HomeMy WebLinkAboutMINUTES - 12022014 - C.139RECOMMENDATION(S):
Approve the attached changes to the 2014 Medical Staff Bylaws and Rules and Regulations, as recommended by the
Medical Executive Committee, the Joint Conference Committee and Health Services Director.
FISCAL IMPACT:
None.
BACKGROUND:
Changes to the 2014 Medical Staff Bylaws and Rules and Regulations will bring into consistency with current
practices in relation to Medical Staff President term of office and Department and Division Head election procedures.
CONSEQUENCE OF NEGATIVE ACTION:
The Medical Staff Bylaws would not be updated.
CHILDREN'S IMPACT STATEMENT:
Not applicable.
APPROVE OTHER
RECOMMENDATION OF CNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE
Action of Board On: 12/02/2014 APPROVED AS RECOMMENDED OTHER
Clerks Notes:
VOTE OF SUPERVISORS
AYE:John Gioia, District I Supervisor
Candace Andersen, District II
Supervisor
Mary N. Piepho, District III
Supervisor
Karen Mitchoff, District IV
Supervisor
Federal D. Glover, District V
Supervisor
Contact: Anna Roth, 370-5101
I hereby certify that this is a true and correct copy of an action taken and entered on the minutes of the Board
of Supervisors on the date shown.
ATTESTED: December 2, 2014
David Twa, County Administrator and Clerk of the Board of Supervisors
By: Stacey M. Boyd, Deputy
cc: T Scott, C Rucker
C.139
To:Board of Supervisors
From:William Walker, M.D., Health Services Director
Date:December 2, 2014
Contra
Costa
County
Subject:Proposed Changes to the 2014 Medical Staff Bylaws and Rules and Regulations
ATTACHMENTS
Proposed
Amendment
Final Bylaws
Contra Costa Regional Medical Center
& Health Centers
Medical Staff Bylaws
Rules & Regulations
2014
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Contents
DEFINITIONS ................................................ 1
ARTICLE 1 ..................................................... 3
NAME AND PURPOSES ............................................3
ARTCLE 2 ....................................................... 3
MEMBERSHIP .........................................................3
2.1 Nature of Membership............................. 3
2.2 Eligibility and Qualifications for
Membership ............................................ 3
2.3 Clinical Psychologists ................................ 4
2.4 Waiver of Qualifications ........................... 4
2.5 Membership Requirements ..................... 4
2.6 Effect of Other Affiliations ....................... 5
2.7 Nondiscrimination .................................... 5
2.8 General Responsibilities of Medical Staff
Membership ............................................ 5
2.9 Harassment and Discrimination
Prohibited ................................................ 6
ARTICLE 3 ..................................................... 7
CATEGORIES OF THE MEDICAL STAFF ......................7
3.1 Categories ................................................ 7
ARTICLE 4 ................................................... 14
ALLIED HEALTH PRACTITIONERS ........................... 14
4.1 Definitions .............................................. 14
4.2 Categories of AHPs Eligible to Apply for
AHP Clinical Privileges or Services ......... 15
Authorizations and Rules regarding them ........... 15
4.3 Eligibility and General Qualifications ..... 15
4.4 Specific Qualifications ............................ 16
4.5 Waiver of Qualifications. ........................ 16
4.6 Prerogatives ........................................... 16
4.7 Responsibilities ...................................... 16
4.8 Procedure for Granting Initial and
Renewal Services Authorizations ........... 16
4.9 Termination, Suspension, or Restriction of
Service Authorizations ........................... 17
ARTICLE 5 ................................................... 17
PROCEDURES FOR APPOINTMENT AND
REAAPOINTMENT ................................................. 17
5.1 General ................................................... 17
5.2 Applicant’s Burden ................................. 17
5.3 Applicant for Initial Appointment and
Reappointment for Medical Staff
Membership .......................................... 18
5.4 Basis for Appointment and
Reappointment to the Medical Staff ..... 18
5.5 Application Procedure. ........................... 18
5.6 Reappointment and Requests for
Modifications of Staff Status or Privileges
............................................................... 26
5.7 Leave of Absence from the Medical Staff
............................................................... 27
5.8 Waiting Period after Adverse Action ...... 27
5.9 Confidentiality and Impartiality ............. 28
ARTICLE 6 ................................................... 28
PRIVILEGES ........................................................... 28
6.1 Exercise of Privileges .............................. 28
6.2 Delineation of Privileges in General ....... 29
6.3 Non-licensed Resident Physicians .......... 29
6.4 Temporary Privileges.............................. 30
6.5 Emergency Privileges ............................. 31
6.6 Focused Professional Practice Evaluation
(FPPE) ..................................................... 32
6.7 Disaster Privileges .................................. 33
ARTCLE 7 ..................................................... 35
GENERAL MEDICAL STAFF OFFICERS ..................... 35
7.1 Identification .......................................... 35
7.2 Qualifications ......................................... 35
7.3 Attainment of Office .............................. 35
7.4 Vacancies................................................ 36
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7.5 Resignation and Removal from office .... 37
7.6 Duties of General Staff Officers.............. 37
ARTICLE 8 ................................................... 38
DEPARTMENT AND DIVISIONS .............................. 38
8.1 Organization of Departments ................ 38
8.2 Assignment to Departments .................. 39
8.3 Functions of Departments...................... 39
8.4 Department Heads ................................. 40
8.5 Election of Department Heads ............... 41
8.6 Functions of Divisions ............................ 43
8.7 Division Heads ........................................ 43
8.8 Election of Division heads ...................... 44
ARTICLE 9 ................................................... 46
COMMITTEES ........................................................ 46
9.1 General Provisions ................................. 46
9.2 Medical Executive Committee ............... 47
9.3 Committees ............................................ 48
