition).

D. Responsibilities in the Instance of Patient Demise

1. If an infant is delivered and dies before being seen by an attending pediatrician or his neonatology consult, that infant is the sole responsibility of the attending obstetrician in every respect, i.e., death note, death certificate and chart completion.

2. If an infant is delivered and is seen by the attending pediatrician or

his neonatology consult prior to death, then the infant is the sole responsibility of the attending pediatrician. A situation may arise where there is only time for the neonatologist to administer to the patient. In this event the attending pediatrician should have been notified of the impending delivery or, lacking adequate time to do this, as soon after the event as possible by either the obstetrician, the attending nurse or neonatologist. If the obstetrician did not have time to call the attending pediatrician but called a neonatologist on an emergency basis, it becomes the responsibility


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of the neonatologist to make certain the attending pediatrician is notified. In this event, the death note, death certificate and chart will be completed by the neonatologist.

E. Transfers In

1. All transfers in will go through the transfer center at Memorial

Hermann Children’s Hospital. Pediatricians not on active staff at Memorial Hermann Memorial City Hospital wishing to transfer a patient into the Neonatal Intensive Care Unit from another facility must first review the case with the neonatologist on call. When the pediatrician wishing to transfer is not an active staff member, then a pediatrician of choice or pediatrician or neonatologist on call will become the physician of record for the admission.

2. The neonatologist on call will be responsible for communications

with the referring pediatrician. 3. If an OB wants to move a patient from another hospital for

imminent delivery at this facility and the baby will be an NICU baby, neo needs to be notified prior to transfer.

F. Quality and Appropriateness of Care

The Neonatology service will participate in reviewing newborn records with the Department of Pediatrics.

G. Review of Charts

1. All nursery deaths 2. All nursery complications 3. All transfers to other hospitals

Approved Executive Committee 1/22/09 PREADMISSION TESTING SECTION I A. Preadmission Testing hours of operation are from 6:45 am to 7:00 pm Monday

through Friday. B. Patients are posted for surgery by calling Main Operating Room posting for

confirmation of date and time of surgery. Admission orders must be hand delivered, telephoned or faxed to the admitting nurse in Preadmission Testing.


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C. Surgeries will be scheduled Monday through Saturday. D. Patients must be interviewed by a registered nurse in Preadmission Testing

either by telephone (if no preoperative tests required) or in person at least two days prior to the day of surgery. This visit may be done up to 30 days prior to the planned surgery. During the interview the patient will:

1. Be interviewed for anesthesia screening. 2. Satisfy financial requirements. 3. Complete preoperative testing 4. Receive instructions and pre-op teaching from the preadmission nurse, if

necessary. 5. Sign surgical consent (if not completed in the physician’s office) and other

related forms, if present in the facility prior to the day of surgery or these are signed the day of surgery.

E. Routine laboratory testing is age and sex specific, according to the current

recommended Anesthesia Preoperative Testing Guidelines. F. All laboratory results will be valid for 30 days unless clinically indicated. EKG

with interpretation will be valid for six months unless clinically indicated. Chest x-rays will be valid for six months unless clinically indicated. All laboratory results, EKG with interpretation, and Chest x-rays will be accepted as part of the Preadmission workup as long as the results are sent to Preadmission Testing via fax or hand delivered preferably when the orders are received.

G. If it becomes apparent during the interview that there is reason to postpone the

surgery, the attending physician will be advised promptly so that he can direct rescheduling.

H. If permit is signed in the physician’s office, the original must be brought to

Preadmission Testing prior to surgical date. Approved Executive Committee December, 1998 SURGERY DEPARTMENT OPERATING ROOM A. Identification of Patients

Patients will await the arrival of their physician for identification in the holding area except for emergency surgery after hours, when they will be placed in the immediate area of the assigned surgery suite.

B. Clothing and Shoes


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Personnel in the operating room will wear scrub clothes that are provided by the hospital and are changed before leaving the facility. Clean footwear, caps, hoods, masks, and protective eyewear must be worn. Hair must be covered. All protective equipment (masks, hats, and shoe covers) must be removed when leaving the OR. Masks will be worn over the nose and mouth. No operating room personnel or physician with infectious or communicable disease will be permitted in the operative suites. Physicians should not visit from room to room until they have removed their soiled gown and gloves.

C. Infections

Personnel with active infections should not be permitted to provide direct patient care. They may do other jobs, but should have as little direct contact with the operative suite as possible. Doctors and assistants who have infections are requested to delay elective procedures until their infections are controlled.

D. Smoking, Food and Drink

Smoking will not be permitted in the operating room suite. No food or beverages will be allowed in the operating room suite.

E. Operating Room Time

At the time of securing operating room time, the physician must indicate all surgery to be performed. Operating room personnel are not to accept a surgical posting from a physician unless it is a complete posting. Elective surgical procedures may be posted in the operating room for Saturday, with the last elective posting being taken at 2:00 P.m. If a physician scheduled for surgery has not arrived in the operating room suite, or notified the operating room within 15 minutes after the scheduled time, his posting may be postponed at the discretion of the Operating Room Manager. The next physician on the schedule will be notified.

If a physician is over 15 minutes late for a 7:30 a.m. posting, his case may be postponed.


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F. Operative Permits

Operative permits must state the surgery to be done and the name of the surgeon. All permits must be properly signed and witnessed prior to pre-medication of patient. Permits shall be required to be signed prior to arteriograms and aortagrams. Orders for permits should be written specifically by the surgeon, specifying the exact wording to be used on the surgical consent form or if such orders are not present on the chart, the charge nurse on the nursing station should call the surgeon before the permit is signed to receive the exact wording of all procedures to be performed.

G. History and Physicals

A routine history and physical including heart and lung status shall appear on the chart in writing prior to the commencement of any surgical procedure. The preoperative diagnosis must be stated on the chart; also, any condition that may affect the type of sianesthea to be administered. The above may be waived only in cases of emergency.

H. Skin Preparation Orders

Standard preparation orders shall be established. If other than the standard preparation orders are required, the surgeon will inform the operating room at the time of posting.

I. Operative Reports

Operative reports shall include a detailed account of the findings at surgery as well as the details of the surgical technique. Operative reports shall be written, or dictated, immediately following surgery for outpatients as well as inpatients and the report promptly signed by the surgeon and made a part of the patient's current medical record.

J. Surgical Privileges

The chief of surgery will enforce the surgical privileges granted to a physician by the Board of Directors. If a physician's ability to perform any procedure appears questionable, the Chairman of the Department of Surgery, acting after consultation with the Committee or singularly in emergency cases, may deny a surgeon the privilege to perform that surgery, or require an assistant, subject to the Chairman's approval.


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K. Anesthesia

No anesthesia will be started unless the surgeon is in the operating room suite. This would include the lounge and the PACU area.

L. The Anesthesiologist

The anesthesiologist will interview and write indicated pre-op orders prior to surgery, except in the case of emergency. The anesthesiologist shall maintain a complete anesthesia record to include evidence of pre-anesthetic evaluation and post-anesthetic follow-up of the patient's condition.

M. Limited Surgery Privileges

All surgeons who have been granted limited surgery privileges who are performing a minor procedure which has the potential of developing into a major operation should have a qualified staff surgeon on standby should the need arise.

N. Tissue Removal

Except as listed below, all tissues removed at the operation shall be sent to the hospital pathologist who shall make such examinations as he may consider necessary to arrive at a tissue diagnosis. His authenticated report shall be made a part of the patient's medical record. The following specimens need not be sent to Pathology when the operating surgeon thinks it would provide no useful medical or legal information:

1. Cataracts 2. Teeth, provided number (including fragments) should be recorded

in the medical record 3. Liposuction fluid (exception being breast or lipoma fluid).

O. Frozen Sections

Physicians will indicate on posting any case where a frozen section might be required.

P. Surgical Assistants

Surgical assistants must be affiliated with the group contracted by the hospital or be individually sponsored by the surgeon(s) for whom he/she is assisting in surgery. All surgical assistants must be credentialed as an Allied Health


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Professional as provided for in the Credentialing Manual, Section 4 G. OR Registered Nurses may provide surgical assistance if requested by the surgeon.

Q. Blood Transfusions

Surgeons who have cases posted must be notified as soon as possible after it has been determined that no blood will be available for surgical procedures. It is left up to the discretion of the individual surgeon and/or the anesthesiologist to cancel an elective surgery because of blood unavailability. Blood is to be drawn, typed and cross-matched before the administration of Dextran on all patients.

R. Cesarean Sections and Sterilizations

Policy concerning tubal ligations and cesarean sections:

1. Physicians having privileges to perform appendectomies may also perform tubal ligations.

2. Physicians without express privileges for cesarean sections may not act

as attending surgeon for a section even if a qualified specialist is present. S. In the O.R., procedures where more than one surgeon is scheduled to operate,

only the surgeon performing the initial procedure must be present for patient identification before the administration of anesthetic. The other surgeon scheduled must be present in Memorial Hermann Memorial City Hospital or in the Professional Buildings and personally inform the OR Manager of their location at the time the procedure is scheduled to begin

T. Outpatient Surgery

See Outpatient Services/Day Surgery Unit section of the Rules and Regulations. U. When a sponge count, needle count, or instrument count is incorrect, an x-ray

may be taken at the discretion of the physician before transporting the patient from surgery to the Recovery Room.

