Board of Visitors minutes :: October 7, 1988 :: University of Virginia Library

Key: ___ Denotes addition --- Denotes deletion
1. To specify that health status is considered in appointment to the Clinical Staff, as required by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) (Article III: Clinical Staff membership, page 4.)
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 reputation, health status (to include physical and mental capabilities), 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.
2. Add specification of who may write patient care orders as required by JCAHO of institutions participating in professional graduate education programs. (Clinical Staff Rules and Regulations, A. Admission and Discharge of Patients, p. 34).
Proposed Addition:
Patient care orders may be written by a member of the Clinical Staff, or a house officer under the supervision of a Clinical Staff member.
3. To strengthen the Clinical Staff member's obligation to abide by Clinical Staff, Medical Policy Committee, and Hospital policies. (Article III: Clinical Staff Membership, Section 3. Conditions and Duration of Appointment, d., page 5.)

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Existing:
d. Every application for staff appointment shall be signed by the applicant and shall contain the applicant's specific acknowledgment of every Clinical Staff member's obligation to provide care and supervision of his patients, to abide by the Clinical Staff Bylaws, Rules and Regulations, to accept committee assignments, to accept consultation assignments, to participate in staffing the emergency service, outpatient area, and other special care units.
Proposed:
Every application for staff appointment or reappointment shall be signed by the applicant andshall contain the applicant's specific acknowledgment of every Clinical Staff member's obligationsspecifically acknowledge his agreement:
1. to provide care and supervision of his patient;
2. to abide by the Clinical Staff Bylaws, Rules and Regulations, Medical Policy Manual, and hospital policies;
3. to accept committee assignments, to accept consultation assignments, to participate in staffing the Emergency Service, outpatient area, and other special care units; and
4. to comply with the rules and regulations regarding medical record documentation including prompt completion and signing of operative notes and discharge summaries.
4. Revise introduction to reappointment process to accurately reflect current operating practice of the Credentials Committee. (Article V: Procedure for Appointment and Reappointment, Section 3. Reappointment Process, a., page 9.)
a. The reappointment process is conducted throughout the year for those practitioners whose privileges are due for review. At least 60 days prior to the final scheduled Medical Policy Committee meeting in the Clinical Staff year.The Credentials Committee shall review all pertinent information available on each practitioner scheduled for periodic appraisal, for the purpose of determining its recommendations for reappointments to the staff and for the granting of clinical privileges for the ensuing period, and shall transmit its recommendations in writing, to the Medical Policy Committee. Where nonreappointment or a change in clinical privileges is recommended, the reason for such recommendation shall be stated and documented.

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5. Revise description of information collected during the reappointment process to include the requirements of JCAHO. (Article V: Procedure for Appointment and Reappointment, Section 3. Reappointment Process, b., page 9.)
b. Each recommendation concerning the reappointment of a staff member and the clinical privileges to be granted upon reappointment shall be based upon such member's professional competence and clinical judgment in the treatment of patients, his current licensure, at least two peer recommendations outside of his chairman's, his ethics and conduct, his attendance at Clinical Staff meetings and participation in staff affairs, his compliance with the Clinical Staff Bylaws, Rules and Regulations, his cooperation with hospital personnel, his use of the hospitals' facilities for his patients, his relations with other practitioners, the results of quality assurance activities and/or other reasonable indicators of continuing qualifications and his general attitude toward patients, the Hospitals, and the public. Reappointment policies must include the periodic appraisal of the professional activities of each member of the Clinical Staff and of all other practitioners with clinical privileges in the hospital. Such periodic appraisal should include consideration of physical and mental capabilities.
6. All references to the Vice President for Health Affairs be changed to read Vice President for Health Sciences, per the May 27, 1988 resolution of the Health Affairs Committtee, Board of Visitors.

University of Virginia Library

APPROVAL OF REVISION OF THE HOSPITAL CLINICAL STAFF BY-LAWS

Section 2. Qualifications for Membership

Proposed Addition:

Existing:

Proposed: