University of Virginia Library

ATTACHMENT A
BYLAWS CHANGES
21 September 1990 APPROVED BY
BYLAWS COMMITTEE, MEDICAL POLICY COUNCIL, AND CLINICAL STAFF

I. All references to the "Hospital" shall be changed to "Medical Center."

II. All references to "Health Affairs" shall be changed to "Health Sciences."

III. All references to "Medical Policy Committee" shall be changed to "Medical Policy Council."

IV. All references to "Chairman" shall be changed to "Chair." All references to "Chairmen" shall be changed to read "Chairs."

V. All references to "he" shall be changed to "he/she." All references to "his" shall be changed to read "his/her."

VI. Change all references to "Joint Commission on Accreditation of Hospitals" to read "Joint Commission on Accreditation of Healthcare Organizations." Change all references to "JCAH" to read "JCAHO."

• VII. On Page 3, Definitions, add the following:
• 18. Senior Associate Appointed by the
• Vice President Vice President of the Health Sciences Center

VIII. On Page 4, Article III, Section 2, Qualifications for Membership, a.

Replace the second clause of the first sentence as shown below.

This is done to add health status, a requirement of the JCAHO.

(2) can sufficiently document their experience, training, professional competence, adherence to professional ethics, good reputation, health status, and ability to work with others to the respective departmental chair to assure the Medical Policy Council that their patients will receive high quality medical care; and

• IX. On Page 5, Article III, Section 3. Replace section d. as follows:
  Every application for staff appointment or reappointment

  ---

  0002

  
  
  shall be signed by the applicant and specifically acknowledge his/her agreement:
• 1. to provide care and supervision of his/her 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.

X. On Page 9, Section 3.a.

a. Delete "At least 60 days prior to the final scheduled Medical Policy Council meeting in the Clinical Staff year" and replace with "The reappointment process is conducted throughout the year for those practitioners whose privileges are due for review."

This is done to reflect the current practice of the Credentials Committee.

• XI. On page 9, Section 3. b. Reappointment Process. First sentence, fourth line down, add:
• "his/her current licensure," after the clause "...treatment of patients" and before "his/her ethics and conduct."

This is done to comply with JCAHO requirements.

XII. Page 9, Section 3. b. Reappointment Process. Add "as indicated by the results of quality assurance activities and other reasonable indicators" in the first sentence after "...treatment of patients."

• Section 3. b. Add the following as the new second sentence:
• "Quality assurance activities will include reviews such as: surgical cases, autopsies, drug usage, blood usage, pharmacy and therapeutics, and medical records."
• This is necessary to comply with JCAHO standards.

XIII. On Page 11, delete Paragraph C. which allows the Executive Director to permit a physician serving a locum tenens member of the Clinical Staff to attend patients without being appointed to the Clinical Staff. This is redundant with the

provisions for temporary privileges.

XIV. On Page 13, add a new section E as follows and re-number the subsequent sections.

E. Automatic Suspension - the Vice President for Health Sciences, the Executive Director of the Medical Center and Department Chairs shall each have authority to automatically suspend the clinical privileges of a practitioner.

• 1. Automatic suspensions shall be done when necessary to protect patient safety or in the best interest of patient care. Indications for automatic suspension include, but are not limited to:
• - if a clinician's health or emotional status is such that it impairs his/her judgment or ability to deliver care.
• - the lack of a valid license.
• - lapse in clinician's liability coverage.
• - the loss of the clinician's faculty appointment.
• - conviction of a felony
• - endangering patient safety.

2. The suspended practitioner's department chair shall have authority to provide for alternative medical coverage for the patients of the suspended practitioner still in the Medical Center at the time of such suspension. The wishes of the patients shall be considered where feasible in the selection of such alternative practitioners.

3. Such suspension shall remain in effect until the intended disciplinary action is effective, except as the department chair, the Grievance Committee, or the Medical Policy Council may otherwise provide for good cause.

• XV. On Page 20, Section 4. Term of Elected Officers, replace the last sentence with the following:
• "Officers shall take office in the annual meeting in which they are elected."

