Mercy Memorial Hospital System


MONROE COUNTY MEDICAL CONTROL BOARD/AUTHORITY BY-LAWS

INDEX

ARTICLE I: Name

ARTICLE II: Affiliation

ARTICLE III: Purpose

ARTICLE IV: Goals

ARTICLE V: Membership

Qualification of the Medical Director

Duties of the Medical Director

Assistant Medical Director

Attendance

ARTICLE VI: Meetings

Committees of the Advisory Board

Continuous Quality Improvement Committee

Operations/Training Committee

E.M.S. Communications Committee (Ad Hoc)

Nominating Committee (Ad Hoc)

ARTICLE VII: Nominations

ARTICLE VIII. Conflict of Interest

ARTICLE IX: Conflict Resolution

ARTICLE X: Parliamentary Procedure

ARTICLE XI: Amendments to the By-Laws

ARTICLE XII: Extension, Withdrawal & Revocation of Cooperation

ARTICLE XIII: Emergency Withdrawal of Cooperation

 

ARTICLE I

Name

The name of the organization shall be the Monroe County Medical Control Authority - Advisory Board.

ARTICLE II

Affiliation

This Advisory Board is organized by approval of the Board of Trustees of Mercy Memorial Hospital Corporation (MMH) and derives its authority from Sections 10918 and 20919 (1) of Act No. 179, Michigan Public Acts of 1990, as amended, and Regulations promulgated there under.

ARTICLE III

Purpose

The purpose of the Monroe County Medical Control Advisory Board is to:

1. Promulgate medical protocols for all prehospital emergency medical care rendered in Monroe County.

2. Assure that prehospital emergency medical care is provided in accordance with applicable standards and regulations.

3. Monitor the human and fixed resources in the county to provide for effective EMS services.

4. Support the organized delivery of Emergency Medical Services (EMS) in the county.

The Advisory Board provides advice to the Medical Control Authority in its responsibility to provide medical control supervision for Monroe County prehospital providers.

ARTICLE IV

Goals

SECT. 1. Establish standard operating procedures, and protocols that provide conformity and consistency at all levels of prehospital care.

SECT. 2. Develop a mechanism to review the standards of care and, where necessary, investigate inappropriate patient care and recommend corrective action to MMH Board of Trustees, and/or the Michigan Department of Consumer and Industry Services EMS Division, as appropriate.

SECT. 3. Perform medical audits of prehospital life support activities to evaluate conformance with, and the effectiveness of, promulgated standards of care.

SECT. 4. Act as a resource for matters which require medical consultation including inter-agency operations, dispatch guidelines, training programs and community education.

SECT. 5. Facilitate the development of on-going training programs for all personnel providing or supporting prehospital emergency medical care.

ARTICLE V

Membership

SECT. 1. The Membership of the Advisory Board shall consist of a minimum of seventeen (17) persons. The members shall be qualified and selected in a manner set forth in these By-Laws.

SECT. 2. The members shall be members of the Advisory Board, a committee of the whole membership, and shall have and exercise all such other rights, powers, duties and privileges as in the manner prescribed in these By-Laws.

SECT. 3. New members shall be appointed by the Advisory Board based on the recommendation of the Nominating Committee. The terms of membership shall be as noted commencing with the April meeting.

a. A minimum of two (2) Michigan licensed physicians (at least one of whom shall be actively engaged in the practice of emergency medicine at MMH) who shall hold the following offices:

1) Current EMS Medical Director.

Department physician from each participating hospital (one of whom shall be designated as Assistant Medical Director).

b. Two (2) registered nurses from MMH Emergency Department staff. (A.C.L.S. Certified)

1) Mercy Memorial Hospital, Director of Emergency Services.

2) RN designated as EMS Continuous Quality Improvement (CQI) Coordinator

c Basic EMT (1 year)

d. EMT - Paramedic (ACLS Certified) (2 years)

e. Mercy Memorial Hospital Pharmacist

f. Monroe County Fire Association Representative/ Medical First Responder (3 years)

g. Mercy Memorial Hospital Administration Representative

h. Monroe County Central Dispatch Director

i. Law enforcement officer (chosen from the law enforcement chiefs in the county). (3 years)

j Citizen at large. (3 years)

k. Monroe County 911 Contracted Ambulance service Representative

l. Monroe County Emergency Medical (Ambulance) Authority Representative (1 year)

m. EMS Education Coordinator/EMT Instructor-Coordinator

n. Monroe County Health Department Representative

o. Emergency Management Division Representative

SECT. 4. Qualifications and Duties of the Authority Medical Director

a. The EMS Medical Director shall be an appointee of the MMH Board of Trustees Hospital Authority with the advice of the Medical Control Authority Advisory Board.

b. Qualifications: Physician licensed in the State of Michigan, Board certified in the provision of emergency medicine.

c. Duties

1. To serve as Chair and provide executive direction to the Advisory Board.

2. To direct, in consultation with the Advisory Board, the implementation of the actions of the Advisory Board that relate to minimum standards of medical care, treatment protocols and operating procedures for their medical correctness.

