University of Virginia Library

ATTACHMENT B =
Revisions to Clinical
Staff By-laws
PROPOSED REVISIONS
to
THE UNIVERSITY OF VIRGINIA HOSPITALS
CLINICAL STAFF BYLAWS/RULES AND REGULATIONS

___denotes proposed addition

--denotes proposed deletion

1. Add provision for the use of special treatment procedures as required of hospitals which provide psychiatric/substance abuse services (Part II: Clinical Staff Rules and Regulations, p.42).

• "When administering special procedures to psychiatric patients, the following treatment protocols shall be met:
• 1. Restraints: The use of restraints must be ordered by a physician and must be reevaluated every twelve (12) hours. The patient must be attended to every fifteen (15) minutes in regard to circulation checks, nutritional needs, and hygienic care. This shall be documented on a General Purpose Flow Sheet.
• 2. Electroconvulsive Therapy: Before initiating electroconvulsive therapy to a child or adolescent, two qualified child psychiatrists who have training or experience in the treatment of children and adolescents and who are not directly involved in the treatment of the patient must:
• a. Examine the patient.
• b. Consult with the psychiatrists responsible for the patient.
• c. Document in the patient's medical record their concurrence with the decision to administer such therapy.

2. Add requirement of monthly meetings by each clinical department. (Article XII: COMMITTEE AND DEPARTMENT MEETINGS. Section 1, p. 29).

Existing:

• Committees shall meet as necessary but no fewer than two meetings per year. Departments shall hold regular meetings to review and evaluate the clinical work of the department.

Proposed:

• Committees shall meet as necessary but no fewer than two meetings per year. Each clinical department shall hold monthly meetings to review and evaluate the clinical work of the department, which shall include the ongoing monitoring and evaluation of the quality and appropriateness of the patient care provided. A written record shall be maintained of these meetings.

3. Add provision for five elements of patient care by the Medical Policy Committee. (Article X, Section 1, b. Duties, p. 26).

• "14. The Medical Policy Committee shall provide for the monitoring and evaluation of the following elements of patient care through its established advisory committees, and according to the standards of the Joint Commission on the Accreditation of Hospitals: Pharmacy and Therapeutics, Blood Utilization, Medical Records, Surgical Case Review, and Antibiotic Usage."

4. Revision of rules and regulations (p. 38, No. 13) to accurately reflect the Federal Register, Vol. 49, No. 171, requirements for physician attestation.

• "All Clinical entries in the patient's medical record shall be accurately dated and authenticated.
• Authentication means to establish authorship by written signature, identifiable initials, or computer key. The use of rubber stamp signatures is unacceptable."

5. Provide clarification regarding the qualifications for membership to the Clinical Staff:

5a. ARTICLE III: CLINICAL STAFF MEMBERSHIP (p. 4)

Section 1. Nature of Clinical Staff Membership

• Membership on the Clinical Staff of the University of Virginia Hospitals is a privilege which shall be extended only to professionally competent physicians (includes M.D.'s and Doctors of Osteopathy), dentists, clinical psychologists, podiatrists, clinical pathologists, audiologists, nurse practitioners, radiological physicists, physician assistants, and other Ph.D. faculty members of clinical departments, who continuously meet the qualifications, standards and requirements set forth in these Bylaws.

Section 2. Qualifications for Membership

• a. Clinical Staff membership shall be limited to those physicians (includes M.D.'s and Doctors of Osteopathy), dentists, clinical psychologists, podiatrists, clinical pathologists, audiologists, nurse practitioners, radiological physicists, physician assistants, and other Ph.D. faculty members of clinical departments, who (1) are licensed to practice in the State of Virginia, where such licensure is required; (2) can sufficiently document their experience, training, professional competence, adherence to professional ethics, good reputations, and ability to work with others to assure the Medical Policy Committee that their patients will receive high quality medical care; and (3) hold a faculty appointment to a clinical department or division of the University of Virginia School of Medicine.
• b. Acceptance of membership on the Clinical Staff shall constitute the Staff member's agreement that he will strictly abide by the Principles of the applicable Code of Ethics promulgated by his respective professional organization (e.g. Medical Ethics of the American Medical Association).

