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					          ORGANIZATION AND FUNCTIONS
                   MANUAL

                                                            OF THE


                                          MEDICAL STAFF

                                                                 OF

              ESTES PARK MEDICAL CENTER

                                                                AND

          PROSPECT PARK LIVING CENTER
                                                October 27, 1998
                                         With Revisions Approved by the Governing Board 3/21/2000




Organization & Function Manual of the Medical Staff                                                 1
                                                        TABLE OF CONTENTS


PART 1. PURPOSE AND DEFINITIONS ..................................................................................... 1

          1.1.      PURPOSE ................................................................................................................... 1

          1.2.      DEFINITIONS ............................................................................................................ 1

           1.3.     ADDITIONAL RULES ............................................................................................. 1

          1.4.      USE OF MANUAL .................................................................................................... 1

PART 2. GENERAL ORGANIZATION ......................................................................................... 2

          2.1       LEADERSHIP ............................................................................................................ 2

                    2.1.1. Purpose ............................................................................................................. 2

                    2.1.2. Officers ............................................................................................................ 2

          2.2.     COMMITTEES / SUBCOMMITTEES ...................................................................... 2

                    2.2.1. Purpose ............................................................................................................. 2

                    2.2.2. Criteria for Establishing Committees / Subcommittees ................................... 2

                    2.2.3. List of Committees .......................................................................................... 2

          2 3.     COMMUNICATION ................................................................................................... 3

          2.4.     ELIGIBILITY TO VOTE ............................................................................................ 3

          2.5.     DELIGATION OF COMMITTEE/FUNCTIONS/ASSISTANCE ............................. 3

PART 3.           PROVISIONS COMMON TO ALL MEETINGS ....................................................... 3

          3.1. FREQUENCY OF MEETINGS / ATTENDANCE REQUIREMENTS ..................... 3

                  3.1.1. Committees ........................................................................................................ 3

          3.2. NOTICE OF MEETINGS ............................................................................................. 3



Organization & Function Manual of the Medical Staff                                                                                                  2
          3.3. QUORUM ...................................................................................................................... 4


                  3.3.1. General and Special Medical Staff Meetings..................................................... 4

                  3.3.2. Medical Executive Committee Meetings ........................................................... 4

                  3.3.3. Committee Meetings .......................................................................................... 4

          3.4. RECORD OF MEETINGS ........................................................................................... 4

          3.5. VOTING ....................................................................................................................... 4

          3.6. RIGHTS OF EX OFFICIO MEMBERS....................................................................... 4

          3.7. EXECUTIVE SESSION ............................................................................................... 4

          3.8. SPECIAL MEETINGS ................................................................................................. 5

PART 4.          COMMITTEES ............................................................................................................. 5

          4.1. MEMBERSHIP.............................................................................................................. 5

          4.2. APPOINTMENT / TER MS OF APPOINTMENT....................................................... 5

          4.3. MEDICAL EXECUTIVE COMMITTEE ..................................................................... 6

                 4.3.1. Authority ............................................................................................................. 6

                 4.3.2. Composition / Terms of Appointment ................................................................ 6

                 4.3.3. Meeting Frequency / Attendance Requirements ................................................. 6

                 4.3.4. Functions ............................................................................................................. 6

          4.4. CREDENTIALS COMMITTEE ................................................................................. 12

                 4.4.1. Authority ........................................................................................................... 12

                 4.4.2. Composition / Terms of Appointment .............................................................. 12

                 4.4.3. Meeting Frequency / Attendance Requirements ............................................... 12

                 4.4.4. Functions ........................................................................................................... 12

          4.5. MEDICAL STAFF QUALITY IMPROVEMENT COMMITTEE ............................ 13


Organization & Function Manual of the Medical Staff                                                                                                 3
                 4.5.1. Authority ........................................................................................................... 13

                 4.5.2. Composition / Terms of Appointment .............................................................. 13

                 4.5.3. Meeting Frequency / Attendance Requirements ............................................... 13

                 4.5.4. Functions ........................................................................................................... 14

          4.6. MEDICAL STAFF BYLAWS COMMITTEE ............................................................ 15

                 4.6.1. Authority ........................................................................................................... 15

                 4.6.2. Composition/Terms of Appointment ................................................................ 15

                 4.6.3. Meeting Frequency/Attendance Requirements ................................................. 16

                 4.6.4. Functions ........................................................................................................... 16

PART 5.          ADOPTION, AMENDMENT, AND REPEAL ........................................................... 16

         5.1. METHOD OF ADOPTION, AMENDMENT AND REPEAL .................................... 16

                 5.1.1. Adoption ........................................................................................................... 16

                 5.1.2. Repeal ............................................................................................................... 16

                 5.1.3. Amendment ....................................................................................................... 17




Organization & Function Manual of the Medical Staff                                                                                                 4
                                          PART 1. PURPOSE AND DEFINITIONS

1.1.     PURPOSE

          This Organization and Functions Manual is intended to outline the functions of the Medical Staff
          of the hospital. Nothing in this Organization and Functions Manual is intended or shall be
          deemed to exercise control, supervision or direction over the provisions of medical services in
          the Hospital by individuals who have been granted Medical Staff appointment and/or clinical
          privileges by the Board.

