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Proposed Sherman Hospital Medical Staff Policy Manual

July, '07


Table Of Contents


ARTICLE I - DEFINITIONS.

ARTICLE II - PURPOSE AND APPROVAL.
Section 1. Purpose.
Section 2. Approval and Amendment.

ARTICLE III - EXCLUSIVE CONTRACTS.
Section 1. Policy.
Section 2. Purpose.
Section 3. Current Exclusive Services and List of Hospital Departments.
Section 4. Materially Changing Service Terms in Existing Exclusive Contracts.
Section 5. Replacement of Current Exclusive Contract Holders.
Section 6. Procedure to Include New Practice Areas or Procedures Under Exclusive Contract.
Section 7. Monitoring Quality and Utilization.

ARTICLE IV - PHYSICIAN RECRUITMENT.
Section 1. Policy.
Section 2. Purpose.
Section 3. Procedure.

ARTICLE V - MEDICAL STAFF SEXUAL HARASSMENT.
Section 1. Policy.
Section 2. Purpose.
Section 3. Definition.
Section 4. Procedure.

ARTICLE VI - MEDICAL STAFF DISRUPTIVE BEHAVIOR.
Section 1. Policy.
Section 2. Purpose.
Section 3. Definition.
Section 4. Procedure.
Section 5. Disruptive Behavior Incident Report.

ARTICLE VII - IMPAIRED PHYSICIAN.
Section 1. Policy.
Section 2. Purpose.
Section 3. Definition.
Section 4. Application of Policy.
Section 5. Physician Assistance Committee.
Section 6. Complaints.
Section 7. Physician Assistance Committee Relationship with Members.
Section 8. Confidentiality.

ARTICLE VIII - QUALITY AND UTILIZATION REVIEW.
Section 1. Policy.
Section 2. Purpose.
Section 3. Procedure.

ARTICLE IX - ADJUNCT PROFESSIONAL PERSONAL.
Section 1. Policy.
Section 2. Purpose.
Section 3. Structure.
Section 4. Demonstrating Need.
Section 5. Procedure.

ARTICLE X - MEDICAL STAFF PEER REVIEW.

ARTICLE XI - MEDICAL STAFF COMMITTEE STRUCTURE.

ARTICLE I

DEFINITIONS.

The following definitions shall apply to terms used in this Manual. The definitions listed in this Article I shall at all times be identical to those provided in Article I Section 1 of the Sherman Hospital Medical Staff Bylaws:

  1. "Adjunct Professional Personnel (APP)" means those Health Care Professionals who are not Members of the Medical Staff but who provide clinical services (for which Clinical Privileges are granted), clinical management (to extend the Clinical Privileges of a Member) or hospital services (excluding Clinical Services for which Members are privileged) in the Hospital and who may provide independent professional recommendations regarding patient care. Persons granted APP status shall not be considered Medical Staff Members (as that term is defined in this Section). APPs are divided into three (3) categories:

    1. "Independent APP". This Category consists of APPs who provide clinical services to patients by expressing independent judgment at the order and under the general supervision of a Member in accordance with the Bylaws and the Adjunct Professional Personnel Policy contained in the Policy Manual attached hereto and incorporated by reference.
    2. "Dependent APP". This category consists of those APPs who provide clinical management to patients pursuant to a documented relationship with an employing or sponsoring Member or Members by performing a portion of the Member's or Members' professional responsibilities to patients in the Hospital under the direct supervision of their employing or sponsoring Member or Members, all in accordance with the Bylaws and the Adjunct Professional Personnel Policy contained in the Policy Manual attached hereto and incorporated by reference.
    3. "Hospital APP". This category consists of those APPs who provide hospital services to patients in the Hospital pursuant to a contract or employment relationship with the Hospital.
  2. "Adverse Action" shall mean an action limiting, reducing, suspending, restricting, or revoking Medical Staff Membership or Clinical Privileges.
  3. "Adverse Decision" shall mean a decision denying or not renewing Medical Staff Membership or Clinical Privileges.
  4. "All Reasons" shall mean each of the defaults, failures, deficiencies or conditions determined to be present by the Medical Executive Committee, Board or Hearing Committee when an Adverse Action or Adverse Decision is recommended or imposed, and the general grounds or findings of fact relied upon for the conclusions reached, including all reasons based on the quality of medical care or any other basis, including economic factors. The term "All Reasons" shall not be interpreted to require a recitation of each fact relied upon by the decision making body or a detailed exposition of the supporting rationale for the decision but such general detail as may be necessary for the affected Provider or, if applicable, the Medical Executive Committee, to properly evaluate the facts and opinions relied upon by the decision maker and to effectively prosecute a hearing or appeal.
  5. "Associated With" means an applicant who is a bona fide current or prospective employee, independent contractor, partner or co-owner in the medical practice of a current Member for which all medical services to be rendered by the applicant for Hospital patients are billed by the current Member's medical practice.
  6. "Board" or "Board of Directors" means the Local Governing Board of Sherman Hospital, which has responsibility for the operation of the Hospital, or other institution where indicated.
  7. "Chief Executive Officer" means the individual appointed by the Board to act on its behalf in the management of the Hospital or his designee.
  8. "Clinical Privileges" means the permission granted to a Practitioner to render specific diagnostic, therapeutic, medical, surgical, podiatric or dental patient care and treatment services ("Clinical Services") in the Hospital.
  9. "Clinical Services" means specific diagnostic and therapeutic medical, dental or podiatric patient care and treatment services for which Clinical Privileges are normally granted.
  10. "Dentist" means an individual who has a doctor of dental surgery degree who is duly licensed to practice dentistry in the State of Illinois.
  11. "Department" shall mean the Clinical and/or Hospital Departments of the Medical Staff as delineated in Article XXI.
  12. "Department Chiefs" shall mean those parties elected or appointed to preside over a Department as provided in Article XXI.
  13. "Economic Factor" shall mean any information or reasons for Adverse Decisions or Adverse Actions unrelated to quality of care or professional competency.
  14. "Employed Practitioner" means a practitioner who is compensated and issued an applicable W-2 form for Clinical Services to patients by an employer under whom the professional fees for those services are billed.
  15. "Ex Officio" means service as a member of a body by virtue of an office or position held and, unless otherwise expressly provided, means without voting rights.
  16. "Fair Hearing" shall mean the procedural rights of applicants and Members under the Fair Hearing Plan set forth in Article XIV.
  17. "Hospital" means Sherman Hospital and, depending on the context, includes both the physical building and the licensed not-for-profit entity which owns and operates the facility including, without limitation, such entity's administrators, employees, agents and assigns.
  18. "Hospital Affiliate" means any parent, subsidiary or affiliate of the Hospital or any joint venture or other business entity in which the Hospital may have a controlling equity or ownership interest.
  19. "Medical Staff" means the Medical Staff Organization the structure of which is defined by these Bylaws and which includes all Members collectively.
  20. "Medical Staff Representative" means any and all Medical Staff officers, Clinical Department Chiefs and Medical Executive Committee members at large.
  21. "Medical Staff Year" shall mean that period commencing on the first day of July of each year and ending on the thirtieth day of June in the following year.
  22. "Member" means any Practitioner who has been granted Medical Staff membership and Clinical Privileges.
  23. "Non-restrictive Actions" shall mean minor disciplinary measures such as issuing a warning to a Member, imposing a probationary period with retrospective review but without special requirements of prior or concurrent consultation and direct supervision, issuing a formal letter of reprimand or other similar actions which do not restrict a Member's right to exercise Clinical Privileges independently.
  24. "Oral and Maxillofacial Surgeon" means an individual who has a doctor of dental surgery degree, has completed a residency in oral and maxillofacial surgery and is state licensed as a Dental Specialist in Oral and Maxillofacial Surgery.
  25. "Pertinent Information" shall mean all written information utilized or reviewed in the decision making process relating to the initial grant or renewal of a Member's Medical Staff membership or Clinical Privileges or to summary suspensions, administrative suspensions or Adverse Actions, or Adverse Decisions, whether threatened or imposed, except the phrase "pertinent information" shall not include credentialing information on other Practitioners, Hospital or corporate business plans, any information obtained or generated which is privileged or confidential as attorney-client privilege, physician-patient privilege, or which is privileged or confidential under any applicable state or federal law, rule or regulation.
  26. "Physician" shall be interpreted to include doctors of medicine ("M.D.s"), doctors of osteopathy ("D.O.s") and Oral and Maxillofacial Surgeons.
  27. "Podiatrist" shall be interpreted to mean a doctor of podiatric medicine ("D.P.M.").
  28. "Policy Manual" means the manual adopted with these Bylaws and approved by the Medical Executive Committee and Board describing certain Hospital policies affecting the Medical Staff.
  29. "Practitioner" means a duly licensed Physician, Dentist or Podiatrist.
  30. "Prerogatives" means the rights granted, by virtue of Staff category or otherwise, to a Member or APP to perform, manage, supervise, assist or otherwise provide clinical services in the Hospital and to participate in Medical Staff Self-government, which rights are exercisable subject to the conditions imposed by these Bylaws and in other Hospital and Medical Staff policies.
  31. "President" means the Physician elected as President of the Medical Staff pursuant to Article XVII.
  32. "Professional Affairs Committee" is a subcommittee of the Board of Directors. The membership of this committee is determined by the Board and may include Medical Staff Members. The members of this committee are appointed by the Board for terms determined by the Board.
  33. "Proximate Service Area" means the geographical area described as that portion of the Elgin Township north of the Illinois Central railroad tracks and that portion of the Dundee Township south of Illinois Route 72.
  34. "Self-government" means the duty of the Members, officers, committees and Departments of the Medical Staff to initiate and carry out the functions assumed by the Medical Staff, to govern their own representative and organizational affairs, and to fulfill the obligations provided for in these Bylaws and by law.
  35. "VPMA" means the individual appointed as Vice President for Medical Affairs or equivalent position of professional liaison between the Hospital Administration and the Medical Staff, such individual preferred to possess both medical knowledge and administrative ability.

ARTICLE II

PURPOSE AND APPROVAL

Section 1. Purpose.

The purpose of this Manual is to include those Hospital policies that affect the Members of the Medical Staff and Adjunct Professional Personnel in a significant manner.

Section 2. Approval and Amendment.

This Manual and its contents are subject to the approval of the Medical Executive Committee (MEC) and Board. Except for the definitions listed in Article I of this Policy Manual, the Manual is subject to amendment, as may from time to time be required and approved by the MEC, and not successfully challenged by the Medical Staff under Section 8 of Article XXV of the Medical Staff Bylaws, and the Board in accordance with the procedures specified in Section 8 of Article XXIV of the Bylaws.

ARTICLE III

EXCLUSIVE CONTRACTS

Section 1. Policy.

