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Medical Executive Committee Approvals
The following items were presented and actions were approved at the September 14, 2010 Medical Executive
Committee meeting:
Department of Anesthesia
A. David Kobayashi, M.D., nominated for Chief of Department of Anesthesia
Department of Family Practice
A. George D. Haas, M.D., nominated for Chief of Department of Family Practice
Department of Medicine
A. Revised ACC – National Cardiovascular Data Registry Required Documentation – changes to definitions
B. Patient Care Policy/Procedure entitled, “Nurse Runner Program”
C. Revised Department of Medicine – Cardiovascular Disease/Cardiology Privilege Card
Revisions:
Removal of the following privileges:
42.25 – Peripheral Angioplasty and other Percutaneous Peripheral Vascular Intervention includes Aortic Orifice Lesions
(Endovascular Procedures, such as Percutaneous Transluminal Angioplasty (PTA), implantation of stent and/or vena cava filter,
thrombolysis, embolization, stent graft repair, angiogram, angioscopy, and atherectomy)
42.26 – Carotid Stent Privileges
42.27 – Thoracic Endovascular Aortic Review (TEVAR)
Department of Obstetrics & Gynecology
A. Nursing Maternal/Child Services Policy/Procedures entitled, “Prevention of Peripheral Hepatitis B Virus Transmission to
Infants”
Department of Radiology
A. Revised Department of Radiology Rules & Regulations
Revisions:
ARTICLE II – PURPOSE, Paragraph 1. To ensure that all patients admitted to the Hospital or treated in the Outpatient Department
outpatient departments receive the best possible radiological services.
ARTICLE III – MEMBERSHIP, Paragraph C. Term of Appointment
The term of appointment shall be for two-years with reappointment every two years at the discretion of the governing Board.
Paragraph E. Temporary Privileges
Temporary privileges may be awarded as outlined in the Medical Staff Bylaws. In no case shall these privileges be for a period
greater than the term of regular appointments to the Department and these appointments are revocable at any time.
ARTICLE V – OFFICERS, A. Chief of Department of Radiology, paragraph 2. In the absence of the Chief, another radiologist
the Vice Chief shall be designated to act as Chief.
Paragraph 3, item a. He/she shall assume and discharge responsibility for professional direction of the Department under the
Bylaws of the Medical Staff of TMMC and for the administrative direction in cooperation with the Hospital Administrator Administration.
ARTICLE VI – MEETINGS, paragraph B. Attendance at Meetings
Active Staff members must meet the Bylaws requirements.
ARTICLE VII – DEPARTMENTAL RULES & REGULATIONS, paragraph B. Requisition for Radiological Consultation
Requests for radiologic services shall be written by attending physicians and contain a concise statement or reason for the examination.
This is the responsibility of the attending physician who shall discharge it personally or by delegation to competent
personnel. The important point is to provide orientation to the radiologist as to the clinical problem at hand. This is vital to the
maintenance of a high quality of radiologic service.
This responsibility is best discharged for:
1. In patients: by a signed request by the attending or house physician.
2. Emergency room patients: by a signed request by the physician in attendance.
3. Outpatients: by a signed request or telephone request from the physician’s office.
Bylaws Committee
A. Transitional Care Unit Rules & Regulations
Revisions:
Section III. MEDICAL DIRECTOR, paragraph 2 – The Medical Director shall uphold the requirements under CMS regulations
for the medical director defined in the State Operations Manual and enforce compliance with these standards and
conditions of participation to admit patients to the Transitional Care Unit.
Section IX. PATIENT SAFETY/PERFORMANCE IMPROVEMENT COMMITTEE
A. RESPONSIBILITIES
1. Safety Plan to Include:
a. A reporting system for patient safety events
b. A process to conduct analysis including but not limited to root cause analyses on reported patient events
c. A reporting process that supports and encourages a culture of safety
d. A process for providing ongoing patient safety training
e. A definition of a patient safety event including but not limited to all adverse events that are determined to
be preventable and health care associated infections that are determined to be preventable
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f. See Patient Safety Plan Administration Manual #800.05_2 Continued on Page 5