5b. ARTICLE IV: CATEGORIES OF THE CLINICAL STAFF (p. 6)

Section 1. The Clinical Staff

• The Clinical Staff shall be divided into active and visiting categories as proposed by departmental chairmen and approved by the Medical Policy Committee, and assigned to a specific clinical department. Joint appointments between clinical departments, or between a clinical department and a hospital department, based on training, duties, and privileges requested, shall be considered on an individual basis.

Section 2. The Active Clinical Staff

• The active Clinical Staff shall consist of physicians (includes M.D.'s and Doctors of Osteopathy), dentists, clinical psychologists, podiatrists, clinical pathologists, audiologists, nurse practitioners, radiological physicists, physician assistants, and other Ph.D. members of Clinical Departments, who regularly attend patients in the Hospital, and who assume all the functions and responsibilities of membership on the active Clinical Staff, including, where appropriate, emergency service care and consultation assignments. Only physicians (includes M.D.'s and Doctors of Osteopathy) and dentists shall have admitting privileges. Members of the active Clinical Staff shall be appointed to a specific department, shall be eligible to vote, to hold office and to serve on Clinical Staff committees, and shall be required to attend Clinical Staff meetings.

Section 3. The Visiting Clinical Staff

• The visiting clinical staff shall consist of physicians (includes M.D.'s and Doctors of Osteopathy), dentists, clinical psychologists, podiatrists, clinical pathologists, audiologists, nurse practitioners, radiological physicists, physician assistants, who qualify for staff membership.but who only occasionally admit patients to the hospital or who act only as consultants. Visiting Clinical Staff members shall be appointed to a specific department or division but shall not be eligible to vote or hold office in this Clinical Staff organization. They shall be requested but not required to attend Clinical Staff meetings. They are eligible for appointment to certain medical staff committees.

6. The bill in Appendix VI, p. 73, outlining when a person is deemed medically and legally dead is now an enacted statute. It is proposed that 32-364, 3:1 be replaced with enacted Statute now Virginia Code Section 54-325. 7 (Below)

Be it enacted by the General Assembly of Virginia:

1. That §§ 54-325.7 and 54-325.8 of the Code of Virginia are amended and reenacted as follows:

§ 54-325.7. When person deemed medically and legally dead.-A person shall be medically and legally dead if

(a)1. In the opinion of a physician duly authorized to practice medicine in this Commonwealth, based on the ordinary standards of medical practice, there is the absence of spontaneous respiratory and spontaneous cardiac functions and, because of the disease or condition which directly or indirectly caused these functions to cease, or because of the passage of time since these functions ceased, attempts at resuscitation would not, in the opinion of such physician. be successful in restoring spontaneous life-sustaining functions. and, in such event, death shall be deemed to have occurred at the time these functions ceased: or(b)

2. In the opinion of a consulting physician, who shall be duly licensed and a specialist in the field of neurology, neurosurgery, or electroencephalography, when based on the ordinary standards of medical practice, there is the absence of spontaneous brain functions and spontaneous respiratory functions and, in the opinion ofthe attendinganother physician and suchconsulting physicianneurospecialist, based on the ordinary standards of medical practice and considering the absence of spontaneous brain functions and spontaneous respiratory functions and the patient's medical record. further attempts at resuscitation or continued supportive maintenance would not be successful in restoring such spontaneous functions, and, in such event, death shall be deemed to have occurred at the time when these conditions first coincide.

Death, as defined in subsection(b)2 hereof, shall be pronounced by one of the attending physiciantwo physicians and recorded in the patient's medical record and attested by theaforesaid consultingother physician.

Notwithstanding any statutory or common law to the contrary, either of these alternative definitions of death may be utilized for all purposes in the Commonwealth. including the trial of civil and criminal cases.

