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Bahamas Statutory Instruments |
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MINISTRY OF HEALTH |
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S.I. No. 92 of 2003 |
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THE PUBLIC HOSPITALS AUTHORITY ACT |
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(CHAPTER 234) |
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THE PUBLIC HOSPITALS AUTHORITY |
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(MEDICAL STAFF) BYELAWS, 2003 |
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The Minister in exercise of the powers conferred by section 6 of the Public Hospitals Authority Act, makes the following Byelaws - |
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PART I |
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PRELIMINARY |
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1.
These Byelaws may be cited as
the Public Hospitals Authority (Medical Staff) Byelaws, 2003.
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Citation. |
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2.
In these Byelaws -
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Interpretation. |
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"admitting privileges" means the admission, attendance, treatment and discharge of a patient to, in or from a hospital in accordance with the physicians hospital rights and privileges; |
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"Authority" means the Public Hospitals Authority established under the Public Hospitals Authority Act; |
Ch. 234. |
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"Chief of Department" means the head of a clinical department and .includes any person appointed to act as head of a clinical department; |
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"Chief of Staff' means the person appointed to head the Medical Staff and includes any person appointed to act as head of the medical staff, (previously referred to as the Medical Staff Coordinator); |
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"clinic patient" means a person who is admitted and registered in a hospital or who has received treatment at a hospital for a period of less than twenty-four hours; |
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"Council" means the group of physicians who are the executive officers of the Medical Staff Association; |
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"Credentials Committee" means the group of persons who consider applications for appointments by medical personnel; |
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"dental services" means services performed by dental surgeons in the clinical department of dentistry; |
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"Director of Services" means the Consultant with responsibility for a unit within a general speciality area; |
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"Executive Management Committee" means the senior management team responsible for overseeing all the day-to-day operations of the hospital; |
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"in-patient" means a person who is admitted and registered in a hospital or who has received treatment at a hospital for a continuous period exceeding twenty-four hours; |
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"junior staff' means physicians below the rank of Consultant who, with the exception of Senior registrars, are usually not certified as Boarded/Fellowship trained in a given medical specialty; |
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These include Senior Registrars, Registrars, Senior House Officers and Interns (see also Resident House Staff); |
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"Locum Tenens" means a medical officer who is appointed to perform a specific function for a limited time period only; |
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"Medical Advisory Committee" means the group of senior physicians who advise the hospitals' Executive Management Committee via the office of the Medical Chief of Staff; |
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"medical or clinical records" means the records of a patient compiled in a hospital by medical practitioners, nurses and allied professional persons, relating to their care and treatment, medical investigations and personal and administrative matters; |
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"medical/patient care" refers to activities that are directly related to the care given by a medical practitioner, |
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"medical practice" means the management and treatment of patients at a hospital of the Public Hospitals Authority and includes the practice of dentistry; |
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"medical staff" means physicians who are appointed to the staff of a hospital (including dental surgeons) who hold the privilege of attending patients in the hospital; |
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"policies and procedures" means the Medical Byelaws, Policy and Practice Guidelines, Physician Reform Document and other rules and regulations of the Public Hospitals Authority"; |
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"private patient" means a person who receives private services at a hospital and who compensates the medical practitioner for his services either directly or by way of private insurance or other non-national insurance coverage or contract; |
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"resident house staff" means a member of the medical staff whose employment in the Public Hospitals Authority requires that they remain in the hospital during their respective hours of duty; |
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"rights and privileges" mean the rights and privileges extended to a member of the medical staff as prescribed by law; |
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"Senior Registrar" means a postgraduate specialty qualified member of the medical staff without ultimate responsibility of a patient; under the supervision of an active Consultant staff member, or head of department; with voting rights in the Medical Staff Association but who will not hold office therein. |
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PART II |
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3.(1)
The Medical Staff shall
comprise the following categories -
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Categories of appointments. |
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(a)
active staff-comprising all
categories of physicians appointed by the Authority -
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(i)
Consultants;
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(ii)
Senior Medical Officers;
and
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(iii)
Junior Physicians - who include,
Senior Registrars, Registrars, Senior House Officers and
Interns;
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(b)
courtesy staff- comprising all
other categories of physicians who are not members of the active
staff and who have limited rights
and privileges -
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(i)
private practitioners;
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(ii)
part-time consultants;
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(iii)
temporary/visiting staff;
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(iv)
locum tenens; and
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(v)
Honorary Physician staff.
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4.(1)
The active staff refers to
physicians applying for appointment as an active staff member and
who may be appointed for a probationary
period if the Authority so
requires.
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Active Staff. |
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(2)
All active staff members are
responsible for ensuring that medical care is provided to all
patients in the hospital.
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(3)
All active staff members shall
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(a)
perform professional services
(treatment and operative procedures) for patients only to the
extent permitted by the privileges granted
by the Authority;
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(b)
be a member or the chairperson of
any committee of the medical staff and hold any position as elected
by the medical staff but only
in accordance with the privileges
granted to their category of appointment as stipulated in these
byelaws;
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(c)
if eligible, vote at meetings of
the medical staff association or at any committee on which they
hold membership;
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(d)
assume the responsibilities and
perform the duties of the medical staff to promote appropriate
patient care either directly or through
committees in keeping with
their category of appointment as provided by these bye-laws;
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(e)
act as supervisor of a member of
the medical or dental staff, which may include medical students as
and when requested by the Chief
or Staff or the Chief of
Department;
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(f)
attend meetings of the medical
staff as required; and
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(g)
abide by the Authority's policies
and procedures.
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5.(1)
The appointment of Senior
Medical Officers will be granted to -
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(a)
members of staff who have
fulfilled some years of specialist training, although they may not
have acquired the specialist certification
by one of the Specialist
Boards/Fellowships or University graduate degree recognized by the
Authority;
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(b)
a senior member of the house
staff with a prerequisite number of years in a given specialty
department and judged competent in that
specialty by the active
consultant medical staff for members for that specialty;
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(c)
the Chief of Department or the
Chief of Staff must recommend this application and the Medical
Advisory Committee must approve it before
the recommendation is
submitted to the Authority;
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(d)
a Senior Medical Officer will be
granted limited private practice within the department under the
supervision and permission of the
Chief of the Department in
accordance with the type of privileges granted by the Authority on
the recommendation of the Medical Advisory
Committee;
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(e)
a Senior Medical Officer shall
work under the supervision of an Active Consultant Medical Staff or
the Chief of the Department.
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(2)
Senior Medical Officers may
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(a)
perform professional services for
patients to the extent permitted by the privileges granted;
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(b)
attend meetings of the Medical
Staff Association;
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(c)
not hold office in the Medical
Staff Association;
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(d)
sit and vote on committees if
required to attend by and on behalf of the Chief of Staff or Chief
of Department; and
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(e)
vote at meetings of the Medical
Staff Association.
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(3)
Members shall abide by the
Authority's policies and procedures.
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(4)
Ensure that appropriate
arrangements are made for the ongoing care of patients.
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6.(1)
A Senior Registrar shall work
for a probationary period under the supervision of an active
consultant medical staff member named by
the Chief of Staff or the
Chief of Department to which they are assigned.
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Senior Registrar |
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(2)
Subject to the provisions of
byelaw 7(4) a Senior Registrar may be permitted to have limited
private practice.
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(3)
All Senior Registrars shall
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(a)
perform professional services
(treatment and operative procedures) for patients only to the
extent permitted by the privileges granted
by the Authority and
only under supervision and/or permission of an active staff medical
member, Chief of Department or Chief of
Staff;
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(b)
be a member, but not the
chairperson of any committee of the medical staff and hold any
position as elected by the medical staff;
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(c)
vote at meetings of the medical
staff or at any committee on which they hold membership;
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(d)
assume the responsibilities and
perform the duties of the medical staff to promote appropriate
patient care either directly or through
committees as provided by
these Bye-laws;
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(e)
act as supervisor of a member of
the medical or dental staff, which may include medical students as
and when, requested by the Chief
of Staff or the Chief of
Department;
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(f)
attend meetings of the medical
staff as required by the rules;
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(g)
abide by the Authority's policies
and procedures;
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(h)
on receipt of an unfavorable
report the Medical Advisory Committee reserves the right to
recommend the termination of the Senior Registrar's
appointment.
