Annual Medical Staff Meeting Bylaw Amendments Approved

By Tonia Parker, CPHQ, CPMSM, CPCS, Director, Medical Staff Support Services

The Seton Family of Hospitals Network Annual Medical Staff Meeting was held Jan. 8 in McFadden Auditorium at Seton Medical Center Austin. Special guest speaker David Nilasena, MD, chief medical officer for CMS Region VI in Dallas, presented “Medicare’s PQRI Program and Hospital-Acquired Conditions.”

During the meeting, two amendments to the Bylaws of the Seton Family of Hospitals Network Medical Staff (the "Bylaws") were considered and approved for presentation to the Clinical Quality Committee of the Board.

The amendments were reviewed and approved at the Clinical Quality Committee of the Board meeting on Jan. 10.

The amendments became effective immediately and are applicable to all members of the Seton Medical Staff. If you would like a copy of the revised Medical Staff Bylaws, please contact Tonia Parker, Director of Medical Staff Support Services at 324-1470.

Highlights of the amendments are as follows: 

 AMENDMENT #1

a.         Changed all references of “peer review” to “Professional Practice Evaluation” in accordance with Joint Commission.

            Section 1.2-23
            Section 2.1 (c)
            Section 3.3-4 (d); Section 3.4-1 (g)
            Section 5.2-2
            Section 7.1-3; 7.1-4
            Section 8.1-7
            Section 9.2-6
            Section 12.1-1; Section 12.4-2
            Section 13.1-4 (f); Section 13.5
            Section 15.1; Section 15.5

b.         Changed name to “Seton Family of Hospitals.”

            Section 1.2-33
            Section 2.1 (a); Section 2.1 (f)
            Section 3.3-3; Section 3.4-1 (c)
            Section 5.2-1
            Section 7.1-4 (d)
            Section 10.9
            Section 13.1-4 (i); (j); (m); Section 13.1-7
            Section 14.2-2
            Section 15.3
            Section 16.1; Section 16.2; Section 16.3; Section 16.4; Section 16.5
            Section 17.1; Section 17.2

c.         Removed references to “CHOA” and replaced with “Dell Children’s Medical Center of Central Texas;” Added “Seton Medical Center Williamson.”

            Section 1.2-33
            Section 13.1-1; Section 13.1-2

 d.         Eliminated Network Performance Appraisal Committee (NPAC).

            Section 1.2-36
            Section 8.1-2; Section 8.1-3; Section 8.1-4
            Section 13.4

e.         Added language for Restricted/Unrestricted License – Privileges Limited to Limits of Licensure.

            Section 3.2-1 (a)

f.          Added requirement of National Provider Identifier (NPI) Number as a Qualification of Membership.

            Section 3.2-1 (l)

 g.         Added provision to allow fellows seeking membership in a primary specialty service to be eligible for privileges during their fellowship.

            Section 7.5-3

 h.         Added provision to allow immediate past chair of credentials committee to remain on the committee after completing term as chair of credentials.

            Section 13.3-1

 AMENDMENT #2

a.         Added provision to physician behavior expectation that allows for corrective action based on conduct that occurs outside of Seton premises or a Seton facility if such conduct implicates the practitioner’s fitness to exercise clinical privileges within the Seton family of hospitals.