ARTICLE 10 ................................................. 64
MEETINGS ............................................................. 64
10.1 Medical Staff Meetings .......................... 64
10.2 Clinical Department and Committee
Meetings ................................................ 64
10.3 Quorum .................................................. 64
10.4 Manner of Action ................................... 65
10.5 Notice of Meetings ................................. 65
10.6 Minutes .................................................. 65
10.7 Agenda ................................................... 65
10.8 Attendance Requirements ..................... 66
10.9 Conduct of Meetings .............................. 66
ARTICLE 11 ................................................. 66
CORRECTIVE ACTION ............................................ 66
11.1 Corrective Action .................................... 66
11.2 Summary Restriction of Suspension....... 68
11.3 Grounds for Automatic Suspensions
and/or Restrictions ................................ 69
ARTICLE 12 ................................................. 72
HEARING AND APPELLATE REVIEWS ..................... 72
12.1 Grounds for Hearing ............................... 72
12.2 Exhaustion of Remedies ......................... 72
12.3 Requests for Hearing .............................. 72
12.4 Hearing Procedure ................................. 74
12.5 Appeals ................................................... 77
12.6 Exceptions to Hearing Rights.................. 79
ARTICLE 13 ................................................. 80
CONFIDENTIALITY ................................................. 80
13.1 General ................................................... 80
13.2 Breach of Confidentiality ........................ 80
13.3 Protection ............................................... 80
13.4 Access by persons or Agencies Outside
the Jurisdiction of the Hospital .............. 81
13.5 Access by Persons within the Jurisdiction
of the Hospital ....................................... 82
ARTICLE 14 ................................................. 84
GENERAL PROVISIONS .......................................... 84
14.1 Rules and Regulations ............................ 84
14.2 Dues or Assessments .............................. 84
14.3 Construction of Terms and Headings ..... 84
14.4 Authority to Act ...................................... 84
14.5 Division of Fees ...................................... 84
14.6 Special Notices ....................................... 84
14.7 Requirements for Elections of Medical
Staff President, Department Heads,
Division heads and for Bylaws
Amendments ......................................... 85
14.8 Disclosure of Interest. ............................ 85
14.9 Authorization, Immunity, and Releases. 86
14.10 Standards for History and Physical
Examination. .......................................... 86
ARTICLE 15 ................................................. 87
ADOPTION AND AMENDMENT OF BYLAWS AND
RULES ................................................................... 87
15.1 Annual Review. ....................................... 87
15.2 Procedure. .............................................. 87
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15.3 Medical Staff Action. .............................. 87
15.4 Approval. ................................................ 87
15.5 Exclusivity. .............................................. 88
RULES AND REGULATIONS .................... 89
1. General Rules ...................................... 89
A. Admissions ............................................. 89
B. Continuous Responsibility for Patients .. 89
1. Inpatient ................................................. 89
2. Outpatient .............................................. 89
C. Medical Records ..................................... 89
1. General Provisions ................................. 89
2. Completion of Records ........................... 90
a. Inpatient Records ............................... 90
3. Delinquency ........................................... 92
4. Disciplinary Proceedings ........................ 92
5. Outpatient Records ................................ 93
6. Outpatient notes should contain the
following elements: ............................... 93
D. Medical Orders ....................................... 93
1. Inpatient ................................................. 93
2. Outpatient .............................................. 94
E. CPR ......................................................... 94
F. Disaster Assignments: Refer to Hospital
Disaster Plan .......................................... 94
G. Consultation Policy ................................. 94
H. Operating Room Policies ........................ 95
1. Consents: ................................................ 95
2. Prompt attendance of surgeon and
attendants: ............................................ 95
I. Supervision of House Staff ..................... 95
J. On-Call Response Time .......................... 96
K. Processing and Delivery of Ordered Blood
Products ................................................. 96
L. Collection and Expenditures of Medical
Staff Funds ............................................. 97
1. Application Fees ..................................... 97
2. Medical Staff Dues ................................. 97
3. Reappointment Late Processing Fees .... 97
4. Expenditure of Funds ............................. 98
M. Medical Staff Evaluation and
Development ......................................... 98
N. Other Policy Manuals ............................. 99
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Definitions
The following definitions apply to these Medical Staff Bylaws:
1. Administrator means the Chief Executive Officer of Contra Costa Regional Medical Center and
Health Centers and her/his designee.
2. Chief Resident means the resident physician chosen by the residents to represent them.
3. Allied Health Practitioners (AHP) are those non-Medical Staff member practitioners described in
Article 4 below.
4. Clinical Privileges or Privileges means permission, granted by this Medical Staff to members of
the Medical Staff, to provide specific diagnostic, therapeutic, medical, dental, podiatric, surgical,
psychiatric or psychology services.
5. AHP Clinical Privileges or Service Authorizations means permission granted by the Governing
Body, upon the recommendation of the Interdisciplinary Practice Committee and the Medical
Staff, to provide diagnostic and therapeutic services within the scope of the AHP’s training and
expertise.