1.2       DEFINITIONS

          The definitions contained in the Medical Staff Bylaws shall apply to like terms contained in this
          manual.

1.3.      ADDITIONAL RULES

          There may be additional policies, procedures, rules, regulations, manuals, guidelines and
          requirements which apply to such Medical Staff appointees and it is each Medical Staff
          appointee’s sole responsibility to obtain, read, understand and abide by all bylaws, policies,
          procedures, rules, regulations, manuals, guidelines and requirements of the Hospital and its
          medical staff that are applicable to him. Such additional policies, procedures, rules, regulations,
          manuals, guidelines and requirements are incorporated herein by reference.

1.4.      USE OF MANUAL

          This Manual and all other bylaws, policies, procedures, rules, regulations, manuals, guidelines
          and requirements of the hospital and/or its Medical Staff, which may apply to applicants and/or
          appointees to the Hospital’s Medical Staff or others with delineated clinical privileges are
          unilateral expressions of the current requirements of, and policies and procedures established by
          the Hospital relating to applicants and appointees to its Medical Staff. This Manual and all other
          bylaws, policies, procedures, rules, regulations, guidelines and requirements of the Hospital
          and/its Medical Staff do not constitute a contract of any kind whatsoever. Applicants and
          appointees to the Hospital’s Medical Staff and others with delineated clinical privileges shall not
          rely on the statements contained in this Manual, and/or all other bylaws, policies, procedures,
          rules, regulations, manuals, guidelines and requirements of the Hospital and/or its Medical Staff
          as same are subject to change at any time. This Manual and other bylaws, policies, procedures,
          rules, regulations, manuals, guidelines and requirements of the Hospital and/or its Medical Staff
          shall be interpreted, applied and enforced within the sole discretion of the Hospital or those
          individuals delegated responsible for interpretation, application or enforcement of same by the
          Board or under this Manual or other bylaws, policies, procedures, rules, regulations, manuals,
          guidelines and requirements of the Hospital and/or its Medical Staff.




Organization & Function Manual of the Medical Staff                                                        1
                                                PART 2. GENERAL ORGANIZATION

2.1.      LEADERSHIP

          2.1.1 Purpose

                     Medical Staff Leadership shall provide leadership and guidance to Medical Staff
                     appointees and others with delineated clinical privileges, promote effective
                     communications and fulfill such other responsibilities as are outlined in this Manual
                     and/or other bylaws, policies, procedures, rules, regulations, manuals, guidelines and
                     requirements of the Hospital or its Medical Staff.

          2.1.2. Officers

                    The Medical Staff shall have officers, as outlined in the Medical Staff Bylaws, which
                    shall include the Medical Staff Chief of Staff, Medical Staff Vice Chief of Staff and
                    Immediate Past Chief of Staff of the Medical Staff.

2.2.     COMMITTEES / SUBCOMMITTEES

           2.2.1. Purpose

                     The Functions of the Hospital’s Medical Staff may be performed as outlined in this
                     Manual and other bylaws, policies, procedures, rules, regulations, manuals, guidelines
                     and requirements of the Hospital or its Medical Staff. Part 4 of this Manual outlines the
                     functions currently assigned to committees.


           2.2.2. Criteria for Establishing Committees / Subcommittees

                      The Medical Executive Committee may establish committees (standing or ad-hoc) to
                      perform one or more Medical Staff functions. In the same manner, the Medical
                      Executive Committee may dissolve committees or otherwise rearrange committee
                      structure, duties or composition as needed to better accomplish Medical Staff functions.
                      Such additions or delegations shall be reported to the Board.

           2.2.3. List of Committees

                     The Medical Staff of the Hospital currently has in place the following standing
                     committee of the Medical Staff.

                    Medical Executive Committee
                    Credentials Committee
                    Medical Staff Quality Improvement Committee
                    Medical Staff Bylaws Committee




Organization & Function Manual of the Medical Staff                                                         2
2.3      COMMUNICATIONS

          Each committee ultimately reports, directly or indirectly, to the MEC. The MEC reports to the
          board.