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(4)
The Medical Advisory Committee
shall, on receipt of a complaint regarding a Senior Registrar,
refer the matter to the Disciplinary
Committee which shall
investigate the matter and upon its finding, make its
recommendations.
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7.(1)
The duties of the junior
physician shall apply to both public and private patients. The
junior physician will be expected to respond
to the care of all
patients attached to their direct attending/Consultant Staff
services and to all patients requiring medical attention
during
their "on-call", on the ins, ructions of the Admitting
Physician.
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Junior Physicians. |
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(2)
A junior physician -
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(a)
shall work under the supervision
of senior medical staff members above his/her rank;
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(b)
shall provide medical care to all
patients in the hospital who are under the care of their senior
staff and undertake such duties
in respect of those patients
classed as emergency cases as may be specified by the Chief of
Staff or the Chief of Department to which
they have been
assigned;
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(c)
may attend meetings of the
Medical Staff Association;
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(d)
with the exception of interns,
will have voting privileges and may be elected to the posts of
Secretary and Treasurer in the Medical
Staff Association;
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(e)
may sit and vote on committees if
required to attend by and on behalf of the Chief of Staff or Chief
of Department;
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(f)
shall perform all the duties of
the medical staff to promote appropriate patient care provided by
these Byelaws;
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(g)
abide by the Authority's policies
and procedures;
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(3)
Any junior physician employed
after the coming into force of these Byelaws shall not be allowed
to engage in independent private practice.
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(4)
A junior physician who,
immediately before these Byelaws came into force, was engaged in
independent private practice may continue
to operate that practice
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(a)
during the period of six months
commencing from the date of the coming into force of these
Byelaws;
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(b)
if within the six months period
application is made for permission to continue in the independent
private practice the junior physician
may continue to do so until
the application is finally disposed of or withdrawn.
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(5)
For the purpose of this
byelaw, "independent private practice" means a practice operated by
a physician on his own without any approved
on-site
supervision.
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8.(1)
A Courtesy Staff post may be
offered to physicians who have active staff appointments in other
regions or jurisdictions. It shall
include physicians who establish
consultant clinics or perform itinerant services in any of the
Authority's facilities and physicians
who, for geographic reasons,
have part of their practice in another region or
jurisdiction.
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Courtesy Staff. |
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(2)
Members of the Courtesy Staff
may -
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(a)
perform professional services for
patients to the extent permitted by the privileges granted;
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(b)
attend meetings of the Medical
Staff Association;
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(c)
not hold office in the Medical
Staff Association; but part-time consultants may vote at Medical
Staff Association meetings;
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(d)
sit and vote on committees if
required to attend by and on behalf of the Chief of Staff or Chief
of Department.
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(3)
Members of the Courtesy Staff
shall abide by the Authority's policies and procedures and ensure
that appropriate arrangements are
made for the on going care of
their patients.
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9.(1)
This category will include all
physicians seeking to access Authority's resources and/or provide
patient services and who are not
otherwise appointed in accordance
with these Byelaws.
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Temporary Visiting Staff. |
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(2)
Such appointments may be
granted to a physician for a defined time and for a specific
purpose detailed in the appointment. Once. the
specific time or
purpose has come to an end, the physician shall cease to be a
member of the medical staff.
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(3)
An appointment to temporary
status will not bestow any additional rights, after expiry of that
temporary status, other than those
that would be available to an
applicant on a subsequent application for appointment to become an
active member of staff.
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(4)
Members of the
Temporary/Visiting Staff may -
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(a)
perform professional services for
patients to the extent permitted by the privileges granted;
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(b)
not hold office in the Medical
Staff Association or be a member of any hospital committee;
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(c)
not vote nor be required to
attend meetings of the Medical Staff Association.
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(5)
Members shall assume all
responsibilities and perform all the duties of the medical staff to
promote appropriate patient care provided
by these Byelaws and
abide by the Authority's policies and procedures.
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10.(1)
The Medical Advisory Committee
upon the request of a member of the medical staff may recommend the
appointment of a locum tenens as
a planned replacement for that
physician for a specified period of time.
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Locum Tenens. |
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(2)
A locum tenens shall -
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(a)
have admitting privileges unless
otherwise specified;
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(b)
work under counsel and
supervision of a member of the active consultant medical staff who
has been assigned this responsibility by
the Chief of Staff or
his/her delegate;
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(c)
attend patients assigned to
his/her care by the active Consultant medical staff member(s), and
shall treat them within the professional
privileges granted by the
Authority on the recommendation of the Medical Advisory
Committee;
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(d)
abide by the rules of the
Authority and the Byelaws specified under Temporary/Visiting
Medical Staff;
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(e)
assume all responsibilities and
perform all the duties of the physician for whom he is
substituting.
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(3)
The locum tenens staff may
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(a)
perform professional services for
patients to the extent permitted by the privileges granted;
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(b)
not hold office in the Medical
Staff Association;
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(c)
not vote nor be required to
attend meetings of the Medical Staff Association.
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11.(1)
The Authority may, on the
recommendation of the Medical Advisory Committee and with the
concurrence of the physician, make an appointment
to the honorary
staff category.
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Honorary Staff. |
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(2)
A physician of the honorary
staff ordinarily should no longer be in full active practice and
have previously given distinguished service.
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(3)
Members of the honorary staff
may attend meetings of the Medical Staff, but shall not be a member
of any committee, have no voting
powers, and shall not be eligible
to hold elected office on the Medical Staff Association; they will
have no assigned duties.
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(4)
The honorary staff shall not
have admitting privileges.
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PART III |
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ESTABLISHMENT, FUNCTIONS AND MANAGEMENT OF THE MEDICAL STAFF ASSOCIATIONS OF THE PUBLIC HOSPITALS |
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12.
There shall continue to exist
a Medical Staff Association for each public hospital which shall
comprise of physicians appointed to
the active staff of the
hospital.
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Establishment |
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13.
The functions of an
Association are to -
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Functions. |
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(a)
ensure that all patients admitted
to the hospitals or treated in an outpatient, emergency service or
any department of the hospitals
receive the best medical care
possible;
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(b)
provide instruction, maintain
educational standards and promote ethics and research;
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(c)
provide members for the standing
hospital committees;
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(d)
act as advisors to the Executive
Management Committee through the Medical Advisory Committee;
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(e)
have representation S on the
Medical Advisory Committee through its President and Secretary who
shall sit on this committee.
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14.(1)
The Medical Staff Association
in each hospital of the Authority shall be managed by an executive
council which shall consist of -
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Management. |
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(a)
a Chairperson and
Vice-Chairperson who shall be active consultant medical
staff;
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(b)
a Secretary and Treasurer who
shall also be active consultant medical staff or a junior physician
above the post of intern;
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(c)
the past Chairperson (if any);
and
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(d)
four other council members of
whom at least two shall be active consultant medical staff and two
shall be junior staff members.
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(2)
Election to these positions
will take place at the Annual General Meetings of the
Association.
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(3)
The executive council shall
meet at such times as may be necessary or expedient for the
transaction of the business of the Association
and such meetings
shall be held at such places and times and on such days as the
executive council may determine, provided that meetings
are held no
less than twice per year.
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15.(1)
The funds of the Association
shall consist of such monies as may from time to time be paid to
the Association for the purposes of
the Association in accordance
with the Authority's policy on gifts and gratuities.
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Funds. |
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(2)
The Authority shall assist in
defraying the costs of the office space and administrative
requirements of the Association.
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16.(1)
Officers of the Medical Staff
Association -
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Duties of officers. |
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(a)
shall hold office for a period
not exceeding one year and shall be eligible for re-appointment,
although no officer shall hold the
same post for more than three
consecutive years;
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(b)
may at any time resign his office
by notice in writing addressed to the Chairperson of the executive
council and such resignation
shall take effect from the date of
receipt by the Chairperson of such notice;
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(c)
should a vacancy occur on the
executive of the Council, the Chairperson shall select another
officer, who shall hold office for the
remainder of the period for
which the previous officer was elected.
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(2)
The Chairperson of the
Executive Council shall -
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(a)
be a member of the Medical
Advisory Committee;
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(b)
report to the Medical Advisory
Committee on any issue raised by the medical staff
association;
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(c)
be accountable to the medical
staff association;
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(d)
advocate fair process in the
treatment of individual members of the medical staff;
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(e)
preside at general meetings of
the medical staff association;
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(f)
call special meetings of the
medical staff association; and
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(g)
be an ex-officio member of all
hospital committees, excluding the Executive Management
Committee.
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(3)
The Vice Chairperson shall
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(a)
in the absence or disability of
the Chairperson perform his duties with all powers attaching to his
position; and
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(b)
perform such duties as the
Chairperson may delegate.
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(4)
The Secretary of the Executive
Council shall -
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(a)
be a member of the Medical
Advisory Committee;
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(b)
attend to the correspondence of
the medical staff association;
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(c)
give notice of meetings by
posting a written notice -
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(i)
in the case of a regular or
special meeting of the medical staff association, at least five
days before the meeting;
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(ii)
in the case of Annual General
Meetings, at least ten days before the meeting;
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(d)
ensure that minutes are kept of
all medical staff association meetings;
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(e)
ensure that an attendance record
is kept of each Medical Staff Association meeting;
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(f)
perform the duties of the
Treasurer and be accountable should a Treasurer not have been
elected; and
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(g)
act in the place of the Vice
Chairperson, performing his duties and possessing his powers in the
absence or disability of the Vice
Chairperson.
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(5)
The Treasurer of the Executive
Council shall -
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(a)
be elected on an annual basis to
keep the funds of the medical staff association in a safe manner
and be accountable for these funds;
and
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(b)
disburse funds on the direction
of the general membership as determined by a majority vote of those
members present (and entitled
to vote) at a medical staff
association meeting.
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MEETINGS |
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ANNUAL MEETINGS |
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17.(1)
The annual general meeting of
the medical staff shall be held in June of each year and shall be
summoned by the Chairperson of the
Executive Council who shall
preside at these meetings.
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Annual general meetings. |
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(2)
Retiring officers must submit
a written report on their activities during their term of office at
the annual meetings.
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(3)
Only members of the active
consultant medical staff shall be elected or appointed to any
position or office. This also shall include
junior physicians who
may serve as council members.
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(4)
A Nominating Committee shall
be appointed by the medical staff for each annual meeting that
shall consist of three members of the
medical staff.
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(5)
Members of the Courtesy and
the Temporary Medical Staff shall not be eligible to hold any
position on the Executive Council of the
Medical Staff
Association.
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(6)
At least thirty days prior to
an annual meeting the Nominating Committee shall post in a
designated place a list of the names of persons
nominated for posts
to be filled by election in accordance with the by-law and the
regulations.
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(7)
Any nomination made after this
time shall be put in writing to the Secretary of the medical staff
no less than fourteen days after
the posting of the names.
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(8)
Two members of the medical
staff who are entitled to vote shall sign all late
nominations.
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(9)
The nominees shall signify in
writing their acceptance of the nomination.
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(10)
Nominations shall then be
posted along with the original list.
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18.(1)
Regular meetings of the
medical staff shall be held once every three months or at such
other time as the Advisory Committee may decide.
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Regular meetings. |
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(2)
A member of the medical staff
shall not, without reasonable excuse submitted prior to the meeting
to the Chairman of the Council,
fail to attend a regular
meeting.
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19.(1)
A special meeting of the
medical staff may be summoned at any time by the Chairman of the
Council or upon the written request of not
less than five members
of the active medical staff.
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Special meetings. |
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(2)
Written notice of the time,
date and place of the meeting and of its purpose must be given to
members of the medical staff not less
than five days prior to the
date of the meeting.
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(3)
No business shall be
transacted at a special meeting other than the purpose for which it
was summoned.
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20.(1)
Members of the Active Medical
Staff shall attend meetings of the clinical departments to which
they are appointed unless a reasonable
excuse for their absence was
submitted prior to the meeting to the Chief of their
departments.
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Attendance at meetings. |
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(2)
Where a general clinical
meeting of the medical staff is directly related to the medical or
surgical practice of the member, the member
shall attend that
general clinical meeting.
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(3)
A member of the Honorary
Consultant Staff, Temporary/Visiting Medical Staff, Senior Medical
Officer and active medical staff shall
be notified of any meeting
at which a case is to be presented which was treated by that
member. That member shall not, without reasonable
excuse, fail to
attend such meeting.
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(4)
Where required by the Chief of
a clinical department, members of the Courtesy Medical Staff who
admit patients shall attend general
clinical meetings. (5) Members
of the Temporary Medical Staff shall not be eligible to vote at any
meeting.
|
||
|
21.(1)
A quorum for a regular or a
special meeting of the members of the medical staff shall be thirty
three per cent of its membership.
|
Quorum. |
|
|
(2)
The quorum for a meeting of a
clinical department shall be two-thirds of the membership of the
department.
|
||
|
22.(1)
The agenda at regular meetings
of the medical staff shall be -
|
Agenda. |
|
|
(a)
reading and confirmation of the
minutes and of the minutes (where not previously approved) of any
special meeting;
|
||
|
(b)
matters arising;
|
||
|
(c)
unfinished business;
|
||
|
(d)
communications;
|
||
|
(e)
reports of the Advisory Committee
and of any standing or special committee; and
|
||
|
(f)
any new business.
|
||
|
(2)
The agenda for meetings of the
clinical departments shall be as follows?
|
||
|
(a)
to review and analyze the
clinical work of the hospital;
|
||
|
(b)
to review the medical care and
treatment of patients in the hospital, with special reference to
diagnosis, treatment and delayed recovery;
selected cases that have
been discharged since the meeting immediately preceding; selected
deaths; unimproved infection cases; complications
error in
diagnosis or treatment and analysis of clinical reports; and
|
||
|
(c)
a discussion of the business
related to the department.
|
||
|
(3)
The agenda for special
meetings of the medical staff shall be as follows -
|
||
|
(a)
presentation of a topic;
|
||
|
(b)
discussion; and
|
||
|
(c)
the making of a decision and
action plan.
|
||
|
PART IV |
||
|
MEDICAL STAFF OF HOSPITAL |
||
|
23.(1)
Every physician who satisfies
the qualifications criteria as laid out in the specified Policy and
Practice Guidelines and Physician
Reform Document shall be eligible
for appointment to any of the established categories of appointment
of a hospital.
|
Appointments. |
|
|
(2)
Prior to any appointment a
physician shall submit an application as is prescribed, through the
Chief of staff, to the respective Executive
Management
Committee.
|
||
|
(3)
The Authority may require an
applicant to attend the hospital for an interview with appropriate
members of the medical staff and the
Hospital Administrator or his
delegate.
|
||
|
(4)
An application shall be
accompanied by -
|
||
|
(a)
a current curriculum vitae;
|
||
|
(b)
a list of privileges that are
requested;
|
||
|
(c)
evidence of adequate training and
experience for the privileges requested;
|
||
|
(d)
evidence of satisfactory medical
malpractice coverage for physicians applying for privileges which
extend to private practice;
|
||
|
(e)
certification of their
professional qualifications and standing; proof of registration
with the Bahamas Medical or Dental Councils,
together with at least
three references;
|
||
|
(f)
the names of three professional
referees, including a report on the experience, competence and
reputation of the applicant from the
Chief of Staff or the Chief of
Department in the last hospital in which the applicant trained or
held an appointment;
|
||
|
(g)
evidence of registration by the
appropriate Council;
|
||
|
(h)
a copy of the applicant's medical
degree;
|
||
|
(i)
a copy of the applicant's
specialist degree and/or a report from the relevant specialty board
or fellowship from which the specialty
degree/certification was
awarded.
|
||
|
(5)
All applications under this
section, except those for Senior House Officer and Internship
postings, shall be submitted to the Credentials
Committee for its
consideration.
|
||
|
(6)
The Credentials Committee
shall consider the application and consult with the Chief of
Service and/or Director of Service of the specialty
to which the
application relates. Thereafter the Credentials Committee shall, at
one of its general meeting, either recommend appointment
to a
particular clinical department specifying the procedural privileges
to be allowed or not recommend the appointment. In either
case, the
Credentials Committee shall then notify the Medical Advisory
Committee of its decision.
|
||
|
(7)
The Medical Advisory Committee
shall decide at a general meeting, whether or not to support the
recommendation for appointment, or
whether to recommend appointment
to another clinical department. The Committee shall then forward
the application through the Chief
of Staff to the Executive
Management Committee, notifying it of its decision.
|
||
|
(8)
The Executive Management
Committee in turn shall submit to the Authority headquarters for
its approval a statement as to whether or
not they support the
appointment or appointment to another clinical department, and if
recommended, for what period of time.