XVI. On Page 20, add a new section 6, shown below, and re-number the subsequent sections.

Section 6 - Removing Elected Officers

A. Elected Officers may be removed by a two-thirds vote of the members of the clinical staff. The clinical staff can, by a two-thirds vote, remove

an elected officer, declare a vacancy, and fill the vacancy with an interim position.

• XVII. On Page 23, Paragraph d, replace the phrase "Clinical Audit Committee with "Quality Assurance Committee." Add a description of quality assurance as follows:
• "Each department is responsible for monitoring and evaluating the care delivered within that department. The responsibility for the quality assurance activities of each clinical department shall rest with the department chair but may be delegated to an individual appointed by the chair. These activities shall include but shall not be limited to the maintenance of an accurate description of the scope of care delivered by the department, the development of a set of clinical indicators which can be monitored and evaluated to assess the care delivered, the establishment of a peer review process to evaluate cases identified through the monitoring process, the formation of a process by which peer review recommendations are distributed to the individual attending physicians, and the documentation of the process by which peer review activities are used in the credentialing and recredentialing of faculty and in improving the quality of care delivered within the department."

XVIII. On Page 24, change "Chairman, Department of Orthopedics and Rehabilitation" to "Chair, Department of Orthopedics."

Add a line, "Chair, Department of Physical Medicine and Rehabilitation."

Change "Chairman, Department of Otolaryngology and Maxillofacial Surgery" to "Chair, Department of Otolaryngology and Head and Neck Surgery."

Change "Chairman, Department of Plastic and Maxillofacial Surgery" to "Chair, Department of Plastic Surgery."

XIX. On Page 26, Section e, delete the old section and replace it with the language shown below. This was done to reflect changes in the Medical Policy Council Agenda Committee.

e. Chair of the Medical Policy Council

• The Chair of the Medical Policy Council shall be the Vice President for Health Sciences (subject to review in the event of a change in the vice presidency). The Chair of the Medical Policy Council may temporarily designate such duties as appropriate to any one of the members of the Medical Policy Council Agenda Committee. Members of the MPC Agenda Committee include: the Senior Associate Vice President, the

  ---

  0005

  
  
  Executive Director of the Medical Center, the Dean of the School of Medicine, the President of the Clinical Staff, the President-Elect of the Clinical Staff, the Director of Clinical Services, the Director of Nursing, and two department Chairs. The MPC Agenda Committee will draw up the agenda for each meeting of the Medical Policy Council. The Vice President shall designate the Chair of the Agenda Committee. The duties of the Chair of the Medical Policy Council are:
• a. Set the agenda through the Agenda Committee, for the Medical Policy Council;
• b. Preside at the meetings of the Medical Policy Council;
• c. Coordinate and appoint committee members to all standing, special, and multidisciplinary subcommittees of the Medical Policy Council, subject to the approval of the Medical Policy Council;
• d. Report quarterly to the Clinical Staff on the activities and progress in the office.

XX. On Page 30, Section 4, Quorum, change "twenty percent" to read "twenty-five percent (25%)." This was done to conform to the 25% attendance requirement in Section 9 on Page 30.

XXI. On Page 30, delete Section 8, Clinico-Pathological Conference, and re-number subsequent sections.

XXII. On Page 32, Article XV: AMENDMENTS, in the next to last sentence which discusses who may ultimately approve amendments to the Clinical Staff Bylaws, delete the phrase "Health Affairs Committee of the Board of Visitors" and replace it with the phrase "Clinical Staff."

• On Page 33, Article XVI: ADOPTION, delete the first paragraph and replace it with the following:
• These Bylaws, together with the appended Rules and Regulations, shall be approved and adopted at any regular or special meeting of the Clinical Staff. The most recently adopted Bylaws shall replace any previous bylaws, rules, and regulations.
• Delete the current practice that Bylaws be signed by the Health Affairs Committee of the Board of Visitors.