V. A physician assigned as "monitor" will examine the chart to review the physical

exam; be present in the O.R. to observe the physician during any surgical procedure; and report his findings to the Chief of Surgery section.

W. The following persons, as approved by the Executive Committee (7/89), may

observe surgery:


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1. Staff physicians 2. Hospital employees whose duties take them to the O.R. 3. Qualified, technical assistants who have been credentialed (Allied Health

Professionals) 4. Students whose clinical program is covered with a written affiliation with

the hospital. 5. Certified, licensed trainers may observe procedures performed on their

athletes in accordance with special criteria. 6. Visiting M.D.'s or dentists. These individuals will be listed in the surgery

visitor's logbook. Permission should be obtained from the patient and documented by the attending physician in the progress notes. The physicians may only observe, not scrub.

7. Others: Permission should be obtained from the patient and documented by the attending physician for: a. Students enrolled in health care professions. b. Sales representatives, if the presence of that sales representative

is requested by a surgeon when utilizing a product sold or distributed by that sales representative. They may not scrub.

X. To participate in surgical procedures in the O.R. suite, R.N.'s, technical

associates, or physician's assistants must present their credentials to the O.R. Manager and be oriented to the policies and procedures of the Department.

Y. Physician Orders

Orders from the anesthesiologist and the attending surgeon have priority over orders given by any other physician. Orders given by any other physician should be cleared either by the attending surgeon or the anesthesiologist before compliance. Where orders by the attending surgeon and the anesthesiologist are in conflict, they will be resolved by direct communication by the surgeon and the anesthesiologist.

Z. Consent Forms

1. Elective surgical cases without a valid operative permit who have received narcotics and/or sedatives must wait at least four hours after the last dose of such medication before signing a valid permit.

2. Legal guardians, family, or attending physician can sign for elective

procedures on adults if proof of guardianship can be shown. Legal guardians or the next of kin may sign permits for minors if proof of guardianship can be shown.

3. Emergency surgical cases without a valid operative permit who have

received narcotics and/or sedatives may be operated upon without delay if the following criteria are met:


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a. Case must be a true emergency, meaning that delay would cause

death, loss of limb, or would be detrimental to the patient's condition.

b. Next of kin or legal guardian understands an emergency exists and

signs the permit. The circumstances will be documented in the chart by the attending physician.

c. In cases where no next of kin or legal guardian is present, the

attending physician can obtain a consult from another physician, and if both are in agreement that the case is a true emergency, surgery may proceed after both physicians have documented the need for emergency surgery in the patient's chart. Consulting physicians can base their decision on the information obtained from the attending physician. This will include the diagnosis, the need for surgery, and the alternatives available. It will not be based on the degree of alertness of the patient following medication, but the need for surgery. Any dispute as to the need for surgery will be settled by the Chief of Surgery or his representative.

AA. "No Met" Surgical Patients

1. If a "No MET" patient should require a surgical procedure, a decision should be made by the patient, or next of kin, after consultation with the physician to remove the "No MET" order. It is the responsibility of the surgeon and the anesthesiologist to discuss the “No MET” status with the patient and the family.

BB. A family member of a patient is permitted to enter the holding area in surgery in

order to spend a brief amount of private time with their family member prior to the surgery. Executive Committee approved: 8/88.

CC. All physicians performing biopsies with surgical or cytologic specimens requiring

cultures should obtain duplicate specimens, one for bacteriology and the other for surgical pathology. The physician himself would be required to divide the specimen for culturing. Executive motion approved: 8/91

DD. Trainers

It is recommended that trainers be permitted to observe surgery when the following conditions are met:

1. There is a formal letter of agreement between the hospital and the school

that is requesting to observe.


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2. The trainer requesting the privilege is the trainer that the patient will rely upon postoperatively for conditioning advice.

3. The attending surgeon documents in the patient's medical record that the

patient, the patient's parents, and the surgeon all agree to the trainer's presence during the operation.

4. The attending surgeon must advise the operating room of the intention for

trainer observation of surgery when the case is posted. 5. The trainer releases the hospital from any liability that may occur due to

the trainer's intolerance or unfamiliarity relating to the observation of surgery by way of a standard release from liability form.

EE. Critical Care Recovery Room (CCRR)

Cardiovascular Surgeons are responsible for their patients admitted to the CCRR. The surgeon will be available on a 24-hour basis, or will arrange for coverage by another Cardiovascular Surgeon on the Hospital Staff. The surgeon will notify the staff in the CCRR any time coverage is arranged. Executive motion approved: 9/92

FF. Criteria for Admission to the Critical Care Recovery Room (CCRR)

Acute post-operative cardiac critical surgical patients and those patients in an exceptional situation who would be at extreme risk to transport to CCU will be admitted to the CCRR. These patients would probably require a respirator and arterial line. (Patients who met CCU admission criteria would be assigned in CCRR when unit is open with the agreement from the attending physician.)

Those patients who, by reason of their condition, may require immediate return to the O.R. shall be given prime consideration. The ultimate decision for admission to the CCRR shall rest with the attending surgeon and the attending anesthesiologist. Requests for admission shall be made as far in advance as possible to facilitate appropriate nursing coverage. The House Supervisor must be notified by the physician requesting use of the facility. Any abuses of the admitting criteria are subject to review by Committee. In addition to above criteria

The following categories of patients can be admitted to the CCRR:

1. All patients that require the use of the bypass pump, regardless of hemodynamic stability or instability, cardiovascular surgery i.e., CAB, MVR, AVR, pump-assisted PTCA.


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a. Patients requiring critical care monitoring, who also necessitate being within close proximity to the Operating Room.

b. Patients requiring critical care monitoring, where the physician feels it is unsafe to transport the patient to CCU.

2. Hemodynamic Instability: a. Hypo/Hypertension = Bp < 90 mmHg b. Tachycardia, Bradycardia c. Elevated pulmonary pressures d. Cardiogenic shock

3. Patients requiring 1:1 assist from IABP to remain hemodynamically stable, i.e., hypotension when IABP auto fills making transfer from the Cath Lab to the CCU difficult and/or unsafe.

4. Dependency on vasoactive drugs with persistent hypo/hypertension.

5. Patients that are ventilator dependent, requiring 100% FIO2, large amounts of PEEP and sedative, narcotic, and/or paralyzing agents to ventilate and maintain acceptable SAO2.

(08/92)

GG. Criteria for Transfer from the Critical Care Recovery Unit (CCRR)

The decision to transfer the patient to another area is the responsibility of the surgeon attending. It will be when proximity to the Operating Room is no longer necessary and/or no extreme risk is involved in transporting to CCU. The CCRR patient will be transferred to the Critical Care Unit when hemodynamically stable, normally within 24 hours, and the following criteria are met:

1. Extubated or able to be removed from ventilator and ventilated via

ambubag for transport without jeopardizing the patient's safety. 2. IAB catheter removed, assist ratio being weaned, or balloon left in solely

to allow patient's heart to rest. 3. Vital signs stable. Systolic blood pressure higher than 90 and less than 160. Heart rate higher than 50 but less than 140. Respiratory rate higher than 10 but less than 40. Temperature higher than 96 but less than 102.


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4. Hemodynamic parameters within acceptable range. Cardiac Output higher than 3.0. Cardiac Index higher than 1.8.

Pulmonary Artery Pressures: Systolic less than 50. Diastolic higher than 25. PCWP less than 20. Urine Output higher than 30cc/hour. 5. Chest tube output will be less than 50cc/hour. (08/92) HH. Policy Regarding Isolation Cases and the CCRR

A patient having a suspected or confirmed positive culture report potentially isolatable organism as defined by CDC disease specific isolation guidelines for infectious bacteria will not be admitted to the CCRR. The CCRR is considered an aseptic unit with a daily census of fresh post-operative patients. (08/92)

II. Emergency Room Back-Up Coverage

Each subspecialty of the Department of Surgery will determine its rules for providing ER back-up coverage.

Approved Executive Committee August, 1998 ANESTHESIA SECTION I A. The Department of Anesthesia will provide anesthesia services on a 24-hour

basis for patients of Memorial City Medical Center Hospital. The anesthesiologists will be assisted in their duties by nurse anesthetists and other assistants. Anesthesia services shall be directed by a physician member of the Anesthesia Service who shall have overall administrative responsibility for the department. Anesthesia services are provided in the Maternity Center, operating suites, Cath Lab, PACU, ER, CCU, Endoscopy, and IMCU.

B. Job Description - Chief of Anesthesia 1. Selection

The Chief of Anesthesia will be appointed each year by the Chief of Staff upon the recommendation of the Anesthesia Department members, as specified in the Medical Staff Bylaws.