3. To review training curricula and to assure that course content is consistent with minimum standards of care and treatment protocols adopted by the Authority and Advisory Board and approved by the EMS Division of the Michigan Department of Consumer and Industry Services.

4. To direct the development of training programs to assure the availability of continuing education at each level of prehospital care practiced in Monroe County.

5. To be accountable for the security of all drugs and restricted medical supplies assigned to field units.

6. To direct the establishment of procedures; to review prehospital care and to determine whether the care rendered conforms with protocols and standard operating procedures.

7. To enforce minimum standards of prehospital care, and, where necessary, initiate disciplinary proceedings.

8. To provide for the emergency withdrawal of cooperation of MMH and the Advisory Board from any individual(s), ambulances, firm and/or organization if in the Medical Director's opinion such care poses a serious threat to the public's health, safety or welfare.

d. Assistant EMS Medical Director

The Assistant EMS Medical Director shall carry out all responsibilities of the EMS Medical Director in the EMS Medical Director's absence.

SECT. 5 Attendance

Any member who does not attend at least 75% of the meetings of the Advisory Board or committee of the Advisory Board which he/she may be a member, or who has more than two unexcused absences, may be removed from office by the members sitting as the Advisory Board.

ARTICLE VI

Meetings

SECT. 1. There shall be an annual meeting of the Monroe County Medical Control Advisory Board, for the purpose of approving nominations for membership. This meeting shall be held in April of each year.

SECT. 2. The Advisory Board shall hold a routine meeting at least every other calendar month. An Executive Committee meeting may be held on alternate months in lieu of a full Advisory Board meeting or as otherwise needed. All meetings will be held at a time and place designated by the EMS Medical Director unless otherwise voted by the majority to cancel or postpone the meeting.

SECT. 3. One-half (50%) of the membership of the Medical Control Advisory Board being present shall constitute a quorum for the transaction of business, and the acts of a majority of the members present at any meeting at which there is a quorum shall be the acts of the members of the Advisory Board, except as otherwise provided by these By-Laws. A minimum of four (4) Executive Committee members shall constitute an Executive Committee quorum.

SECT. 4. Special meetings may be called by the EMS Medical Director when deemed necessary.

SECT. 5. The Medical Director or his designee shall preside at meetings of the Advisory Board. The Medical Director shall have such powers and duties as are vested in this position by these By-Laws and as may be determined by the Advisory Board. In no regard may the Advisory Board nor the By-Laws interfere with the Medical Director's authority and responsibility as defined by Michigan law.

SECT. 6. Committees of the Medical Control Advisory Board

A. The members of the Advisory Board may, at any meeting, establish such committees as they deem necessary to consider and render advice on any matters pertinent to the membership or to the Advisory Board.

B. The members of such committees shall be selected as determined by the Advisory Board.

C. All such committees shall be directly responsible to the Medical Director.

D. Standing Committees

1. The Executive Committee

It will be the responsibility of this Committee to act on behalf of the Advisory Board to further the projects and plans of the whole Board. It may take actions consistent with but not superceding the policies, procedures or planning which the Advisory Board has set (with approval of the Hospital Authority). Written minutes will be kept at all meetings and all actions taken must be reported to the Medical Control Board at its next meeting. All Advisory Board members will be notified of, and may participate in, the scheduled meetings of the Executive Committee.

The Committee shall consist of the following members:

a. EMS Medical Director (Chairperson)

b. CQI Coordinator

c. Mercy Memorial Hospital, Emergency Department Director

d. Mercy Memorial Hospital Administration Representative

e. Monroe County Central Dispatch Director

f. EMS Education Coordinator/EMT Instructor-Coordinator

g. One Advisory Board Member appointed by the Medical Director

2. The Continuous Quality Improvement Committee

It will be this Committee's responsibility to review prehospital care rendered within the Authority's jurisdiction and recommend actions through the Mercy Memorial Hospital Administration to the Mercy Memorial Hospital Board of Trustees regarding the extension, withdrawal and suspension of Medical Control Authority cooperation.

The Committee shall consist of the following members:

a. EMS Medical Director (Chairman)

b. EMT-Paramedic

c. Mercy Memorial Hospital, Emergency Department, Director

d. Ambulance Service Representative

e. Mercy Memorial Hospital EMS CQI Coordinator

f. EMS Education Coordinator/EMT Instructor-Coordinator

All actions taken by the committee will be kept confidential to the extent that it is consistent with the laws of the State of Michigan.

3. The Operations/Training Committee

This Committee shall be charged with the development, implementation and modification of protocols and standard operating procedures. Areas to be addressed by this Committee include, but are not limited to, standing orders, medical protocols and treatment procedures, drugs and drug exchange, equipment and equipment failure, methods of documentation as well as medical areas within operating procedures.

The Committee shall be responsible for reviewing the course content of all training programs. In addition, this Committee shall facilitate the development of on-going training programs for all personnel providing or supporting prehospital emergency care.