§ 54-325.8. Persons who may authorize postmortem examination of decedent's body. Except in cases of death where official inquiry is authorized or required by law,Any of the following personsafter receiving actual notice of death, in order of priority stated. may authorize and consent to a postmortem examination and autopsy on a decedent's body for the purpose of determining the cause of death of the decedent, for the advancement of medical or dental education and research, or for the general advancement of medical or dental science; provided, that.if: (i) no person in a higher class exists or no person in a higher class is available at the time of deathauthorization or consent is given, (ii) there is no actual notice of contrary indications by the decedent, and (iii) there is no actual notice of opposition by a member of the same or a prior class.

The order of priority shall be as follows: (1) the spouse; (2) an adult son or daughter. (3) either parent; (4) an adult brother or sister; (5) a guardian of the person of the decedent at the time of his death; or (6) any other person authorized or under legal obligation to dispose of the body.

If the physician or surgeon has actual notice of contrary indications by the decedent or of opposition to an autopsy by a member of the same or a prior class, the autopsy shall not be performed. The persons authorized herein may authorize or consent to the autopsy after death orimmediatelybefore death.

7. Revision of the functions of Department Chairmen, Article IX, Section 3, p. 22, to reflect existing practice. DELETE:

d.Appoint a departmental committee to conduct the initial phase of patient care evaluation required by these Bylaws.

8. Addition of definition for Chairman of the Medical Policy Committee to Article X, Section 1, Medical Policy Committee of the Clinical Staff.

• Chairman of the Medical Policy Committee: The Chairman of the Medical Policy Committee shall be the Vice President for Health Sciences (subject) to review in the event of a change in the Vice Presidency). The Chairman of the Medical Policy Committee may temporarily designate such duties as appropriate to any one of three Vice Chairmen. These Vice Chairmen should be the Dean of the School of Medicine, the Executive Director of the Hospital, and the President of the Clinical Staff. The three Vice Chairmen will constitute an Agenda Committee which will draw up the agenda for each meeting of the Medical Policy Committee. The Vice President shall designate the Chairman of the Agenda Committee. The duties of the Chairman of the Medical Policy Committee are:
• a. Set the agenda through the Agenda Committee, for the Medical Policy Committee;
• b. Preside at the meetings of the Medical Policy Committee;
• c. Coordinate and appoint committee members to all standing, special and multi-disciplinary subcommittees of the Medical Policy Committee, subject to the approval of the Medical Policy Committee;
• d. Report quarterly to the Clinical Staff on the activities and progress in the office.

9. Revision of the definition for the President of the Clinical Staff, Article VIII, Section 6, page 20: Existing:

• a. President: The President shall serve as the chief administrative officer of the Clinical Staff to:
• 1. Act in coordination and cooperation with the Chief of Staff and Hospital Executive Director in all matters of mutual concern within the hospital.
• 2. Call, preside at, and be responsible for the agenda of all general meetings of the Clinical Staff.
• 3. Serve on the Medical Policy Committee.
• 4. Serve as ex officio member of all other Clinical Staff committees without vote.
• 5. Represent the views, policies, needs and grievances of the Clinical Staff to the Medical Policy Committee, the Hospital Executive Director, the Chief of Staff, and the Dean of the School of Medicine.
• 6. Receive and interpret the policies of the Medical Policy Committee to the Clinical Staff and report to the Medical Policy Committee on the performance and maintenance of quality with respect to the Clinical Staff's delegated responsibility to provide medical care.

10. Addition of definition for Chief of Staff to Article VIII: Officers, page 21.

• Chief of Staff: The Chief of Staff shall be the Vice President for Health Sciences (subject to review in the event of a change in the Vice Presidency.) The Vice President may not delegate such duties. These duties include the following:
• a. Be responsible for the enforcement of the Clinical Staff Bylaws, Rules and Regulations; policies approved by the Medical Policy Committee; and for implementing sanctions where these are stipulated for non-compliance;
• b. Resolve patient care clinical issues among the Clinical Staff, President of the Clinical Staff, Dean of the School of Medicine, and Executive Director of the Hospital;
• c. Coordinate through the Medical Policy Committee, the President of the Clinical Staff, the Dean of the School of Medicine, and the Executive Director of the Hospital, the internal medical staff quality assurance activities, including patient care evaluation, clinical monitors and physician credentials;
• d. Determine the primary spokesperson for the Clinical Staff in its external professional and public relations.

