NORTH SHORE UNIVERSITY HOSPITAL MEDICAL STAFF SOCIETY INC

THE NORTH SHORE UNIVERSITY HOSPITAL MEDICAL STAFF SOCIETY ("STAFF SOCIETY") CONSISTS OF ALL MEDICAL DOCTORS WHO ARE ON THE MEDICAL STAFF OF NORTH SHORE UNIVERSITY HOSPITAL AT MANHASSET ("NSUH") BY VIRTUE OF HAVING HOSPITAL ADMITTING PRIVILEGES. THE STAFF SOCIETY SEEKS TO PROMOTE AND MAINTAIN THE HIGHEST PROFESSIONAL STANDARDS OF THE MEDICAL DOCTORS WHO PROVIDE MEDICAL CARE TO PATIENTS ADMITTED TO NSUH, TO ASSIST NSUH IN ASSURING THAT THE CARE PROVIDED TO PATIENTS MEET THE HIGHEST CLINICAL STANDARDS, AND, WITH RESPECT TO SUCH CARE, THE HOSPITAL MEETS ALL CLINICALLY RELATED CERTIFICATION REQUIREMENTS OF EXTERNAL HOSPITAL CREDENTIALING AUTHORITIES INCLUDING THE JOINT COMMISSION OF ACCREDITATION OF HEALTH ORGANIZATIONS (JCAHO) AND OFFICIAL AUTHORITIES SUCH AS THE NEW YORK STATE DEPARTMENT OF HEALTH. THE STAFF SOCIETY ALSO PROMOTES THE PROFESSIONAL INTEREST OF ITS MEMBERSHIP BY PROVIDING TIMELY INFORMATION AND ADVICE TO ASSIST THE MEMBERS IN PERFORMANCE OF THEIR MEDICAL PRACTICES. WITH RESPECT TO ITS MISSION TO ASSIST THE HOSPITAL, THE STAFF SOCIETY, THROUGH ITS OFFICERS AND MEMBERS, SERVE ON A VARIETY OF CLINICAL BOARDS AND COMMITTEES OF THE HOSPITAL INCLUDING, BUT NOT LIMITED TO, THE MEDICAL BOARD, CREDENTIALING COMMITTEE, MEDICAL RECORD COMMITTEE, PERFORMANCE IMPROVEMENT COORDINATING GROUP, AND PHARMACY AND THERAPEUTICS COMMITTEE. BY SERVING ON THE HOSPITAL'S MEDICAL BOARD, STAFF SOCIETY OFFICERS HELP GOVERN THE MEDICAL STAFF, ADVISE THE BOARD OF TRUSTEES, THE HOSPITAL'S EXECUTIVE DIRECTOR, THE HEALTH SYSTEM CEO, CHIEF MEDICAL OFFICER AND CHIEF OPERATING OFFICER IN MATTERS RELATING TO THE WELFARE OF THE HOSPITAL AND MEDICAL STAFF; MAKE RECOMMENDATIONS TO THE HOSPITAL'S BOARD OF TRUSTEES FOR ITS APPROVAL, SUCH AS RECOMMENDATIONS PERTAINING TO: THE STRUCTURE OF THE MEDICAL STAFF, PLANNING FOR CLINICAL DEPARTMENTS; THE MECHANISM USED TO REVIEW CREDENTIALS AND TO DELINEATE INDIVIDUAL CLINICAL PRIVILEGES; RECOMMENDATIONS FOR DELINEATED CLINICAL PRIVILEGES FOR EACH ELIGIBLE INDIVIDUAL; THE PARTICIPATION OF THE MEDICAL STAFF IN ORGANIZATIONAL PERFORMANCE-IMPROVEMENT ACTIVITIES; THE MECHANISM BY WHICH MEDICAL STAFF MEMBERSHIP AND CLINICAL PRIVILEGES MAY BE TERMINATED OR LIMITED; THE MECHANISM FOR FAIR-HEARING PROCEDURE; REQUIREMENTS FOR THE MEDICAL CARE AND TREATMENT