6. County means County of Contra Costa, California.
7. Department or Clinical Department means a clinical structure of the Medical Staff as further
identified in these Bylaws.
8. Department Head means the practitioner elected or appointed, pursuant to these Bylaws to be
responsible for the function of a Clinical Department.
9. Medical Director of Contra Costa Regional Medical Center, also referred to simply as the Medical
Director, means the physician appointed by the Administrator to oversee clinical activities of the
hospital.
10. Chief Medical Officer of the Health Services Department means the physician appointed by the
Director of the Health Services Department to oversee the clinical activities of the Health
Services Department.
11. Ex-officio means service as a member of a body by virtue of an office or positions held and,
unless expressly provided, without voting rights.
12. Governing Body means the County Board of Supervisors.
13. Hospital or Medical Center means the Contra Costa Regional Medical Center and Health
Centers.
14. Health Centers means the outpatient clinical facilities operated by the County where the
Members of this Medical Staff provide patient care.
15. Medical Staff Year means the twelve (12)-month period commencing on the first of July of each
year and ending on the thirtieth (30th) of June of the following year.
16. Member or Medical Staff Member means any Practitioner or Resident who has been appointed
to the Medical Staff pursuant to these Bylaws.
17. Member in Good Standing means a Member of the Medical Staff who is not under a suspension.
18. Physician means an individual with a M.D. or D.O. degree who is currently licensed to practice
medicine in the State of California.
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19. Practitioner means a physician, dentist, clinical psychologist, or podiatrist who is currently
licensed by the State of California to provide patient care services.
20. Residency Director means the physician who directs the postgraduate Family Medicine training
program based at the Hospital.
21. Resident means a physician in training who is participating in a residency of fellowship approved
by the American Council of Graduate Medical Education.
22. Rules or Rules and Regulations mean the Medical Staff Rules and Regulations that are contained
under separate cover and are adopted to the Bylaws.
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ARTICLE 1
NAME AND PURPOSES
1.1 The name of this organization is the Medical Staff of the Contra Costa Regional Medical Center
and Health Centers.
1.2 The Medical Staff purposes are:
1) To assure that all patients treated by any of its members receive the best possible care.
2) To provide for professional performance that is consistent with the mission and goals of the
Hospital.
3) To maintain Rules for the Medical Staff to carry out its responsibilities for the professional
work performed in the Hospital.
4) To provide a means for the Medical Staff, Governing Body and Hospital Administration to
discuss issues of mutual concern.
5) To provide for accountability of the Medical Staff to the Governing Body.
ARTCLE 2
MEMBERSHIP
2.1 Nature of Membership
Appointment to the Medical Staff shall confer only such Privileges and Prerogatives as have
been granted by the Governing Body in accordance with these Bylaws. Only Members of the
Medical Staff may care for patients in our Hospital and Health Centers.
2.2 Eligibility and Qualifications for Membership
2.2.1 General Qualifications
Membership on the Medical Staff and Privileges shall be extended only to Practitioners who
are professionally and ethically competent and continuously meet the qualifications,
standards, and requirements set forth in these Bylaws, Rules and Regulation, and Medical
Staff Policies.
Except for Honorary and Resident membership, only physicians, dentists, podiatrists and
clinical psychologists who;
A. Document current licensure; adequate experience, education and training; professional
and ethical competence; good judgment; adequate physical and mental health status;
and current eligibility to participate in Medicare, Medicaid or other federally-sponsored
health care program; and who
B. Abide by the ethics of their profession; work cooperatively with others; maintain
confidentiality as required by law; and will participate in and discharge their
responsibilities as required by the medical staff shall be deemed to possess the basic
qualifications and eligibility for membership on the Medical Staff.
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2.2.2 Specific Qualifications:
To be eligible and qualified for Medical Staff Membership and Privileges, the Practitioner
must, meet the basic standards outlined in ‘Eligibility and General Qualifications,’ and these
Specific Qualifications;
Physicians seeking membership, privileges or reappointment must have satisfactorily
completed an approved postgraduate residency training program. An approved
postgraduate training program is a program approved by the Accreditation Council for
Graduate Medical Education (ACGME).
Resident Physicians. An applicant for Resident Physician membership on the Medical Staff
must have a valid M.D. or D.O. degree or equivalent degree. The applicant must have been
accepted for training by a residency program affiliated with the Hospital and must be a
member in good standing of the residency. Resident physicians do not need to have a full
license to practice medicine independently; however, if they do not have such an
unrestricted license, a Licensed Physician Member of the Medical Staff must supervise any
patient care in which the resident is involved.
Controlled Substance Prescriber. Practitioner members on the Medical Staff must have a
Federal DEA number if prescribing controlled substances.
Dentists. An applicant for dental membership on the Medical Staff must have a DDS or
equivalent degree. The Practitioner must have a valid, unsuspended license to practice
dentistry issued by California Board of Dental Examiners.
Podiatrists. An application for Podiatric Membership in the Medical Staff must have a
D.P.M. or equivalent degree. The Practitioner must have a valid, unsuspended license to
practice podiatry issued by the California Board of Podiatric Medicine.
2.3 Clinical Psychologists
An applicant for Clinical Psychologist Membership on the Medical Staff must have a doctorate
degree in clinical psychology. The Practitioner must have a valid, unsuspended license to practice
clinical psychology issued by the California Board of Psychology.
