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Policy and Procedure ManualChapter 200, Campus Organization and Management Responsible Department: Offices of the Chancellor and Provost Note: Effective July 1, 2007 through June 30, 2009, the authorities described as being held by the Provost and Executive Vice Chancellor for administration and operations of hospital and clinics and for acting as the Governing Body have been delegated to the Vice Chancellor--Human Health Sciences/Dean--School of Medicine. See UCD DA 500. The purpose of this section is to provide in a consolidated manner documentation of policies and procedures relating to operation of the University of California, Davis, Medical Center, Sacramento (UCDMC), Hospital & Clinics. With approval of the Chancellor and within the context of delegation from The Regents and the President, this section constitutes the bylaws of the Governing Body of the Hospital & Clinics as required by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), CMS Conditions of Participation, and the provisions of Title 22 of the California Code of Regulations, and shall serve to identify how governing body responsibilities of The Regents of the University of California, the corporation that is the licensed owner of the Hospital & Clinics, are fulfilled on the Davis campus and at UCDMC. This policy shall be reviewed by the Joint Management Council at least every two years and revised as necessary, subject to approval by the Chancellor. 1. The Hospital & Clinics shall be operated as a primary, secondary, and tertiary care teaching hospital/clinics. As a minimum, its range of services shall be sufficient to satisfy: a. Those teaching and research needs of the University of California, Davis, School of Medicine as determined by the Chancellor upon advice from the Vice Chancellor--Human Health Sciences/Dean--School of Medicine and faculty of the School; b. Legal requirements for hospitals and clinics of this classification; and c. The contractual obligations between The Regents of the University of California and the County of Sacramento. 2. The Hospital is licensed as a general acute care hospital with supplemental services and hospital-based clinics. It also has special permits to provide the following services: a. Burn center. b. Cardiovascular surgery service. c. Chronic dialysis service. d. Comprehensive emergency medical service. e. Intensive care newborn nursery service. f. Renal transplant service. g. Radiation therapy service. 3. The Hospital operates, under a separate State License, Home Care Services and Hospice Services. The Home Care program, in addition to skilled nursing, includes home health aid services, medical social services, occupational therapy, physical therapy, and speech therapy. B. Applicability of University policies University and Davis campus policies pertaining to personnel, financing, use of facilities, and other matters apply to the operation of the Hospital & Clinics, unless specifically excepted herein or in policies and procedures adopted by the Hospital administration or the Medical Staff and approved by the Provost and Executive Vice Chancellor as the Governing Body. C. Professional activities of physicians, dentists, psychologists, and podiatrists 1. Policies governing the professional activities of physicians, clinical psychologists, dentists, and podiatrists shall be developed by a self-governing organization known as the Medical Staff of the University of California, Davis, Health System, Sacramento. Bylaws of the Medical Staff organization are effective when endorsed by an appropriate action of its membership and approved by the Provost and Executive Vice Chancellor, acting as the Governing Body on behalf of The Regents through delegation from the President of the University and the Chancellor of the Davis campus. 2. The bylaws shall provide, as a minimum, that only members of the Medical Staff shall have admitting privileges and only Medical Staff with such privileges may admit patients. A Medical Staff member shall be responsible for diagnosis and treatment of patients only within the area of the member's privileges; each patient's general medical care is the responsibility of a physician member of the Medical Staff. The bylaws shall also specify the conditions under which persons in training programs or other professional personnel may provide medical care under supervision of a Medical Staff member. 3. Rules and regulations pertaining to implementation of the Medical Staff bylaws and to such other matters necessary to proper conduct of Medical Staff business shall be adopted in accordance with provisions of the bylaws. D. Hospital/Clinics administrative policies Policies relating to management of Hospital/Clinics administrative matters shall be adopted in a manner determined by the Chief Executive Officer--UCDMC and maintained in the UCDHS Hospital/Clinics Policies & Procedures Manual, for which online access (http://intranet.ucdmc.ucdavis.edu/policies/hosp/index.html) is in the Office of the Provost and Executive Vice Chancellor, acting as the Governing Body of the Hospital/Clinics. No policy that is less stringent than, or otherwise conflicts with, existing University or Davis campus policy may be adopted without prior approval by the Provost and Executive Vice Chancellor. A. Provost and Executive Vice Chancellor 1. The Provost and Executive Vice Chancellor is delegated governing body responsibility for the Hospital & Clinics. The selection and appointment of the Provost and Executive Vice Chancellor shall be in accordance with University and Davis campus policies and procedures pertaining to the UC Personnel Policies for Senior Managers Group. 