2. Responsibilities


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a. Recommending privileges for all individuals with primary anesthesia responsibility which shall be processed through the appropriate medical staff committees.

b. The monitoring of the quality of anesthesia care rendered in the

hospital. c. Recommending to Administration and the Medical Staff the type

and amount of equipment necessary for administering anesthesia and for related resuscitative efforts.

d. Development of regulations concerning anesthetic safety and

satisfactory operation of the department. e. Review and evaluate monthly the quality and appropriateness of

anesthesia care, using a pre-established criteria and covering the scope of anesthesia services provided, not only morbidity and mortality.

f. Encourage a continuing education program for physicians with

anesthesia privileges and in-service training for anesthetists, PACU and other appropriate personnel.

g. Provide professional input, where possible, to the cardiopulmonary

resuscitation course. h. Provide consultation in acute and chronic respiratory insufficiency

problems as well as other diagnostic and therapeutic measures, i.e., nerve blocks, epidural steroids, related to patient care.

C. Job Description - Anesthesiologists 1. Qualifications

a. The anesthesiologists shall be physicians whose practice is confined to the art and science of anesthesia as defined by the American Society of Anesthesiologist's Code of Ethics.

b. The anesthesiologists shall be graduates from an approved U.S.

medical school or if from a foreign medical school, will have passed the examination of the Educational Council for Foreign Medical Graduates.

c. They will hold a proper and current license to practice medicine in

the state of Texas and have satisfactorily completed at least a one year internship and two years training in anesthesiology. These


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studies must be from a program approved by the American Medical Association and the American Society of Anesthesiologists. Furthermore, all applicants for initial appointment to the Medical Staff must either be board certified in a specialty recognized by the American Board of Medical Specialties (ABMS), or have satisfactorily completed a residency program approved by the Accreditation Council for Graduate Medical Education (ACGME) no more than five years prior to the date of their application.

2. Work Performed

a. Perform accepted procedures commonly employed to render the patient insensible to pain for the performance of surgical and obstetrical procedures or other pain producing clinical maneuvers.

b. Support life functions during the period of anesthesia. c. Provide appropriate pre-anesthesia and post-anesthesia

management of the patient. d. Provide consultation services relating to various forms of patient

care, such as inhalation therapy and emergency cardiopulmonary resuscitation, and special problems in pain relief.

e. Provide special procedures as deemed appropriate for the best

care of the patient such as controlled hypotension during surgery, induced hypothermia, insertion of special venous and arterial catheters and tracheostomy.

f. Keep proper records of anesthesia services performed such as

pre- and post-operative notes, accurate records as to times of anesthesia and physical status of the patient during anesthesia. Any untoward reactions or complications arising during anesthesia will be recorded on the patient's chart.

g. Provide coverage by M.D. anesthesia on a 24-hour basis. h. Maintain anesthesia and resuscitative equipment in proper working

order and assuring their availability in the obstetrical and surgical areas on a 24-hour basis.

i. Provide in-service education in the form of seminars, lectures, etc.,

for appropriate hospital personnel. D. Job Description - Nurse Anesthetist


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1. Job Summary

a. The nurse anesthetist is a non-physician who has been trained in the art and sciences of administering anesthetics to render patients insensible to pain for surgical procedures. They will have been trained to handle emergency situations where resuscitation and maintenance of bodily functions are mandatory. Such care will be under the supervision of a physician licensed by the State of Texas for the practice of medicine and surgery.

2. Qualifications

a. The nurse anesthetist will have completed a training course in general nursing in a school approved by the A.A.N.A.

b. After completion of the basic nursing program, the nurse must hold

a proper, current license in nursing in the State of Texas. c. The nurse anesthetist will successfully complete a minimum of 18

months in an accredited school for nurse anesthetists as approved by the A.A.N.A.

d. The nurse anesthetist will complete and pass the examination of

the A.A.N.A. as a certified registered nurse anesthetist. e. A nurse anesthetist shall meet the approval of the Administration

Staff of Memorial Hermann Memorial City Hospital. 3. Work Performed

a. As employees of the anesthesiologist, they will be subject to those regulations as established by that employer.

b. Nurse anesthetists may provide anesthesia services under the

overall direction of the surgeon or obstetrician responsible only during the absence of the anesthesiologist when undue circumstances prevent the attendance of the responsible anesthesiologist.

c. They may provide the following services:

1. Induction of general anesthesia 2. Maintain anesthesia at the required levels 3. Manage untoward reactions 4. Provide professional observations and resuscitative care

until the patient has regained control of his vital functions


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5. Provide local anesthesia as outlined in Section II 6. Assist the surgeon or obstetrician in the capacity as an

advisor in the management of their respective cases.

d. The nurse anesthetist will participate in educational meetings. They will participate as both instructor and student. They will instruct nursing and paramedical personnel at appropriate intervals in the care of patients undergoing anesthesia and/or resuscitation.

SECTION II A. All general and regional anesthetics will be administered and performed by

qualified anesthesiologists whenever possible. In the event that they are not available, anesthesia may be performed by appropriately designated physician supervised personnel approved by the Chief of the Service and qualified by training and experience, i.e., nurse anesthetists. A registered nurse may interview and collect data from patients going for surgery for pre-anesthetic evaluation. However an anesthesiologist must see the patient to discuss anesthetic management and risks prior to surgery.

B. The Chief of Anesthesia will take responsibility to provide a call schedule that

ensures all services are provided with 24 hours of coverage, 7 days a week. C. All patients coming to the operating room for anesthesia must have a valid

signed permit for surgery and anesthesia, a history and physical examination and appropriate laboratory work in the chart prior to induction.

Preoperative tests will be ordered according to the Preoperative Testing Guidelines, as follows:

Pre-Operative Testing Guidelines

H&H EKG

GLUCOSE

CREAT/BUN

ELECTRO-LYTES

PT/PTT/ PLATELETS

CXR

Female>12 yrs. X Female>55 yrs. X X Male>45 yrs. X Male>60 yrs. X X Medical Problems: Ischemic Heart X X X


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Disease, Previous CAB, Arrhythmias, Cardiac Failure

Patients on following:

Antihypertensive meds, Beta Blockers, Calcium Channel Blockers, Digoxin, Diuretics, or other cardiac medications

X X X

Diabetics on Insulin, oral agents or diet

X X X (morning of surgery)

X

Patients on anticoagu-lants, history of bruising, bleeding, or liver disease

X

Renal failure/Dialysis X X X

X (morning of surgery)

Pulmonary disease on admission (i.e. COPD)

X X X

> 75 yrs. X X

If the history and physical examination have been dictated but are not present on the chart, a note by the attending physician or surgeon must be made to that effect and all pertinent data and information must be made on an appropriate "short form" prior to induction. In any case, it is the responsibility of the surgeon to inform anesthesia of any abnormal findings or conditions. A minimum of 10 grams of Hgb or a 30% Hct will be used as a cutoff point for elective surgery. Lower levels may be acceptable after special consideration at the discretion of the anesthesiologist and surgeon. If it is known that blood replacement will be necessary, blood must be available prior to induction. If blood is not available, the case will be delayed or canceled until blood is available, if at all feasible.

D. All patients going to surgery will have prosthetics removed except for unusual

cases and with the permission of the attending anesthesiologist. Should patients insist on keeping their dentures, etc., then they must assume full responsibility for loss or damage. Prosthetics include items such as dentures, hearing-aids, and contact lenses. If patient is unwilling or unable to remove jewelry, then


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patient must be warned of associated risks with the use of electrocautery and potential for electrical shock or burn.

E. Anesthesia will be provided for elective surgery between the hours of 7:30 a.m.

and 7:00 p.m., weekdays. Minor elective surgery may be posted on Saturdays from 7:30 a.m. to 2:00 p.m. All after-hour postings should be restricted to emergencies or urgent procedures. All efforts will be made to post urgent cases at the surgeons convenience whenever possible.

F. Patients arriving for surgery will be held for 30 minutes past the posted operating

room time if the surgeon is late. After this, the surgery time may be rescheduled. The patient will not go to the Operating Room until the surgeon is ready to accompany the patient. Executive motion approved: 11/92

G. Post Anesthesia Care Unit (PACU)

All patients receiving general or regional anesthesia must go to an appropriate recovery area. If special post anesthesia care is necessary, such as a patient requiring isolation (infected case,) special arrangements will be made to recover the patient in a separate facility such as a designated isolation area, etc. Patients may be sent to CCU or IMCU for recovery care. This decision will be a mutual one by the surgeon and the anesthesiologist. All patients will have a post-anesthesia record with appropriate notations. Patients will be discharged from the PACU by Anesthesia approved discharge criteria. The operating room surgeon may discharge the patient, in which case, he will assume full responsibility for such discharge. No visitors will be allowed in the Phase I PACU except when it is approved by the anesthesiologist or surgeon. Outpatients are allowed one (1) visitor in pre-op and in Phase II recovery of the PACU.

H. Local Anesthesia - Local anesthesia may be administered by the surgeon without the presence of an anesthesiologist or an anesthetist, providing the patient is continually monitored by a blood pressure cuff, pulse rate and respiratory rate.

Appropriate resuscitative equipment must be available in the surgical and obstetrical areas. All procedures done under local anesthesia in conjunction with narcotics or hypnotic drugs must be done supervision of the anesthesiologist or anesthetist. If the attendance of a member of the Anesthesia Department is desired during such a procedure under local anesthesia, the case should be booked as MAC (monitored anesthesia care) and an appropriate charge to the patient will be made for such services.