2.4 Waiver of Qualifications
The Credentials Committee may recommend that certain eligibility criteria be waived by the
Medical Executive Committee (MEC.) The Practitioner must demonstrate that he or she has the
equivalent qualifications or that exceptional circumstances exist which warrant granting the
waiver. The Practitioner has no right to have his or her waiver request considered or granted and
denial of a waiver confers no right to a hearing or appellate review.
2.5 Membership Requirements
An applicant for Membership appointment or reappointment on the Medical Staff must document
his or her adequate experience, education, and training in the requested Privileges. The applicant
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must demonstrate current professional competence and good judgment in the use of such
Privileges. The applicant must demonstrate his or her ability to exercise such Privileges for quality
patient care at a level recognized as appropriate to a similar professional within the community.
The MEC must determine that the applicant adheres to the lawful ethics of his or her profession; is
able to work cooperatively with others in the Hospital so as not to adversely affect patient care or
Hospital operations; and is willing and able to participate in and properly discharge Medical Staff
responsibilities as describes in these Bylaws, the Rule and Regulations and applicable Medical Staff
Policy.
2.6 Effect of Other Affiliations
No Practitioner is entitled to Medical Staff Membership merely because he or she holds a certain
degree, is licensed to practice medicine in this or in any other state, is a member of any
professional organization, is certified by any clinical board, or because he or she had, or presently
has, Medical Staff Membership or Privileges at another health care facility.
2.7 Nondiscrimination
Medical Staff Membership or particular Privileges shall not be denied on the basis of age, gender,
sexual orientation, race, religion, color, national origin, physical or mental impairment, marital
status or disability that does not pose a threat to the quality of patient care or substantially impair
the ability to fulfill required staff obligations.
2.8 General Responsibilities of Medical Staff Membership
Each Medical Staff Member exercising Privileges in the Hospital and Health Centers shall
continuously meet all of the following responsibilities:
2.8.1 Provide his or her patients with care meeting the professional standards of the Medical
Staff of this Hospital.
2.8.2 Abide by the Medical Staff Bylaws and the Rules and all other lawful standards, policies,
and rules of the Medical Staff and the Hospital.
2.8.3 Abide by all applicable laws and regulations of governmental agencies and comply with
applicable standards of the TJC.
2.8.4 Discharge such Medical Staff, department, division, committee, and service functions for
which he or she is responsible by appointment, election, or otherwise.
2.8.5 Prepare and complete in a timely manner the Medical and the required records for all
patients to whom the Practitioner in any way provides services to the Hospital.
2.8.6 Abide by the ethical principles of his or her profession.
2.8.7 Work cooperatively with other Medical Staff Members, nurses, administrators, and other
members of the health care team so as not to adversely affect patient care.
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2.8.8 Participate in educational programs approved by the Medical Staff and designed to
improve the quality of patient care.
2.8.9 Refuse to engage in any improper inducements for patient care referrals.
2.8.10 Make appropriate arrangements for coverage for his or her patients when an absence is
anticipated.
2.8.11 Complete continuing education programs that are required by the Medical Staff.
2.8.12 Participate in emergency service coverage and consultation (on-call) panels as may be
required by the Medical Staff.
2.8.13 Accept responsibility for participating in Medical Staff FPPE in accordance with the Bylaws.
2.8.14 Pay Medical Staff dues and assessments within sixty (60) days of invoice receipt.
2.8.15 Participate in the resident training program as requested by the Residency Director.
2.8.16 Promptly notify the Medical Staff Office of any professional liability action the member is
involved in as soon as the member becomes aware of his or her involvement.
2.8.17 Participate in quality assurance programs as determined by the Medical Staff.
2.8.18 Discharge such other duties and obligations as may be lawfully established from time to
time by the Medical Staff, the Medical Executive Committee, the Member’s Department,
or the Administrator.
2.9 Harassment and Discrimination Prohibited
2.9.1 Statement of Policy
The Medical Staff is committed to providing a workplace free of sexual harassment or
discrimination as well as unlawful harassment or discrimination based upon age, ancestry,
color, marital status, medical condition, mental disability, physical disability, national
origin, race, religion, gender, or sexual orientation. The Medical Staff does not tolerate
harassment or discrimination by Medical Staff Members of resident physicians, support
staff, County employees, patients, or other Medical Staff Members.
2.9.2 Harassment Defined
A. Harassment is unwelcome verbal, visual, or physical conduct that creates an
intimidation, offensive or hostile working environment or that interferes with work
performance. Such conduct constitutes harassment when:
1) Submission to the conduct is made either an implicit or explicit condition of
employment;
2) Submission to or rejection of the conduct is used as the basis for an employment
decision; or
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3) The harassment unreasonably interferes with work performance or creates an
intimidating, hostile or offensive work environment.
2.9.3 Harassing conduct can take many forms and includes, but is not limited to, slurs, jokes,
statements, gestures, pictures, or cartoons regarding a person’s age, ancestry, color,
marital status, medical condition, mental disability, physical disability, national origin, race
religion, gender or sexual orientation. Sexually harassing conduct in particular included all
of these prohibited actions as well as requests for sexual favors, conversion containing
sexual comments, and unwelcome sexual advances.