2.4       ELIGIBILITY TO VOTE

          A practitioner who is otherwise entitled to vote at a committee or staff meeting shall not be
          permitted to vote if he is the subject of the action/recommendation being considered. The
          Practitioner who is the subject of an action or recommendation being considered at a Committee
          or Staff meeting may not be present at the meeting unless he is specifically requested to appear.
          This requirement applies even if the affected Practitioner would otherwise be entitled to attend
          the meeting. The affected Practitioner may not vote on any matter of which he is the subject.

2.5.     DELEGATION OF COMMITTEE/FUNCTIONS/ASSISTANCE

          Each committee has the authority to seek input, assist, and/or delegate its functions and duties,
          except for its reports. However, committees may not incur any expenses in connection with such
          input, assistance, or delegating its functions, except as approved in advance by the CEO.

                             PART 3. PROVISIONS COMMON TO ALL MEETINGS

3.1.      FREQUENCY OF MEETINGS / ATTENDANCE REQUIREMENTS

          The CEO or his designee may attend any Medical Staff committee or staff meeting as an ex
          officio member without vote.

          3.1.1. Committees

                     Medical Staff committees shall meet as often as necessary to perform their required
                     functions, but not less than four (4) times per year at times set by the chairman.
                     Attendance requirement for committee or subcommittee meetings shall be mandated by
                     that committee or subcommittee, as applicable.


3.2.      NOTICE OF MEETINGS

          Notice of department or committee meetings will be posted in the monthly calendar agenda or
          otherwise provided at least five (5) days in advance of the meeting. As appropriate, other
          methods of notification may be used: facility newsletter, mail, phone, fax, e-mail or hand
          delivery. Notices will include the date, time and place of the meeting.




Organization & Function Manual of the Medical Staff                                                      3
3.3.     QUORUM

         3.3.1.      General and Special Medical Staff Meetings

                    Those members of the Active Staff present.

         3.3.2.      Medical Executive Committee Meetings

                     Those members of the Active Staff present.

         3.3.3.      Committee Meetings

                     Those members of the Active Staff present.

3.4.     RECORD OF MEETINGS

          Minutes of each committee or subcommittee meeting shall be prepared and shall include but not
          be limited to the following components: date of meeting, attendance (present/absent),
          recommendations/reports made (votes taken, as applicable), action taken, follow up required,
          items tabled. The minutes shall be signed by the Chairman or other committee/subcommittee
          member assigned to conduct the applicable meeting. A record of each meeting will be
          maintained in the facility’s Medical Staff Office.

3.5.     VOTING

          Any individual who attends a meeting in more than one capacity shall be entitled to only one
          vote. Voting by proxy is not permitted.

          In the event it is necessary for a committee to act on a question when it is not practicable to call a
          meeting, the voting members may be presented with the question, in person or by mail, and their
          vote returned to the Chairman of the committee. Such a vote shall be binding so long as the
          question is voted on by a majority of the committee members eligible to vote.

3.6.     RIGHTS OF EX OFFICIO MEMBERS

          Ex officio members are entitled to attend meetings and, unless specifically granted in the
          composition of the committee are not entitled to vote.

3.7.     EXECUTIVE SESSION

          Any committee of the Medical Staff may go into executive session, during which time all ex-
          officio members may be excused.




Organization & Function Manual of the Medical Staff                                                           4
3.8.     SPECIAL MEETINGS

          The agenda for any special meeting shall be limited to the purpose for which it was called.
          Notice of any special meeting will be given, as outlined in Section 3.2 above, at least five (5)
          days prior to the meeting unless the special meeting is called for time when the giving of five (5)
          days notice is impossible. A special meeting of any committee or subcommittee may be called
          by the Chairman of the committee or subcommittee, the Medical Staff Chief of Staff, by
          Administration or by a request of 51% of the voting members of the committee or subcommittee,
          as applicable.

                                                      PART 4. COMMITTEES

4.1.     MEMBERS

          Committee membership, unless otherwise specified in the Medical Staff Bylaws or elsewhere in
          this Manual, shall consist of Medical Staff appointees and may include, when appropriate, non-
          appointees with delineated clinical privileges, AHP’s, Administration, the Board, and
          representatives of nursing, quality management, medical records, pharmacy, social services or
          other Hospital services. However, at all times the majority of the membership of Medical Staff
          Committees and Subcommittees shall be physicians. Appointees to the Medical Staff may be
          required from time to time to participate in any Hospital deliberations which affect the discharge
          of Medical Staff responsibilities.