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Following surgery under local anesthesia, patients will be returned to their rooms. Those patients requiring the additional or extended services will be sent to the PACU. If a patient has received MAC, I.V. sedation, or regional blocks, it will be left to the discretion of the anesthesiologist whether a patient returns to Day Surgery, goes to PACU, or to the patient care area post-op. All procedures done under general or regional anesthesia require that the patient have an IV started prior to the time of anesthesia. IV's may be deleted if mutually agreed on by the anesthesiologist and surgeon.

I. Nurse anesthetists may use appropriate local anesthesia agents in the following

situations:

1. Topically on the upper respiratory airways for comfortable and safe endotracheal intubation of patients,

2. Intradermally for the insertion of venous and arterial catheters, 3. IV regional blocks of the extremities, and 4. IV for treatment of arrhythmia’s. J. Miscellaneous 1. There will be three basic categories of anesthesia coverage:

a. Staff Anesthesia: Defined as an anesthetic administered or supervised by a member of the anesthesia staff, including regional, general inhalation and intravenous anesthesia, etc.

b. Local Anesthesia: Defined as the use of local anesthetic

administered by the surgeon and not requiring the presence of a member of the anesthesia staff.

c. MAC (monitored anesthesia care): Defined as local anesthesia

wherein a member of the anesthesia staff is required or requested to be present throughout part or all of the procedure.

2. The choice of anesthetic agents and techniques shall be determined by

the anesthesiologist taking into consideration any requests by the surgeon and the patient. It is suggested that any surgeons desiring spinal, epidural or other special types of anesthesia discuss this with the patient prior to posting whenever possible and that any special requests be made at the time of posting.


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3. All personnel in the operating room will wear scrub clothes that are

provided by the hospital and are changed before leaving the facility. Clean footwear, caps, hoods, masks, and protective eyewear must be worn. Hair must be covered. All protective equipment (masks, hats, and shoe covers) must be removed when leaving the OR.

Masks will be worn over the nose and mouth. No personnel or physician with infectious or communicable disease will be permitted in the operative suites. Physicians should not visit from room to room until they have removed their soiled gown and gloves.

4. All pitocin drip infusions will be the full responsibility of the attending

obstetrician. Anesthesia will not bear responsibility for providing this coverage. It is strongly advised that pitocin inductions be done according to F.D.A. regulations.

5. OB patients will be monitored for their vital signs. Any patient for delivery

will have an intravenous infusion started prior to going to the delivery room. Anesthesia services will be notified in advance as soon as possible that a delivery is anticipated. One anesthesiologist, on a call schedule, will be assigned to the Maternity Center at all times.

6. Supplemental oxygen must be available for Endoscopy patients and if the

oxygen saturation is less than 90 percent on the pulse oximeter, oxygen may be utilized at the physician's discretion.

7. Explosive inhalation gases will not be used. 8. Needles and syringes will be destroyed in accordance with established

techniques, such as destruc-clip boxes, etc., and needles and syringes will be placed in appropriate containers for disposal to protect personnel and to prevent illegal or illicit use.

9. In cases where the surgeon has posted an emergency case and the case

does not appear to be a legitimate emergency by nursing personnel or attending physician from the anesthesia department, the decision to go ahead with the case shall be made by the informed Chief of Surgery or Chief of the Medical Staff.


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SECTION III A. The patient's physician and anesthesiologist will do a pre anesthesia evaluation

with appropriate documentation of pertinent information relative to the choice of anesthesia and the surgical or obstetrical procedure anticipated. This evaluation should include the patient's previous drug history, other anesthetic experiences and any potential anesthetic problems.

B. The evaluation will be made of the patient's condition prior to induction of

anesthesia. This should include a review of the chart, with regard to completeness, pertinent laboratory data, time of administration and the dosage of pre-anesthesia medications, together with an appraisal of any changes in the patient's condition, as compared with that noted on previous visits.

C. Prior to beginning the administration of anesthesia, the anesthesiologist shall

check the readiness, availability, cleanliness and working condition of all equipment used in administration of anesthetic agents. In addition, each anesthetic gas machine in all anesthetizing areas shall have a pin-index safety system. Following the procedures for which anesthesia was administered, the anesthesiologist, or his designee, shall remain with the patient as long as necessary. Personnel responsible for post-anesthetic care should be advised of specific problems presented by the patient's condition.

Decisions relative to the discharge of patients from any post-anesthesia care unit will be made by a physician.

D. The recording of all events taking place during the induction of, maintenance of,

and emergence from anesthesia, including the dosage and duration of all anesthetic agents, other drugs, intravenous fluids and blood or blood fractions will be made.

E. The recording of post-anesthetic visits that includes at least one note describing

the presence or absence of anesthesia-related complications will be made. SECTION V A. As designated by the Anesthesia Service, there will be an anesthesiologist assigned to the Obstetrics Department 24 hours a day. B. The OB anesthesiologist will be available to provide anesthesia services any time a patient is in active labor. If there are no patients in active labor, the OB anesthesiologist will not be restricted to the obstetrical service. C. A Chief of OB Anesthesia will be selected on an annual basis. All questions and

problems should be brought to the attention of this anesthesiologist. Executive motion approved: (7/91)


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D. A CRNA is able to be present for a delivery if the anesthesiologist cannot be immediately available or in an emergency situation. (9/94) Approved Executive Committee December, 1998 OUTPATIENT ANESTHESIA SECTION I A. Patients admitted to the MHMC Hospital for surgical procedures under general

anesthesia will be accepted only if they comply with the following conditions:

1. The patient must have complete and adequate briefing by the attending surgeon in reference to the operative permit, the laboratory tests, the type of anesthesia, recovery room, the discharge procedures, and the costs involved. All patients will be instructed to fast from midnight until the time of surgery.

2. Only those patients that are free of serious disease will be accepted for

day surgery, i.e., Class ASA I to III. 3. All patients must be seen prior to surgery by the anesthesiologist so that

pre-anesthesia evaluation, pre-medication, and choice of anesthetic, may be made. At this time, the patient will be informed of the possible complications and of the possible need for extended care and prolonged hospitalization.

4. A responsible person must accompany an outpatient home upon

discharge, or (1) the patient will be admitted to the hospital for observation, or (2) the patient's surgery will be rescheduled. The patient will not be permitted to operate motor vehicles within 24 hours after his surgery. He will also not be permitted to participate in any activities that might cause him or others injury because of the persistent influence of drugs used in the anesthetic. Patients must be informed of these limitations.

SECTION II The Anesthesiologist and His Duties, Responsibilities and Relationship to the Hospital

1. Anesthesiologists and hospital should, as a minimum, completely fulfill the standards for anesthesia care, as published in the Accreditation Manual for Healthcare Organizations published by the Joint Commission.


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2. Anesthesiologists should have the same relationship to the hospital as other staff members have to the hospital.

3. The hospital will provide the necessary equipment, drugs, and gases that

a specialist in anesthesiology may require, in the manner and to the extent that such items are furnished for use by other physicians practicing in the hospital.

SECTION III A. Policies for Administration of Local Anesthesia in the O.R.

1. All patients having minor or major procedures done in the operating room under regional or block anesthesia must have an IV started prior to the time of surgery.

2. All minor or major procedures done in the operating room under local

anesthesia only(example: xylocaine) may be done without the monitoring of an M.D. anesthesiologist or a nurse anesthetist.

3. All minor or major procedures done under block or local anesthesia in

conjunction with narcotic or hypnotic drugs must be done under the supervision of an M.D. anesthesiologist.

4. The patient must be monitored for blood pressure, pulse and respirations,

while under the influence of the narcotic or hypnotic drug.

5. A written order must be given postoperatively by the attending surgeon as to the deposition of the patient to the recovery room or special duty nurses for local cases.

6. All patients in the operating room having local anesthesia with a narcotic,

hypnotic drug, barbiturate drug, and all patients under general anesthesia should go to the recovery room or to their room with the recovery room personnel until released by the M.D. anesthesiologist or the attending surgeon.

B. Policies for Administration of Intravenous Conscious Sedation

Conscious Sedation is defined as a patient who has a depressed level of consciousness, but retains the ability to independently and continuously maintain a patent airway and respond appropriately to physician stimuli and/or verbal commands. Conscious sedation applies to providing sedation for therapeutic and diagnostic procedures.


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Any patient who receives intravenous conscious sedation must be appropriately monitored and meet criteria before being discharged. (See Administrative Policy on Intravenous Conscious Sedation)

Approved Executive Committee December, 1998 ACTIONS INVOLVING THE IMPAIRED PHYSICIAN MEDICAL STAFF PRACTITIONER 1. The quality of patient care is the responsibility of the Memorial Hermann Hospital

System Board of Directors as well as the Medical Staff. The Board of Directors also recognizes its responsibility to maintain a high degree of confidentiality when dealing with matters of clinical competence and/or professional conduct. To meet this responsibility, it is necessary that a mechanism be established whereby the conduct, condition, or action by Medical Staff members, which could compromise the quality of patient care, can be identified, reviewed, and resolved.