2.9.4 Investigating and Corrective Action
A. Every complaint of harassment made to the Medical Staff will be investigated
thoroughly and promptly. The Medical Staff will attempt to protect the privacy of
individuals involved in the investigation when appropriate. The Medical Staff will not
tolerate retaliation against anyone who reports harassing conduct. Other entities,
such as the County and legal authorities, may also separately investigate such
complaints. When appropriate, the Medical Staff shall share investigatory information
with such authorities.
B. If the Medical Staff determines that harassment occurred, the Medical Staff will take
corrective action up to and including termination of Medical Staff Privileges or
Membership. Corrective actions taken by the Medical Staff related to such harassing
conduct are not grounds for a hearing unless those actions affect a Member’s
Privileges or Membership status on the Medical Staff. When appropriate, corrective
action may include reporting the harassment to appropriate legal, administrative, and
governing authorities.
ARTICLE 3
CATEGORIES OF THE MEDICAL STAFF
3.1 Categories
The Medical Staff Members are divided into the following categories of membership; active,
temporary, courtesy, provisional, honorary, administrative and resident. Each Medical Staff
Member shall be assigned to a Medical Staff category based upon the respective qualifications set
forth in theses Bylaws. Members of each Medical Staff category shall have the respective
prerogatives and responsibilities as set forth in these Bylaws. Action may be initiated to change
the Medical Staff category to terminate the membership of any Member who fails to meet the
qualifications or fulfill the responsibilities as described in the Bylaws. Changes in Medical Staff
category shall not be grounds for hearing unless it affects the Member’s Clinical Privileges.
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3.1.1 The Honorary Medical Staff
The honorary Medical Staff consists of practitioners who are not active in the Hospital or
who are honored by emeritus positions. These may be practitioners who have retired
from active hospital practice or who are of outstanding reputation, not necessarily
residing in the community. Honorary staff members are not eligible to admit, care for or
consult on patients, to vote, to hold office, or to serve on standing Medical Staff.
3.1.2 The Administrative Medical Staff
A. Qualifications
1) Administrative category membership shall be held by any physician, who is not
otherwise eligible for another staff category and who solely performs ongoing
medical administrative activities.
2) Document their (1) current licensure, (2) adequate experience, education and
training, (3) current professional competence, (4) good judgment, and (5) current
physical and mental health status, so as to demonstrate to the satisfaction of the
Medical Staff they are professionally and ethically competent to exercise their
duties;
B. Prerogatives
The Administration Staff shall be entitled to attend meetings of the Medical Staff and
various departments and education programs, but shall have no right to vote at such
meetings. Administrative Staff members shall not be eligible to hold office in the
Medical Staff Organization, admit patients, or exercise clinical privileges.
3.1.3 The Active Medical Staff
A. Qualifications
The active staff consists of physicians, dentists, podiatrists, and licensed psychologists,
each of whom;
1) Meets the qualifications for Medical Staff membership set forth in the Bylaws;
2) Has an office and residence that, in the opinion of the Medical Executive
Committee, is located closely enough to the Hospital to provide appropriate
continuity of quality care;
3) Regularly admits patients to the Hospital, is regularly involved in the care of
patients at the Hospital, or regularly uses the Hospital and/or Health Centers in
the care of patients;
4) Has satisfactorily completed his/her term in the provisional staff category.
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B. Prerogatives
Each member of the active staff is entitled to:
1) Admit patients and/or exercise Clinical Privileges as are granted to him/her;
2) Attend and vote on all matters presented at general and special meetings of the
Medical Staff, his/her department, and or committees to which he/she is a
member;
3) Attend any staff or Hospital education programs;
4) Hold staff and/or departmental offices and service on committees to which
he/she has been appointed.
C. Responsibilities
Each member of the active Medical Staff is responsible for the following:
1) Carrying out the basic responsibilities of Medical Staff membership set forth in the
Bylaws;
2) Providing for the continuous care and supervision of each patient in the Hospital
and Health Centers for whom he/she is providing services, including arranging for
care and supervision in his/her absence and outside of his/her area of professional
competence;
3) Providing consultation, supervision, and monitoring of patients, when requested;
and
4) Attending meetings of the Medical Staff, his/her department, and committees of
which he/she is a member in accordance with the Bylaws.
D. Demotion of Active Staff Member.
After one year in which a Member of this active staff fails to regularly care for patients
in this hospital or Health Centers be regularly involved in Medical Staff functions as
determined by the Medical Staff, that Members may be demoted to a lower staff
category.
3.1.4 Courtesy Staff
A. Qualifications
The courtesy staff consists of practitioners, each of whom:
1) Meets the qualifications for Medical Staff membership set forth in the Bylaws;
2) Has an office and residence that, in the opinion of the Medical Executive
Committee, is located closely enough to the Hospital to provide appropriate
continuity of quality care;
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3) Admits patients to the Hospital on an irregular basis, is occasionally involved in
the care of Hospital patients, or occasionally uses the Hospital and/or Health
Centers in the care of patients;
4) Is a member of the active staff of another licensed hospital unless the Medical
Executive Committee, in writing, for good cause shown, waives this requirement.
Dentists holding only General Dentistry, Endodontia, Periodontia, or Orthodontia
privileges are exempt from this requirement.
5) Has satisfactorily completed his/her term in the provisional staff category.
