McLaren Greater Lansing Rules of the Department of Cardiology ARTICLE I. PURPOSE AND ORGANIZATION

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1 1.1 PURPOSE McLaren Greater Lansing Rules of the Department of Cardiology ARTICLE I. PURPOSE AND ORGANIZATION The purpose of the Department of Cardiology shall be to perform the organizational responsibilities incumbent upon Professional Staff departments as prescribed in the Bylaws and specific to the practice of Cardiology, including credentialing, recredentialing, peer review and quality assessment/improvement activities, operational policies and the evaluation of equipment, service, and facility needs. (Ref. Bylaws, Article XII). 1.2 ORGANIZATION The Department of Cardiology is established to conform with Article XIII of the Bylaws. ARTICLE II. DEPARTMENT MEMBERSHIP 2.1 NATURE OF THE DEPARTMENT MEMBERSHIP The Department of Cardiology shall consist of Members of the Professional Staff who have been recommended to the Department of Cardiology by the Credentials Committee and Professional Staff Executive Committee (PSEC) and appointed by the Board of Trustees. 2.2 ASSIGNED ALLIED HEALTH PROFESSIONALS Allied Health Professionals with specified service authority to provide dependent services shall be those as recommended by the Credentials Committee and PSEC and appointed by the Board of Trustees and as departmentally assigned per established policy and as consistent with the Special Policy for Allied Health Professionals of the Bylaws. 2.3 QUALIFICATIONS Members/applicants of the Department shall meet the basic qualifications for membership on the Professional Staff. (Bylaws, Article IV) Members/applicants must have successfully completed a residency program in internal medicine accredited by the Accreditation Council for Graduate Medical Education (ACGME) or the American Osteopathic Association (AOA). Initial Approval: 12/95 Page 1

2 2.3.3 Members/applicants must have completed cardiology specialty training in an ACGME, AOA or American Medical Association (AMA) recognized program Members/applicants of the Department who are fellowship-trained, if requesting privileges to apply skills obtained in such a fellowship program, must be eligible to sit for the certifying examination in the applicable specialty board recognized by the ACGME or AOA. If the ACGME or AOA does not accredit the fellowship and no specialty board exists, the member/applicant must submit the program curriculum, procedure logs and a signed attestation from the Program Director that the practitioner met the program requirements Members/applicants must have a practice limited primarily to cardiovascular diseases Initial applicants must appear for a personal interview by the Chairman. 2.4 RESPONSIBILITIES Responsibilities of Department Members shall be as described in the Professional Staff Bylaws (Bylaws) Participation in the observation system by Active Members and other Members as assigned by the Department Chairman Participation in the emergency call rotation as assigned by the Department Chairman. ARTICLE III. CLINICAL PRIVILEGES 3.1 DETERMINATION OF CLINICAL PRIVILEGES As consistent with the Bylaws, determination of clinical privileges shall be made based on documented evidence of training and experience and other indicators of the applicant s competence. Specific criteria relative to privileges in the Department are specified on the Privilege Request Form. In developing credentialing policy, the Department shall take into account interdepartmental considerations and shall make every effort to establish consistent criteria, where appropriate. 3.2 SCOPE OF CLINICAL PRIVILEGES The scope of clinical practice within the Department shall include diagnostic and therapeutic management of cardiovascular diseases and directly associated conditions. Specific clinical privileges must be requested on the Privilege Request Form. Members whose primary membership is in the Department of Cardiology must apply for all cardiology-related privileges through the Department only. Initial Approval: 12/95 Page 2

3 3.3 ADDITIONAL PRIVILEGES Additional privileges may not be requested in conjunction with reappointment and must be submitted on the acceptable request form. A request will be considered in completed unless accompanied by supporting documentation as may be applicable. 3.4 NEW TECHNIQUES/PROCEDURES Prior to performing new techniques/procedures the applicable credentialing must occur. Please refer to the Practitioner Apprenticeship in Established Techniques/Procedures and Privileging for New Techniques/Procedures located in the General Policies of the Bylaws. 4.1 OBSERVATION REQUIREMENTS ARTICLE IV. OBSERVATION Initial applicants appointed to the Department of Cardiology are provisional and subject to satisfactory completion of the observation requirements Specific privilege observation requirements for initial appointees are delineated in the Core Privileges form. Concurrently, physician-specific quality improvement information is reviewed on an on-going basis for all Department Members Extensions: Any Professional Staff Member with specific privilege observation may, in writing or in person, request extension of the observation period not to exceed two years from the initial appointment date or reconsideration of his application. A recommendation of extension of observation period may also be recommended by the Department upon the request of the observer(s). 4.2 COMPLETION OF OBSERVATION Upon completion of observation requirements, the observer(s) shall review and evaluate the Member s performance and shall make a recommendation in writing to the Department Chairman for consideration Upon receipt of a written recommendation, the Department shall consider the recommendation and shall forward its written recommendation to the Professional Staff Executive Committee (PSEC) through the Credentials Committee to 1) recommend approval without further observation; 2) extend the observation period; or 3) recommend that the Member s request be denied and/or that Professional Staff membership be terminated. The reasons for denial/revocation of appointment and/or clinical privileges shall be explicitly defined. Initial Approval: 12/95 Page 3

