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Medical staff duties and responsibilities

ملتقى الجودة وسلامة المرضى
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  #1  
قديم 02-08-2011, 03:21 PM
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تحسين الآداء will become famous soon enough


DUTIES AND RESPONSIBILITIES

Medical Director
  • Conduct ongoing review of department policies and procedures used in Medical Services, and the provision of patient care.
  • Serve as a liaison between members of the Medical Staff, Hospital Administration, Nursing Personnel and Ancillary Clinical Services personnel.
  • Make patient rounds with Medical Services personnel to observe patient responses, treatment and medications, pre******ions, use of equipment, and review patient records.
  • Reviews and approves policies and procedures written by the Department Heads.
  • Encourage Medical Services personnel to pursue continuing education.
  • Recommend use of specific equipment to enhance delivery of Medical Services.
  • Certify medical direction for the purpose of licensure and/or registration of Medical Services personnel.
  • Participate in the hospital Performance Improvement program, which includes review of all aspects of the Medical services.
  • Evaluate and ensure clinical competency of all clinical members of medical staff.
  • Ensure quality and safety of medical services through monitoring and evaluations, and verify that appropriate action is taken based on findings of such evaluations.

Department Head

1. Cooperate with other head of the department both professionally and administratively.
2. Correlate and coordinate the medical, nursing and administrative duties in the conduct of work in the department.
3. Monitor the competence professional behavior and medical ethics of members in the department.
4. Planning and organizing continuous medical education and in-service training for all individuals who provide care within the department. In-service training shall be based, in part, on the results of monitoring and evaluation activities.
5. Performs management activities, such as interviewing, hiring, termination and assessment of staff clinical competency.
6. Recommends appointments and transfer of various staff members.
7. Appoint committees/teams to conduct departmental affairs and appoint a deputy to represent him during his absence.
8. Arrange and chair the monthly departmental meetings.
9. Evaluate and assess the work performance of the Consultants, Specialists and Residents.
10. Approval of evaluations and recommendations for the Specialists and Residents done by the concerned Consultants.
11. Recommends the type and amount of physical resources (equipments, machines etc.) necessary to meet the medical care needs of the patients.
12. Ensures compliance with policies and procedures regarding department operations, fire, safety and infection control.
13. Works at maintaining a good rapport and a cooperative working relationship with physicians, departments and staff.
14. Resolves personnel concerns at the department level, utilizing the grievance process as required.
15. Maintains performance improvement, Continuous Quality Improvement and quality control activities for department.
16. Communicates the mission, ethics and goals of the hospital as well as the focus statement of the department.
17. Attends committee, CQI and management meetings as appropriate
18. Complies with all organizational policies regarding ethical business practices

Consultant

1. Primary responsible for the whole patient care, plan and management including emergency and plan operations.
2. Performs at least two rounds daily, morning round with main unit and afternoon round with his team.
3. Act as the decision maker after discussion with other consultant in his units and his team doctors.
4. Decides when patient will be discharge.
5. Takes regular on-call as planned by Department Head.
6. Supervision and training of Specialists, Residents, Interns and update Head of Department about their progress.
7. Continuously assess Specialists, Residents, Interns and give feedback to the Head of the Department about his team.
8. Provides time for discussion, teach in daily rounds and train his team in various skills focusing especially with Saudi/ Arab boards candidates, Royal Colleges fellowship trainees and interns and sign the logbooks for them.
9. Supervise and check the clerking, discharge summaries and daily progress notes.
10. For urgent consultation the consultant discusses the case with the referring consultant.
11. Attends their clinic on time and according to the schedule.
12. Attends to other wards to see the referred cases and do follow – up as necessary.
13. Endorse to the On Call Consultant the serious critically ill patients.
14. Follow – ups his patients mortality report and reviews it and discusses in the Department meeting to be prepared for discussion within the intra department mortality and morbidity meetings.
15. Participates in hospital teaching program with other departments and presents periodic topics in Tuesday lectures.
16. Participate in the Quality Improvement activities in the hospital.


