RULES AND REGULATIONS THE DEPARTMENT OF MEDICINE THE STAMFORD HOSPITAL

Transcription

1 RULES AND REGULATIONS OF THE DEPARTMENT OF MEDICINE OF THE STAMFORD HOSPITAL

2 Membership 1. The staff of the Department of Medicine of Stamford Hospital shall include those physicians who have met the qualifications for Stamford Hospital membership in accordance with the By-Laws of the Medical Staff, and whose primary medical practice is in the field of General Internal Medicine and/or in any of the following medical sub-specialties: Allergy and Immunology, Cardiology, Dermatology, Endocrinology, Gastroenterology, Geriatrics, Hematology, Hospital Medicine, Infectious Diseases, Nephrology, Neurology, Occupational Medicine, Oncology, Pain Management, Palliative Care, Physical Medicine and Rehabilitation, Pulmonary Medicine, and Rheumatology. All physicians who serve as medical hospitalists are also included in the staff of the Department of Medicine. 2. Based upon qualifications, physician membership may be within General Internal Medicine, within a departmental specialty or specialties, or within both General Internal Medicine and a departmental specialty or specialties. In accordance with IV of the By-Laws of the Medical Staff, the applicant must have become board certified in that specialty and (where applicable to the practitioner s practice) subspecialty after completing residency and within five years after completing any fellowship training. In addition, ongoing re-certification within Internal Medicine, or within a specialty of Internal Medicine, is a requirement for continued staff membership. 3. During the provisional period of applicant appointment to the Active Staff of the Department of Medicine, the Chair of the Department of Medicine, or his designee, will serve as preceptor to that physician. For physicians who are granted provisional status in a specialty of the Department, the Director of that section or his/her designee will serve as preceptor. In appropriate circumstances, more than one preceptor may be assigned. Prior to the meeting of anticipated Medical Executive Committee action on the provisional status of that applicant, the Chair of the Department of Medicine or Section Director, whoever may be relevant, shall be prepared to communicate formal assessment of that applicant s skills and performance as they may be relevant to his/her staff appointment. The guidelines, as established by the American Board of Internal Medicine, and other relevant specialty boards, shall serve as a reference on which to base such skills and performance. Medical Sub-Specialties 1. Medical sub-specialties within the Department are comprised of those physicians who have met and continue to meet all the following criteria: a. Membership on the Active Medical Staff of the Department of Medicine of Stamford Hospital. b. Formal certification by the American Board of Internal Medicine. Board 1

3 Certification in Internal Medicine, however, is not a prerequisite for the sub-specialties of Dermatology, Neurology, Pain Management, and Physical Medicine and Rehabilitation. c. Pre-requisite credentials and formal training for consideration for formal certification by that respective sub-specialty board. d. Board certification in that sub-specialty within four years of sub-specialty membership. This criterion does not apply to physicians who are already formal members of sub-specialty sections. Specialty in Geriatrics is formally recognized by Added Qualifications in that specialty. Recertification for all physicians in the practice of sub-specialties can be obtained in that subspecialty and need not be additionally obtained in Internal Medicine. e. Recognition as a duly-trained, knowledgeable and competent physician in that sub-specialty. f. Active involvement in continued medical education in that sub-specialty as evidenced by such criteria as attendance at formal professional meetings and seminars, commitment to teaching, and continued self-education. g. Membership in professional organizations that seek to foster the development of excellence in that sub-specialty. 2. Factors not necessary, but supportive for sub-specialty appointment include: a. Fellowship in the American College of Physicians or its equivalent. b. Faculty appointment at a medical school. c. Active participation in organizations committed to the fostering and development of excellence in that sub-specialty. 3. The medical sub-specialties shall have directors appointed by the Chair of the Department of Medicine. Appointments are made in accordance with the By-Laws of Stamford Hospital and are on a biennial basis. Associate directors for each subspecialty may be appointed in a similar manner. 4. Sub-specialty Section functions are to include: a. Development and fostering of standards of professional quality and academic excellence. b. Ongoing review of clinical and procedural performance within that subspecialty. 2

4 c. Development of educational programs. d. Teaching of house staff and medical students. e. Development and surveillance of criteria for the performance of procedures and practices within that sub-specialty. 5. Sub-specialty sections are to function as divisions within the Department of Medicine and may hold formal meetings. Annual reports of each subspecialty section are to be submitted to the Department for incorporation in the Annual Report of the Department of Medicine. 6. Physicians granted sub-specialty membership must demonstrate continued clinical skills and procedural competence commensurate with recognition as a specialist and with continued re-certification by that specialty board. Attestation of such skills and competence will be regularly reviewed as part of the re-appointment process, in accordance with the By-Laws of Stamford Hospital. Department of Medicine Meetings 1. The Department of Medicine will hold regular business meetings in accordance with the guidelines set forth by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and to which its entire active staff will have been invited. Other members of the Department may attend. All topics relevant to departmental activities including quality assurance, departmental affairs, medical education, performance improvement, and patient care are to be discussed. Minutes of these meetings will be kept, a copy of which will be submitted to the Medical Executive Committee. 2. Regularly scheduled departmental meetings will be held four times a year. Special meetings of the Department may be called at other times. Members will receive notices in advance of each meeting. Attendance rosters will be kept. An excused absence shall not constitute a missed meeting. Commitment of the Department of Medicine to Graduate Medical Education and to the Academic Affiliation with Columbia University College of Physicians & Surgeons 1. The Department of Medicine is strongly committed to the Residency Program in Internal Medicine and to the academic affiliation with Columbia University College of Physicians & Surgeons. The Department is committed to an institutional environment that attracts and trains medical residents with the highest standards of academic excellence and clinical performance. It additionally supports all measures that secure the strength of the Columbia University College of Physicians and 3

