Actions of the MEC   

Actions of the MEC

Action Items from the August 8, 2022 Medical Executive Committee

  1. Delineation of Privileges Revisions – APPROVED

Action Items from the July 11, 2022 Medical Executive Committee

  1. DNR/DNI Orders by Advanced Practice Providers (APPs) – APPROVED

Action Items from the May 9, 2022 Medical Executive Committee

  1. Change pronouns on Procedural Consents from him/his to them/their – APPROVED
  2. Department of Urology – Creation of an academic Department of Urology – APPROVED
  3. Interim Chair - Dr. Matthew Tobin would sit as interim Chair of the newly developed
    Department of Urology while a national search is conducted for a permanent Chair –
    APPROVED

Action Items from the April 11, 2022 Medical Executive Committee

  1. List of Approved Reference Laboratories for 2023 – APPROVED

Action Items from the March 14, 2022 Medical Executive Committee

  1. CVAD Care & Maintenance in Adult Patients – APPROVED

Action Items from the February 14, 2022 Medical Executive Committee

  1. Pre-Application Questionnaire - Edited changes from MCC – APPROVED

Action Items from the December 13, 2022 Medical Executive Committee

  1. The current medical and dental staff officers were re-elected for a one-year term
  2. extension from 01/01/23 through 12/31/23 - APPROVED
  3. President – Glenn Parker, MD
  4. New Medical and Dental Staff Officers were elected for a one-year term from
    01/01/23 through 12/31/23 - APPROVED
  5. Vice President - Andrew Blechman
  6. Secretary - Eric Costanzo, DO
  7. Sally-Jo Placa, DMD

Action Items from the October 11, 2022 Medical Executive Committee

  1. New Core Privilege Forms - Acupuncture – APPROVED
  2. Termination - Sandip Parikh, M.D. - Medicine/Internal Medicine - As per the Medical and
    Dental Staff Bylaws of JSUMC, Article IX, Section 9.4 – APPROVED

Action Items from the September 13, 2022 Medical Executive Committee

  1. New Core Privilege Forms - Minor edits made to Plastic Surgery, Neurology, and
    Neurological Surgery – all APPROVED
  2. New Core Privilege Forms - Nurse Practitioner and Physician Assistant Psychiatry –
    APPROVED

Action Items from the August 9, 2022 Medical Executive Committee

  1. New Core Privilege Forms – all APPROVED
  2. Certified Nurse Midwife
  3. Nurse Practitioner and Physician Assistant - Surgery
  4. Nurse Practitioner and Physician Assistant Critical Care Specialties
  5. Nurse Practitioner and Physician Assistant Neonatology Specialties
  6. Psychology
  7. Registered Professional Nurse First Assistant (RNFA)
  8. Certified Registered Nurse Anesthetist (CRNA)
  9. Adult Medicine - including all Subspecialities
  10. Emergency Medicine including Pediatric Emergency Medicine
  11. Family Medicine
  12. Interventional Pain Medicine
  13. Pathology
  14. Physical Medicine and Rehabilitation
  15. Psychiatry
  16. Radiation Oncology
  17. Radiology
  18. Pediatric - including all Subspecialities

Action Items from the July 12, 2022 Medical Executive Committee

  1. New Core Privilege Forms for Obstetrics & Gynecology – APPROVED

Action Items from the June 14, 2022 Medical Executive Committee

  1. New Core Privilege Forms for Anesthesiology, Conscious Sedation, Dentistry, Oral and Maxillofacial Surgery, Orthopedic Surgery, Podiatry, Neurological Surgery, Cardiac Surgery, Colon Rectal Surgery,General Surgery, Ophthalmology, Otolaryngology, Pediatric Surgery, Plastic Surgery, Thoracic Surgery, Urology, Vascular Surgery.  – Approved

Action Items from the April 12, 2022 Medical Executive Committee

  1. New Core Privilege Forms for for Obstetrics & Gynecology, Pediatrics and all subspecialties, Radiology, Radiation Oncology, Orthopedic Surgery, Neurological Surgery, Cardiac Surgery, Colon Rectal Surgery, Ophthalmology, Otolaryngology, Pediatric Surgery, Plastic Surgery, Thoracic Surgery, Urology, Vascular Surgery.  – Approved

Action Items from the March 8, 2022 Medical Executive Committee

  1. New Core Privilege Forms for Neurology and Pathology  – Approved

Action Items from the February 8, 2022 Medical Executive Committee

  1. New Core Privilege Forms for The Section of Advanced Pain Medicine, the Department of Dentistry, the Department of Emergency Medicine, The Department of Family Medicine, the Department of Medicine including all Subspecialties – Approved
  2. Policies for three-year review with no changes) - Confidentiality of Credentials Files - Approved

Action Items from the January 11, 2022 Medical Executive Committee

1. Restrict Ivermectin - Requires an ID Consult to Prescribe - Approved

Action Items from the December 14, 2021 Medical Executive Committee

  1. Motion to allow a Sleep Educator to place verbal orders for sleep medicine consults in Epic  – Approved
  2. Revised Department of Medicine Rules and Regulations as presented with changes – Approved
  3. Approval of 065-Manager Infection Control job description in accordance with the Joint Commission Standard  –  Approved

