The patient’s physician is encouraged, but not required to inform the patient who will be performing significant surgical during the patient’s operation and what each person will be doing. 2.3 Documenting Informed Consent The physician document in the patient’s medical record that a discussion was held that included discussion of all material information as described above, that the patient indicated understanding of the material information and informed consent was obtained. Informed consent may be documented in any of the following areas of the medical record: History and physical/Consultation Progress Note Pre-printed and approved informed consent formats Faxed copy from a physician’s office Special Circumstances in which a physician is not required to fully inform the patient: When the patient has requested that he/she not be so informed. (Thoroughly document this request in the medical record). Therapeutic Privilege – Defined as whenever such disclosure would likely result in serious harm rather than benefit the patient. In these instances the physician shall fully document in the medical record the facts that resulted in invoking therapeutic privileges. See Policy #113 “Consent, Obtaining and Documenting”. When an emergency procedure or operation is required, the physician must sign the “Physician Certificate of Emergency” on the consent form and in the progress notes the reason for the emergency procedures when consent cannot be obtained. 2.4 Physician orders The staff physician is responsible for orders for care prior to or promptly after admission. Verbal orders are discouraged. Telephone and/or verbal orders must be authenticated by the ordering physician within 48 hours. All entries in the medical record must be dated, timed and authenticated.
Performance Improvement Monitoring Pertinent findings of PI monitoring will be communicated through the Medical Governance Structure as appropriate. Restraint: Psychiatric Services Order, continuation, patient assessment and documentation of restraint in the Della Martin Center is governed by the Huntington Hospital Policy, “Restraints and Seclusion”. 2.17 Autopsies: The Pathology Department shall attempt to notify the physician(s) involved in the patient’s care that an autopsy is being performed and that the autopsy results will be forwarded to them. Deaths in which an autopsy would be especially encouraged are: Deaths in autopsy may help to explain unknown and unanticipated medical complications to the attending physician All deaths in which the cause of death or a major diagnosis is unknown with reasonable certainty on clinical grounds Cases in which autopsy may help to allay concerns of the family and/or the public regarding the death and to provide reassurance to them regarding the same Unexpected or unexplained deaths occurring during or following any dental, medical or surgical diagnostic procedures and/or therapies Deaths of patients who have participated in clinical trials (protocols) approved by institutional review boards. Unexpected or unexplained deaths are apparently natural and not subject to a forensic medical jurisdiction Natural deaths which are subject to, but waived by a forensic medical jurisdiction such as (a) persons dead on arrival at hospitals (b) deaths occurring in hospitals within 24 hours of admission, and (c) deaths in which the patient sustained or apparently sustained an injury while hospitalized. Deaths resulting from high-risk infectious and contagious diseases. All obstetric deaths. All prenatal and pediatric deaths. Deaths at any age in which it is believed that autopsy would disclose a known or suspected illness which also may have a bearing on survivors or recipients of transplant organs.
6.3 Cancer Committee Purpose The Cancer Committee is a standing Medical Staff committee which provides program leadership for the Cancer Program, as described in the Guidelines of the Commission on Cancer. The Chair is appointed by the Chief of Staff. Composition The membership composition be multidisciplinary and shall include representatives of all specialties involved in the care of patients with cancer. Voting membership include the American College of Surgeons physician liaison and physicians representing surgery and surgery sub-specialties, medical, oncology, diagnostic radiology, radiation oncology and pathology. Also voting are representatives from administration and nursing, including pain control. Non voting members include social services, the cancer registry and quality management. Duties Develops and evaluates annual goals and objectives for the clinical, educational and programmatic endeavors related to cancer. Promotes a coordinated, multidisciplinary approach to patient management. Establishes, monitors, and evaluates the cancer conference frequency, format, care presentation and multidisciplinary attendance requirements. Ensures that an active education supportive care system is in place for patients, families and staff. Promotes clinical research. Establishes and implements a plan to evaluate the quality of cancer registry data and activity on an annual basis. The plan include procedures to monitor case finding, accuracy of data collections, abstracting timeliness, follow-up and data reporting. Monitors quality management and improvement through completion of quality management studies that focus on quality, access to care, and outcomes. Upholds medical ethical standards. Meetings The committee meets quarterly. Reporting Process The committee shall maintain a record of its proceedings and actions and shall report to the Quality Management Committee.
Assurance that data is systematically aggregated and analyzed on an ongoing basis. Comparison of organization performance both internally and externally over time. Intensive analysis of undesirable patterns or trends in performance and sentinel events. Periodic review of performance of the following: Patient safety Clinical and operational performance (service line and dashboard reports) Utilization management Risk management findings Quality management and peer review findings (Executive Session) Medication usage Blood and blood product usage Approval of Clinical and Administrative Policies that have both a clinical component and an organization wide Meetings The committee will meet 10 per year. Reporting Structure The Quality Management Committee reports to the Executive Committee and through the Executive Committee to the Board. 6.14 Robotic Committee Composition The Robotic Committee shall consist of members from the Obstetrics and Gynecology Department and the Surgery Department involved in the performance of robotic surgery. The chair shall be appointed by the President of the Medical Staff and include representatives from Administration, Nursing and Quality Management. Duties The Committee shall be responsible for: 1) The evaluation of quality improvement data related to robotic surgery; 2) Making recommendations to the appropriate Medical Sections or Departments regarding proposed privileging criteria and proctoring requirements for robotic surgery; 3) Review by the Committee Chair of all requests for robotic surgery privileges and forwarding privileging recommendations to the appropriate Section or