XXIII. On Page 34 Section 2 in the Rules and Regulations, add a new paragraph 3 (shown below) and re-number the subsequent sections.

3. A member of the Housestaff who is a licensed physician in a residency program in the University Medical Center may, under Clinical Staff supervision, write patient care orders, insure the prompt completeness and accuracy of the medical record, and the transmittal of necessary special instructions and reports of the condition of the patient to the referring or other health practitioners and to relatives of the patient. Whenever these duties are transferred to another housestaff officer who is a licensed physician, a note covering the transfer of duties shall be entered on the progress note of the medical record. All physician members of the clinical care team are permitted to write patient care orders. Each medical department shall develop a brief plan describing how attending physicians supervise and evaluate housestaff officers. Copies of these plans will be kept in the Medical Staff and Residency Office.

• XXIV. On Page 34, Section A. Admission and Discharge of Patients, add the following to comply with JCAHO requirements:
• 10. 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.

XXV. Replace Page 44, Appendix I, Patient Bill of Rights, with the most current Patient Bill of Rights, Hospital Policy 26 (R).

XXVI. Delete pages 61 through 70, Appendix III, Senate of the University of Virginia. The description of the faculty senate is redundant and does not need to be included in the Bylaws.

XXVII. On page 71, Appendix IV, Disaster Plan, delete the one-page summary and re-number the subsequent appendices.

XXVIII. On page 73, Appendix VI, Code of Virginia Definition of Death. Delete this page and re-number the subsequent appendices.

• XXIX. On page 77, Appendix VII, Physician Assistants - Clinical Privileges. In the first sentence of the second paragraph:
• DELETE: "It is important that" and begin the sentence with "Patients must"
• In the third paragraph, add the following sentence after the last sentence:
• "The supervising physician shall be responsible for the

  ---

  0007

  
  
  following:"
• 1. Seeing and evaluating any patient who presents with the same complaint twice in a single episode of care and has failed to improve significantly. For continuing illnesses, the physician shall see and evaluate not less than every fourth visit.
• 2. Reviewing the record of services rendered to a patient by a Physician Assistant and signing such records within 24 hours after the services were rendered.
• Add the following sentence to the end of the fourth paragraph: "No attending physician shall be allowed to supervise more than two (2) Physician Assistants at any time."
• Add the following sentence to the end of the fifth paragraph: "Each Physician Assistant shall be prohibited from performing the following:
• 1. Establishing a final diagnosis or treatment plan.
• 2. Prescribing of drugs.
• 3. Performing the initial evaluation, or instituting treatment of a patient who presents to the emergency room or is admitted to the hospital for a life-threatening illness or injury. However, in noncritical areas the Physician Assistant may perform the initial evaluation in an outpatient setting provided the physician evaluates the Physician Assistant's performance within eight (8) hours.
• 4. Physician Assistants may not assist with any service which the supervising attending physician is not also qualified to perform.

• XXX. On page 78, Appendix VII, Rules and Regulations, add a new section defining clinical privileges for Optometrists as shown below:
• OPTOMETRISTS - CLINICAL PRIVILEGES
• The optometrist must be certified by the appropriate governing body in his/her specialty and he/she must possess the necessary licensure to comply with local and state laws. The optometrist shall have the privilege of participating and teaching in educational activities conducted in the hospital and have access to medical records for such purposes. The optometrist may also participate in various

  ---

  0008

  
  
  administrative and staff conferences, organizations and projects as may be appropriate to his/her duties and responsibilities as a staff optometrist.
• The optometrist shall not have admitting privileges, these being under the purview of the attending physician. The optometrist shall not perform invasive procedures on patients such as the incision of skin or piercing of ocular membranes, nor shall he/she inject medications or substances into a human body.
• The clinical privileges of an optometrist include: performance of all tests of a noninvasive nature, examination of the eyes with ophthalmic instruments, application of topical agents in accordance with the regulations promulgated by the Board of Optometry and the Board of Medicine; and evaluation, recommendation, and fitting with appropriate corrective lenses or contact lenses.

end of file c:\wp\LAWS