Action Items from the November 9, 2021 Medical Executive Committee

  1. Department of Psychiatry:
    • Creation of an Addiction Medicine Section under the Department of Psychiatry - Approved
    • Creation of a Digital Psychiatry Section under the Department of Psychiatry - Approved
    • Creation of a Forensic Psychiatry Section under the Department of Psychiatry - Approved
  2. New Policy (from Med Council)
  3. Policies for three-year review (with changes)
    • Guidelines for Care of the Adult Patient with Sepsis/ Septic Shock - Approved
  4. Policies for three-year review (no changes)

Action Items from the October 12, 2021 Medical Executive Committee

  1. Policies for Three-Year Review (with no changes) - Approved
    • Policy on Stat LTM Video EEG On Call Protocol for Pediatric Patients
    • Policy on Stat LTM Video EEG Protocol for Adult Patients
    • Policy on Stat Routine EEG On Call Protocol for Adult Patients
    • Policy on Stat Routine EEG On Call Protocol for Pediatrics

Action Items from the September 14, 2021 Medical Executive Committee

  1. Autopsy Policy - 3 year review. No changes made
  2. Policy on Guidelines for Institutional Minimum Procedure Volumes- Approved with changes
  3. Policy on Surgical Necessity/Appropriateness- Approved with changes
  4. Policy on Guidelines for Incorporating Surgeon Specific Volumes in the Credentialing/Re-Credentialing Process - Approved with changes
  5. Policy on Procedural Indications for Elective Total Knee Arthroplasty - New - Approved
  6. Policy on Procedural Indications for Elective Total hip Arthroplasty - New - Approved

ANNOUNCEMENTS

  1. Announcement of Shabbar Danish, MD as the new Chair of the Department of Neurosurgery
  2. Announcement of Dr. Alan Colicchio, MD as the new Chair of the Department of Neurology
  3. Announcement of Wahid Girgis, MD  as the new Chair of Radiology
  4. Announcement of the requirement for weekly antigen testing for those providers that are not vaccinated or have been given a medical or religious exemption. Please see https://myhmh.hmhn.org/en/Clinical/COVID-19-Vaccination-Education-Center

Action Items from the August 10, 2021 Medical Executive Committee

  1. COVID-19 Vaccination Policy - APPROVED
    Requests for exemptions must be submitted using the attached form and sent to covidvaccine@hmhn.org by August 15, 2021. 

Action Items from the July 13, 2021 Medical Executive Committee

Click here to view action items

Action Items from May Medical Executive Committee

  1. 2021 Hackensack Meridian Health Hospital Campus Utilization Management Plan(attached) – APPROVED
  2. Implementation of a suspension plan for Epic Chart Incompletion as presented by Dr. Kim Carpenter (attached) – APPROVED
  3. Policies for three-year review (with no changes) – APPROVED
    • Surgical Necessity/Appropriateness
    • Guideline for Incorporating Surgeon Specific Volumes in the               Credentialing/Re-Credentialing Process
    • Guideline for Institutional Minimal Procedural Volumes
  4. By regulation, Physician Assistant's are no longer required to have their orders co-signed by the supervising physician. A proposal was made to change the JSUMC Rules and Regulations to remove the requirement for a co-signature on PA orders. This will be discussed further at the next meeting of the Medical Executive Committee and is being posted for comments. Please share your comments by sending an email to medstaffcredentialing@hmhn.org. See attached document. 

Action Items from March 9, 2021 Medical Executive Committee

Department of Neurology – Creation of the Academic Department of Neurology – APPROVED

Policies for three-year review (with no changes) – APPROVED 
          a.    Appraisal of Emergencies

Policies for three-year review (with changes) – APPROVED

a.      BME Reporting
b.      Communication to the Medical Staff
c.       Credentialing and Privileging
d.      Dissemination Process
e.      NPDB
f.        Temporary Privileges
g.    Verification of Identity

Action Items from February 9, 2021 Medical Executive Committee

  • Secure Epic Chat – Accept the Utilization of Epic Secure Chat messaging – APPROVED
  • Quality Improvement & Outcomes – APPROVED:
  1. Narrative Work Plan - 2021
  2. 2021 Quality & Performance Improvement Plan – Attached
  3. Calendar Work Plan 2021 - Special Report Schedule
  • Family Medicine – Family Medicine Rules and Regulations update – APPROVED
  • Pediatric Policies (three-year review with no changes) – APPROVED:
  1. Pediatric Cardiology
  2. Pediatric Gastroenterology
  3. Pediatric Hematology/Oncology
  4. Pediatric Neurology
  5. Pediatric Pulmonology

The Epic hard stop for orders will start on Monday, February 15th.  Physicians will not be able to add new orders if they have any orders over 72 hours old that have not yet been signed. - APPROVED

Action Items from January 12, 2021 Medical Executive Committee

  • Four Hour Admission Rule – All COVID Patients to be admitted to the Hospitalist or Intensivist – APPROVED
  • Four Hour Rule – Non-COVID patients – in light of the COVID emergency and surge of patients, and in the interest of safety for our patients, the four-hour admission rule for all COVID and non-COVID admissions was approved.
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