|
||
|
(9)
The Executive Management
Committee may recommend the appointment of any person and shall, at
the time of such appointment, specify
in writing, the clinical
department, assignments and hospital rights and privileges which
apply in respect of that person.
|
||
|
(10)
Persons so appointed shall
submit a signed statement to the effect that they understand and
accept the rights and privileges granted
and will comply with the
existing rules and regulations relating to members of the medical
staff.
|
||
|
(11)
Medical staff who are in the
employ of the Authority, shall apply for re-appointment not later
than three months prior to the date
of expiration of his
appointment, or previous re-appointment. Provisions for
re-appointment shall apply, with necessary modification,
as they
apply in relation to initial applications for appointment.
|
||
|
(12)
Notwithstanding the provisions
of this byelaw, the Chief of Staff or any person authorized by the
Chief of Staff, acting on the recommendation
of the Medical
Advisory Committee may, in special circumstances, recommend the
appointment to the Temporary Medical Staff or Locum
Tenens staff
any person who is eligible for such appointment, for a period not
exceeding six months.
|
||
|
(13)
The Chief of staff or any
person authorized by the Chief of Staff acting on the
recommendation of the Medical Advisory Committee,
may appoint
members to the post of Senior House Officer and Intern subject to
the approval of the Authority to fulfill the needs
of the clinical
services in accordance with policies established by the Public
Hospitals Authority.
|
||
|
24.(1)
A complaint that any member of
the medical staff has been engaged in -
|
Complaints against members of Medical Staff of Hospital. |
|
|
(a)
any illegal, improper or
unethical medical practice;
|
||
|
(b)
any act prejudicial to the
interest of his patient; or
|
||
|
(c)
any contravention of these
Byelaws or any other rule relating to a hospital,
|
||
|
may be made to the Chief of Staff in writing by any person and shall bear the date of the complaint and the signature of the complainant but, subject to this, shall be in no particular form. |
||
|
(2)
The Medical Advisory
Committee, on receipt of a complaint regarding a staff member up to
the level of Senior Registrar shall refer
the matter to the
Disciplinary Committee, which shall investigate the matter and upon
its finding, make its recommendations.
|
||
|
(3)
Whenever a vacancy occurs on
the Disciplinary Committee, the Medical Advisory Committee shall in
a special meeting, recommend to the
Chief Hospital Administrator,
the appointment of another person to fill the vacancy.
|
||
|
(4)
Complaints made in respect of
Consultants shall be referred to the Authority through the
Executive Management Committee.
|
||
|
25.(1)
The Disciplinary Committee
summoned under section 24 shall hear all complaints referred to it
and in the conduct of the hearing shall
ensure -
|
Procedure on referral of complaint to the Disciplinary Committee. |
|
|
(a)
that the person complained about
be given not less than fourteen days notice of the proceedings;
and
|
||
|
(b)
that the notice specifies the
complaint in the form of a charge.
|
||
|
(2)
The date for the hearing shall
not be fixed earlier than twenty-eight days after the notice has
been served on the person complained
about except with his
consent.
|
||
|
(3)
The notice of hearing shall be
served personally or sent by prepaid registered post to the last
known address of the person complained
about. A copy of the notice
shall be sent to the complainant.
|
||
|
(4)
The person complained about
shall be entitled to receive free copies of or be allowed access to
any documentary evidence relied on
for the purpose of the hearing.
After the hearing is completed he shall also be given, upon
request, a copy of the evidence including
copies of documents
entered in evidence.
|
||
|
(5)
The person complained about
shall have the right to be represented by a counsel or attorney or
a representative of the Medical Staff
Association in any
disciplinary proceedings instituted against him. He must, however,
give the Chairperson of the subcommittee not
less than three days
notice of his intention to exercise this right.
|
||
|
(6)
If a person complained about
does not appear at the date fixed for the hearing of the complaint
the subcommittee may, if it is satisfied
that a notice of hearing
has been served on the person, and the Committee is not aware of
any mitigating circumstances, proceed with
the hearing.
|
||
|
(7)
The subcommittee may call
witnesses and may adjourn the proceedings from time to time.
|
||
|
(8)
If the sub-committee calls
witnesses, the person complained about
|
||
|
or his attorney shall be given an opportunity to put questions to the witnesses. |
||
|
(9)
No documentary evidence shall
be used against the person complained about unless he has
previously been supplied with copies or given
access to them. He or
counsel of his choice shall be permitted to give evidence, call
witnesses and make submissions orally or in
writing.
|
||
|
(10)
At the conclusion of the
hearing the committee shall forward its findings and all the
recorded evidence to the Medical Advisory Committee
who shall
forward their recommendation to the Authority through the Executive
Management Committee.
|
||
|
26.(1)
Where the person complained
against is a member of the Active Medical Staff, the Chairperson of
the Medical Advisory Committee shall,
on receipt of the findings
and evidence, forward the complaint, after review, together with
the findings and evidence to the Authority
through the Executive
Management Committee.
|
Procedure of Medical Advisory Committee on receipt of Disciplinary Committee's findings. |
|
|
(2)
Where the person complained
against is not a member of the Active Medical Staff, the Medical
Advisory Committee may accept, reject
or vary the findings of the
Disciplinary Committee and may impose any one or any combination of
the following penalties -
|
||
|
(a)
reprimand;
|
||
|
(b)
deprivation of any hospital
rights and privileges to which the person complained against may
have been entitled;
|
||
|
(c)
suspension from membership of the
medical staff for a specified period; and
|
||
|
(d)
revocation of the appointment to
membership of the medical staff.
|
||
|
(3)
When acting under the
provisions of subsection (2), the Medical Advisory Committee must
give notice of its recommendations in writing
to the person
complained about and such person, if aggrieved with any
recommendations made against him, may appeal to the Executive
Management Committee within twenty-one days of receipt of the
recommendation.
|
||
|
(4)
The Executive Management
Committee may, on appeal affirm, vary or set aside the decision
appealed against.
|
||
|
27.(1)
Notwithstanding the provisions
of any previous rules if, in the opinion of the Medical Advisory
Committee, acting on the advice of
the Chief of the Department, it
is inexpedient or dangerous or not in the public interest for a
person complained about to continue
as a member of the medical
staff pending an inquiry into the complaint, the Chief of Staff
shall -
|
Immediate suspension of membership. |
|
|
(a)
where the person is a member of
the active consultant medical staff, order their immediate
suspension and forthwith forward the complaint
to the authority
through the EMC; the suspension should not normally exceed one week
prior to the initial hearing of the complaint;
|
||
|
(b)
where the person is not a member
of the active consultant medical staff, order their immediate
suspension until the next sitting of
the Medical Advisory Committee
for a period not normally exceeding one week prior to the initial
hearing of the complaint .
|
||
|
(2)
The Chief of Staff shall
straightway submit to the Medical Advisory Committee a written
report of the complaint in respect of which
the suspension was
ordered. The Medical Advisory Committee shall consider the report
as if it were a complaint submitted by a disciplinary
subcommittee.
|
||
|
(3)
The suspended member should
continue to receive full pay until a final decision is made.
|
||
|
(4)
Any breach of the terms and
conditions of an employment contract shall lead to disciplinary
action or termination of service at the
discretion of the
Authority. In such cases the Authority's appropriate policy and
procedure and/or the standard labour relations
appeals process will
apply.
|
||
|
PART V |
||
|
28.(1)
The Authority shall appoint a
member from the Active Consultant Medical Staff to be the Chief of
Staff. Consideration will be given
to the recommendations of the
Selection Committee on the advice of the Medical Advisory Committee
through its Executive Management
Committee. The appointee shall
have at least three years experience as a Chief of Department
|
Chief of Staff. |
|
|
(2)
The membership of the
Selection Committee may include -
|
||
|
(a)
the Medical Advisor to the Public
Hospitals Authority, who will act as the chairperson; and
|
||
|
(b)
two Members of the Medical
Advisory Committee.
|
||
|
(3)
An appointment under this
section shall be for a term of three years or, if necessary, until
a successor is appointed.
|
||
|
(4)
The Chief of Staff shall hold
office for a maximum of two terms, provided however that there must
be a break of at least one year
before the same person may be
re-appointed to this post for a third term.
|
||
|
29.