B. Responsibilities
Each member of the courtesy staff is responsible for the following:
1) Carrying out the basic responsibilities of Medical Staff membership set forth in the
Bylaws;
2) Providing for the continuous care and supervision of each patient in the Hospital
for whom he/she is providing services, including arranging for care and
supervision in his/her absence and outside of his/her area of professional
competence;
3) Providing consultation, supervision, and monitoring of patients, when requested;
and
4) Attending meetings of the Medical Staff, his/her department, and committees of
which he/she is a member in accordance with the Bylaws.
C. Limitation
Courtesy staff members shall not be eligible to hold office in this Medical Staff
organization nor shall they be eligible to vote on matters presented at general and
special meetings of the Medical Staff, departmental meetings, division meetings, or
committee meetings except as specifically provided in the Bylaws.
3.1.5 Provisional Staff
A. Qualifications.
The provisional staff consists of practitioners, each of whom:
1) Meets the qualifications for Medical Staff membership set forth in the Bylaws;
2) Immediately prior to his/her application and appointment was not a member (or
was no longer a member) in good standing of this Medical Staff;
3) Has an office and residence that, in the opinion of the Medical Executive
Committee, is located closely enough to the Hospital to provide appropriate
continuity of quality care.
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B. Prerogatives.
Each member of the provisional staff is entitles to;
1) Admit patients and exercise such Clinical Privileges as are granted pursuant to the
Bylaws;
2) Attend meetings of the staff and the department of which he/she is a member
and any staff or hospital education programs;
3) Be appointed to any committee except the Medical Executive Committee. The
provisional staff members shall not have the right to vote unless the Medical Staff
President confers that right at the time of the committee appointment.
C. Responsibilities
Each member of the provisional Medical Staff is responsible for the following:
1) Carrying out the basic responsibilities of Medical Staff membership set forth in the
Bylaws;
2) Providing for the continuous care and supervision of each patient in the hospital
for whom he/she is providing services, including arranging for care and
supervision in his/her absence and outside of his/her area of professional
competence;
3) Providing consultation, supervision, and monitoring of patients, when requested;
4) Attending meetings of the Medical Staff, his/her department, and committees of
which he/she is a member in accordance with the Bylaws.
D. Limitation
Provisional staff members are not eligible to vote on matters presented at general and
special meetings of the Medical Staff, department meetings, division meetings, or
committee meetings except as specifically provided in the Bylaws.
E. Monitoring of Provisional Staff Member
Each provisional staff members shall undergo a period of monitoring. The monitoring
shall be to evaluate the members’ (1) proficiency in the exercise of Clinical Privileges
initially granted and (2) overall eligibility for continued staff membership and
advancement within staff categories. Monitoring of provisional staff members shall
follow whatever frequency and format each department deems appropriate in order
to adequately evaluate the provisional staff member including, but not limited to,
concurrent or retrospective chart review, mandatory consultation, and/or direct
observation. The results of the monitoring shall be communicated by the department
chairperson to the Credentials Committee.
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F. Term of Provisional Staff Status
A Member shall remain on the provisional staff for a period of six months unless the
Medical Executive Committee or the Credentials Committee extends that status for an
additional period of up to six months upon a determination of good cause, which
determinations shall not be subject to review. In special circumstances wherein the
Member has had minimal activity at the Hospital and Health Centers, and current
information is inadequate to allow a determination to conclude the provisional staff
status, the Medical Executive Committee may extend the provisional staff status for
an additional period of up to twelve (12) months, which determination shall not be
subject to review. In no event shall the total provisional staff status of a member
exceed twenty-four (24) months. At the conclusion of provisional staff status, further
staff status is determined as stated below.
G. Action at Conclusion of Provisional Staff Status
1) If the Provisional Staff Member has satisfactorily demonstrated his or her ability
to exercise the Clinical Privileges initially granted and otherwise appears qualified
for continued Medical Staff membership, the Member shall be eligible for
placement in the active or Courtesy Staff, as appropriate, upon recommendation
of the Medical Executive Committee (MEC.) The Administrator and the Governing
Body shall act upon this MEC recommendation. Should any disagreement occur
between the MEC, the Administrator, and the Governing Body, resolution shall
occur in compliance with the Bylaws.
2) In all cases, the appropriate department shall advise the Credentials Committee,
which shall make its report to the Medical Executive Committee, which, in turn,
shall make its recommendation to the Professional Affairs Committee regarding a
modification or termination of Clinical Privileges, or termination of Medical Staff
membership.
3.1.6 Resident/Fellow Staff
A. Qualifications for Residents/Fellow
The resident/fellow staff consists of Members, each of whom;
1) Meets the qualifications for Medical Staff membership set forth in the Bylaws;
2) Exercise Clinical Privileges under appropriate supervision and direction of the
Program Director, and the head of the department in which he/she is exercising
Privileges;
3) Attend meetings of the Medical Staff and, if invited, the departments to which
he/she is currently assigned;
4) Be appointed to any committee except the Medical Executive Committee. The
Resident/Fellow staff member shall not have the right to vote unless that right is
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conferred by the Medical Staff President at the time of the committee
appointment;
5) If licensed, apply for provisional status on the Medical Staff without relinquishing
his or her resident status with regard to these Bylaws.