4.2.     APPOINTMENT / TERMS OF APPOINTMENT

          Unless otherwise specified in the Medical Staff Bylaws or elsewhere in this Manual, members of
          each committee shall be appointed every two (2) years by the Chief of Staff not more than thirty
          (30) days after the election of a new Chief of Staff. There shall not be limitations in the number
          of terms a committee member may serve. Administration, the Chief of Staff or their respective
          designees shall be ex officio members of all committees of the Medical Staff.

          All appointed committee and subcommittee members may be removed and vacancies filled at the
          discretion of the Chief of Staff. If it is determined by the committee or subcommittee chairman
          that a committee or subcommittee member’s absence from that committee or subcommittee’s
          meeting is adversely impacting the functions and/or operations of the committee or
          subcommittee, as applicable, the chairman, in consultation with the Chief of Staff, may remove
          and replace the committee or subcommittee member without prior notice.




Organization & Function Manual of the Medical Staff                                                        5
4.3.    MEDICAL EXECUTIVE COMMITTEE

        4.3.1.     Authority

                   The Hospital shall have a Medical Executive Committee. The Medical Executive
                   Committee shall report and make recommendations to the Board directly or through its
                   subcommittees or designees. The MEC may delegate or assign all or any of its functions
                   or responsibilities to another committee or appoint an ad hoc committee to perform any of
                   its functions or responsibilities.

        4.3.2. Composition / Term of Appointment

                    Voting members of the Medical Executive Committee shall be all of the Active Staff
                    appointees to the Medical Staff in good standing. Ex officio members (without vote) of
                    the Medical Executive Committee shall include, but not be limited to, the Hospital’s Chief
                    Executive Officer, the Director of Nursing for Estes Park Medical Center and the Director
                    of Nursing of Prospect Park Living Center. A majority of the voting members of the
                    Medical Executive Committee shall be physicians. The Chief of Staff shall serve as the
                    Chairman of the Medical Executive Committee. Each member of the MEC shall serve
                    successive terms as long as the member is appointed to the Active Staff and is in good
                    standing.

        4.3.3.     Meeting Frequency / Attendance Requirements

                     The Medical Executive Committee shall meet not less than four (4) times per Medical
                     Staff year. Additional meetings, as needed, may be called by the Chairman of the
                     Medical Executive Committee or his designee. The first MEC meeting of each calendar
                     year shall be designated as the annual meeting of the MEC. Members of the Medical
                     Executive Committee are strongly encouraged to attend these meetings.

        4.3.4.      Functions

                     The Medical Executive Committee shall represent and act on behalf of the Hospital’s
                     Medical Staff and perform duties in relation thereto, subject to such limitation, if any, as
                     may be imposed by the Medical Staff Bylaws, including but not limited to the following:

                     4.3.4.1. The Medical Executive Committee shall act for the Medical Staff on all matters
                     except election and removal of officers of the Medical Staff.

                     4.3.4.2. The duties and responsibilities of the Medical Executive Committee shall
                     include those delegated to it by the Board from time to time.




Organization & Function Manual of the Medical Staff                                                            6
                     4.3.4.3. The Medical Executive Committee shall receive and act on reports and
                     recommendations from Medical Staff committees, ad hoc committees and other assigned
                     functions by the Medical Executive Committee.

                     4.3.4.4.  The Medical Executive Committee shall be responsible for making Medical
                     Staff recommendations directly to the Board for its consideration.          Such
                     recommendations shall relate to, but not be limited to the following:

                               4.3.4.4.1.       The Medical Staff’s structure;

                               4.3.4.4.2. The mechanism used to review credentials and to delineate individual
                               clinical privileges;

                               4.3.4.4.3.       Recommendations of individuals for Medical Staff appointment;

                               4.3.4.4.4. Recommendations for delineated clinical privileges for each eligible
                               individual;

                               4.3.4.4.5. Recommendations regarding adoption, amendment or repeal of the
                               Medical Staff Bylaws, Manuals and Rules and Regulations.

                               4.3.4.4.5. Recommendations for AHP appointment and specified services, as
                               outlined in the AHP Rules and Regulations.

                               4.3.4.4.7. The participation of the Medical staff in the Hospital’s performance-
                               improving activities, to include establishing a mechanism designed to conduct,
                               evaluate and revise such activities;

                               4.3.4.4.8. The mechanism by which Medical Staff appointment may be
                               terminated; and

                               4.3.4.4.9. The mechanism for fair-hearing procedures

                     4.3.4.5. Monitor and review, as referred to it, in the policies adopted by the Hospital
                     which are applicable to the Medical Staff.

                     4.3.4.6. Participate in planning. Implementing, evaluating and reviewing, as requested
                     by Administration or the Board, new clinical procedures, devices and/or treatment which
                     may be provided at the Hospital.