11. Nurse Practitioners - Clinical Privileges (p. 78)

• Clinical privileges for Nurse Practitioners at the University of Virginia Hospitals shall be limited to Nurse Practitioners who have successfully completed an accredited program specifically designed to prepare Registered Nurses as "Nurse Practitioners", and has been duly certified by the Virginia Joint Board of Medicine and Nursing.

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• A written statement of procedure shall be jointly developed by the supervising physician(s) and Nurse Practitioner defining the steps to be taken and the delegated medical acts to be performed in the care and management of patients. These statements and procedures should include roles in areas such as:
• a. medical histories and systems review,
• b. physical examinations,
• c. the initiation, performance and interpretation of selected diagnostic procedures and tests,
• d. the recommendation of diagnosis and/or treatment plan for the physician and,
• e. the implementation of a treatment plan upon the direction of the physician.
• These documents shall be maintained in the clinical department of employment and within the appropriate hospital division.
• Patients must be advised that a Nurse Practitioner will participate in their care under the supervision of an attending physician who has clinical privileges at the University of Virginia Hospitals.
• Nurse Practitioners may not assist any service which a supervising attending physician is not also qualified to perform.

12. Physician Assistants - Clinical Privileges (p. 77)

• Clinical privileges for Physician Assistants at the University of Virginia Hospitals shall be limited to Physician Assistants who have successfully completed an accreted Physician Assistant program; and are certified by the Virginia State Board of Medicine.
• 1. Patients must be advised that a Physician's Assistant will participate in their care under the supervision of an Attending Physician who has clinical privileges at the University of Virginia Hospitals.
• 2. All patient related activities performed by a Physician's Assistant shall be under the supervision of an Attending Physician at the University of Virginia Hospitals.
• 3. Patient orders initiated by a Physician's Assistant must be countersigned by an Attending Physician or House Officer at the University of Virginia Hospitals before they are implemented.
• 4. Activities performed by a Physician's Assistant without direct supervision of an Attending Physician shall be delineated in the appointment process of each practitioner.
• 5. Physician Assistants may not assist any service which a supervising Attending Physician is not also qualified to perform.

13. All references to groups who may apply for clinical privileges shall include nurse practitioners, physician assistants, and other Ph.D. faculty members who render clinical care. These groups are not currently included among those who may apply.

14. To provide for the Rules and Regulations governing the clinical privileges of Ph.D. members of Clinical Departments:

• PhD CLINICAL PATHOLOGISTSPhD in CLINICAL DEPARTMENTS - CLINICAL PRIVILEGES
• The following are the rules and regulations governing the clinical privileges of the PhDClinical Pathologistsmembers of Clinical Departments at the University ofVirginia Hospitals:
• The clinical privileges of PhDClinical Pathologistsmembers of Clinical Departments shall include the performance of laboratory tests and the examination of specimens from inpatients and outpatients of the hospital.referred to the Department of Pathology. They will be authorized to accept requests for consultation regarding suchpatients and have access to appropriate hospital records.
• PhDClinical Pathologistsmembers of Clinical Departments shall have the privileges of participation in teaching and educational activities conducted in the hospital and have access to medical records for such purposes. They may also participate in various administrative and staff conferences, organizations, and projects as may be appropriate to their duties and responsibilities.as a staff pathologists.

15. Revise first sentence of Article XII, Section 1, p. 29, to support the statement in Article X that a complete listing of the MPC's Committees shall appear in the Medical Policy Manual with their meeting frequencies.

• Existing:
• "Committees shall meet as necessary but no fewer than two meetings per year."
• Proposed:
• "Committees shall meet in accordance with the provision of Article X."