Specialist

Supervises the Residents.
Help in the clerking and discharge summaries in case there is no Resident or if the Resident is attending to other patient.
Shares in the planning, work-up and management of the patients performing and assisting the surgery under the supervision of the Consultant.
Cover Specialist Clinic in Outpatient Department.
Communicate and arrange for the procedures or appointment with other Consultants or hospitals.
Arrange for inter hospital referral and transfer of patients.
Takes on-call duty as approved by Head of the Department.
Discusses the provisional diagnosis, differential diagnosis, investigations and plans of management with his resident during the duty calls for each admission from the ER as well as instruct him regarding results for follow up.
Attends the daily ward rounds in the morning and document it in the file.
Supervises the Residents and Interns regarding presentation during the grand rounds and present the cases in the absence of the Resident of the unit.
Sees consultations from other departments and informs the consultants (to see the case and follow-up)
Conducts teaching programme for residents, interns and nurses staff.
Ensures a close follow up of their patients and the outcome of management.
Writes and presents the morbidity and mortality meetings in the department.
Writes medical reports for cases when requested by the Consultants.
Endorses each cases and consultations to the incoming team before going off duty.
Participates in the Quality Improvement activities of the hospital.

Resident Surgeon

Check patient’s blood pressure, pulse and temperature by himself.
Responsible for clerking, discharge summary, ICD coding and daily progress notes.
Attends two rounds daily (morning and afternoon) with the Consultants.
Do evening rounds during the on-calls.
Write request for investigations and follow up results of the investigation such as: Histopathology results, Ultrasounds, X –Rays and etc.
Sign results of investigations upon receipt with date and time before inserting it in the patient record.
Present cases admitted in the previous 24 hours during the morning meetings.
Present the cases of the unit in the grand rounds.
Attends OPD clinics to help the consultant in the absence of Specialist.
Informs the Specialists about new arising problems, result of investigations and critical decision related to patient care.
Actively involved in continuous education of the department and hospital educational programs.
Accompany patient during interhospital transfer.

منقول
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مشاركة في فيسبوك مشاركة في تويترمشاركة في قوقل بلص


من مواضيعي : تحسين الآداء
  رقم المشاركة : [ 2 ]
قديم 02-08-2011, 03:24 PM
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تحسين الآداء will become famous soon enough
افتراضي Medical Record Documentation Guidelines

  • Discharge summary should include a detailed de******ion about all the events during the entire course of hospitalization especially for long stay patients.
  • All forms of documentation in the patient records must be legible and clearly readable to ensure appropriate and safe delivery of medical care.
  • The Diagnostic specification of patient in ER should be more accurate especially for the ones which are referred to the specialist on call & discharged home. There should be appropriate justifications for ordering laboratory and radiological investigations for patient who receive management in Emergency.
  • Provisional Diagnosis (es) should always be documented on History and Physical examination (Form No. 4) and the Consultant in-charge must countersign it as a routine in line with the hospital documentation policy.
  • The plan of management for emergency admission should be either documented personally by the Consultant in-charge or reviewed and countersigned by him/her at the earliest possible time after patient admission. This should be applicable to all the patients admitted during working hours and all high risk and critically ill patients on a 24 hour basis.
  • Pre******ion of medications whether in patient, Out patient or Emergency should generally based on specific clinical indications.
  • The Consultant in-charge should either document the progress notes personally countersign it once everyday.
  • Diagnosis (Primary & Secondary) and surgical procedure(s) should be documented correctly in ICD Coding Form 8. This will help in the allocation of specific ICD code to the diagnosis as well as surgical procedures by the ward clerks and ICD secretary. Almost all the ICD codes are available in the Hospital Information System (HIS) for instant review and confirmation.
  • All patient consultations should be countersigned by the consultant un-charge during the official working hours. The Consultant on-call must personally see the patient for evaluation and further follow-up. After the working hours, only urgent consultations should be ordered, they can be countersigned by the Specialist on-call. The Consultant on-call should be informed and his opinion incorporated in the management plan of the patient.
  • In cases where the Specialists encounter doubts in eliciting the required physical signs to make a correct diagnosis, they must seek immediate opinion of Consultant to safeguard the interests and rights of patient and also improve their own clinical judgment.
  • The Consultant in-charge must ensure that upon discharge of patients from hospital care, the referral letter from Primary Health Care should be completed. It is done for two purposes; feedback to the concerned Primary Health Care and cancellation of the particular referral episode.
  • The legibility of documentation need to be improved with more consistency to achieve desired Quality Improvement standards.
  • The “SOAP” criteria for documentation of progress notes should be implemented to ensure better organization, presentation and interpretation of Medical Records.
  • Transfer of management for further care for in-patients to another consultant should be documented by the primary consultant in-charge in the file. This documentation should be timed dated and authenticated by signature and stamp of the endorsing Consultant.
  • The use of liquid erasure in all forms of documentations should be prohibited.
  • The Consultant in-charge must review the discharge summary for the accuracy and adequacy of its contents.
  • The Consultant in-charge must ensure that comprehensive plans for management are documented in the patients file at the time of admission as discharge.
  • Consultations and referrals should be countersigned by the Consultant in-charge and based on adequate justification in terms of their contribution towards improved patient care.
  • The policy for the conversion of patients status (whether admitted or accepted for transfer) from urgent to non-urgent should be made more clear for proper implementation. This needs better coordinated efforts between Heads of Clinical Departments and Hospital Administration.
  • The process of history taking has to be more specific and detailed both for acute as well as chronic cases.
  • Accurate history and systematic physical examination should be used as a fundamental basis to make working provisional diagnosis/es which is appropriate and relevant to the case.
  • Attempts should be made to follow a consistent pattern with the use of Standards Medical Nomenclature with regards to the documentation of Diagnosis.
  • Patients presenting to the Emergency with acute significant illness (chest pain etc.) should be referred for further evaluation to the concerned Specialist on-call.
  • Discharge summary should contain some details about the subsequent status of premature babies delivered by Cesaerian section.
  • The Heads of Clinical Departments should ensure that the progress notes are documented in line with the “SOAP” criteria,
All Laboratory results should be signed and stamped by the
doctors who seen it before filing in the patient’s file
منقول
من مواضيع : تحسين الآداء
تحسين الآداء غير متواجد حالياً  
  رقم المشاركة : [ 3 ]
قديم 02-08-2011, 11:48 PM
صحي نشط
 