                     4.3.4.7. Review, plan and evaluate, as requested by Administration or the Board,
                     programs for continuing medical education and the Hospital’s medical library.

                     4.3.4.8. Assist, as requested by Administration or the Board, in developing, reviewing
                     and implementing and emergency preparedness plan.




Organization & Function Manual of the Medical Staff                                                             7
                     4.3.4.9. Appoint Medical Staff appointees to participate on committees responsible for
                     the functions outlined in this Section 4.3.4.8. and monitor, as deemed appropriate,
                     Medical Staff participation and involvement in at least the following areas:

                               4.3.4.9.1. Setting and services required to meet patient care goals are identified,
                               planned, and provided if appropriate.

                               4.3.4.9.2. When care is not planned to meet all identified needs, this is
                               documented in the medical record:

                               4.3.4.9.3. Care is planned and provided in an interdisciplinary, collaborative
                               manner by qualified individuals;

                               4.3.4.9.4. Patient care procedures are performed in a manner that respects
                               privacy; and

                               4.3.4.9.5. The progress of patients is periodically evaluated against care goals and
                               the plan of care, and when indicated, the plan or goals are revised.

                               4.3.4.9.6. Medication use processes are organized and systematic throughout the
                               hospital;

                               4.3.4.9.7. Patient’s nutrition care is planned, as necessary.

                               4.3.4.9.8. Rehabilitation services are provided by individuals with appropriate
                               licensure, regulation, registration, certification and/or qualifications.

                               4.3.4.9.9. The hospital ensures that special treatment procedures are safely and
                               appropriately used.

                               4.3.4.9.10. Assisting in the formation of broad professional policies regarding the
                               evaluation, appraisal, selection, procurement, storage, distribution, use, safety
                               procedures and all other matters relating to drugs in the Hospital;

                               4.3.4.9.11. Advising the Medical Staff and Administration on matters pertaining
                               to the choice of available drugs;

                               4.3.4.9.12. Making recommendations concerning drugs to be stocked on the
                               nursing units and by other services;

                               4.3.4.9.13. Developing and reviewing periodically a drug list for use in the
                               Hospital, prescribe the necessary operating rules for its use and assure that said
                               rules are available to all staff members.




Organization & Function Manual of the Medical Staff                                                              8
                               4.3.4.9.14. Developing a mechanism to identify, review and receive reports on all
                               unexpected drug reactions;

                               4.3.4.9.15. Evaluating clinical data concerning new drugs or preparations
                               requested for use in the Hospital;

                               4.3.4.9.16. Establishing standards concerning the use and control                   of
                               investigational drugs and of research in the use of recognized drugs;

                               4.3.4.9.17. Reviewing and evaluating drug therapy practices and drug utilization
                               at least quarterly, including review of the appropriateness of empiric and
                               therapeutic use of drugs;

                               4.3.4.9.18. Reviewing and evaluating on an on-going basis the appropriateness,
                               safety, and effectiveness of the prophylactic, empiric and therapeutic use of
                               antibiotics in the Hospital, reporting conclusions, recommendations, actions taken
                               and action resulting on at least a quarterly basis;

                               4.3.4.9.19. Reviewing and evaluating medical records to determine that the
                               medical records: (1) properly describe the condition and progress of the patient,
                               the therapy and tests provided, the results thereof, and the identification of
                               responsibility for all actions taken; and (2) are sufficiently complete at all times so
                               as to facilitate continuity of care and communications between all those providing
                               patient care services in the Hospital;

                               4.3.4.9.20. Developing, reviewing, enforcing and maintaining surveillance over
                               enforcement of staff and Hospital policies and rules relating to medical records,
                               including medical records completion, preparation, forms, formats, filing,
                               indexing, storage, destruction and availability and recommend methods of
                               enforcement thereof and changes therein;

                               4.3.4.9.21. Providing liaison with administration, nursing service and medical
                               records professionals in the employ of the Hospital on matters relating to medical
                               record practices;

                               4.3.4.9.22. Developing and implementing a system for reporting, identifying and
                               analyzing the incidence and cause and reviewing the proper management and
                               epidemic potential of infection among patients;

                               4.3.4.9.23. Developing and implementing a preventive and corrective program
                               designed to minimize infection hazards, including establishing, reviewing and
                               evaluating aseptic, isolation and sanitation techniques;




Organization & Function Manual of the Medical Staff                                                                 9
                               4.3.4.9.24. Developing, evaluating and reviewing preventive, surveillance and
                               control policies and procedures relating to all phases of the Hospital’s activities,
                               including: operating rooms, delivery rooms, central service, housekeeping and
                               laundry; sterilization and disinfection procedures by heat, chemicals, or
                               otherwise; isolation procedures, prevention of cross-infection by anesthesia
                               apparatus or inhalation therapy equipment; testing of Hospital personnel for
                               carrier status; disposal of infectious material; food sanitation and waste
                               management; and other situations as requested;

                               4.3.4.9.25. Reviewing education programs and needs for pre-operative services,
                               operating room services an recovery room services; and

                               4.3.4.9.26. Reviewing the utilization of the operating rooms at the Hospital, wait
                               times and scheduling.