2. Purpose:

a. To ensure quality of care for all patients.

b. To maintain a safe environment for patient, employees, and other Medical Staff members.

c. To provide a positive medical assistance program to the impaired

practitioner. 3. It shall be the policy of the Medical Staff of Memorial Hermann Memorial City

Hospital to provide a procedure for the possible identification, intervention, and referral for treatment for a member of the Medical Staff who is an impaired practitioner.

4. Impaired Practitioners is defined as one who is potentially unable to practice

medicine with reasonable skill and safety to patients because of impaired judgment due to physical or mental illness, including deterioration through the aging process, or loss of motor skill, psychological dysfunction, or use or abuse of drugs or chemical, including alcohol.

5. Report and Investigation:

If a Medical Staff member and/or an individual working in the Hospital have a reasonable suspicion that a practitioner’s judgment is impaired, the following steps shall be taken:


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a. A written report is to be given to the Chief of Staff. The report should include a description of the incident(s), which led to the belief that the practitioner may be impaired. The report must be factual and objective. The Chief of Staff receiving the report shall provide a copy to the Hospital CEO.

b. The Chief of Staff and the CEO will meet and discuss the report with the

individual who filed it. If the Chief of Staff believes there is enough information to warrant an investigation, the Chief of Staff, at his/her direction, the Chairman of the Department to which the request is made, may immediately appoint an ad hoc committee of at least three members of the Active Staff to investigate the matter. The committee may request an interview with the practitioner, and he/she shall cooperate with the committee in its investigation. As promptly as practical after the request for investigation is made, the committee shall transmit a written investigation report to the Chief of Staff.

c. As soon as practical following receipt of the ad hoc committee report, the

Chief of Staff shall forward the report to the Executive Committee which shall take action on the request. Some of the actions that could be considered by the Executive Committee could be the following:

1) Require the practitioner to undertake a rehabilitation program as a

condition of his/her continued use of the Hospital; 2) Impose appropriate restrictions on his/her Hospital practice; 3) Immediately suspend the practitioner’s practice in the Hospital until

an appropriate rehabilitation has been successfully completed. 4) All monitoring required of the practitioner should be done through

the Harris county Medical Society or its equivalent.

d. The original report and description of the actions taken by the Chief of Staff should be included in the practitioner’s peer review file. If the investigation reveals that there is no merit to the report, the report shall state so and be filed in a confidential peer review file separate from the practitioner’s credentials file. If the investigation reveals that there may be some merit to the report, but not enough to warrant immediate action, the report shall be included in a confidential peer review file and the practitioner’s activities and practice shall be monitored until it can be established that there is, or is not, an impairment.

e. Throughout this process, all information will be kept confidential and any

discussions will be among the involved parties only.


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6. Rehabilitation

While the Hospital and Medical Staff and leadership is usually unable to participate in the rehabilitation and recovery process, they should encourage it and assist the practitioner in locating a suitable rehabilitation program. A practitioner will not be reinstated until he establishes, to the Hospital’s satisfaction, that he has successfully completed a program in which the Hospital has confidence. (See Reinstatement of Impaired Practitioner.)

7. Reinstatement:

Upon sufficient proof that a practitioner suffering from an impairment has successfully completed a rehabilitation and is successfully in recovery and upon the recommendation of the Medical Executive Committee, the Board of Directors, at its sole discretion, may consider that practitioner for reinstatement to the Medical Staff. (See Reinstatement Impaired Practitioner.)

8. Report to the Texas State Board of Medical Examiners:

Any action adversely affecting the clinical privileges of the practitioner for a period longer than thirty (30) days or an opinion by the Committee that the practitioner poses a continuing threat to the public welfare through the practice of medicine will be reported to the Texas State Board of Medical Examiners pursuant to the Texas Medical Practice Act and the Health Care Quality Improvement Act of 1986.

9. Practitioner Cooperation:

If at any point during the process of evaluation, rehabilitation or reinstatement the practitioner refuses or fails to comply with this procedure, he/she will summarily be suspended from the Medical Staff and afforded due process as defined by the Procedural Review Plan of the Medical Staff of Memorial Hermann Memorial City Hospital.

REINSTATEMENT OF IMPAIRED MEDICAL STAFF PRACTITIONER 1. It shall be the policy of Memorial Hermann Memorial City Hospital to consider

reinstating recovering impaired members of the Medical Staff of the Hospital. 2. Purpose:

It is the goal of the Medical Staff with the reinstatement of the impaired Medical Staff practitioner to:

a. Reasonably ensure the safety and quality of care of all patients admitted

to or treated at the Hospital.


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b. Reasonably ensure that the impaired Medical Staff member is

successfully recovering from the problems associated with impairment. 3. A member of the Medical Staff who has taken a leave of absence from the

Medical Staff (voluntary or involuntary), or who has been suspended from the Medical Staff, must submit a request for reinstatement. The following information will be requested by the Chief Executive Officer and/or the Credentials Committee:

a. A letter from an involved treatment center which covers the following:

1) Description of the impairment; 2) Current status of the impairment; 3) Description of the treatment; and 4) Statement of the long term prognosis.

b. A letter from the impaired Staff Member’s personal physician covering the

four points listed in A above and:

1) Personal Physician’s opinion of the effect of impairment on Staff Member’s professional performance.

2) Personal Physician’s statement that the impaired Staff Member is successfully recovering; and

3) Any additional pertinent information.

c. A letter from the impaired Staff Member which covers the following:

1) Description of impairment; 2) Impaired Staff Member’s opinion as to whether he is successfully

recovering and what his/her professional performance has been affected; and

3) Statement that Staff Member will accept periodic medical evaluations at the request of Administration, Chief of Staff Credentials Committee, Board of Directors and/or the appropriate Chairperson. The evaluation is to be performed by a Physician qualified by education, training and experience to care for an individual with the condition for which the impaired Staff Member was treated, who has been chosen by or is acceptable to the Hospital.

d. The Hospital may request periodic status reports covering all points in

item b above.

e. Reappointment to the Medical Staff shall be on an annual basis, subject to evaluation at any time, for a period of at least five years.


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f. The impaired Staff Member must, prior to consideration for reinstatement,

provide a valid certificate of insurance evidencing professional liability coverage. This coverage must be continuously maintained for five years and prior events coverage should be maintained for all subsequent years.

g. If at any point during the process of evaluation, rehabilitation or

reinstatement the impaired Staff Member refuses/fails to comply with this procedure, he/she will be summarily suspended from the Medical Staff and afforded due processes as defined by the Procedural Review Plan of the Medical Staff of Memorial Hermann Memorial City Hospital.

VOTING PROCEDURES - Approved by MEC 11/30/2010 & DQC 1/20/2011

1. Ballots will be mailed/hand-delivered to you with a return envelope with your

name on it, or you can get one at the meeting. a. Ballots will NOT BE name-labeled; one vote per qualified active staff

member to be signed for at the meeting or returned by mail, postmarked no later than the final voting date.

b. Ballots will be inside an unlabeled envelope, which will be inside an envelope with staff member’s name on it.

c. Ballot envelopes are to be placed in the ballot box or returned by mail/hand-delivery no later than the final day of voting. 1) To whom non-ballot box ballots will be forwarded will be

determined prior to a particular vote (Chief of Staff, Harris County Medical Society monitor, etc.).

2) Ballot Box entries, a) Will be documented on a Ballot Box Ledger by a monitor as

they are deposited. b) Will use the same envelope system/rules as mail-in ballots.

2. Voter qualifications, a. Active staff member

3. Closed vote (ballots) on the issue (not necessarily other motions at the meeting, unless so moved) a. VOTE MUST HAVE YOUR NAME ON THE RETURN ENVELOPE FOR IT

TO BE COUNTED (to assure one vote per active staff member) COUNTING WILL BE ENTIRELY CONFIDENTIAL: Only one vote counter will see names on outer envelopes,

b. Envelopes will be unopened until before a Vote Counting Committee. 1) Chief of Staff; Chief of Staff, Elect; Immediate Past Chief of Staff;

Bylaws Committee Chair; Chief Medical Officer; Harris County Medical Society/TMA representative (optional); Medical Staff Services Director

c. Your name will be checked off active staff ledger as having voted, then the outer envelope will be discarded by one counter.


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d. Ballot inside inner, blank envelope will be handed (unopened) to another counter to place in ballot box.

e. Anonymous ballots counted and saved f. Final Vote Count: To be done 2 workdays after the final voting day (to

allow votes postmarked on the final vote day to be counted).

4. Specific medical staff members at the meeting will oversee a. Distribution of ballots b. Ballot box entries c. Initialing/Signing of,

1) Active Medical Staff Ledger when receiving a ballot 2) Ballot Box Ledger when depositing a ballot

5. Return/postmark your vote within 14 days any of Special Staff Meeting initial notice or the final date of voting for the specific vote. a. Return by mail or hand-deliver at the meeting (ballot box). b. Return by email, if confidentiality is of no concern to you.