The duties of the Chief of
Staff are -
|
Duties of Chief of Staff. |
|
|
(a)
to be accountable to the
Executive Management Committee of the Hospital;
|
||
|
(b)
to be responsible for clinical
matters to the Medical Advisor of the Authority;
|
||
|
(c)
to sit as a member on the
Executive Management Committee;
|
||
|
(d)
to organize the medical and
dental staff to ensure that the quality of care given to all
patients of the hospital is in accordance
with policies established
by the Executive management Committees;
|
||
|
(e)
to chair the Medical Advisory
Committee;
|
||
|
(f)
to advise the Medical Advisory
Committee and the Executive management Committee with respect to
the quality of medical and dental
diagnosis, care and treatment
provided to patients of the hospitals;
|
||
|
(g)
to assign, or delegate the
assignment of the medical and dental staff;
|
||
|
(h)
to supervise the professional
care provided by the medical and dental staff and ensure that their
conduct conforms with the requirements
of the Bahamas Medical
Dental Council as appropriate;
|
||
|
(i)
to be responsible to the
Executive Management Committee through and with the Administrator
for the appropriate utilization of resources
by all medical and
dental departments;
|
||
|
(j)
to report to the Medical Advisory
Committee on activities of the hospital including the use of
resources and quality assurance;
|
||
|
(k)
to participate in the development
of the hospital's mission, objectives and strategic plan;
|
||
|
(l)
to work with the Medical Advisory
Committee to plan the medical manpower needs of the hospital in
accordance with the hospital's strategic
plan;
|
||
|
(m)
to participate in hospital
resource allocation decisions;
|
||
|
(n)
to ensure a process of regular
review of the performance of the Chiefs of Department;
|
||
|
(o)
to ensure there is a process for
participation in continuing medical and dental education and in
collaboration with the Education
Committee, Chiefs of Department
and Services, coordinate the educational activities of the Medical
Staff;
|
||
|
(p)
to receive and review performance
evaluations and the recommendations from the Chiefs of Department
on re-appointments. Ensure that
the evaluations and recommendations
are tabled at the Medical Advisory Committee;
|
||
|
(q)
to advise the medical and dental
staff on current hospital policies, objectives and rules;
|
||
|
(r)
to delegate appropriate
responsibility to the Chiefs of Department;
|
||
|
(s)
to promote a harmonious
relationship among members of the medical and dental staff and
other employees of the hospital.
|
||
|
30.(1)
The Deputy Chief of Staff,
where applicable, shall be a member of the Active Consultant staff
and shall be appointed by the Authority
on the advice of the
Medical Advisory Committee through the Executive Management
Committee. He shall be responsible to the Chief
of Staff in the
exercise of such duties as may be approved by the Chief of
Staff.
|
Appointment to Deputy Chief of Staff. |
|
|
(2)
The authority of the Deputy
Chief of Staff shall, in relation to the medical staff organization
be one of line authority.
|
||
|
(3)
An appointment to Deputy Chief
of Staff shall be for a term of three years, but the Deputy Chief
of Staff shall hold office until
a new Deputy Chief of Staff is
appointed.
|
||
|
(4)
The Deputy will serve for a
maximum number of two terms.
|
||
|
31.(1)
The Executive Management
Committee, on the advice of the Advisory Committee, after
considering the recommendation of the Chief of
the department, may
divide a department into services when warranted by need and
professional resources.
|
Director of Services. |
|
|
(2)
The Authority, on the advice
of the Medical Advisory Committee, through its Executive Management
Committee and on the recommendation
of the Chief of Department,
shall appoint a Director to head the services within the clinical
departments. The Director shall be
responsible to the Chief of the
Department for the quality of medical care rendered to patients in
that service.
|
||
|
(3)
A Director of Service shall be
appointed for three years, but shall not vacate office until a
successor is appointed.
|
||
|
(4)
The Director shall hold office
for a maximum of two terms provided, however, that there shall be
an interval of at least one year
before he can be
re-appointed.
|
||
|
32.
The clinical departments of
each hospital are -
|
Clinical Departments. |
|
|
(a)
The Princess Margaret Hospital
-
|
||
|
(i)
Medicine;
|
||
|
(ii)
Surgery -
|
||
|
(a)
General Services;
|
||
|
(b)
Ophthalmology;
|
||
|
(c)
Emergency medicine;
|
||
|
(d)
Dental surgery;
|
||
|
(e)
Orthopaedics;
|
||
|
(iii)
Obstetrics and
Gynaecology;
|
||
|
(iv)
Paediatrics;
|
||
|
(v)
Neonatology;
|
||
|
(vi)
Radiology;
|
||
|
(vii)
Pathology;
|
||
|
(viii)
Anaesthesiology;
|
||
|
(ix)
Intensive Care;
|
||
|
(x)
Family Practice,
|
||
|
or any other clinical department the Executive Management Committee, acting on the recommendation of the Medical Advisory Committee, may from time to time establish. |
||
|
(b)
The Rand Memorial Hospital
-
|
||
|
(i)
Medicine;
|
||
|
(ii)
Surgery;
|
||
|
(iii)
Obstetric and Gynaecology;
|
||
|
(iv)
Paediatrics;
|
||
|
(v)
Radiology;
|
||
|
(vi)
Pathology;
|
||
|
(vii)
Anaesthesiology,
|
||
|
or any other clinical department the Executive Management Committee may from time to time establish, acting on the recommendation of the Medical Advisory Committee. |
||
|
(c)
The Sandilands Rehabilitation
Center -
|
||
|
(i)
Psychiatry;
|
||
|
(ii)
Community Mental Health;
|
||
|
(iii)
Gerontology,
|
||
|
or any other clinical department the Executive Management Committee may from time to time establish as may be necessary, acting on the recommendation of the Advisory Committee. |
||
|
33.(1)
The Consultants in a clinical
department shall select a candidate from the Active Consultant
Medical Staff for appointment to this
position, which shall be
ratified by the Medical Advisory Committee. The nominee will in
turn be recommended through the Executive
Management Committee to
the Public Hospitals Authority for formal appointment.
|
Chiefs of Clinical Departments. |
|
|
(2)
The Chief of Department shall
be appointed for a term of three years, but shall remain in office
until a successor is appointed.
|
||
|
(3)
A Chief of Department shall
normally hold office fora maximum of two terms, provided however
that there must be a break of at least
one year between any
re-appointment.
|
||
|
(4)
No person shall be recommended
for appointment as Chief of a clinical department unless -
|
||
|
(a)
he is a member of the Active
Medical Staff;
|
||
|
(b)
holds a certificate or fellowship
in the specialized area of medical practice of that department;
and
|
||
|
(c)
has at least five years of
experience in that area.
|
||
|
(5)
A person appointed as Chief of
a clinical department shall be responsible to the Medical Advisory
Committee and accountable to the
Chief of Staff.
|
||
|
(6)
The functions of the Chief of
Department are -
|
||
|
(a)
to supervise the professional
care provided by all members of the medical and dental staff in
their department;
|
||
|
(b)
to participate in the orientation
of new members of their medical and dental staff;
|
||
|
(c)
to be responsible for the
organization and implementation of a quality assurance program in
their department;
|
||
|
(d)
to advise the Medical Advisory
Committee along with the Chief of Staff with respect to the quality
of medical and, where appropriate,
dental, diagnosis, care and
treatment provided to the patients and out-patients of their
department;
|
||
|
(e)
to advise the Chief of Staff of
any patient who is not receiving appropriate treatment and
care;
|
||
|
(f)
to be responsible to the Chief of
Staff through the Administrator for the appropriate utilization of
the resources allocated to the
department;
|
||
|
(g)
to report to the Medical Advisory
Committee and to the department on the department's activities
including the utilization of resources
and quality assurance;
|
||
|
(h)
to make recommendations to the
Medical Advisory Committee regarding medical manpower needs of the
department in accordance with the
Hospital's strategic plan
following consultation with medical staff of the department, the
Chief of Staff and, where appropriate,
Heads of Services;
|
||
|
(i)
to direct the development of the
department's mission, objectives and strategic plan;
|
||
|
(j)
to direct department resource
allocation decisions;
|
||
|
(k)
to review or cause to be reviewed
the privileges granted members of the department including members
of the dental staff for the purpose
of making recommendations for
changes in the kind and degree of such privileges;
|
||
|
(l)
to review and make written
recommendations in respect of the annual performance evaluations of
members of their department, including
members of the dental staff
and in respect of the re-appointments. These recommendations must
be forwarded to the Medical Advisory
Committee;
|
||
|
(m)
to sit as a member of the Medical
Advisory Committee;
|
||
|
(n)
to establish a process for
continuing medical education related to their department;
|
||
|
(o)
to advise the members of their
department, including members of the dental staff regarding current
hospital and departmental policies,
objectives, and rules;
|
||
|
(p)
to hold regular meetings with the
staff of their department and, where appropriate, with the Heads of
Services within their department;
|
||
|
(q)
to notify the Chief of Staff of
his or her absence, and designate an alternate from within the
department; and
|
||
|
(r)
to delegate appropriate
responsibility to the Heads of Services within their
department.