2. The Provost and Executive Vice Chancellor shall be responsible for providing that governing body responsibilities required by JCAHO, CMS Conditions of Participation, and Title 22 of the California Code of Regulations are fulfilled. a. The Provost and Executive Vice Chancellor shall provide that this section of the UCD Policy & Procedure Manual is revised as necessary to comply with changes in JCAHO, CMS Conditions of Participation, or Title 22 regulations. b. The Provost and Executive Vice Chancellor shall receive periodic reports from the Chief Executive Officer--UCDMC and the Chief of Staff and shall review these and other reports to determine that the Hospital & Clinics are properly administered, that the safety management program is effectively maintained, that the quality improvement program is operating effectively, and that deficiencies in administrative, safety management, or patient-care activities are identified and actions taken for their correction. Reports from the Chief of Staff shall include: 1) Reports at least quarterly from the following Medical Staff Committees: Executive, Credentials and Privileges, Medical Records, Medical Staff Health, Quality of Care/Patient Safety, Invasive Procedures Review, Transfusion, Utilization Management, Infection Control, Pharmacy and Therapeutics. 2) Reports at least quarterly from the Environmental Health and Safety Programs and Practices Committee. 3) Reports at least annually from each of the clinical departments. c. The Provost and Executive Vice Chancellor shall be responsible for seeing that the activities of the Hospital & Clinics conform to applicable Federal, State, and local laws and regulations. 3. The Provost and Executive Vice Chancellor shall act upon all appointments and reappointments to and resignations from the Medical Staff within 60 days of receipt of recommendation from the Medical Staff Executive Committee endorsed by the Chief of Staff. Such recommendations shall be accompanied by certification that peer review has been accomplished by appropriate committees of the Medical Staff who have examined the credentials and performance records of the applicant and found them to be in compliance with Title 22 and Medical Staff bylaw requirements for the privileges to which the appointment or reappointment pertains. 4. In accordance with provision (f) of Bylaw 12.7 of the Board of Regents, the Provost and Executive Vice Chancellor shall report at least annually to the Chancellor, and through the Chancellor, to the President and the Board of Regents on significant matters relating to these governing body responsibilities. 5. The Provost and Executive Vice Chancellor shall provide that the Governing Body evaluates its own performance. The self-evaluation shall be accomplished annually by way of the Joint Management Council's annual report to the Chancellor and other reviews as appropriate. 6. The Provost and Executive Vice Chancellor shall provide appropriate medical sciences planning, ensuring coordination with the Hospital & Clinics, Medical Staff, and School of Medicine (referred to as the University of California, Davis, Health System--UCDHS). 7. The Provost and Executive Vice Chancellor shall be responsible for maintaining adequate interaction among administrative offices at the Davis campus, Office of the President, and Hospital & Clinics. Within the context of the University, campus, and Hospital & Clinics policies and subject to availability of funds, the Provost and Executive Vice Chancellor shall provide that timely responses are made to documented personnel, equipment, and other resource requirements of the Medical Center. 8. The Provost and Executive Vice Chancellor, as the Governing Body, shall be responsible for notifying the State Department of Health Services Licensing Division of any changes in licensed services listed in II.A, above. 9. The Provost and Executive Vice Chancellor shall facilitate coordination between the Medical School and the Hospital & Clinics. 10. To assist in fulfilling the duties described above, the Provost and Executive Vice Chancellor shall establish and chair a Joint Management Council comprised of at least the following members: Provost and Executive Vice Chancellor, Director and Senior Associate Director of Hospital & Clinics--Patient Care Services, Vice Chancellor--Human Health Sciences/Dean--School of Medicine and Executive Associate Dean--Academic Affairs of the Medical School, Chief of Staff, and Chief Medical Officer. The Committee shall meet at least quarterly and shall maintain records of matters discussed and actions taken. 11. The Provost and Executive Vice Chancellor shall act upon recommendations from the Medical Staff relating to Medical Staff issues (e.g., appointments to membership) within a reasonable period of time. The Provost and Executive Vice Chancellor shall not take an action contrary to such recommendations without first discussing the matter with the membership of the Joint Management Council and based upon the advice of its members, especially that of the Chief of Staff and Chief Medical Officer, providing an opportunity to discuss the rationale for his/her proposed action with the Executive Committee of the Medical Staff. B. Medical Staff 1. The Medical Staff bylaws shall provide procedures for evaluation of candidates for membership of the Medical Staff in accordance with the requirements of Section 70703 of Title 22 of the California Code of Regulations. a. Nominations for membership shall be forwarded to the Chief of Staff by the appropriate department chair; the Chief of Staff shall arrange for evaluation of credentials and other information by an appropriate committee of the Medical Staff, which shall forward its recommendations to the Executive Committee of the Medical Staff. Upon action by the Executive Committee, the nomination shall be endorsed by the Chief of Staff and transmitted to the Provost and Executive Vice Chancellor for approval. Documentation shall include the privileges for which membership is requested and certification by the evaluation committee that the candidate's capability relating to each of these privileges has been examined. b. Recommendations for reappointment to the Medical Staff shall follow the same procedures outlined above and shall provide evidence of the candidate's completion of continuing education or other requirements necessary to satisfy regulations pertaining to the privileges for which reappointment is being recommended. c. The Medical Staff and appropriate administrative officers shall observe UC policies pertaining to nondiscrimination. 2. The Medical Staff bylaws shall provide for appointment of standing and special committees sufficient, as a minimum, to fulfill the requirements of JCAHO, CMS Conditions of Participation, and Title 22. The Executive Committee shall be charged with responsibility to see that all committees properly fulfill their responsibilities. The Executive Committee shall review all committee and departmental minutes. 