6. NOTE: a. More than one checked box/ballot item = invalidated vote (check only one

action) b. No votes accepted after the final vote day (votes postmarked that day will

count). c. Ballots not inside name-labeled envelopes will be discarded (not counted). d. Envelope/Ballot Instructions:

1) NO name on the inner envelope containing the ballot 2) PRINT and SIGN your NAME and MEDICAL STAFF NUMBER across

the outer envelope sealed edge 3) 3rd envelope contains the above package, and is mailed/forwarded

to whomever designated per 1.,c.,1). (email ballot if confidentiality not important to you)

DISRUPTIVE AND INAPPROPRIATE BEHAVIOR - Approved by MEC 02/23/2012 & DQC 05/01/2012 Purpose: To create a work environment that fosters respectful and constructive relationships among and between healthcare professionals, patients, and staff. Policy Statements: 1. This policy applies to all members of the medical staff and allied health staff who

may provide care, treatment, and/or service on behalf of the organization. 2. We strive to create the best possible clinical outcomes with exceptional patient care

experiences! To help us achieve this, we have established a set of operating principles and behaviors to guide our actions.


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3. Memorial Hermann Memorial City Medical Center medical staff and allied health staff members, who provide care, treatment and/or service, are expected to adhere to these operating principles and behaviors.

Definitions: Acceptable behavior is defined as behavior which enables others to perform their duties and responsibilities effectively, promotes the orderly conduct of the organization, and results in respectful and constructive communication. Examples of acceptable behavior include, but are not necessarily limited to: Respectful communication in a calm and professional manner Addressing disagreements professionally and factually without animus or personal

attacks Timely and appropriate response to requests and concerns Communication and personal interaction in a manner that is respectful.

Disruptive or inappropriate behavior is defined as behavior which interferes with others’ ability to perform their duties and responsibilities effectively or interferes with the orderly conduct of the organization. Examples of disruptive or inappropriate behavior include, but are not necessarily limited to: Use of profanity and vulgar expressions or gestures Disrespectful language that impugns an individual’s race, creed, color, national

origin, religious, or political beliefs. Intimidating behaviors such as slamming or throwing of objects, verbal abuse

(yelling, shouting, etc), physical aggressiveness, and sexual harassment Lack of timely and appropriate response to requests and concerns Retaliation against anyone who has reported or assisted in investigating

allegations of disruptive or inappropriate behavior Criticism of an individual in front of patients or other healthcare professionals

unless part of appropriate chain of command reporting mechanisms. Policy: 1. Any individual who provides care, treatment, or service on behalf of this organization

will conduct themselves in accordance with the acceptable behaviors as defined in this policy. This organization will not tolerate displays of disruptive or inappropriate behavior.

2. Informing Individuals about the Code of Conduct: Members of the medical staff shall be informed of this code of conduct as part of their initial appointment and reappointment process. Individuals already providing care, treatment, or service at the time this policy takes effect shall also be informed.

3. Reporting Violations of the Code of Conduct: An individual who witnesses or is the recipient of disruptive or inappropriate behavior should report such occurrence to their immediate supervisor or through the established chain of command or via the Physician Hotline or Physician On-Line Reporting Process. It is the responsibility of


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the organization’s leadership to not tolerate retaliatory action towards anyone who reports such behaviors,

4. Addressing Violations of the Code of Conduct: Medical staff and allied health staff members who engage in disruptive or inappropriate behavior are subject to disciplinary or other action through appropriate channels. a. Medical Staff process:

i. Issues are addressed immediately (when possible within 48 hours) with a face to face meeting with the individuals involved, the CEO/designee and/or the Chief of Staff/ designee and the appropriate area director with a goal of reaching resolution.

ii. If there is no resolution, the issue is reviewed by the department chair and/or the chief of staff

iii. The “Behavioral Issue Review” form (Attachment A) is used to evaluate medical staff behavioral issues and/or by a letter from the Chief of Staff.

iv. Discussions with physicians are documented and placed in the physician’s quality file along with any correspondence regarding the incident.

v. A summary report of behavioral issues is presented to the Credentials committee.


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THE MEDICAL STAFF STATUSES Affiliate - Courtesy. The Courtesy Staff shall consist of members who qualify for Affiliate Staff membership but use the Medical Center infrequently. They shall not be required to attend General Staff meetings or Department/Section meetings, shall not be eligible to vote or hold elective office, and shall be limited to twenty-four (24) admissions, deliveries, consultations, or procedures each year. This would include patients or procedures in the Medical Center, Outpatient area, and Day Surgery area, including Observation patients. A Courtesy Staff member who exceeds the total of twenty-four (24) activities in one year must apply for Active Staff membership in order to continue medical staff membership. Affiliate - Consulting. Any member who provides evidence of special qualifications in a field of practice shall be eligible for Consulting Medical Staff status. A member of the Consulting Medical Staff shall be eligible to consult, within the scope of the privileges delineated, upon request but shall not hold admitting privileges. A member of the Consulting Medical Staff may render a consultation on as many patients as requested. Members of the Consulting Medical Staff shall not be required to attend meetings of the Medical Staff and shall not vote or hold office therein. They may serve as ex-officio members (without vote) on all committees except the Medical Executive Committee. Affiliate - Refer and Follow. Appointment to the Refer/Follow Staff medical staff status may be requested by practitioners who wish to have an affiliation with the Hospital for purposes of referring patients, following patients through access to the electronic record, seeing their patients while hospitalized, consultation with the attending practitioner, and obtaining the results of tests and therapy. Refer/follow appointees may perform a History and Physical for out-patient procedures.

Refer/Follow Staff members are not required to attend medical staff meetings, may not vote or hold elective office, and may not make entries in the in-patient medical record. Refer/Follow members do not have clinical privileges and may not admit or attend patients in the Medical Center.

Refer/Follow Staff members may be appointed to Medical Staff Committees as voting members.

GRANDFATHERING PROVISIONS Board Certification – Must have been a member of the Memorial Hermann Memorial City Medical Center medical staff on or before October 1, 1999. Oral/Maxillofacial Surgery – Each dentist member or applicant seeking clinical privileges in oral/maxillofacial surgery must document Board certification in a specialty recognized by the American Dental Association (ADA) or satisfactory completion of a specialty residency program approved by the American Dental Association. or


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was a member of the Memorial Hermann Memorial City Medical Center medical staff on or before October 1, 1999, the date of grandfathering. DUES All members of any category shall pay dues in an amount and frequency set by the Medical Executive Committee the first meeting of the medical staff year. Failure to pay dues in a timely manner shall be grounds for ineligibility for membership renewal or for corrective action. OFFICERS (refer to Section 9.1 in Bylaws) Secretary/Treasurer of Medical Staff. The Secretary/Treasurer shall be a voting member of the Medical Executive Committee and shall keep records of all meetings of the Medical Staff and of the Medical Executive Committee. He/she shall give notice of all meetings of the Medical Staff and of the Medical Executive Committee. He/she shall attend to all correspondence. If there are funds to be accounted for, he/she shall account for all Medical Staff funds and shall present a financial report to the General Medical Staff annually. DEPARTMENTS AND SECTIONS The Medical Staff will establish and maintain Department and Section designations which support an efficient operational structure for the delivery of health care services. The Department and Section designations are listed below:

Department Section Anesthesia Emergency Medicine Family Practice Medicine Hematology/Oncology Neurology Pulmonary Diseases Cardiology Obstetrics & Gynecology Orthopedic Surgery Pediatrics Radiology Surgery Cardiovascular & Thoracic Surgery General Surgery


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Oral & Maxillofacial Surgery/Dentistry Ophthalmology Otolaryngology Pathology Plastic Surgery Podiatry Urology

Term of Office. Chairpersons shall serve for two (2) calendar years, beginning in January. The Chairperson of any Department/Section may be re-elected any number of times unless specific rules limiting the number of terms are voted by individual Department/Section or the Medical Executive Committee. LISTING OF COMMITTEES:

• Bylaws Committee • Cancer Committee • CME Committee • Credentials Committee • Critical Care Committee • Endoscopy Committee • Medical Ethics Committee • Medical Informatics Committee • Medical Peer Review Committee • Patient Care Committee • Pharmacy & Therapeutics/Infection Control Committee • Surgical Peer Review Committee • Utilization Management Committee

BYLAWS COMMITTEE MEMBERSHIP: Voting Members: • Members at Large: 8 The term of office shall be two years, with appointments staggered to replace half of the members each year. Three (3) voting members shall constitute a quorum. PURPOSE: It is the responsibility of the Bylaws Committee to review annually the medical staff bylaws and the medical staff rules and regulations and to report the results of this review to the Medical Executive Committee. Proposed bylaws amendments shall be


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endorsed by the Bylaws Committee and approved by the Medical Executive Committee prior to presentation to the medical staff. MEETINGS: Meetings shall be called by the Chairperson. The Bylaws Committee shall meet with such frequency as is necessary to conduct its business, but no less frequently than annually.