تحسين الآداء will become famous soon enough
افتراضي Medical Staff By laws



PURPOSE
1. To define the functions, rules and regulations related to the Medical staff in relevance with the objectives of the medical staff as mentioned below:

1.1 To ensure that patients treated in the hospital, inpatient and outpatient settings, receive appropriate and quality medical attention and care.

1.2 To conduct self-governance of the Medical Staff in conformity with the MOH

1.3 To provide adequate ways and means to communicate officially among medical staff, the Hospital and the Directorate of Health Affairs.

1.4 To provide peer evaluation and review of the credentials and performance of applicants to the Medical Staff and members thereof through processes such as credentials review, delineation of individual clinical privileges, ongoing quality assurance and improvement, risk management, and other functions, and to advise the Executive Committee on appropriate matters.


DEFINITIONS
For the purpose of these By laws, the following terms shall have the meaning stated, unless the context clearly requires otherwise. The meanings shall equally applicable to the masculine and feminine, singular and plural forms.
Board means the Admin Board of the HOSPITAL.
Clinical Privileges means authorization by the Board of the Hospital following recommendation by appropriately authorized committees of the Medical Staff to provide specific patient care and treatment services at the Hospital, based on the individuals license, education, training, experience, competence and judgment.
Head of Department means the individual charged with the medical direction of a Division.
Resident means an individual pursuing specialty qualified and licensed under the supervision of specialist and consultant who holds such licenses as are required by the Kingdom to provide patient care services.
Hospital means ........ HOSPITAL
Medical Staff means the physicians, dentist, and other practitioners herein specified who have been granted membership on the Medical Staff with clinical privileges to attend patients at the Hospital.
Medical students/ intern means an individual enrolled in an undergraduate training program affiliated with the HOSPITAL.
Peer Review means the process that includes monitoring, evaluation, or action taken to improve the delivery, quality and efficiency of health care services of the HOSPITAL, including but not limited to recommendations, consideration of recommendations, actions with regard thereto, the implementation of these action.
Physician means an individual who has received a doctor of medicine degree and who is currently fully licensed in the Kingdom to practice Medicine.
Nursing Staff means certified nurse practitioners and certified nurse-midwives who are authorized to provide patient care services in the Hospital because they are employees of the Hospital or otherwise have defined responsibilities under contractual relationships.
“Contractual relationships” means formal contractual relationships between the Hospital and other institutions, organizations, groups, or physician members of the Medical Staff, which contracts have been approved by the appropriate Department Head and by the Hospital officials.
Technateint this means staff assigned to perform specific technical and instrument task ( directly or indirectly) related to patient care supervision or unsupervide.

Whenever any provision of these Bylaws assigns authority or responsibility to any named official: (a) such provision shall apply to the official who in fact exercises substantially such authority or responsibility, regardless of remaining of such position or reallocation of other authorities or responsibilities, and (b) such provision shall mean that such authority or responsibility may be exercised by such official or his/her designee(s) unless these Bylaws require that a given task be performed personally.