B. Responsibilities
Each member of the Resident/Fellow staff is responsible for the following:
1) Carrying out the basic responsibilities of Medical Staff membership set forth in the
Bylaws and Rules;
2) Contributing to the organization and administrative affairs of the Medical Staff by
participating on staff, in the departments, and on committees as reasonably
requested, and by participating in fulfilling such other staff functions as are
reasonably requested.
C. Limitation
Resident/Fellow staff members shall not be eligible to hold office in this Medical Staff
organization nor shall they be eligible to vote on matters presented at general and
special meetings of the Medical Staff, departmental meetings, division meetings, or
committee meetings except as specifically provided in the Bylaws.
3.1.7 Temporary Staff
A. Qualifications
Temporary staff consists of Members, each of whom:
1) Meets the qualifications for Medical Staff membership set forth in the Bylaws;
2) Has been granted temporary privileges and is not currently on the active,
courtesy, provisional, or resident staff.
B. Prerogatives
Each Member of the temporary staff in entitled to:
1) Admit patients and exercise Clinical Privileges as are granted to him/her;
2) Attend meetings of the staff in the department of which he/she is a Member and
any staff and hospital educational programs.
C. Responsibilities
Each Member of the temporary staff is responsible for the following:
1) Carrying out the basic responsibilities of Medical Staff membership set for in the
Bylaws;
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2) Providing for the continuous care and supervision of each patient in the Hospital
for whom he/she is providing services, including arranging for care and
supervision in his/her absence and outside of his/her area of professional
competence;
3) Providing consultation, supervision, and monitoring of patients, when requested;
and
4) Attending meetings of the Medical Staff, his/her department, and committees of
which he/she is a member.
D. Limitations
Temporary staff members are not eligible to hold office in this Medical Staff
organization nor are they eligible to vote on matters presented at general and special
meetings of the Medical Staff, departments, divisions, or committees. In the event
that a practitioner’s temporary clinical privileges are terminated, said practitioner’s
temporary staff status is also deemed terminated and the practitioner is thereafter
entitled to the procedural rights afforded by the Bylaws.
3.1.8 Limitation of Prerogatives
The prerogatives set forth under each membership category are general in nature and
may be subject to limitation by special conditions attached to a particular membership by
other sections of these Bylaws and by the Rules.
3.1.9 Modification of Membership
On its own, upon recommendation of the Credentials Committee, or pursuant to a
request by a member, the Medical Executive Committee may recommend a change in the
Medical Staff category of a member consistent with the requirements of the Bylaws.
ARTICLE 4
ALLIED HEALTH PRACTITIONERS
4.1 Definitions
4.1.1 Allied Health Practitioner (AHP) means a health care professional, other than a physician,
dentist, podiatrist or clinical psychologist, who holds a license, as required by California
law, to provide certain professional services.
4.1.2 AHP Clinical Privileges or Service Authorization means the permission granted by the
Governing Body, upon the recommendation of the Interdisciplinary Practice Committee
and the Medical Staff, to provide diagnostic and therapeutic services with the scope of the
AHP’s training and expertise.
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4.2 Categories of AHPs Eligible to Apply for AHP Clinical Privileges or Services
Authorizations and Rules regarding them
4.2.1 The categories of AHPs, based upon occupation or profession that shall be eligible to apply
for AHP Clinical Privileges shall be designated by the Governing Board, upon
recommendation of the MEC. Currently, the AHPs include the following categories;
A. Nurse Practitioners who are registered nurses with additional training, expertise,
certification and licensing that is recognized and authorized by the State of California
to provide specific diagnostic and therapeutic services.
B. Optometrists who are licensed by the State of California to provide specific
optometric services.
C. Midwives (Certified Nurse Midwives, Licensed Midwives, Certified Professional
Midwives) who are health care providers with additional training, expertise, and
certification that is recognized and authorized by the State of California, under the
supervision of a licensed physician or surgeon, to attend cases of normal childbirth
and to provide prenatal, intrapartum and postpartum care.
D. Physician Assistants who are healthcare professionals with specialized medical
training from a program associated with a medical school and who are licensed by the
California Physician Assistant Board to provide patient education, evaluation, and
health care services under the supervision of a licensed physician.
4.3 Eligibility and General Qualifications
An AHP is eligible for a Service Authorization in this hospital if he or she;
1) Holds a valid, unsuspended license, certificate, or other legal credential in a category of AHP
which the Governing Body has identified as eligible to apply for Service Authorization pursuant
to the Bylaws; and
2) Documents his or her experience, background, training, current competence, judgment, and
ability with sufficient adequacy to demonstrate that any patient treated by the practitioner
will receive care at the generally recognized professional level of quality established by the
Medical Staff; and
3) Is determined, on the basis of documented references to:
A. Adhere strictly to the lawful ethics of his or her profession;
B. Work cooperatively with others in the hospital setting so as not to adversely affect patient
care;
C. Be willing to commit to and regularly assist the Medical Staff in fulfilling its obligations
related to patient care; and
1) Agrees to comply with all Medical Staff and Department and Division Bylaws, Rules
and Regulations and protocols to the extent applicable to the AHP;
2) Documents his or her current eligibility to participate in Medicare, Medicaid or other
federally-sponsored health care program.
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4.4 Specific Qualifications
In addition to meeting the basic standards as outlined in “Eligibility and General Qualifications,” an
AHP shall have the following specific qualifications to be eligible and qualified for AHP Clinical
Privileges or Service Authorization in this hospital;
1) Certified Nurse Midwives
A CNM shall have a current license and furnishing number which authorizes ordering of drugs
or devices if applicable to the CNM’s practice.