CANCER COMMITTEE

MEMBERSHIP: The Cancer Committee shall be composed of at least one board certified physician representative from the following specialties: Medical Oncology, Surgery, Diagnostic Radiology, Pathology, Urology, Gastroenterology/Colorectal Surgery, Radiation Oncology, Gynecology/Gynecologic Oncology, and Internal Medicine/Family Practice. The Cancer Committee membership shall also include at least one representative from the following non-voting members: Administration, Nursing, Social Services, Cancer Registry, Quality Resource Management, and Pastoral Care. DUTIES: The Cancer Committee responsibilities include, but are not limited to: • Develop and evaluate the annual goals and objectives for the clinical, educational,

and programmatic activities related to cancer services at Memorial Hermann Memorial City Medical Center.

• Promote a coordinated, multidisciplinary approach to cancer patient management. • Conduct and evaluate educational and consultative cancer conferences. • Develop and evaluate support services for cancer patients and their families. • Monitor quality management and improvement through completion of quality

management studies that focus on quality, access to care and outcomes. • Promote clinical research. • Supervise and evaluate the cancer registry to ensure accurate, timely abstracting,

staging, and follow-up reporting. • Develop and publish an annual report that meets the guidelines, and otherwise meet

the standards, of the American Joint Committee on Cancer of the American College of Surgeons.

• Uphold medical ethical standards. MEETINGS: The Cancer Committee shall meet at least four (4) times per year and upon the call of the Chairman as needed. A quorum consists of one/third of the voting membership. Written records of its proceedings and actions shall be maintained and reports made thereof to the Medical Executive Committee.


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CREDENTIALS COMMITTEE MEMBERSHIP: Voting Members: Twelve members of the Active Medical Staff representing: • Family Practice • Medicine • Obstetrics and Gynecology • Surgery • Dental /Oral Surgery • Pediatrics • At Large* • Secretary/Treasurer of the Medical Staff *At large members should be selected from those Departments/Sections not represented. Ex-officio Member (non voting): • President of the Medical Staff The term of office shall be two (2) years, with elections staggered to replace one member from each Department/Section and one member at large every year, with the dentist being replaced every other year. Six (6) members shall constitute a quorum. The Chairperson shall be appointed by the President-Elect. The Chairperson must have served as a member of the Credentials Committee for a minimum of one year before serving as Chairperson. PURPOSE: The Committee shall investigate the credentials, qualifications, and ethical practices of all applicants for membership on the Medical Staff. The record of the applicant shall be reviewed from the time of entrance into medical school and shall be accounted for in chronological order. When a Department/Section recommends one or more of the following actions, the Credentials Committee shall evaluate the performance of the Medical Staff member and render a report and/or recommendation: • Advancement of a member from Provisional Staff Status • Changes in clinical privileges • Change in assignment to a Department/Section • Investigation of alleged violations of professional ethics and performance All recommendations of the Credentials Committee shall be directed to the Medical Executive Committee. MEETINGS:


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The Committee shall meet as often as necessary at the call of the Chairperson, but at least nine (9) times annually.


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MEDICAL ETHICS COMMITTEE

The Medical Ethics Committee will be composed of five (5) members of the Medical Staff, the Chief Nursing Officer, the Intensive Care Unit Nursing Manager, and at least three representatives from the Community. The purpose of the Medical Ethics Committee will be to serve as an advisor body for patients, families, physicians, and staff on the formulation of policies and/or guidelines dealing with bioethics issues which influence the level and quality of care, the dignity of patients and their self-determination. The Medical Ethics Committee shall meet as needed at the call of the Chairman but at least quarterly and will be available for unscheduled meetings at the request of patients, staff, or Medical Staff. Five (5) members shall constitute a quorum. All recommendations of the Medical Ethics Committee shall be directed to the Patient Care Committee. (presented to MEC 10/22/2015 and approved by active medical staff 12/19/2015)

MEDICAL EXECUTIVE COMMITTEE MEMBERSHIP: Voting Members: • Chief of Staff 1 • Secretary 1 • Chief of Staff Elect 1 • Immediate Past Chief of the Medical Staff 1 • All Chairpersons of Departments 1 each • Chairperson, Bylaws Committee 1 • Chairperson, Credentials Committee 1 • Chairperson, Endoscopy Committee 1 • Chairperson, Medical Informatics Committee 1 (approved 11/13/2013) • Chairperson, Medical Peer Review Committee 1 • Chairperson, Patient Care Committee 1 • Chairperson, Pharmacy/Therapeutics/Infection

Control Committee 1 • Chairperson, Surgical Peer Review Committee 1 • Chairperson, Utilization Management Committee 1 (approved 11/13/2013 Ex-officio Members (non voting): • Chairpersons of Other Medical Staff Committees not listed above 1 each


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MEDICAL INFORMATICS COMMITTEE MEMBERSHIP: The Medical Informatics Committee shall consist of at least fifteen (I5) physician members representing the various specialties and clinical departments. The term of office for the Practitioner members is for two (2) years with terms staggered to replace half of the members each year. In addition, the Administrator, the Assistant Administrator for Nursing, and the Director of Medical Records shall be members of the Committee. Five (5) members shall constitute a quorum. PURPOSE: The Medical Informatics Committee shall be responsible for insuring that all medical records are established and maintained in a manner consistent with the standards of patient care established by the Hospital. The records shall be reviewed monthly for the timely completion, clinical pertinence, legality, and overall adequacy for use in quality assessment activities, and as a medical-legal document. The medical record review shall assure that the records reflect the condition and progress of the patient, including results of all tests and therapy given. The committee will determine the format of the complete medical record, the forms used in the record and the use of microfilming. The medical record evaluations will be applied to inpatient, ambulatory care, skilled nursing facility, and emergency medical records. The committee will study the various situations encountered and make recommendations concerning delinquency in the completion of medical records. MEETINGS: The Medical Informatics Committee shall meet as often as necessary at the call of the Chairperson, but at least nine (9) times annually. A written record of the proceedings and actions shall be maintained for each meeting in the manner prescribed by the Chairperson and reports made thereof to the Executive Committee.

MEDICAL STAFF HEALTH COMMITTEE

PURPOSE: The purpose of the Medical Staff Health Committee (“MSHC”) is to promote the health and well-being of members of the medical staff and allied health professionals. The committee seeks to identify and assist those licensed independent practitioners and allied health professionals (collectively referred to in this section as “practitioners”) who may have health problems that impair their ability to provide care and services. DEFINITION OF IMPAIRED PRACTITIONER: As used in this section, the term “impaired practitioner” means a licensed independent practitioner or allied health professional who is unable or potentially unable to render professional services with reasonable skill or safety to patients because of mental illness, or cognitive deficiency, disruptive behavior temperament, or physical illness


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including, but not limited to, deterioration through the aging process, loss of motor skills or excessive use of drugs, including alcohol. COMPOSITION: The MSHC shall be composed of at least three (3) medical staff members. The members of the MSHC shall be appointed by the chief of staff, may come from any category of the medical staff, and shall have experience or at least an interest in impairment. Members of the MSHC will be appointed for staggered terms of three years and may be reappointed for successive terms. If practicable, one member of the committee should be a practitioner who is recovering from impairment. No member of the MSHC shall be a department chair, member of the Credentials or Medical Executive Committee or otherwise hold a leadership position with authority to limit or suspend a practitioner’s privileges. DUTIES: The duties of the MSHC are to:

1. Provide advocacy, assistance, and education to practitioners regarding illness, conditions and behavior that may impair an individual’s ability to practice medicine or exercise practice prerogatives. 2. Invite self-referrals from practitioners, referrals from other staff of the Medical Center, reports, and other information related to practitioner impairment. 3. To provide educational/informational materials and programs about illness and impairment recognition issues to practitioners and other staff of the Medical Center. 4. To evaluate reports of behaviors or activities which might indicate that a practitioner has an impairment. The evaluation shall include direct discussions with the practitioner named in the report. 5. To arrange for intervention when the MSHC concludes there is a potential or real impairment. 6. To evaluate the credibility of a complaint, allegation, or concern. 7. To refer the affected practitioner to the appropriate professional internal or external resources for evaluation, diagnosis and/or treatment of the condition or concern. 8. To facilitate the monitoring of the affected practitioner and the safety of patients during the course of a rehabilitation. Facilitation of monitoring may include making inquiries, receiving and evaluating reports from the facilities or programs through which treatment and rehabilitation are being provided, and such other activities as may be determined necessary by the MSHC.


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9. Maintain the confidentiality of the practitioner seeking referral or referred for assistance except as limited by law or ethical obligation or when the safety of patients is threatened. 10. Report to medical staff leadership for appropriate corrective action any determination that a practitioner may be providing unsafe treatment.

MEETINGS: The MSHC shall meet as needed but at least once each quarter. The MSHC shall conduct all deliberations relating to practitioners in executive session and shall maintain all records of the committee relating to individual practitioners in a confidential manner.