OF PATIENTS IN THE HOSPITAL AND PROGRAMS OF EDUCATION, RESEARCH AND PREVENTATIVE MEDICINE CONDUCTED AT THE HOSPITAL. BY PARTICIPATING ON THE HOSPITAL'S CREDENTIALS COMMITTEE, STAFF SOCIETY MEMBERS REVIEW THE COMPLETED APPLICATIONS OF ALL APPLICANTS FOR MEMBERSHIP ON THE MEDICAL STAFF WHO DESIRE TO PRACTICE AT THE HOSPITAL IN COMPLIANCE WITH THE HOSPITAL'S BYLAWS (INCLUDING, BUT NOT LIMITED TO, INTERVIEWING SUCH CANDIDATES AS IS IT DEEMS NECESSARY OR APPROPRIATE); MAKE RECOMMENDATIONS TO THE MEDICAL BOARD ON EACH SUCH APPLICANT REGARDING INITIAL APPOINTMENT, REAPPOINTMENT AND DELINEATION OF CLINICAL PRIVILEGES, INCLUDING SPECIFIC CONSIDERATION FOR RECOMMENDATIONS OF THE CHAIR OF THE CLINICAL DEPARTMENT IN WHICH THE APPLICANT REQUESTS PRIVILEGES INCLUDING RECOMMENDATIONS BY THE CHAIR FOR THE REVISION OF PRIVILEGES IN BETWEEN REAPPOINTMENT PERIODS; PROVIDE CONSULATATIVE REVIEW OF DELINEATED PRIVILEGES IN NEW AND EVOLVING AREAS OF MEDICAL PRACTICE. BY PARTICIPATING ON THE HOSPITAL'S MEDICAL RECORD COMMITTEE, STAFF SOCIETY MEMBERS HELP ESTABLISH AND COORDINATE A PROCESS INVOLVING THE MEDICAL AND ANCILLARY DEPARTMENTS THAT MEET THE REQUIREMENTS OF THE JCAHO (AND ALL OTHER APPLICABLE ACCREDITING AND CERTIFYING BOARDS AND BODIES) AND THE NEW YORK STATE DEPARTMENT OF HEALTH'S REVIEW OF MEDICAL RECORDS TO ASSURE APPROPRIATE CLINICAL INFORMATION IS CONTAINED WITHIN THE PATIENT'S CHART; REVIEW MEDICAL RECORDS FOR TIMELY COMPLETION, CLINICAL PERTINENCE, OVERALL COMPLETENESS AND ADEQUACY FOR QUALITY ASSESSMENT ACTIVITIES; ADVISE AND RECOMMEND POLICIES FOR MEDICAL RECORD MAINTENANCE; MAKE RECOMMENDATIONS TO THE MEDICAL BOARD AND TO THE PERFORMANCE IMPROVEMENT COORDINATING GROUP WHENEVER NECESSARY TO DESIRABLE RELATIVE ANY CHANGES IN THE FORMAT OF THE MEDICAL RECORD, AS WELL AS TO ITS PROPER FILING, INDEXING, STORAGE, RETENTION PERIOD AND AVAILABILITY, TOGETHER WITH ANY RECOMMENDED RULES AND REGULATIONS IN CONNECTIONS THEREWITH; ADVISE AND DEVELOP POLICIES, WITH THE ASSISTANCE OF COUNSEL, TO GUIDE THE MEDICAL RECORD LIBRARIAN, MEDICAL STAFF AND ADMINISTRATION WITH RESPECT TO PRIVILEGED COMMUNICATIONS AND THE LEGAL RELEASE OF INFORMATION. BY PARTICIPATING ON THE HOSPITAL'S PERFORMANCE IMPROVEMENT COORDINATING GROUP, STAFF SOCIETY MEMBERS PROVIDE LEADERSHIP AND GUIDANCE IN THE HOSPITAL'S ORGANIZATIONAL PERFORMANCE IMPROVEMENTS