                               4.3.4.9.27. The Medical Staff shall participate in the development, establishment
                               and maintenance of a Quality Management Program, as reasonably requested by
                               the Hospital; that complies with the regulations adopted by the Colorado
                               Department of Public Health and Environment (the “CDPHE”). The Quality
                               Management Program shall include the following elements:

                                          4.3.4.9.27.1. A general description of the types of cases, problems, or
                                          risks to be reviewed and criteria for identifying potential risks, including
                                          without limitation any incidents that may be required by CDPHE
                                          regulations to be reported to the CDPHE;

                                          4.3.4.9.27.2. Identification of the personnel or committees responsible for
                                          coordinating quality management activities and the means of reporting to
                                          the administrator or Board of the facility;

                                          4.3.4.9.27.3. A description of the method for systematically reporting
                                          information to a person designated by the facility within a prescribed time;

                                          4.3.4.9.27.4. A description of the method for investigating and analyzing
                                          the frequency and causes of individual problems and patterns of problems;

                                          4.3.4.9.27.5. A description of the methods for taking corrective action to
                                          address the problems, including prevention and the minimizing problems
                                          or risks;

                                          4.3.4.9.27.6. A description of the method for the follow-up of corrective
                                          action to determine the effectiveness of such action;




Organization & Function Manual of the Medical Staff                                                                10
                                          4.3.4.9.27.7. A description of the method for coordinating all pertinent
                                          cases, problem, or risk-review information with other applicable quality
                                          assurance and/or risk management activities, such as procedures for
                                          granting staff or clinical privileges, review of patient or resident care,
                                          review of staff or employee conduct, the patient grievance system. And
                                          education and training programs;

                                          4.3.4.9.27.8. Documentation of required quality management activities,
                                          including cases, problems, or risks identified for review, finding of
                                          investigations, and any actions taken to address problems or risks; and

                                          4.3.4.9.27.9. A schedule for plan implementation not to exceed ninety
                                          (90) days after the date the facility receives written notice of the CDPHE’s
                                          approval of the Quality Management Plan if an existing plan is not in
                                          effect or is modified for any reason.

                               4.3.4.9.28. The Medical Staff shall participate in the coordination and
                               implementation of a procedure or policy by which the facility documents
                               evidence of its compliance with Medicare conditions of participation, or other
                               acceptable standards regarding risk management and quality assurance functions.

                               4.3.4.9.29. If the facility makes a permanent and substantive change in its
                               Quality Management Plan, the Medical Staff shall participate, as requested, in the
                               coordination, of the preparation and submission of a description of such change to
                               the CDPHE prior to implementation, with the approval of the Board.

                     4.3.4.10. Make recommendations to Administration regarding medico-administrative,
                     Hospital management and planning matters.

                     4.3.4.11. Assessing and recommending to the relevant Hospital authority off-site sources
                     for needed patient care services not provided by the department or the Hospital;

                     4.3.4.12. Perform such other responsibilities, duties and functions as are reasonably
                     requested by Administration or the Board.

4.4. CREDENTIALS COMMITTEE

        4.1.1.Authority

                 The hospital shall have a Credentials Committee. The Credentials Committee shall report to
                 the MEC.

        4.4.2. Composition / Terms of Appointment




Organization & Function Manual of the Medical Staff                                                                11
                  Voting members of the Credentials Committee shall be the Medical Staff officers. Ex
                  officio members may include Administration. At all times a majority of the members of
                  the Credentials Committee shall be physicians. Appointment shall be for a term of two (2)
                  years and members may serve successive terms. The Vice Chief of Staff shall be the
                  Chairman of the Credentials Committee.

        4.4.3. Meeting Frequency / Attendance Requirements

                   The Credentials Committee shall meet not less than one (1) time per Medical Staff year.
                   Additional meetings, as needed, may be called by the Chairman of the Credentials
                   Committee.

        4.4.4. Functions

                    4.4.4.1. The Credentials Committee shall make reports to the MEC concerning
                    appointments and reappointment to the Medical Staff and the granting of initial, renewed,
                    or revised clinical privileges, as outlined in the bylaws, policies, rules, regulations,
                    manuals, guidelines and requirements of the Hospital and its Medical Staff.