The Hospital may change exclusive contract holders or enter into exclusive contracts for medical services not previously covered by an exclusive contract only in accordance with this Policy and the Medical Staff Bylaws.

Section 2. Purpose.

The purpose of this policy is to involve Medical Staff leadership in the Hospital's decision regarding its current exclusive contracts, terminating exclusive contracts, entering into new exclusive contracts for services previously under exclusive arrangements and exclusively contracting for services that were not previously subject to an exclusive contract. The Hospital and/or Medical Staff shall use legal counsel to ensure that when modifying contracts, terminating contracts and entering into new contracts, legal contractual requirements are met and Members have been afforded their rights under the Medical Staff Bylaws and state and federal law.

Section 3. Current Exclusive Services and List of Hospital Departments.

The Medical Staff Bylaws provide for this Policy Manual to include a list of Hospital Departments. Currently the Hospital maintains exclusive contracts with medical professional corporations, medical professional partnerships, or individual independent physicians in the practice areas listed. This list may be updated without Amendment to reflect current practice in the Hospital.

  1. Anesthesiology
  2. Emergency Medicine
  3. Neonatology
  4. Pain Management
  5. Pathology
  6. Pediatric Hospitalist Care
  7. Radiology

The Hospital will review the performance of all exclusive contract holders on a periodic basis. The review may be done by written survey developed with input from the MEC, Board, Administration and exclusive contract holders. Members and possibly patients will be surveyed on such issues as quality and timeliness of services provided. For problems identified, the exclusive contract holder will be asked to develop a corrective plan of action. The results of the review and the proposed plan, if any, will be shared by Administration with the Medical Executive Committee.

Section 4. Materially Changing Service Terms in Existing Exclusive Contracts.

Existing exclusive contracts may be modified in accordance with the service terms of the contract. The Hospital agrees, however, to comply with the following procedure when materially modifying service terms in existing exclusive contracts:

  1. Discuss with the exclusive provider the rationale for mutually modifying the service term(s).
  2. Notify the Medical Executive Committee of the intention to materially modify service term(s). The notification should include the rationale for why the service term(s) need to be materially modified.
  3. An unfavorable or unsupportive recommendation from the Medical Executive Committee will be considered if accompanied by an alternative modification or corrective plan.
  4. In the event that the Board disagrees with the Medical Executive Committee's recommendation, either the Board or the Medical Executive Committee may elect to bring the matter before the Joint Conference Committee for recommendation.
  5. Hospital administration will develop contract language.

Section 5. Replacement of Current Exclusive Contract Holders.

Existing exclusive contracts may be terminated in accordance with the contract terms. The Hospital, however, agrees to comply with the following procedures when terminating existing exclusive contracts or replacing the exclusive provider:

  1. Discuss with the exclusive provider the rationale for termination or replacement.
  2. Except in case of emergency, notify the Medical Executive Committee of the intention to terminate the exclusive contract or seek a replacement provider. The notification should include the rationale for the termination and/or replacement.
  3. An unfavorable or unsupportive recommendation from the Medical Executive Committee will be considered by Administration and the Board if accompanied by an alternative corrective plan.
  4. In the event that the Board disagrees with the Medical Executive Committee's recommendation, either the Board or the Medical Executive Committee may elect to bring the matter before the Joint Conference Committee for recommendation.
  5. The MEC may assist Hospital administration in the development of a Request for Proposal (RFP).
  6. Hospital administration will identify potential new contractors.
  7. Hospital administration will assess responses to the RFP and make a recommendation to the MEC and the Board including a description of all responses received.
  8. The MEC will assess responses to the RFP and make a recommendation to the Board.
  9. Hospital administration will develop and implement a contract consistent with the Board's decision.

Section 6. Procedure to Include New Practice Areas or Procedures Under Exclusive Contract.

Practice areas or procedures not currently under an exclusive contract may be made exclusive only in accordance with this Policy and the Medical Staff Bylaws.

  1. The Hospital, Medical Executive Committee or any Department may request consideration of an exclusive contract for specific clinical services. The request should be brought before the MEC in writing and describe:

    1. All reasons for the exclusive contract, including:
      1. the anticipated benefits and risks for patients, including quality of care and service impact,
      2. the effect on hospital operations, and
      3. the economic impact on the hospital, and communities served.
    2. The method of ongoing performance measurement and improvement of contracted services.
    3. The effect on the Medical Staff, including any economic impact on Members with clinical privileges in the practice area which is the subject of the exclusive contract.
  2. The MEC and Hospital will assess whether an exclusive contract is an appropriate way to meet the needs of the Hospital, its Medical Staff and the patient community. The MEC and Hospital will assess the impact that a new exclusive contract in this practice area would have on the Medical Staff, the Hospital's strategic plan, and the patient community. In particular, a major consideration for the members of the MEC shall be their advocacy for those Medical Staff Members whose privileges or Medical Staff membership might be adversely affected by the exclusive contract. Notice and Hearing Rights of such Members are provided for in Section 12 of Article XIV of the Medical Staff Bylaws.
  3. Within sixty (60) days after receipt of the request, the Medical Executive Committee shall provide to the Hospital Board its written findings and recommendations with regard to the request.
  4. An unfavorable or unsupportive recommendation from the Medical Executive Committee will always be considered by the Board before a final decision is reached.
  5. In the event that the Board disagrees with the Medical Executive Committee's recommendation, either the Board or the Medical Executive Committee may elect to bring the matter before the Joint Conference Committee for recommendation.
  6. The Board will consider recommendations from the MEC and the Joint Conference Committee, if invoked, before it makes its final decision.
  7. The MEC may assist Hospital administration in the development of a Request for Proposal (RFP).
  8. Hospital administration and the MEC will identify potential contractual providers, including current Members.
  9. The MEC may review the potential contractual providers and make a recommendation to the Board.
  10. The Board will have the ultimate authority to choose an exclusive provider and enter into an exclusive contract. Medical Staff Members who are able and willing to provide the services needed on an exclusive basis and fulfill and agree to the other contract provisions will be given priority consideration.
  11. Consistent with the RFP and Board decision, Hospital administration will develop and implement a contract under which the exclusive services will be provided.