ACTIVITIES, MEDICAL STAFF PROFESSIONAL REVIEW, HEALTH INFORMATION MANAGEMENT, UTILIZATION MANAGEMENT, INFECTION CONTROL, RISK MANAGEMENT, HOSPITAL SAFETY PROGRAM, SPECIAL CARE NUTRITIONAL SUPPORT, AND PHARMACY AND THERAPEUTICS FUNCTIONS THEREBY IMPLEMENTING A UNIFIED PROGRAM THAT IMPROVES ORGANIZATIONAL PERFORMANCE BY ESTABLISHING MULTI-DISCIPLINARY TEAMS TO DESIGN, MEASURE, ASSESS AND IMPROVE THE ORGANIZATIONAL FUNCTIONS IDENTIFIED BY THE JCAHO (AND ANY OTHER APPLICABLE ACCREDITING AND CERTIFYING BOARDS AND BODIES); OVERSEE, COORDINATE AND PRIORITIZE QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT ACTIVITIES BY, AMONG OTHER THINGS, APPROVING AND ADMINISTERING AN ANNUAL HOSPITAL-WIDE PERFORMANCE IMPROVEMENT PLAN BY PROMOTING AND ASSISTING, WHERE NEEDED, IN THE DEVELOPMENT FOR THE PLAN BY FOCUSING ON ITS DESIGN, IMPLEMENTATION, MEASUREMENT METHODOLOGY, MEANS OF ASSESSMENT AND IMPROVEMENT, AND ASSISTING IN COORDINATING THE DIMENSIONS OF PERFORMANCE WITH PATIENT CARE AND ORGANIZATIONAL FUNCTIONS; REAPPRAISING THE HOSPITAL'S QUALITY ASSURANCE, QUALITY MANAGEMENT, PERFORMANCE IMPROVEMENT, RISK MANAGEMENT AND SAFETY PROGRAMS FOR THEIR EFFECTIVENESS AND THE DEGREE TO WHICH THEY INTEGRATE AND COORDINATE THEIR EFFORTS AND APPLY TO ALL DEPARTMENTS, SERVICES AND PRACTITIONERS OF THE HOSPITAL. BY PARTICIPATING ON THE HOSPITAL'S PHARMACY AND THERAPEUTICS COMMITTEE, STAFF SOCIETY MEMBERS HELP IN THE DEVELOPMENT AND SURVEILLANCE OF THE DRUG UTILIZATION POLICIES AND PRACTICES WITHIN THE HOSPITAL IN ORDER TO ASSURE OPTIMUM CLINICAL RESULTS AND A MINIMUM POTENTIAL FOR HAZARD; THE DEVELOPMENT OF FORMULARY OR DRUG LIST, WHICH IS REVIEWED AT STATED INTERVALS; THE REVIEW OF UNTOWARD DRUG REACTIONS; THE PERFORMANCE OF THE ANTIBIOTIC USAGE REVIEW ASSESSMENT FUNCTION THAT INCLUDES CLINICAL REVIEW PLUS ANY STATISTICAL/PREVALENT STUDY OF ANTIBIOTIC USAGE. THE STAFF SOCIETY WILL PUBLISH QUARTERLY NEWSLETTERS REGARDING THE DEVELOPMENTS AT THE HOSPITAL THAT AFFECT THE PHYSICIANS AND/OR REQUIRE THEIR COMPLIANCE AND COOPERATION WITH RELEVANT POLICIES AND PROCEDURES AT THE HOSPITAL. THE STAFF SOCIETY PROVIDES TIMELY UPDATES TO THE MEMBERS THROUGH "GLOBAL" FAX BROADCASTS AS WELL AS VIA E-MAIL. ACTIVITY % TIME SERVE ON HOSPITAL COMMITTEES 75% INTERNAL ORGANIZATIONAL ACTIVITIES, MEETINGS 15% PUBLICATIONS OF NEWSLETTERS AND GLOBAL 10% COMMUNICATIONS