                    4.4.4.2. The Credentials Committee shall utilize the processes outlined in the Credentials
                    and Hearing and Appellate Review Policy and Procedure Manual and other bylaws,
                    policies, procedures, rules, regulations, guidelines and requirements of the Hospital and its
                    Medical Staff.

                    4.4.4.3. The Credentials Committee shall conduct a review and report to the MEC
                    concerning the provisions of the Credentials and Hearing and Appellate Review Policy
                    and Procedure Manual.

                    4.4.4.4. The Credentials Committee shall perform such other duties and functions as are
                    reasonably requested by the MEC, Administration or the Board.

4.5. MEDICAL STAFF QUALITY IMPROVEMENT COMMITTEE

        4.5.1. Authority

                The Hospital shall have a Medical Staff Quality Improvement Committee. The Medical Staff
               Quality Improvement Committee (‘MSQU”) shall report and make recommendations directly
               to the MEC concerning its activities and activities reported to it by other Medical Staff
               committees. Nothing in this Manual is intended to require that the MSQI perform Hospital
               quality improvement functions. While the MSQI and the

                Hospital’s Quality Improvement Council may need to collaborate and/or report information
                to one another, the professional/peer review functions of the Medical Staff shall be
                performed by Medical Staff committees such as the MSQI separate from Hospital quality
                improvement activities. The MSQI may appoint subcommittees to perform all or some of its
                functions and may delegate its functions to other committees and/or Medical Staff



Organization & Function Manual of the Medical Staff                                                           12
                appointees. The MSQI shall refer issues to its subcommittees and the subcommittees of the
                MSQI shall report directly back to the MSQI.

      4.5.2. Composition / Terms of Appointment

                 Voting members of the MSQI shall consist of a Chairman and up to four (4) additional
                 members. Ex officio members may include Administration. At all times a majority of the
                 members of the MSQI shall be physicians. Appointment shall be made by the Chief of
                 Staff. Each member shall serve a two (2) year term and members may serve successive
                 terms. The Chairman of the MSQI shall be appointed by the Chief of Staff.

      4.5.3.     Meeting Frequency / Attendance Requirements

                  The MSQI shall meet not less than four (4) times per Medical Staff year. Additional
                  meetings, as needed, may be called by the Chairman of the MSQI.

      4.5.4.     Functions

                  4.5.4.1. The MSQI shall make reports to the MEC concerning management and quality of
                  patient care in specific care areas as necessary or advisable under the circumstances. The
                  MSQI will review cases that fall out of screening criteria and shall make reports concerning
                  the following:

                         4.5.4.1.1. A pre-anesthesia assessment is performed for each patient before
                         anesthesia induction;

                         4.5.4.1.2. The patient’s post-procedure status is assessed on admission to and
                         before discharge from the post-anesthesia recovery area;

                         4.5.4.1.3. The Medical Staff defines the scope of assessment for operative and other
                         procedures.

                         4.5.4.1.4. The MSQI shall perform routine professional review by:

                                  4.5.4.1.4.1. Adopting, modifying, supervising and coordinating the conduct
                                  and findings of the clinical monitoring activities;

                                  4.5.4.1.4.2. Conducting review of mortalities, including analysis of autopsy
                                  reports when available;

                                  4.5.4.1.4.3. Conducting surgical case review, including tissue review,
                                  evaluation and comparison of preoperative and postoperative diagnosis,
                                  indications for surgery, actual diagnosis of tissue removed, and situations in
                                  which no tissue was removed;




Organization & Function Manual of the Medical Staff                                                          13
                                  4.5.4.1.4.4. Conducting blood usage reviews at least quarterly, including
                                  evaluation of appropriateness of all transfusions (whole blood and blood
                                  components), review of all confirmed transfusion reactions, and review of
                                  ordering practices for blood and blood products (including the amount
                                  requested; the amount used and the amount wasted);

                                  4.5.4.1.4.5. Reviewing on a continuous bases other general indicator of the
                                  quality of care and of clinical performance, including unexpected patient care
                                  management events;

                                 4.5.4.1.4.6. Reviewing, as reasonably requested by the Hospital, established
                                 Hospital policies and protocols relating to clinical practice in the Hospital;

                                 4.5.4.1.4.7. Conducting case reviews of all cases that fall out of screens;

                                 4.5.4.1.4.8. Reviewing and making recommendations to the MEC concerning
                                 review indicators and screens;

                               4.5.4.1.4.9. Reviewing and making recommendations concerning the utilization
                               of Hospital resources in the provision of patient care at the Hospital and
                               compliance with policies concerning utilization management;