Section 7. Monitoring Quality and Utilization.

The Hospital and MEC shall jointly develop systems to ensure that quality and utilization is monitored effectively for exclusive contract holders. This system may utilize outside providers or providers from other Hospitals to perform quality and utilization functions. These outside providers will be compensated by the Hospital.

ARTICLE IV

PHYSICIAN RECRUITMENT

Section 1. Policy.

The Hospital will maintain a Medical Staff Development Plan which may be modified as needed, based in part on input from the MEC. The Medical Staff Development Plan will be utilized in the Hospital's Physician Recruitment Program. The Professional Affairs Committee will monitor the recruitment process. With the exception of those physicians employed prior to the adoption date of this Policy, the Hospital will not provide recruitment incentives for physicians in a manner inconsistent with this process or the Medical Staff Bylaws.

Section 2. Purpose.

The purpose of this policy is to develop and implement physician recruitment initiatives consistent with the needs of the Hospital, Medical Staff and patient community as indicated in the Medical Staff Development Plan. In addition, the purpose of this policy is to ensure Medical Staff participation in the recruitment processes as well to give the Medical Staff, through its individual Members, a reasonable opportunity to recruit needed physicians to the Hospital's service area.

Section 3. Procedure.

  1. The Professional Affairs Committee may recommend modifications of the Medical Staff Development Plan, update the Plan, develop recruiting strategies, review recruiting efforts and may recommend the engagement of a consultant. It will present the plan to the Medical Executive Committee for input when major modifications occur.
  2. The Medical Staff Development Plan and the recruitment effort should promote relationship building between the Hospital and Medical Staff. The Medical Staff Development Plan and the recruitment effort should:

    1. Establish effective relationships with Members of the Medical Staff to work as partners in meeting the patient care needs of the communities served.
    2. Establish a measurable framework for development of the Medical Staff
    3. Augment the current Medical Staff through recruitment efforts focusing on working with current Members and existing practices to establish new sites and expand services, and recruiting new physicians to meet the needs of the Hospital's patient communities.
  3. The Professional Affairs Committee shall define the categories of physicians needed to be recruited. It is the Hospital's intention to encourage current Members to recruit, hire or partner with the necessary physicians. The Hospital will work with the Medical Staff to recruit physicians to meet the objectives of the Medical Staff Development Plan.
  4. The Hospital will provide recruitment incentives to new physicians to meet its recruitment needs and give the Medical Staff the opportunity to recruit the specified physicians with comparable recruitment incentives, and it will be with the intention of transitioning the physician into independent practice as soon as reasonably possible and in any case limiting the duration of the recruitment incentives to five (5) years.
  5. Reasonable deadlines may be established by the Hospital for the Members to undertake an opportunity presented. The Hospital will apprise the MEC to allow for review and comment on the Hospital's adherence to this policy.
  6. The Professional Affairs Committee may develop minimum criteria for current Members to receive assistance from the Hospital in recruitment efforts. Items such as honesty, quality of care, reputation and institutional loyalty may be considered.
  7. The Hospital will be responsible for responding to Medical Staff concerns and may perform recruitment tasks such as participating in the plan development, calling interested candidates, coordinating interviews and site visits, providing appropriate follow-up, assisting as needed in contract negotiations, overseeing physician retention efforts, and succession planning.
  8. The Hospital, with input from the Professional Affairs Committee, will prepare the recruitment incentives within budgeting, legal and tax exemption requirements.
  9. One goal of this process is to ensure that a comparable package is offered for a given opportunity and that when a Member benefits from a recruitment incentive provided by the Hospital, both the Member and the Hospital participate in the recruitment effort.

ARTICLE V

MEDICAL STAFF SEXUAL HARASSMENT

Section 1. Policy.

In keeping with the Hospital's philosophy that recognizes the dignity and worth of each individual, it is the policy of the Hospital and Medical Staff to provide a working environment free of sexual harassment. Any manner or form of sexual harassment by Medical Staff Members and APP is expressly prohibited.

Section 2. Purpose.

The policy is established to discourage sexual harassment of employees, patients, Members of the Medical Staff or APP and to provide a procedure for investigating and processing complaints.

Section 3. Definition.

Sexual harassment is defined as unwelcome sexual advances, requests for sexual favors and other verbal or physical conduct of a sexual nature. Some examples of sexual harassment may include unwanted sexual advances, demands for sexual favors in exchange for favorable treatment or continued employment, repeated sexual jokes or sexually explicit language or the display in the workplace of sexually suggestive objects or pictures.

Section 4. Procedure.