The Committee shall consist of the following members:

a. EMS Medical Director (Chairman)

b. Mercy Memorial Hospital, Emergency Department, Director

c. Mercy Memorial Hospital Pharmacist

d. EMT

e. EMT Paramedic

f. Fire Association Representative

g. EMS Education Coordinator/Instructor-Coordinator

h. Ambulance Service Representative

I. EMS CQI COORDINATOR

4. The Communications Committee (Ad Hoc)

An Ad Hoc committee of the Advisory Board, the Committee shall be responsible for the technological recommendation and modification of communication equipment and procedures. Voice communication protocols between various professionals within the EMS community will be undertaken and developed by Operations/Training Committee.

The Ad Hoc Communications Committee shall consist of the following members:

a. Monroe County Central Dispatch Director (Chairman)

b. Fire Association Representative

c. Mercy Memorial Hospital Administration Representative

d. Ambulance Service Representative

5. The Nominating Committee

The Committee shall consist of three members of the Advisory Board appointed by the Medical Director.

SECT. 6. Meetings

Meetings of the Medical Control Board and its Committees are subject to the Michigan Open Meetings Act.

ARTICLE VII

Nominations

The Nominating Committee will meet during January of each year to develop a slate of candidates for each position. These recommendations will be forwarded to the Advisory Board at the February meeting. All candidates will be voted on at the April Annual Meeting. Special meetings of the Nominating Committee may be called by the Medical Director to assist in recommending candidates to fill temporary vacancies.

ARTICLE VIII

Conflict of Interest

SECT. 1. The following provisions are designed to preclude the use of membership on the Advisory Board or on any committee for purposes which are, or give the appearance of being, motivated by private gain on the part of any individual:

a. Members of the Advisory Board or any of its organizational units with conflicts of interest may participate in the discussion of a matter in which they have an interest, but in no case shall be allowed to vote on that matter.

b. The applicant and/or guests will not participate in discussions of the body considering a matter in which they have an interest unless recognized or requested to do so by the Chair.

c. For purposes of applying the above rules as conflict of interest, a conflict shall exist under the following conditions:

1. The organization member has, or within the twelve months preceding the vote had, a substantial ownership, employment, medical staff, fiduciary, contractual creditor or consultative relationship in regard to the matter to be considered.

2. The organization member has a personal and direct monetary and fiduciary interest in an agency, organization or institution which has an intent as defined in number one above.

d. Prior to a matter being considered at a meeting, a written disclosure of conflict of interest shall be made by persons having an interest as defined in c(1) and c(2) above and such conflict of interest shall be announced at the meeting.

e. Questions regarding conflict of interest shall be settled by majority vote of the Advisory Board.

ARTICLE IX

Conflict Resolution

The Medical Control Advisory Board shall develop, as an operating procedure, a mechanism for conflict resolution. In the event of impasse, the MMH Board of Trustees shall make a final determination. Because of the medical nature of the decisions involved, the Medical Director and the Advisory Board will have an opportunity to address the medical issues prior to the MMH Board of Trustees taking action. The procedure for resolution of conflicts is outlined in Appendix B (Quality Review) and Appendix F (Withdrawal of Cooperation).

ARTICLE X

Parliamentary Procedure

SECT. 1. Any question concerning procedure arising at any Advisory Board or committee meeting shall be resolved by the Chairman in accordance with these By-Laws, and in the case of a question not resolved by these By-Laws, the Chairman shall resolve the question by reference to the latest edition of Robert's Rules of Order Revised, and the meeting shall proceed in accordance with his/her decision based upon said Rules.

ARTICLE XI

Amendments to the By-Laws

SECT. 1. Notice of any proposed change of the By-Laws must be sent to the members, in writing, ten (10) days prior to the meeting and the proposed changes must be set forth in full in the Notice.

SECT. 2. These By-Laws may be amended and supplemented with provisions consistent with the objectives and purposes of the Monroe County E.M.S. Authority by two-thirds vote of a majority of the Advisory Board.

SECT. 3. Any changes in By-Laws must be approved by the Mercy Memorial Hospital Board of Trustees.

ARTICLE XII

Extension, Withdrawal & Revocation of Cooperation

The Continuous Quality Improvement Committee shall make recommendations to MMH Administration regarding the extension, withdrawal and revocation of cooperation to basic, limited and advanced mobile emergency care services and personnel. MMH Administration shall approve or disapprove all recommendations made by the Advisory Board. Specific procedures are outlined in Appendix B and Appendix F.

 

ARTICLE XIII

Emergency Withdrawal of Cooperation

Because of a need to maintain high quality prehospital care, the Medical Director, acting in cooperation with Mercy Memorial Hospital Administration, shall be empowered to temporarily withdraw cooperation from any basic, limited, advanced mobile emergency care service or personnel, as authorized under Michigan Department of Public Health Rule R325.23707, January 5, 1984, or as later amended.

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