3. The Chief of Staff and the Chief Executive Officer--UCDMC shall provide that the reports required under III.A.2.b and III.B.2, above, shall include, but not be limited to, information necessary to document implementation of an effective quality improvement/patient safety program. The reports shall contain description of significant deficiencies identified in the patient-care system and actions taken or to be taken for their correction. 4. The Medical Staff shall share responsibility with the Hospital administration for the maintenance of accurate medical records sufficient, as a minimum, to comply with requirements of JCAHO, CMS Conditions of Participation, and Title 22. 5. Medical Staff members shall be responsible for calling to the attention of their department chair any matter that in their judgment influences the ability to provide quality patient care. The department chair shall transmit the information and, when appropriate, recommendations for action to an appropriate administrative office, or if the information is a Medical Staff matter, to the Chief of Staff or Chief Medical Officer, and/or to the Chief Executive Officer--UCDMC, and/or to the Vice Chancellor--Human Health Sciences/Dean--School of Medicine. The Chief of Staff, Medical Director, CEO, and Vice Chancellor/Dean shall establish procedures to assign action on each issue so identified and to provide a timely response to the department chair. Major quality of care issues shall be items for discussion by the Joint Management Council, which will also make appropriate assignments of responsibility for action when necessary. 6. The Executive Committee of the Medical Staff, in cooperation with the Chief Medical Officer and the Chief Executive Officer--UCDMC, shall be responsible for compliance with all provisions of the bylaws of the Medical Staff and for providing comprehensive review, and as necessary, proposals for amendment of these bylaws at least annually. 7. The Chief of Staff, who is the elected leader of the Medical Staff and the Chair of the Executive Committee, shall be responsible for compliance with these delegations and with implementation of provisions of the bylaws, rules, and regulations of the Medical Staff. The Chief of Staff shall be assisted in fulfilling these responsibilities by the Chief Medical Officer, who shall be appointed by the Chancellor after consultation with the Vice Chancellor--Human Health Sciences/Dean--School of Medicine, CEO, and Chief of Staff. The Chief of Staff may delegate any of his/her assigned duties to the Chief Medical Officer. C. Chief Executive Officer--UCDMC 1. The Chief Executive Officer--UCDMC is the chief executive officer of the Hospital & Clinics. The selection and appointment of the CEO shall be in accordance with University and Davis campus policies and procedures pertaining to the UC Personnel Policies for Senior Managers Group. 2. Under the delegation from the Provost and Executive Vice Chancellor, the CEO has operational and financial authority for the ongoing management of the Hospital & Clinics within the policies of the University and guidelines established by any specific functional (e.g., personnel) delegations. The CEO shall be accountable for satisfying requirements of JCAHO, CMS Conditions of Participation, and Title 22 pertaining to physical facilities and other administrative matters. The CEO shall communicate with the State Department of Health Services on matters relating to operations with the exception of licensing matters described in III.A.6, above. In cooperation with the Chief of Staff and the Vice Chancellor--Human Health Sciences/Dean-School of Medicine, the CEO shall provide that requirements relating to quality of patient care and patient safety are satisfied. 3. The CEO shall be responsible for compliance with applicable University and Davis campus policies in Hospital & Clinics operations and for developing and implementing, in accordance with the process described in II.B, above, appropriate policies and procedures specific to the Hospital & Clinics. 4. In cooperation with the Chief of Staff, the Chief Medical Officer, and the Executive Committee of the Medical Staff, the CEO shall develop procedures to effect compliance with the bylaws and rules and regulations of the Medical Staff. It is assumed that such compliance will be managed largely through the chairs of clinical departments acting under delegations from the CEO and Vice Chancellor--Human Health Sciences/Dean--School of Medicine; such delegations shall include, but not be limited to, performance of duties specified in the bylaws of the Medical Staff. 5. The CEO shall recommend to the Chancellor appointment of Senior Managers and Managers and Senior Professional employees in accordance with University and Davis campus personnel policies pertaining to these programs. The CEO shall appoint other administrative officers as required and in accordance with established personnel policies. 6. The CEO and the Vice Chancellor--Human Health Sciences/Dean--School of Medicine shall recommend jointly to the Chancellor the names of individuals to serve as chairs and vice chairs of medical service departments. In accord with provisions of the Medical Staff bylaws, unless otherwise provided, each clinical department chair shall be chair of the equivalent department in the School of Medicine. D. Vice Chancellor--Human Health Sciences/Dean--School of Medicine The Vice Chancellor/Dean shall share with the Chief Executive Officer--UCDMC and the Chief of Staff responsibility for the quality of care and for provision of reports to the Provost and Executive Vice Chancellor, as the Governing Body, on the quality of medical care and steps undertaken to correct deficiencies. Although matters relating to patient care and Hospital/Clinics management are delegated primarily to the Medical Staff and the Chief Executive Officer--UCDMC, the inseparable nature of patient care with teaching and research activities and the primacy of the Vice Chancellor/Dean's role in selection, recruitment, and evaluation of Medical Staff require participation by the Vice Chancellor/Dean in matters relating to quality of patient care and patient safety. Copyright © 2006 The Regents of the
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