POLICY

1. Composition of the Medical Staff and Membership:
1.1 Membership is a Privilege: Membership on the Medical Staff and individually delineated clinical privileges are benefits or privileges granted by the Admin Board, on the recommendation of the Medical Staff, extended to those individuals who are duly licensed in the Kingdom of Saudi Arabia, who are competent in their respective fields, and who continuously meet the qualifications, standards and requirements of these Bylaws. Membership and clinical privileges are not rights, licenses or entitlements of any person. Gender, race, creed and national origin are not used to make decisions regarding granting or denying of medical staff privileges. Members of the Medical Staff may perform only those services and functions, as they are authorized in their individually delineated clinical privileges, and only so long as their privileges continue in effect and unencumbered, as provided in these Bylaws.
1.2 Categories of Medical Staff: the Medical Staff shall consist of Active, Courtesy, Provisional, Administrative, Leave of Absence and Retired staff. Specific Clinical privileges to admit, attend or to render other services are indicated by the category of membership as delineated by the Medical Staff.
1.2.1 Active (permanent/contracted): The Active Staff shall consist of those members who have been granted appointments and clinical privileges in accordance with these Bylaws, frequently use the Hospital facilities, satisfactionally assume the duties and responsibilities of Active Staff membership and who have been members of the Provisional Staff for twelve months preceding their advancement to Active Staff, unless such period is waived on the recommendation of the Credentialiy and Privilegis and Executive Committees. Such individuals are privileged to admit and/or treat patients in the Hospital as set forth in their delineation or clinical privileges.
1.2.2 Courtesy (locum): The Courtesy staff shall consist of members otherwise eligible for Active Staff membership and who have been granted appointments and clinical privileges in accordance with these Bylaws. Such individuals are privileged to admit and/or treat for patients defined period of time. Courtesy staff members are not allowed to be part of the Executive Committee. In the event the Courtesy staff wishes to be Active member of the Medical staff, he/she may apply.
1.2.3 Provisional: The Provisional staff shall consist of those members who have been granted an initial appointment and clinical privileges in accordance with these Bylaws. Assignment to the Provisional Staff shall be not less than twelve months from the date of initial appointment, unless suspended or canceled for due cause. Such individuals are privileged to admit and/or treat patients as set forth in the delineation of Clinical Privileges. Provisional staff may also include those members of the Medical Staff who have been subject to an action to restrict the member’s staff status or clinical privileges as set forth in these Bylaws. During the provisional appointment period, the performance and clinical competence of the Medical Staff member shall be reviewed by the responsible department head(s). At the recommendation of the responsible Head(s), such provisional appointment may be, but need not be, extended for a period not to exceed one additional year. In the event of an adverse decision to appoint the Medical Staff member to Active or Courtesy status, the membership and clinical privileges of the Provisional Staff member shall be terminated, upon written notice to him/her by the Medical Director stating the reasons for the adverse decision.
1.2.4 Administrative: The Administrative staff shall consist of those Medical Staff members who serve the Hospital in assuming administrative responsibilities, by employment or contract. They participate fully as members of the Medical Staff.
1.2.5 Leave of Absence Status( Unpaid Leave): Individuals on Medical Staff in an Active, Provisional, Courtesy or Administrative status may convert their status to that leave of absence for a period not to exceed one year. Request s for such conversion shall be made in writing to the Medical Director through the appropriate Department Head.
1.2.6 Retired: The retired staff shall consist of individuals who no longer practice at the Hospital because of retirement or disability. Conversion to Retired status may be granted by the Medical Director upon the request of the individual and concurrence by the Department Head. Retired Staff are not eligible to practice in the Hospital, but they may serve upon committees, departmental meetings and educational programs.


1.3 Medical Staff Structure:
Membership on the Medical Staff in Hera General Hospitals follows the organization structure mentioned below:
1.3.1 Medical Director
1.3.2 Executive Committee
1.3.3 Head of Departments
1.3.4 Consultants
1.3.5 Specialists
1.3.6 Residents
1.3.7 Medical Students and interns

1.4 Medical Staff Related Committees:
1.4.1 Credential and Appointment Committee
1.4.2 Drug Utilization Review Committee
1.4.3 Mortality and Morbidity Committee
1.4.4 Blood Usage Review Committee
1.4.5 Cardio Pulmonary Resusitation Committee
1.4.6 Cancer Committee
1.4.7 Pharmacy and Theraputic Committee
1.4.8 Quality Mangement Committee
1.4.9 Tissue Committee
1.4.10 Safety Committee
1.4.11 Operating Room Committee
1.4.12 Medical Records Committee
منقول
من مواضيع : تحسين الآداء
تحسين الآداء غير متواجد حالياً  
موضوع مغلق

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