|
||
|
34.(1)
Where an in-patient may
require dental services, he may be admitted to the clinical
department of surgery by a medical practitioner
who is a member of
staff.
|
Chief of Dental Department. |
|
|
(2)
The chief of the department
shall ensure that a surgeon is responsible for the medical care and
treatment of that patient while in
hospital, but the provision of
dental services shall be the responsibility of a member of the
medical staff who holds hospital rights
and privileges in respect
of the proposed dental procedure.
|
||
|
(3)
The dental surgeon shall hold
consultations and shall before performing any dental surgery, write
a complete dental history of the
patient and obtain from the
surgeon responsible for his medical care and treatment, a report of
his physical condition.
|
||
|
35.
Every -
|
||
|
(a)
Chief of Staff;
|
||
|
(b)
Deputy Chief of Staff;
|
||
|
(c)
Chief of Department; and
|
||
|
(d)
Director of Services,
|
||
|
shall ensure that all physicians for whom they are responsible comply with the Authority's policies and procedures. |
||
|
36.(1)
Members of the medical staff
shall come under the administrative jurisdiction, direction and
control of the Chief of the Department
to which they are appointed.
They must, in addition, comply with all general and departmental
staff rules and regulations.
|
Medical staff. |
|
|
(2)
Except in cases of emergency,
members of the medical staff are only allowed to practice medicine
in the clinical department to which
they have been appointed and in
their specialized areas of medical practice in accordance with
their hospital rights and privileges.
|
||
|
(3)
Members who have been granted
privileges in the Clinical Department of Family Practice, may, with
the approval of the relevant Chiefs
of Department, pursue their
medical practice in a clinical department and in a specialized
area, to which they have not been appointed.
|
||
|
(4)
Honorary Consultant staff
shall be comprised of physicians who are not active medical staff
members and who are not ordinarily resident
in The Bahamas.
Eligibility for this appointment shall be qualifications in a
specialty.
|
||
|
(5)
Active medical staff
consultants will be allowed to have admitting privileges for
private patients.
|
||
|
(6)
Resident house staff, under
the supervision of the relevant Chief of Department, shall attend
in-patients and clinics, perform in
the department to which they
are appointed and carry out such other functions as are assigned to
them. However, they shall not have
ultimate responsibility for, or
admit private or public patients under their own name without the
consent of the Medical Advisory
Committee.
|
||
|
(7)
Heads of clinical departments
to which medical staff are appointed shall be responsible for
supervising their work. The head may designate
a member of the
active senior staff to whom they shall be immediately
responsible.
|
||
|
(8)
Non-active medical staff who
have been granted admitting privileges to the private wards except
where indicated above, shall not be
eligible to vote or hold office
and shall not be obliged to attend designated meetings of the
medical staff and their respective
department.
|
||
|
(9)
The retirement age of the
medical staff shall be in accordance with the relevant section of
the Pensions Act.
|
Ch. 43. |
|
|
(10)
Notwithstanding subparagraph
(9), a person shall be eligible for early retirement after thirty
years of service, at which time, such
person shall be eligible for
appointment under special circumstances.
|
||
|
(11)
Members of the Active medical
staff may be appointed to the courtesy staff on their retirement
from public office.
|
||
|
37.
All physicians who have been
granted the privilege of private practice shall, prior to
employment and thereafter on an annual basis,
show evidence of
malpractice coverage.
|
Medical Malpractice. |
|
|
PART VI |
||
|
STANDING COMMITTEES |
||
|
38.
The Standing Committees of the
hospitals shall consist of any one or more of the following -
|
Standing Committees. |
|
|
(a)
the Medical Advisory
Committee;
|
||
|
(b)
the Credentials Committee;
|
||
|
(c)
the Medical Records
Committee;
|
||
|
(d)
the Utilization Committee;
|
||
|
(e)
the Quality Assurance
Committee;
|
||
|
(f)
the Education Committee;
|
||
|
(g)
the Intensive Care
Committee;
|
||
|
(h)
the Library Committee;
|
||
|
(i)
the Infection Control
Committee;
|
||
|
(j)
the Tumor Board (Princess
Margaret Hospital);
|
||
|
(k)
the Pharmacy and Therapeutics
Committee;
|
||
|
(l)
the Theatre Committee;
|
||
|
(m)
the Experimental Medicine and
Research Committee; or
|
||
|
(n)
the Transfusion Practices
Committee.
|
||
|
39.(1)
The Medical Advisory Committee
members shall appoint the Chairman and members of a standing
committee.
|
Composition and function of a Standing Committee. |
|
|
(2)
Standing Committee members
shall appoint a Secretary from among themselves.
|
||
|
(3)
The Chief of Staff shall
provide the terms of reference and method of operation of a
Standing Committees.
|
||
|
(4)
Unless otherwise provided in
these rules, a Standing Committee shall submit to the Executive
Management Committee on a quarterly basis
report of the work of
their respective committees.
|
||
|
(5)
Membership of a Standing
Committee may vary at each of the hospitals so as to reflect the
scope of services offered.
|
||
|
40.
This Committee shall be
comprised of the Chief of Staff who shall be the Chairperson each
Chief of Department, the Chairperson of
the Medical Staff
Association Council and the Directors of Services.
|
Medical Advisory Committee. |
|
|
41.(1)
The Medical Advisory Committee
shall carry out such functions as are required for the promotion of
a good relationship with the Executive
Management Committee and
without prejudice to the generality of the foregoing, the Advisory
Committee shall -
|
Functions of Medical Advisory Committee. |
|
|
(a)
acting on the recommendation of a
sub-committee appointed for this purpose, appoint the Chairman and
members of the other Standing
Committees and the Special
Committees;
|
||
|
(b)
give due consideration to and act
upon where necessary, reports and recommendations of other
committees;
|
||
|
(c)
gather and disseminate to members
of the medical staff all information which in the opinion of the
Advisory Committee may be of interest
to them;
|
||
|
(d)
provide advice on the clinical
organization and supervision of work carried out in the
hospital;
|
||
|
(e)
advise the Executive Management
Committee on matters pertaining to clinical organization, medical
equipment and when requested by
the Executive Management Committee,
on medical matters of an administrative nature;
|
||
|
(f)
arrange scientific programs for
presentation at meetings of the medical staff;
|
||
|
(g)
arrange, convene and conduct the
regular and special meetings of the medical staff. At every regular
meeting it shall submit a report
on the work carried out by the
Advisory Committee for the information of the Authority.
|
||
|
(h)
perform such other duties as may
be required by law;
|
||
|
(i)
provide a structure where the
members of the medical staff can participate in the hospital's
planning, policy development and decision-making;
|
||
|
(j)
serve as a quality assurance
system for medical care rendered to patients in the hospital by the
medial staff and to ensure the continuing
improvement of the
quality of medical care;
|
||
|
(k)
enact and implement rules and
regulations for medical staff governance and enforce compliance
with them.
|
||
|
(2)
The Advisory Committee shall
meet at least once per month and minutes of each meeting shall be
kept and a report submitted within
a reasonable time to the
Executive Management Committee.
|
||
|
(3)
Where the Advisory Committee
intends to consider any subject which properly lies within the
jurisdiction of another committee, the
Chairman shall invite and
inform that committee's Chairman of the date, time and place of the
meeting at which the subject will be
considered.
|
||
|
(4)
The functions of the Advisory
Committee shall be exercised by a quorum of the Advisory Committee
consisting of two-thirds of the members.
|
||
|
(5)
The Chairman of the Advisory
Committee shall not have an original vote but shall only have a
casting vote whenever the voting is equal.