ENDOSCOPY COMMITTEE MEMBERSHIP: The Endoscopy Committee shall consist of practitioners that represent each specialty with Clinical Privileges for use of the equipment in the Endoscopy Unit (gastroenterologists, general surgeons, otolaryngologists). In addition, the Administrator or his/her designee shall be represented at each meeting. Fifty percent constitutes a quorum. PURPOSE: The Endoscopy Committee shall serve as an advisory group to the Medical Center and the Medical Center Staff on matters pertaining to the function of the Endoscopy Unit. The Endoscopy Committee will assist in the implementation and enforcement of the policies and procedures it approves. The Endoscopy Committee shall review the condition and progress of patients and therapy provided within the Unit and assure quality of patient care provided in conjunction with treatments offered in the Endoscopy Unit. The Endoscopy Committee shall review a practitioner’s endoscopic clinical privileges for appropriateness and determine new credentialing criteria for endoscopic procedures/equipment when necessary. MEETINGS: The Endoscopy Committee shall meet at least quarterly and upon the call of the Chairperson. A written record of the proceedings and actions shall be maintained for each meeting in the manner prescribed by the Chairperson and reports made thereof to the Medical Executive Committee.

MEDICAL PEER REVIEW COMMITTEE

MEMBERSHIP: Representatives elected by the Departments as follows: at least two (2) representatives from the Medicine Department; at least one (1) representative from the Family Practice, Cardiology, and Pediatrics Departments/Sections; and representatives from such other departments or sections as may be designated in the Medical Staff Performance Improvement Plan. Other specialties are to be invited to the meeting when


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that discipline is being reviewed. When other specialties are invited, they shall be non-voting and shall not be counted toward a quorum. PURPOSE: To review charts in the identification of opportunities to improve patient care. RESPONSIBILITIES:

• To improve the quality of care provided at MHMCMC. • To identify opportunities for performance improvement. • To monitor significant trends by analyzing aggregate data.

MEETINGS: The Medical Peer Review Committee shall meet as often as necessary at the call of the Chair (elected by the Medical Peer Review Committee), but at least six (6) times annually. Four (4) members shall constitute a quorum.

SURGICAL PEER REVIEW COMMITTEE

MEMBERSHIP: Representatives elected by the Departments representing: at least two (2) representatives from the Surgery Department; at least one (1) representative from the Ob/Gyn Department, the Anesthesia Department and the Pathology Section; and representatives from such other departments or sections as may be designated in the Medical Staff Performance Improvement Plan. A representative from the surgery subspecialties and any other discipline being reviewed are to be invited to attend the meeting. When other specialties are invited, they shall be non-voting and shall not be counted toward a quorum. PURPOSE: To review charts in the identification of opportunities to improve patient care. RESPONSIBILITIES:

• To improve the quality of care provided at MHMCMC. • To identify opportunities for performance improvement. • To monitor significant trends by analyzing aggregate data.

MEETINGS: The Surgical Peer Review Committee shall meet as often as necessary at the call of the Chair (elected by the Medical Peer Review Committee), but at least six (6) times annually. Four (4) members shall constitute a quorum.


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PATIENT CARE COMMITTEE

MEMBERSHIP: Voting Members: • Anesthesia 1 • Cardiology 1 • Emergency 1 • Family Practice 1 • Gastroenterology 1 • General Surgery 1 • Hematology/Oncology 1 (approved 11/13/2013) • Infectious Diseases 1 • Medicine 1 • Neurology 1 • Obstetrics and Gynecology1 • Orthopedics 1 • Pathology 1 • Pediatrics 1 • Psychiatry 1 • Radiology 1 • Chair, Ethics Committee 1

The Chairperson of the Patient Care Committee shall be appointed by the Chief of Staff Elect. One physician may represent both committee and/or Department/Section. Appointments will be for two years with terms staggered to replace half of the members each year. Fifty percent (50%) of the voting members shall constitute a quorum. PURPOSE: 1) Performance Improvement The Patient Care Committee will provide general direction and coordination of all quality assurance activities in the Medical Center. This will be accomplished by the establishment of a Medical Center -wide performance improvement plan that provides for the objective and systematic identification, solution and follow-up of problems that occur in the Medical Center. The committee will review and accept reports of all performance improvement activities, refer all matters requiring educational or corrective action to the appropriate department Chairperson with recommendations and target dates for follow-up, and conduct an annual evaluation of the effectiveness of all the Medical Center’s performance improvement activities.


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4) Blood Utilization Review The Patient Care Committee shall establish criteria for the use of blood and blood products. Review and evaluation of the utilization of blood and blood products will be performed Medical Center -wide and by clinical departments. Concerns noted from the monitoring and evaluation of the utilization of blood and blood products will be forwarded to the appropriate clinical department for peer review as indicated in the Performance Improvement Plan. MEETINGS: The Committee shall meet as often as necessary at the call of the Chairperson, but at least nine (9) times annually. A written record of the proceedings and actions shall be maintained for each meeting in the manner prescribed by the Chairperson and reports made thereof to the Medical Executive Committee.

PHARMACY & THERAPEUTICS/INFECTION CONTROL COMMITTEE MEMBERSHIP: The Pharmacy & Therapeutics Committee will consist of representatives of each of the Medical Staff Departments as well as a physician representing Infectious Diseases. The Director of Pharmacy will also serve as a voting member on the Committee. Administration, the Performance Improvement Specialist, a representative from Nursing, the Manager of Food and Nutrition Services, the Infection Control Nurse, and the Occupational Health Nurse will serve as ex officio members. The Manager of Environmental Services, the Manager of the Central Process Department, and the Manager of Engineering/Maintenance are to be available for consultative purposes. Fifty percent of the voting members shall comprise a quorum. PURPOSE: The Pharmacy & Therapeutics/Infection Control Committee will facilitate the implementation of System initiatives with regard to the best use of drugs and other therapeutic agents to include drug selection and appropriate utilization. The Committee will also facilitate the dissemination of information to Medical Center physicians, nurses, staff and patients with regard to the safe, legal and efficient distribution and storage of drugs and therapeutic agents. Other responsibilities will include: • The facilitation of bi-directional communication between the Medical Center’s

Medical Staff and the System Pharmacy and Therapeutics Committee. • Implement, at the Medical Center, policies developed by the System Pharmacy and

Therapeutics Committee. • Recommend policy changes regarding drug utilization, formulary composition, or

other issues to the System Pharmacy and Therapeutics Committee. • Accept and facilitate the requests of Medical Center’s Medical Staff for review

and/or evaluation by the System Pharmacy and Therapeutics Committee. • Review all issues regarding drug utilization and medication variances within the

Medical Center.


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MEETINGS: The P&T/Infection Control Committee shall meet as often as necessary at the call of the Chairman but shall meet at least quarterly. A written record of the proceedings and actions shall be maintained for each meeting in the manner prescribed by the Chairperson and reports made thereof to the Patient Care Committee and the Medical Executive Committee.

CRITICAL CARE COMMITTEE MEMBERSHIP: The Critical Care Committee shall be composed of physicians selected to represent each service with clinical privileges. The Critical Care Committee shall be comprised of no fewer than five (5) physicians. Administration shall be represented at each meeting. PURPOSE: The Critical Care Committee shall serve as an advisory committee to the hospital and the hospital staff on matters pertaining to the function of the critical care unit. The Committee will assist in the implementation and enforcement of the policies and procedures it approves. The Committee shall review the condition and progress of patients, therapy provided within the Critical Care unit, and assure quality of patient care provided in conjunction with treatments offered in the Critical Care unit. MEETINGS: The Critical Care Committee shall meet at least quarterly and upon the call of the Chairperson. Written records of its proceedings and actions shall be maintained for each meeting in the manner prescribed by the Chairperson, and reports made thereof to the Medical Executive Committee.

UTILIZATION MANAGEMENT COMMITTEE

MEMBERSHIP: The Utilization Management Committee shall be composed of at least two doctors of medicine or osteopathy. Other members may be other types of practitioners, as defined in the Medicare Conditions of Participation. Physicians, if they were professionally involved I the care of the patient whose case is being reviewed, may not participate in the review. PURPOSE: The purpose of the Utilization Management Committee is to promote efficient utilization of services at the most appropriate level of care through the activities defined in the Utilization Management Plan. MEETINGS: The Utilization Management Committee shall meet as often as necessary at the call of the Chairman but shall meet at least nine (9) times during the year. A written record of the proceedings and actions shall be maintained for each meeting in the manner prescribed by the Chairperson and reports made thereof to the Medical Executive Committee.


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NOMINATING COMMITTEE No later than 2 months before the last General Medical Staff meeting of the year, the Chief of Staff shall convene a nominating committee and call a time for the Committee to meet. The Nominating Committee shall consist of department chairs or their designee with proportional number of votes equal to the number of Active members in their department. The Chief of Staff shall be an ex-officio member of the Committee. The members of the Committee shall elect a chairperson at the meeting. Members of this committee shall not be candidates for office. The committee shall offer at least one nominee for the office of Vice Chief and Secretary/Treasurer, by September. These nominations must be approved by the Medical Executive Committee and must be mailed to the Active Staff at least 30 days prior to the Annual Medical Staff Meeting. SECTION 2 ADOPTION/AMENDMENT A. These Rules and Regulations for the Medical Staff shall be adopted and

amended as provided by the Medical Staff Bylaws.

B. The policies and procedures in these Rules and Regulations for the Medical Staff will be reviewed at least on an annual basis by the Executive Committee.

rules and regulations for the medical staff of …€¦ · physician assistant and of termination...

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