4 4.3 FAILURE TO COMPLETE OBSERVATION REQUIREMENTS Failure of the Professional Staff Member to complete the observation requirements within the designated period shall result in re-evaluation of the application for appointment and/or privileges in the Department as applicable. Any Professional Staff Members with observation status may, in writing or in person, request extension of the observation period or reconsideration of his application. Extensions of the observation period shall not extend such time beyond two (2) years from the initial appointment date Professional Staff Members who fail to complete the observation requirements due to inactivity may reapply for Professional Staff membership and/or clinical privileges. ARTICLE V. REAPPOINTMENT AND RENEWAL OF CLINICAL PRIVILEGES 5.1 ANNUAL/BIENNIAL REAPPOINTMENT Reappointment and renewal of clinical privileges is carried out as prescribed by the Bylaws. 5.2 CLINICAL PERFORMANCE ASSESSMENT In connection with reappointment/renewal of clinical privileges, observed clinical performance and results of quality improvement activities of the Professional Staff shall be considered. Evaluation of practice experience of Members shall be specifically evaluated against professionally recognized standards and comparative practice pattern analysis as established by the Department. 5.3 BIENNIAL PRIVILEGE RENEWAL/RECREDENTIALING Activity benchmarks will be considered in conjunction with clinical performance as demonstrated through the quality assessment/improvement activities in the Department and in conjunction with activity Members generated in other local institutions with regard to privilege renewal. Refer to the Core Privileges form for specific requirements. ARTICLE VI. QUALITY IMPROVEMENT AND PEER REVIEW 6.1 COMPOSITION The Quality Improvement Committee shall consist of Active staff members who remain in good standing throughout the tenure of membership on the Committee. Those present and eligible to vote (but not less than three members) shall constitute a quorum. The Committee will meet no less than quarterly. Initial Approval: 12/95 Page 4

5 6.2 SELECTION AND TENURE Member volunteers will be solicited by the Department Chair. If additional members are needed to fulfill composition requirements, members will be selected by the Department Chair Each member shall serve a two (2) year term, commencing on the first day of the calendar year following his/her appointment to the Committee. Members may remain on the Committee for as long as they remain Active staff members Committee members will appoint a Chairperson who is currently an active Committee member, who will fulfill a two (2) year term as that officer. The Chairperson will be responsible to train the Chairperson-elect, prior to vacating office Selection and tenure of members will occur on a staggered schedule, to ensure continuation and understanding of Committee functions and duties. 6.3 FUNCTIONS AND DUTIES The Committee, as directed by the Hospital Quality Improvement Plan, will work to ensure effective function of methods for quality assessment and improvement activities The mechanisms for review may include primary retrospective review of patient care for the purposes of evaluating the quality of care and selecting cases for discussion and education of department members. Results of the surveillance and review activities will be reported to the appropriate departments/committees, as directed by the Bylaws or other governing documents. 7.1 QUALIFICATIONS OF OFFICERS ARTICLE VII. OFFICERS Department Chairman and Vice Chairman shall be board certified Members of the Active Staff. 7.2 ELECTION PROCESS Active Members of the Department shall elect a Chairman and Vice Chairman for a two (2) year term beginning in January of even numbered years by a two-thirds (2/3) majority vote of the eligible voting Members A Nominating Committee of three (3) Active Members shall be appointed by the Chairman in August of odd numbered years and shall present a slate of candidates at the September Department meeting. At this time, nominations from the floor will be accepted Following closure of nominations, ballots will be mailed to eligible, voting Members. Initial Approval: 12/95 Page 5

6 7.3 CHAIRMAN The Chairman shall be the presiding officer of the (at a minimum) quarterly Department meetings The Chairman shall be responsible for carrying out all responsibilities and functions as designated in the Bylaws and shall serve as the representative of the Department of Cardiology on the PSEC The Chairman shall appoint all special committees The Chairman shall be responsible for establishing and supervising the emergency call rotation schedule The Chairman shall be an Ex-Officio Member of all committees of the Department unless otherwise designated VICE CHAIRMAN A Vice Chairman shall be elected to act on behalf of the Chairman in his absence or to assist in carrying out specific duties on behalf of the Department, as may be designated by the Chairman. ARTICLE VIII. MEETINGS/ATTENDANCE 8.1 DEPARTMENT MEETINGS The Department shall at a minimum meet quarterly at a time and place as established by the Chairman in consultation with Department Members. 8.2 QUORUM Members eligible to vote and present, but at least three (3), shall constitute a quorum. 8.3 DEPARTMENT ATTENDANCE REQUIREMENTS Meeting attendance requirements shall be as consistent with the Bylaws and General Rules Each Member of the Active Category is encouraged to attend at least fifty percent (50%) of all Department meetings. ARTICLE IX. ADOPTION AND AMENDMENT 9.1 DEPARTMENT RESPONSIBILITY AND AUTHORITY Initial Approval: 12/95 Page 6

7 9.1.1 The Department shall have the responsibility and delegated authority to formulate, adopt and recommend Rules and Amendments for the Department of Cardiology after recommendation to the PSEC and subject to the approval of the Board of Trustees. 9.2 AMENDMENT Upon recommendation to the PSEC and subject to the approval of the Board of Trustees these Rules may be amended by a two-thirds (2/3) majority of the eligible voting Members of the Department. 9.3 PERIODIC REVIEW OF DEPARTMENT RULES AND REGULATIONS These Rules shall be reviewed at least every two (2) years, and either accepted or revised by a two-thirds (2/3) majority vote of the Department membership. 9.4 GLOSSARY All terms utilized in the context of these Rules shall be consistent with terms defined in Article II of the Bylaws. 9.5 ADOPTION The foregoing Rules were adopted and recommended to the PSEC and the Board of Trustees, in accordance with and subject to the Bylaws. ADOPTED AND APPROVED: Department of Cardiology Professional Staff Executive Committee Board of Trustees Date Date Date Initial Approval: 12/95 Page 7