|
||
|
42.(1)
This committee shall consist
of not less than three members of the Active Medical Staff, which
shall include the Chief of Staff and
the Chief of the relevant
Departments.
|
Credentials Committee. |
|
|
(2)
The Credentials Committee
shall -
|
||
|
(a)
carry out all the functions
prescribed in Part IV above;
|
||
|
(b)
review and assess all information
related to the qualifications, experience and competence of members
applying for appointment to
the medical and dental staff; and
|
||
|
(c)
make recommendations to the
Advisory Committee in respect of the procedure for appointment and
assignment of persons to clinical departments
and their respective
categories of appointment.
|
||
|
43.(1)
The Medical Records Committee
shall consist of not less than three members of the active medical
staff.
|
Medical Records Committee. |
|
|
(2)
The senior Medical Records
Officer shall not be eligible to vote at any meeting of the Medical
Records Committee.
|
||
|
(3)
The committee shall recommend
procedures to the Medical Advisory Committee in keeping with
hospital regulations and byelaws.
|
||
|
(4)
The procedures recommended
shall relate to -
|
||
|
(a)
rules to govern the completion of
medical records;
|
||
|
(b)
the review of medical records for
completeness and quality of recording;
|
||
|
(c)
written reports to the Medical
Advisory Committee with respect to -
|
||
|
(i)
the review of the medical
records and the results thereof; and
|
||
|
(ii)
the names of delinquent members
of the medical and dental staff;
|
||
|
(d)
review and revision of forms as
they pertain to medical staff record keeping; and
|
||
|
(e)
the retention of medical records
and notes, charts and other material relating to patient
care.
|
||
|
(5)
The Medical Records Committee
shall perform any other duties pertaining to medical record keeping
as may be requested by the Medical
Advisory Committee.
|
||
|
44.(1)
The Utilization Committee
shall consist of -
|
Utilization Committee. |
|
|
(a)
four members of staff from the
clinical departments of medicine, surgery, obstetrics and
gynaecology, and paediatrics, medical;
|
||
|
(b)
one member of the Advisory
Committee (who shall be the Chairman of the Admissions and
Discharge Utilization Committee);
|
||
|
(c)
the Chief Medical Records
Officer;
|
||
|
(d)
one senior nursing officer;
and
|
||
|
(e)
the Hospital Administrator or his
representative.
|
||
|
(2)
The functions of the
Utilization committee are -
|
||
|
(a)
to review utilization patterns in
the hospital and identify where improvements can be achieved;
|
||
|
(b)
to monitor overall trends in
admission, length of stay, volumes of day programs and provide
reports to management on a regular basis;
|
||
|
(c)
to monitor responses to committee
recommendations that have been approved by the Medical Advisory
Committee and Hospital management
and report on the progress
achieved;
|
||
|
(d)
to report appropriate information
on an annual basis to Chiefs of Department and Heads of
Service;
|
||
|
(e)
to review each department's
utilization review reports;
|
||
|
(f)
to ensure that Chiefs of
Department are educated about utilization review issues and about
their responsibility to report regularly
to their departments on
utilization trends;
|
||
|
(g)
to report findings and make
recommendations to the Medical Advisory Committee and the medical
staff on the Committee's activities;
|
||
|
(h)
to comment on the resource
implications of proposed additions to the medical staff; and
|
||
|
(i)
to perform such other duties as
may be requested from time to time by the Medical Advisory
Committee.
|
||
|
45.(1)
The Medical Quality Assurance
Committee shall consist of a representative from each Clinical
Department and Nursing personnel.
|
Medical Quality Assurance Committee. |
|
|
(2)
The Medical Quality Assurance
Committee shall -
|
||
|
(a)
develop a Medical Quality
Assurance Program which includes mechanisms to -
|
||
|
(i)
monitor trends and
activities;
|
||
|
(ii)
identify potential problem
areas;
|
||
|
(iii)
develop action plans and provide
follow-up.
|
||
|
(b)
report to the Medical Advisory
Committee and to the Quality Assurance Committee of the
Board.
|
||
|
(c)
receive reports of and monitor
the functioning of Medical Staff Committees reporting to the
Medical Advisory Committee.
|
||
|
(d)
monitor the functioning of the
Medical Advisory Committee;
|
||
|
(e)
review, evaluate and make
recommendations on the following matters affecting the medical and
dental staff -
|
||
|
(i)
privileges;
|
||
|
(ii)
human resource planning, impact
analysis;
|
||
|
(iii)
departmental and service
activities;
|
||
|
(iv)
process for handling complaints;
and
|
||
|
(v)
byelaws, rules and policies of
the Hospital.
|
||
|
(f)
recommend procedures to the
Medical Advisory Committee to establish an ongoing peer review
process to assess the quality of patient
care. That is, to study,
record, analyze and consider agreements or disagreements between
pre-operative diagnoses of the hospital
records and the pathology
reports on tissues removed from patients, or post mortem
reports;
|
||
|
(g)
regularly review medical
records;
|
||
|
(h)
submit reports to the Medical
Advisory Committee and to the appropriate Chiefs of
Departments;
|
||
|
(i)
review all hospital deaths to
assess the quality of care that was provided;
|
||
|
(j)
identify the continuing
educational needs of the medical, dental, allied health and nursing
staff and ensure that the recommendations
of the Committee are
acted on; and
|
||
|
(k)
ensure that medical and dental
audits are undertaken as necessary in other Departments; and
|
||
|
(l)
perform such further duties as
the Medical Advisory Committee may direct in relation to the
quality and quantity of professional work
performed in any
department by the medical staff.
|
||
|
46.(1)
The Infection Control
Committee shall consist of -
|
Infection Control Committee. |
|
|
(a)
the Chief Consultant or his
representative who shall be in charge of -
|
||
|
(i)
surgery;
|
||
|
(ii)
medicine;
|
||
|
(iii)
obstetrics &
gynaecology;
|
||
|
(iv)
pediatrics; and
|
||
|
(v)
pathology;
|
||
|
(b)
the Quality Assurance Risk
Manager; and
|
||
|
(c)
the Director of the Intensive
Care Unit or his representative.
|
||
|
(2)
The Committee shall -
|
||
|
(a)
be responsible for the
surveillance of nosocomial infections in the hospital and for
ensuring the protection of patients and members
of the staff of the
hospital from such infections; gather and disseminate information
relating to nosocomial infections in the hospital
and prescribe
measures for the control of such infections;
|
||
|
(b)
make recommendations to the
Medical Advisory Committee on Infection Control matters related to
-
|
||
|
(i)
immunization programs;
|
||
|
(ii)
visitor restrictions or
instructions in both general terms and in special
circumstances;
|
||
|
(iii)
patient restrictions or
instructions;
|
||
|
(iv)
educational programs for all
persons working in the hospital;
|
||
|
(v)
isolation procedures;
|
||
|
(vi)
aseptic and antiseptic
techniques; and
|
||
|
(vii)
environmental sanitation in the
Hospital;
|
||
|
(c)
make recommendations to the
Administrator on infection control matters related to an
Occupational Health & Safety and Health Surveillance
Programmes;
|
||
|
(d)
follow-up and evaluate the
results of each of its recommendations in respect of the above
subsections;
|
||
|
(e)
develop, monitor and evaluate an
infection control program that includes a reporting system by which
all infections, including post
discharge infections will be brought
to the Committee's attention;
|
||
|
(f)
review reports from all
departments and programs in the hospital;
|
||
|
(g)
meet at least quarterly and as
required at the call of the Committee Chair; and
|
||
|
(h)
take the necessary action to
prevent or control the spread of infection within the hospital, and
with the permission of the Executive
Management Committee to
-
|
||
|
(i)
move any patient from one
hospital unit to another;
|
||
|
(ii)
isolate any patient or restrict
or prohibit the entry into any hospital unit of any person;
or
|
||
|
(iii)
request cultures from any
patient or member of the staff or from any environmental
source.
|
||
|
47.(1)
The Tumor Board Committee
shall consist of not less than four members of the Active Medical
Staff. The Oncologist or his designate
shall act as chairperson.