                              4.5.4.1.4.10. Conducting any special studies of the inputs, processes or outcomes
                              of care that may be required to determine the appropriateness of clinical
                              performance;

                              4.5.4.1.4.11. Reviewing patient care processes, including education of patients
                              and families and coordination of care between Practitioners and Hospital
                              personnel, as relevant to the care of an individual patient;

                              4.5.4.1.4.12. Reviewing whether autopsies are being performed when appropriate,
                              whether permission for autopsies are being appropriately secured and processes
                              for notification of the attending Practitioner when an autopsy is being performed;

                              4.5.4.1.4.13. Maintaining surveillance over the Hospital’s infection control
                              program;

                              4.5.4.1.4.14. Conducting on a periodic basis statistical/prevalence studies of
                              antibiotic usage and susceptibility/resistance trend studies;

                 4.5.4.2. The MSQI shall make reports to the MEC regarding the activities of and reports
                 made to the MSQI by its subcommittees, delegatees and other Medical Staff committees
                 reporting to the MSQI.

                 4.5.4.3. The MSQI shall perform such other duties and functions as are reasonably
                 requested by the MEC, Administration or the Board.



Organization & Function Manual of the Medical Staff                                                            14
4.6.     MEDICAL STAFF BYLAWS COMMITTEE

        4.6.1.       Authority

                     The Hospital shall have a Medical Staff Bylaws Committee. The Medical Staff Bylaws
                     Committee shall report to the MEC.

        4.6.2.      Composition/Terms of Appointment

                     Voting members of the Medical Staff Bylaws Committee shall be the Chief of Staff, Vice
                     Chief of Staff and Immediate Past Chief of Staff. The immediate Past Chief shall serve
                     as the Chairman of the Medical Staff Bylaws Committee. Ex officio members may
                     include Administration. At all times a majority of the members of the Medical Staff
                     Bylaws Committee shall be physicians. Appointment shall be for a term of two (2) years
                     and members may serve successive terms by virtue of their Medical Staff office
                     positions.

         4.6.3.     Meeting Frequency/Attendance Requirements

                     The Medical Staff Bylaws Committee shall meet t least one (1) time per Medical Staff
                     year. Additional meetings, as needed, may be called by the Chairman of the Medical
                     Staff Bylaws Committee.

        4.6.4.       Functions

                     4.6.4.1. The Medical Staff Bylaws Committee shall conduct at least an annual review of
                     the Medical Staff Bylaws and shall review such other Medical Staff documents as
                     requested by the MEC, Administration or the Board.




Organization & Function Manual of the Medical Staff                                                     15
                     4.6.4.2. The Medical Staff Bylaws Committee shall make recommendations to the MEC
                     concerning amendment of the Medical Staff Bylaws and/or the manuals and rules and
                     regulations of the Medical Staff.

                     4.6.4.3. The Medical Staff Bylaws Committee shall perform such other duties and
                     functions as are reasonably requested by the MEC, Administration or the Board.

                                          PART 5. ADOPTION, AMENDMENT, AND REPEAL

5.1.    METHOD OF ADOPTION, AMENDMENT AND REPEAL

         Manuals may be adopted, amended or repealed by the following action:

         5.1.1.     Adoption

                     This Manual may be adopted only by affirmative action of Board after the Manual is
                     approved by the MEC. This Manual is effective when adopted by the Board. Once
                     adopted, this Manual supersedes and replaces the provisions of any bylaws, policies,
                     procedures, rules, manuals, regulations, guidelines, and requirements by the Hospital or
                     its Medical Staff which were previously adopted and which are covered in this Manual.

         5.1.2.     Repeal

                     This Manual may be repealed, in whole or in part, only by Action of the MEC and
                     approval by the Board.

         5.1.3.      Amendment

                     Once adopted, this Manual may be amended by the MEC. Such amendments are
                     effective when approved by the MEC, but are to be reviewed by the Board and are
                     subject to repeal by the Board. If the Board chooses to repeal an amendment approval to
                     this Manual by the MEC, the Board shall notify the MEC of such repeal and the reasons
                     thereof.

APPROVED by the Medical Staff on_________________________ 1999.


                                                      _____________________________________________________
                                                      Chief of Staff




Organization & Function Manual of the Medical Staff                                                       16
THIS ORGANIZATION & FUNCTION MANUAL WAS ADOPTED by the Park Hospital Board of
Directors on _________________________, 1999.


                                                      _____________________________________________________
                                                      Chairman, Park Hospital Board of Directors




Organization & Function Manual of the Medical Staff                                                      17

				
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