  1. Conduct of this nature may subject the offending Member or APP to disciplinary actions when:

    1. Submission to such conduct is made either explicitly or implicitly a term or condition of employment.
    2. Submission to or rejection of such conduct is a factor in an employment decision affecting the individual.
    3. Such conduct has the purpose or effect of unreasonably interfering with an individual's work performance or creating an intimidating, hostile or offensive working environment.
  2. All Members and APP are expected to cease, correct or avoid any conduct toward Hospital employees, other Practitioners, other APP, patients and visitors which could be interpreted as sexual harassment.
  3. The President of the Hospital will inform the President of the Medical Staff and the VPMA of any allegations of sexual harassment by a Member or APP. The President of Hospital or his or her designee, the President of the Medical Staff or his or her designee, the two being of opposite gender, will conduct an informal investigation.

    1. If a complaint against a Member is found to have merit by both of the investigators, prompt Corrective Action under the Medical Staff Bylaws will be initiated. A letter will be prepared and sent to the Member and placed in the individual's file. A copy will be sent to the Department Chairman and shown to the President of the Hospital and President of the Medical Staff.
    2. If a complaint against an APP is found to have merit by both of the investigators, the matter will be referred to the MEC as provided for in Section 7 of Article III of the Medical Staff Bylaws. A letter will be prepared and sent to the APP and placed in the individual's file. A copy will be sent to the Department Chairman and the APP's employer/sponsor and shown to the President of the Hospital and President of the Medical Staff.
    3. All letters will be expunged if the complaint is ultimately determined to be unfounded.
  4. The Hospital Executive Team, the Medical Executive Committee and the Board of Directors will be informed of this action.
  5. If there is a second report of an allegation of sexual harassment by a Member or APP, the MEC and Board will jointly investigate the matter or arrange for the matter to be investigated. A letter detailing the result of the investigation will be prepared and placed in the Member's or APP's file. A copy will be sent to the Department Chairman, President of the Medical Staff and the Chief Executive Officer of the Hospital.

    1. If a complaint against a Member is found to have merit, prompt Corrective Action under the Medical Staff Bylaws will be initiated.
    2. If a complaint against an APP is found to have merit, a letter stating the result of the investigation will be sent to the APP's employer/sponsor and the matter will be referred to the MEC as provided for in Section 7 of Article III of the Medical Staff Bylaws.
  6. Each Member and each APP has an obligation to the other Members, APP and all employees and patients of the Hospital to assist in the elimination of sexual harassment from the workplace. In addition to acts of sexual harassment, retaliation of any type would be considered a violation of this policy. Breaches of confidentiality concerning the investigations or decisions made pursuant to this policy also will be considered a violation of the policy, as a breach of confidentiality may discourage victims of sexual harassment from coming forward or harm the rights and interests of the accused.
  7. This policy is meant to be a general guideline.

ARTICLE VI

MEDICAL STAFF DISRUPTIVE BEHAVIOR

Section 1. Policy.

The Hospital requires that Members of the Medical Staff adhere to the philosophy of respecting each person as one of the core values of the organization.

Section 2. Purpose.

The policy is established to discourage disruptive behavior, to define and allow Members to identify objectively disruptive behavior and to provide a mechanism for the Hospital and Medical Staff to manage effectively incidents of inappropriate conduct.

Section 3. Definition.

Disruptive behavior is a descriptive term which encompasses a variety of inappropriate conduct which is intentionally destructive or abusive, or disruptive to generally accepted Hospital operations. Such conduct harms rather than promotes the philosophy of respect to members of the community and collegiality among health care professionals.

Section 4. Procedure.

  1. Documentation of disruptive conduct is critical since it is ordinarily not one incident that justifies disciplinary action, but rather a pattern of conduct. Practitioners, nurses, and other Hospital employees who observe disruptive behavior by any Member or APP shall document the incident using the Disruptive Behavior Incident Report (Section 5 of this Article).
  2. The report shall be submitted to the Chief Executive Officer (CEO) of the Hospital and placed on the agenda for Executive Team review. A copy will also be sent to the President of the Medical Staff and the VPMA. The President of the Medical Staff, the VPMA and the CEO of the Hospital will discuss whether a formal investigation is necessary and may cause an investigation of the alleged disruptive behavior.
  3. Complaints Against an APP. If a complaint against an APP is found to have merit, the APP's employer/sponsor may be notified in writing and the matter will be referred to the MEC as provided for in Section 7 of Article III of the Medical Staff Bylaws.
  4. Complaints Against a Member of the Medical Staff.

    1. For all documented incidents, the minimum response will be for the President of the Medical Staff and the VPMA to meet with the Member and emphasize that such conduct is inappropriate.
    2. If an incident of disruptive behavior is determined to be very significant or that a pattern of disruptive behavior is developing, the President of the Medical Staff and the VPMA shall discuss the matter formally with the Member, indicating the behavior is unacceptable. The following shall occur as part of this discussion:

      1. The approach should be collegial and designed to be helpful to the Member.
      2. The Member will be warned that, if the behavior continues, more formal action will be taken.
      3. All such meetings shall be documented.
      4. A follow-up letter to the Member shall state that the Member is required to behave professionally.
      5. The letter will be reviewed at the next MEC meeting and the Board meeting. The letter will also become part of the Member's permanent file.
      6. Nothing in this Section prohibits initiation of corrective action if it is determined the incident warrants such action.
    3. If the disruptive behavior continues, the President of the Medical Staff, VPMA and the Hospital CEO shall meet with and advise the Member that such conduct is not tolerable and must stop. This meeting is not a discussion, but rather shall constitute the Member's final warning. It shall be followed with a letter reiterating the warning. The letter will be reviewed at the next MEC meeting, the Member's specific Department Steering Committee meeting, the by the Board of Directors. All future discussion with the Member shall be documented in writing. These letters shall become a part of the Member's permanent file with a copy sent to the President of the Hospital, President of the Medical Staff and the Chairman of the Department in which the Member maintains privileges.
    4. A single additional incident shall result in initiation of Corrective Action pursuant to the Medical Staff Bylaws. The MEC, the Member's specific Department and the Board of Directors shall be kept fully apprised of the action taken per the Medical Staff Bylaws process.
  5. Each Member of the Medical Staff and APP has an obligation to the other Members of the Medical Staff and all employees of the Hospital to assist in the elimination of disruptive behavior. In addition to disruptive behavior, retaliation of any type is considered a violation of this policy. Breaches of confidentiality concerning the investigations or decisions made pursuant to this policy also will be considered a violation of the policy, as a breach of confidentiality may discourage victims of disruptive behavior from coming forth and/or lessen the rights and interests of the aggrieved individual.
  6. This policy is meant to be a general guideline.

Section 5. Disruptive Behavior Incident Report

Please complete the following questions to document the incident of disruptive Physician or Adjunct Professional Personnel behavior. The report will be submitted to the Administrative Council, The President of the Medical Staff and the VPMA.

Name of Disruptive Individual:

Today's Date:

Date of Incident:

Name of Reporting Individual:

Time of Incident:

1. Describe the situation prior to the disruptive behavior.




2. In a factual manner, describe the disruptive behavior.




3. Did the behavior affect or involve a patient(s) in any way? If yes, name the patient(s) and describe how the patient(s) were involved.




4. Note the consequences of the behavior related to patient care or Hospital operations.




5. Record any action (if any) taken to remedy the situation. Include the date, time, place, who and specific action taken.

ARTICLE VII

IMPAIRED PHYSICIAN

Section 1. Policy.

It is the desire of the Hospital and Medical Staff to establish a system for handling Members suffering physical, emotional or mental impairment while at the same time protecting the safety of the Hospital's patients, employees and other Members.

Section 2. Purpose

The purpose of the policy is to establish a system in which the Medical Staff, through a Physician Assistance Committee, may act as an advocate for recovery and rehabilitation of any Member who has or believes he suffers physical, emotional or mental impairment while at the same time ensuring that the Hospital's patients are not receiving services from any Member who cannot provide services with reasonable skill and safety because of a physical, emotional or mental impairment.

Section 3. Definition.

As this Policy Manual is adopted, the American Medical Association defines the impaired physician as "one who is unable to practice medicine with reasonable skill and safety to patients because of a physical or mental illness, including deterioration through the aging process or loss of motor skill, or excessive use or abuse of drugs including alcohol."

Section 4. Application of Policy.

Because the term "impaired physician" includes a variety of problems from age to substance abuse or mental illness, the steps given will not be suitable in every circumstance. Specific needs and varying circumstances preclude a single inflexible mechanism for dealing with all impaired Physicians. The number of incidents with the Physician, for example, and their seriousness may dictate a different response. Moreover, the risk of patient harm must be of paramount concern. Immediate action may be necessary. One exception to this policy is impairment due to age and irreversible medical illness or other factors not subject to rehabilitation.

Section 5. Physician Assistance Committee.

  1. Composition. The Physician Assistance Committee shall be chaired by a physician appointed by the President of the Medical Staff. This committee shall consist of at least four (4) Members, including the chairman, selected from different fields of professional practice. No member of the committee may be presently serving as a member of the Medical Executive Committee, the Credentials Committee, or as a member of any hearing committee reviewing disciplinary action against a Member.
  2. Duties. This committee shall act as an advocate for recovery and rehabilitation of any Member who has or believes he suffers physical, emotional or mental impairment, or may become impaired in the future. Impairment includes that which can result from alcohol or drug use. The committee is not a disciplinary committee. It shall:

    1. assist in fulfilling the Medical Staff's responsibility for the provision of competent patient care;
    2. educate the Medical Staff and Hospital community about issues concerning physician impairment;
    3. investigate reports of alleged Member impairment;
    4. assist in bringing the impaired Member to treatment;
    5. select and approve professionals to treat and assist the Member in overcoming his impairment;
    6. adopt or approve a plan of treatment appropriate to the individual Member;
    7. assure that the plan of treatment is followed;
    8. take monitoring and case management responsibility to facilitate the formerly impaired Member's return to practice including meeting periodically with each Member who seeks the Committee's help, and with each Member who the Committee believes may suffer an impairment;
    9. help the formerly impaired Member to reestablish optimal professional function in active patient care;
    10. inform the Medical Staff President and Chief Executive Officer when a Member has refused all efforts for assistance and endangers patient care.
  3. Meetings. The Committee shall meet as necessary. The chairman may appoint a subcommittee of the Committee to meet and work with any individual Practitioner on occasions other than when the Practitioner may meet with the full Committee. The Committee shall maintain a record of its proceedings and actions and shall advise the Medical Executive Committee of its actions.

Section 6. Complaints.