5 Surgeons affiliation, and the conduct of that affiliation with seriousness of purpose, and responsibility for the education of future physicians and medical colleagues. 2. The Program Director in Internal Medicine additionally serves as Associate Chair, Department of Medicine, and the Associate Program Director as Medical Director of Ambulatory Medicine. 3. The Chair of the Department of Medicine serves as Chair of the Clinical Competence Committee. This committee is the Accreditation Council for Graduate Medical Education (ACGME) mandated committee of oversight of resident performance, and additionally serves to review the status of the Program and the associated requirements of the ACGME. Membership on this Committee additionally includes the Residency Program Director, the Associate Residency Program Director, the Assistant Residency Program Director for In-patient Medicine and key teaching faculty. 4. The Department supports the need for active institutional support to sustain its commitment to and quality of graduate medical education, including the necessary resources to provide the infrastructure of medical education, and the specific educational endeavors that define a teaching institution of merit and purpose. 5. Physicians individually committed to medical education will have the opportunity, in a wide range of forums, to be involved in the education of residents and medical students, as well as be actively participatory in continuing medical education. Physicians actively involved in the teaching program will be recommended for appropriate medical school faculty appointments at Columbia University College of Physicians & Surgeons. Medical Performance Review Committee 1. The Medical Performance Review Committee shall have a chairperson and appointed representatives from both the Department of Medicine and the Department of Family Practice. All relevant items of review and discussion will be given to the Chair of Medicine. 2. In accordance with the By-Laws of Stamford Hospital, this committee shall review the quality and appropriateness of patient care provided on the medical service. The committee is responsible for fostering a uniformly high quality of care provided by physicians with delineated clinical privileges. Education 1. The Department of Medicine is strongly committed to the continuous upgrading of clinical and academic skills and knowledge. All active members are encouraged to 4

6 attend relevant regional, national and international meetings and conferences that support these goals. 2. Attendance at Medical Grand Rounds and other formal continuing medical education activities of the Department of Medicine is urged and encouraged. Through input obtained at departmental meetings and in review of evaluations completed at the end of hospital-based CME activities, programs of relevance to the needs of staff membership are addressed. 3. Autopsy analysis of a deceased patient remains a significant resource of physician education. When appropriate, consent for autopsy should be sought. 4. Research projects of all types are considered a vital part of the educational process. They are strongly encouraged and, when feasible, will be financially supported. The Department of Medicine will work clearly with the Director of Research in all relevant activities. 5. Evidence of continued medical education (CME), as documented on medical staff re-appointment applications, will be a prerequisite for continued staff appointment to Stamford Hospital. At a minimum, there must be 25 credits of Category I credit per year, under the criteria of the American Medical Association (AMA) Physician Recognition Award. The number of credits is commensurate with CME requirements for license renewal in the State of Connecticut, which requires 50 hours of CME in that physician s related specialty, but in addition, requires that there be at least one hour each of CME credit in Infectious Disease included but not limited to HIV, Patient Quality and Safety, Sexual Assault, Cultural Competence and Domestic Violence. Patient Care 1. Patient Care provided by attending physicians must conform to the By-Laws of the Medical Staff. 2. All patients admitted to the teaching service of the Department of Medicine must be seen and evaluated by the relevant house staff and have a detailed history and physical examination written within six hours of admission. All patients, whether on the general medical units, the Intermediate Care Unit or the Intensive Care Unit, and whether staff, private, or non-teaching, must be evaluated, on an initial and ongoing basis, by the attending physician of record, in accordance with the By-Laws of The Medical Staff of Stamford Hospital. 3. The assigned private or attending physician must countersign all written histories and physical examinations completed by house officers or medical students, and should note in writing any corrections or additions deemed significant. 5

7 4. A documented history and physical examination, assessment, and plan, as well as daily progress notes are required of the attending physician on all patients, whether or not they be on the teaching service, and whether or not they be staff or private patients. When applicable, and in the context of countersignature of house staff progress notes, a relevant and detailed supplement to that note demonstrating meaningful attending participation in care, and concordance and support of the written note, will suffice as a formal progress note. 5. Physician assignments to the Ambulatory Clinic, and for the care of staff patients, will be made by the Chair of the Department of Medicine, in concert with the respective specialty director. Signature: Noel I. Robin, M.D. Chair, Department of Medicine Date: November 18,