Other members of the Committee shall be appointed by the Chief of
Departments of -
|
Tumor Board Committee. |
|
|
(a)
Pathology;
|
||
|
(b)
Surgery;
|
||
|
(c)
Obstetrics & Gynaecology;
and
|
||
|
(d)
the Oncology nurse of whom shall
himself sit on the Committee.
|
||
|
(2)
A Registrar for the Tumor
Board shall be selected by the Chief of Staff of the hospital after
consultation with the Hospital Administrator
but that person will
have no voting rights on the Tumor Board Committee.
|
||
|
(3)
The Tumor Board Committee
shall provide advice in respect of -
|
||
|
(a)
matters relating to neo-plastic
disease in the hospital;
|
||
|
(b)
the composition of the
neo-plastic registry; and
|
||
|
(c)
the functioning of the
neo-plastic conference.
|
||
|
(4)
The Tumor Board Committee
shall meet not less than once per month.
|
||
|
48.(1)
The Pharmacy and Therapeutic
Committee shall consist of -
|
Pharmacy and Therapeutics Committee. |
|
|
(a)
the Chief Pharmacist who shall be
the Secretary of the Committee;
|
||
|
(b)
the Director of the Bahamas
National Drug Agency;
|
||
|
(c)
any six members of staff from the
clinical departments of medicine, surgery, obstetrics and
gynaecology, paediatrics, dentistry, anaesthesiology
, psychiatry,
where appropriate;
|
||
|
(d)
the Principle Nursing Officer or
designate;
|
||
|
(e)
the Hospital Administrator or his
designate; and
|
||
|
(f)
any other representative whom the
chairperson may request as deemed necessary.
|
||
|
(2)
The committee shall -
|
||
|
(a)
serve in an advisory capacity to
the medical and dental staff by making regular assessments of the
appropriateness and adequacy of
medication-related policies;
|
||
|
(b)
make policy recommendations to
the Medical Advisory Committee regarding drug utilization to ensure
safe, effective and economical
use of drugs;
|
||
|
(c)
evaluate drug utilization, new
drugs and current therapeutics and develop a formulary that is
suited to the hospital's needs and periodically
assess the
effectiveness of and adherence to the formulary;
|
||
|
(d)
develop a procedure for the use
of non-formulary drugs and mechanisms for their evaluation;
|
||
|
(e)
periodically analyze a summary of
medication errors and their causative factors and make appropriate
recommendations regarding prevention
or error to the medical,
dental, nursing and pharmacy staff;
|
||
|
(f)
develop an adverse drug
reaction-reporting program, review reports on them and ensure that
a summary is circulated to medical, dental
and nursing staff when
the need arises;
|
||
|
(g)
annually review all standing
orders, or more often if deemed necessary;
|
||
|
(h)
develop protocols governing
programs such as total parenteral nutrition, investigational drugs,
self-medication, or ensure that such
protocols have been developed
after a quality committee review;
|
||
|
(i)
identify and arrange appropriate
educational programs for the medical, dental and Hospital staff
that will enhance their knowledge
of drug therapy and
practices;
|
||
|
(j)
perform such other duties as the
Medical Advisory Committee may direct;
|
||
|
(k)
meet quarterly or more frequently
at the call of the Committee Chair.
|
||
|
49.(1)
The Theatre Committee shall
consist of -
|
Theatre Committee. |
|
|
(a)
the Chief of the Departments of
Surgery, Orthopaedics, Obstetrics/Gynaecology and Anaesthesiology,
who shall rotate among themselves,
every two years, the position of
Chairman or their designate;
|
||
|
(b)
one representative from the
active medical staff;
|
||
|
(c)
the Nursing Area
Supervisor;
|
||
|
(d)
the Nursing Officer-in-Charge of
Theatre who shall be the Secretary of the Committee;
|
||
|
(e)
one representative from
Administration; and
|
||
|
(f)
one representative from the
support staff.
|
||
|
(2)
The functions of the Committee
are -
|
||
|
(a)
to allocate operating time and
space for all respective surgical disciplines;
|
||
|
(b)
to set policies, rules and
guidelines to govern the daily operations of the Theatre;
|
||
|
(c)
to ensure the efficient
functioning of theatres in the Hospitals and for that purpose,
ensure compliance with any written law or guideline;
|
||
|
(d)
to appoint from among the Medical
Staff or Senior Theatre Nursing staff, a theatre manager who will
be paid and authorized to manage
the theatre's daily flow of
activities and recommend and/or affect solutions to problems that
may arise in the course of the day;
|
||
|
(e)
to recommend to the Medical
Advisory Committee any necessary changes in the operation of the
Theatre that would improve efficiency;
|
||
|
(f)
to review disputes among staff
members in Theatres that cannot be resolved without arbitration;
and
|
||
|
(g)
to perform such other duties as
may be assigned from time to time by the Medical Advisory
Committee.
|
||
|
(3)
The Theatre Committee shall
meet at less than once every three months, but may meet more often
if the need demands it.
|
||
|
50.(1)
The Experimental Medicine and
Research Committee shall consist of?
|
Experimental Medicine and Research Committee. |
|
|
(a)
the heads of the clinical
departments;
|
||
|
(b)
two members of the medical staff;
and
|
||
|
(c)
the Hospital Administrator or his
representative.
|
||
|
(2)
The functions of the
Experimental Medicine and Research Committee are -
|
||
|
(a)
to review any research proposal
submitted to it and, based on the review, make recommendations to
the Advisory Committee in respect
of the research proposal;
|
||
|
(b)
to make recommendations to the
Advisory Committee to ensure the maintenance of international
standards in the medical practice at
the hospital.
|
||
|
(3)
The Medical Advisory Committee
shall submit such recommendations to the Executive Management
Committee for its approval.
|
||
|
51.(1)
The members of the Transfusion
Practices Committee shall consist of -
|
Transfusion Practices Committee. |
|
|
(a)
six members of the Active Medical
staff representing the departments of medicine, surgery,
anaesthesia/intensive care, obstetrics/gynaecology,
paediatrics,
and pathology and laboratory medicine;
|
||
|
(b)
a senior representative from the
Blood transfusion service a senior nurse;
|
||
|
(c)
a senior volunteer with public
relation skills;
|
||
|
(d)
such other personnel as deemed
necessary in specific areas.
|
||
|
(2)
The duties of the Committee
are -
|
||
|
(a)
to develop and implement policy
and guidelines on the clinical use of blood;
|
||
|
(c)
to develop standard operating
procedures for the implementation of the guidelines, including
procedures for ordering and handling
blood and investigating
suspected transfusion reactions;
|
||
|
(d)
to provide education and
continuing training of all clinical and blood bank staff involved
in the transfusion process;
|
||
|
(e)
to monitor the use of blood and
blood products;
|
||
|
(f)
to review incidents of suspected
transfusion reactions or errors associated with transfusion, and
implement corrective action when
necessary; and
|
||
|
(g)
to monitor the safety and
adequacy of the blood supply and blood products and implement
corrective action when necessary.
|
||
|
SPECIAL COMMITTEES |
||
|
52.(1)
The Advisory Committee may
appoint special committees which shall consist of members of the
medical staff, acting on the recommendation
of its chairman, who
may see fit to appoint persons to assist medical staff in the
execution of their duties.
|
Special Committees. |
|
|
(2)
The members of the special
committee shall appoint a Chairman and a Secretary from among
themselves.
|
||
|
(3)
A special committee shall
carry out only those functions for which it was appointed and shall
not have a power of action unless so
enabled at the time of
appointment.
|
||
|
(4)
The special committee shall
submit to the Advisory Committee a written report of the work
carried out by it.
|
||
|
MISCELLANEOUS |
||
|
53.
Members of the active medical
staff may be appointed to the Honorary Consultant Staff on their
retirement from public office.
|
Retirement. |
|
|
54.(1)
Members of the medical staff
shall be granted Hospital rights and privileges in keeping with
their medical training, experience and
competence. (2) Where a
member may wish to be granted additional rights and privileges,
consideration will also be given to the views
of members of the
Active Medical Staff and to the reports of the Credentials
Committee.
|
Hospital rights and privileges. |
|
|
55.(1)
All physicians who have been
granted the privilege of private practice such as Active Staff,
Senior Medical Officers, Temporary/Visiting,
Courtesy and and Locum
Tenens shall, prior to employment and thereafter on an annual
basis, show evidence of malpractice coverage.
|
Medical Malpractice coverage. |
|
|
Made this 11th day of December, 2003. |
||
|
Signed |
||
|
DR. MARCUS C. BETHEL |
||
|
Minister Responsible for Health |
||
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URL: http://www.commonlii.org/bs/legis/num_reg/tphal2003sb2003543