  1. This policy and educational materials related to the recognition of impairment will be available to all Medical and Hospital Staff through the Hospital's library services and periodic educational programs. All individuals working in the Hospital who have a reasonable suspicion that a Member may be impaired, are required to file a written report with any one of the following; President of the Medical Staff, VPMA, the Chief Executive Officer (CEO) of the Hospital, the Department Chair or any member of the Physician Assistance Committee. The report shall include a description of the incident(s) that led to the belief that the Member may be impaired. The report must be factual. The individual making the report does not need to have proof of the impairment, but must state the facts leading to the suspicions. The individual receiving the report shall forward a copy of the report to the Physician Assistance Committee and the above identified officials. The report will be held confidential until reviewed by the Physician Assistance Committee.
  2. The Physician Assistance Committee in its discretion may order any Member who is under investigation or for whom there is reasonable cause to believe is chemically impaired, to immediately submit to a urinalysis or blood test for substance abuse.
  3. The Physician Assistance Committee shall discuss the report with the individual filling the report and the Member involved. The Physician Assistance Committee shall then discuss its findings with the President of the Medical Staff, The VPMA, and the CEO of the Hospital to determine if there is enough information to warrant further investigation. If further investigation is felt to be necessary, the Physician Assistance Committee may:

    1. Continue the review by the Physician Assistance Committee or engage other individual(s) or consultants appropriate under the circumstances to help in the review.
    2. If in the judgment of the Physician Assistance Committee patients' health and/or safety may be jeopardized, recommend to the President of the Medical Staff and the CEO of the Hospital that immediate action be taken to suspend or terminate the Member's privileges in accordance with the procedures set forth in the Fair Hearing Plan of the Medical Staff Bylaws.
  4. Depending upon the severity of the problem, and the nature of the impairment, at least one of the following options should be exercised:

    1. Assist in bringing the impaired Member to treatment.
    2. Select and approve professionals to treat and assist the Member in overcoming his impairment.
    3. Adopt or approve a plan of treatment and ensure the plan is followed.
    4. Monitor and facilitate the Member's return to practice.
    5. Require the Member to undertake a rehabilitation program as a condition of continued appointment and clinical privileges.
    6. Recommend that appropriate restrictions on the Member's Hospital practice be imposed.
    7. Recommend suspension of the Member's privileges in the Hospital until rehabilitation has been accomplished if the circumstances warrant and the Member does not agree to discontinue practice voluntarily.
  5. If the matter cannot be handled internally, or jeopardizes the safety of the Member or others, the Hospital shall seek the advice of Hospital counsel to determine whether any conduct must be reported to law enforcement authorities or other governmental agencies and what further steps must be taken.
  6. The original report and description of the actions taken by the Physician Assistance Committee should be included in the Physicians' file, unless the investigation reveals that there is no merit to the report, in which case the report will be destroyed. If the investigation reveals that there may be some merit to the reports, but not enough to warrant immediate action, the report shall be included in a confidential and solely internal portion of the Member's file and the Member's activities and practice shall be monitored until it can be established that there is, or is not an impairment problem. This information will not be kept from the Member.

Section 7. Physician Assistance Committee Relationship with Members.

Any Member may seek assistance of the committee by contacting the chairman of the Committee or any member. In addition to those who seek the assistance of the Committee, the Committee is responsible to review any concerns about impairment that are communicated to its chairman, and to determine whether the concern is justified. If the Committee concludes there is a basis for concern for whether a Member may be physically, mentally or emotionally impaired, or is likely to become impaired, the Member will be informed, in a confidential manner, of the particular concern before the Committee. The Committee shall assist the Member who is impaired, or likely to become impaired, to initiate a voluntary diagnostic, therapeutic and rehabilitative program, and to secure appropriate professional resources to perform that program.

The Committee shall encourage the Member to consent to systematic reports to the Committee by the person or facility responsible for the diagnostic, therapeutic or rehabilitation program on the status of and prognosis for the Member.

After successful rehabilitation of the Member, the Committee shall assist the Member in reestablishing his practice. In the event a Member's clinical privileges have been limited or curtailed, the Committee shall assist in removing the limitation or restoring the appropriate clinical privileges.

Section 8. Confidentiality.

Except for any report to the President of the Medical Staff and the CEO of the Hospital that a Member refuses efforts for assistance or endangers patient care, the proceedings and reports of the Physician Assistance Committee involving specific Members are confidential and may not be disclosed. They are part of the Hospital's peer review process to improve and maintain the quality of patient care at the Hospital. Written reports of the committee to the MEC shall be as brief and general as possible, and shall not identify a particular Member, except when the purpose is to report the refusal of a Member to accept assistance and such refusal may endanger patient care or when the privileges of a Member need to be limited in order to safeguard patient care.

Throughout this process, all parties should avoid speculation, gossip, and any discussions of this matter with anyone outside those described in this policy.

ARTICLE VIII

QUALITY AND UTILIZATION REVIEW

Section 1. Policy.

Sherman Hospital will monitor and evaluate Member's utilization of resources in such a manner that considers quality of services and efficient utilization of Hospital resources.

Section 2. Purpose.

The purpose this policy is to promote appropriate utilization of Hospital resources, facilities and services so that quality patient care is provided at reasonable cost.

Section 3. Procedure.

  1. The Quality and Utilization Review process shall facilitate implementation of fact finding instruments to provide information to the Medical Staff and individual Members regarding the following:

    1. utilization of pharmaceuticals outside acceptable parameters
    2. length of stay
    3. clinical documentation
    4. appropriateness of patient care as related to utilization management
    5. performance improvement
    6. case management
  2. The primary reason for gathering and reviewing this information is to provide the Member with data to make decisions to improve quality while maintaining cost-effective use of resources.
  3. The Hospital and MEC shall establish on an annual basis a Quality/Resource Utilization Management Plan to guide the performance of Quality/Resource Utilization Management. If a Plan is not developed, the Plan from the previous year or that Plan as amended shall be considered the Quality/Resource Utilization Management Plan. The Plan must include the establishment of the Physician Quality & Utilization Summary Measurement Tool. The Physician Quality and Utilization Summary Measurement Tool shall be approved on an annual basis by the MEC. The Measurement Tool shall be provided on an annual basis to the Department Chairman for each Member and on a biennial basis at reappointment time to the MEC. The Measurement Tool will establish guidelines so a Member's utilization of Hospital resources (providing quality and cost effective care) can be measured against acceptable parameters and can be monitored, allowing deviations from acceptable parameters to be corrected.

ARTICLE IX

ADJUNCT PROFESSIONAL PERSONAL

Section 1. Policy.

The Hospital, the Medical Staff and the Members of the Medical Staff should have the ability to utilize the services of a variety of duly licensed Health Care Professionals to enhance patient care within the Hospital. Such Health Care Professionals are referred to and provided for in the Sherman Hospital Medical Staff Bylaws as Adjunct Professional Personal (APP).

Section 2. Purpose.

The purpose of this policy is to provide a mechanism, consistent with the Sherman Hospital Medical Staff Bylaws, through which duly licensed Health Care Professionals, who may not be eligible for Medical Staff membership, can participate in the care of patients in the Hospital by the order of, under the general or direct supervision of, or as an agent of a Medical Staff Member or the Hospital as APP. This policy also delineates the entities responsible for the conduct of APP in the Hospital and assures that the quality of APP services in the Hospital meet the standards that the Medical Staff and Hospital may set forth.

Section 3. Structure.

All APP must be health care professionals licensed in the State of Illinois. APP services are ordinarily ordered by a Medical Staff Member.

  1. Independent APP are credentialed and privileged by the Medical Staff and have many of the rights and responsibilities that Medical Staff Members have. Independent APP provide clinical services at the order and under the general supervision of a Medical Staff Member.
  2. Dependent APP are credentialed but not privileged by the Medical Staff. Dependent APP provide clinical management strictly as an agent of an employing, sponsoring or collaborative physician Member of the Medical Staff and may serve only to extend the existing privileges of their employer, sponsor, or collaborative physician Member within the scope of their training, experience and licensure.
  3. Hospital APP are not credentialed or privileged by the Medical Staff. Hospital APP provide hospital services strictly as an agent of the Hospital, pursuant to a contract or employment relationship with the Hospital.

Section 4. Demonstrating Need.

  1. Independent APP: The permissible specialties of Independent APP shall be listed in the Medical Staff Bylaws and approved by the Medical Staff and Hospital Board of Directors as bylaws.
  2. Dependent APP: The permissible specialties of Dependent APP shall be recommended by the Medical Executive Committee and the applicable Departments and Divisions before consideration by the Hospital Board of Directors.
  3. Hospital APP: The permissible specialties of Hospital APP are approved by the Hospital with the advice and consent of the Medical Executive Committee.

Section 5. Procedure.

  1. Qualifications.

    1. Independent APP qualifications are provided for in the Medical Staff Bylaws.
    2. Dependent APP must submit a written agreement together with his or her employing, sponsoring or collaborative physician Member describing the nature of their professional relationship, the Dependent APP's expected clinical duties and responsibilities in the Hospital, documentation of the appropriate licensure in the State of Illinois to provide such duties and responsibilities, State or Federal photo-identification satisfactory to the Hospital Administration, at least one (1) reference to document that the APP will adhere strictly to the ethics of his or her profession and will work cooperatively with others, and other materials that may be required with APP applications by the Medical Staff or the Hospital. The employing, sponsoring or collaborative physician Member must also attest in writing on a form approved by the Medical Executive Committee and Hospital that the Dependent APP acts as his or her agent in the Hospital and that he or she assumes full responsibility and is fully accountable for the professional conduct of the Dependent APP in the Hospital.
    3. Hospital APP must meet any qualifications set forth by the Hospital, be licensed in the State of Illinois to perform the applicable hospital services and be trained to perform those services in a manner satisfactory to the Hospital and the Medical Staff.
  2. Application.

    1. Independent APP application procedure is provided for in the Medical Staff Bylaws.
    2. Dependent APP must submit their qualifications and other documentation to the Chief Executive Officer through the Medical Staff Office. After confirmation of the applicant's credentials, the application will be forwarded to the employing, sponsoring or collaborative physician Member's Department for review. The Department recommendation should be acted upon by the Medical Executive Committee not longer than ninety (90) days after the application was received and deemed complete.
    3. Hospital APP must submit their application to the Hospital for processing.
  3. Reappointment.

    1. Independent APP are subject to the reappointment process in the same way as Medical Staff Members as provided for in the Medical Staff Bylaws.
    2. Dependent APP are subject to reappointment whenever their employing, sponsoring or collaborative physician Member is subject to reappointment. Their written agreement, documentation of licensure and attestation must be resubmitted and/or updated for processing in the same manner as the initial application.
    3. Hospital APP are not subject to Medical Staff reappointment processing.
  4. Removal. The procedures for removal of APP are provided for in the Medical Staff Bylaws.

ARTICLE X

MEDICAL STAFF PEER REVIEW

ARTICLE XI

MEDICAL STAFF COMMITTEE STRUCTURE