2) Physician Assistant
A PA shall have a current license and furnishing number which authorizes the PA to provide
drug and medication orders, if applicable to the PA’s practice.
4.5 Waiver of Qualifications.
When exceptional circumstances exist certain eligibility criteria may be waived by the MEC upon
recommendation by the Interdisciplinary Practice Committee or its designee the Credentials
Committee. The AHP requesting the waiver bears the burden of demonstrating exceptional
circumstances and/or that his or her qualifications are equivalent to or exceed the
criterion/criteria in question.
4.6 Prerogatives
The prerogatives, which may be extended to an AHP, include:
1) Provision of specified patient care services consistent with the Service Authorization granted
to the AHP and within the scope and licensure or certification of that AHP;
2) Service on Medical Staff and Hospital committees except as otherwise provided in the Bylaws.
An AHP may not serve as chair of a Medical Staff committee;
3) Attendance at meetings of the department to which he or she is assigned. An AHP may not
vote at department/division meetings.
4.7 Responsibilities
Each AHP shall:
1) Meet those responsibilities required by the Medical Staff Rules and Regulations.
2) Retain appropriate responsibility within his or her area of professional competence for the
care of each patient in the hospital for whom he or she is providing services.
3) Participate, when requested, in patient care and audit and other quality review evaluation and
monitoring activities required of AHPs and other functions as may be required by the Medical
Staff from time to time.
4.8 Procedure for Granting Initial and Renewal Services Authorizations
1) An AHP who practices under Standardized Procedures must apply and qualify for a Service
Authorization. An AHP must reapply for a renewed Service Authorization every two years.
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2) AHP application for initial granting and renewal of service authorization shall be submitted to
the Interdisciplinary Practice Committee (IPC), which may delegate the processing of such
applications to the Credentials Committee. Credentialing and Privileging is processed in a
parallel manner to that provided for the Medical Staff by the Bylaws. At the discretion of the
Credential Committee an initial application of reappointment may be sent to the IPC for
review.
3) The Credential Committee shall, as delegated by the IPC, make recommendations to the MEC
and the Governing Body regarding the granting of individual Service Authorizations to AHP
applicants.
4) Upon approval by the MEC and the Governing Body, an applicant AHP shall be granted Service
Authorization and assigned to the clinical department appropriate to his or her occupation
and training. The AHP is subject to the relevant rules and regulations of that department.
4.9 Termination, Suspension, or Restriction of Service Authorizations
1) The termination, suspension or restriction of Service Authorization shall be done as if the
Service Authorization was a clinical privilege rendered to a Member of the Medical Staff. The
AHP shall have the same procedural rights as a Medical Staff Member would have with the
termination, suspension or restriction of privileges.
ARTICLE 5
PROCEDURES FOR APPOINTMENT AND REAAPOINTMENT
5.1 General
The Medical Staff shall consider each application for appointment, reappointment, and privileges,
and each request for modification of Medical Staff category using the procedures and the
standards set forth in the Bylaws. The Medical Staff shall evaluate each applicant before
recommending action by the Governing Body. The Governing Body is ultimately responsible for
granting Medical Staff membership and Clinical Privileges. Temporary Privileges may be granted
to a practitioner, pursuant to these Bylaws and the Rules, prior to final action by the Governing
Body. By applying to the Medical Staff for appointment or reappointment, the applicant agrees
that, whether or not he or she is appointed or granted Privileges, he or she will comply with the
responsibilities of Medical Staff Membership and with the Medical Staff Bylaws and Rules as they
exist and as they may be modified from time to time.
5.2 Applicant’s Burden
An applicant for appointment, reappointment, advancement, transfer, and/or Privileges shall have
the burden of producing accurate and adequate information for a thorough evaluation of the
applicant’s qualifications and suitability for the requested status and Privileges, resolving any
reasonable doubts about these matters and satisfying requests for information. The provision of
information containing significant misrepresentations or omissions and/or a failure to sustain the
burden of producing information shall be grounds for denying an application or request. To the
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extent consistent with law, this burden may include submission to a medical or psychological
examination, at the applicant’s expense, if deemed appropriate by the Medical Executive
Committee (MEC.) The applicant may select the examining physician from an outside panel of
three physicians chosen by the MEC.
5.3 Applicant for Initial Appointment and Reappointment for Medical Staff Membership
Applicants for appointment or reappointment must complete, sign and date the prescribed
application form provided by the Medical Staff. The application shall request detailed information
about the applicant and shall document the applicant’s agreement to abide by the Medical Staff
Bylaws, Rules, and other terms. The applicant must provide all of the requested information, the
agreements, and all supporting documentation to the Medical Staff office. An application which is
incomplete will not be accepted for review. The applicant must pay the required fee, if any, at the
time the application is submitted or it will not be accepted for review.
5.4 Basis for Appointment and Reappointment to the Medical Staff
Recommendations for appointment and reappointment to the Medical Staff and for granting and
renewal of Privileges shall be based upon:
1) The applicant’s or Member’s professional performance at this Hospital and in other settings;
2) Whether the applicant or Member meets the qualifications and is able to carry our all of the
responsibilities specified in these Bylaws and the Rules; and
3) The Hospital’s patient care needs and ability to provide adequate support services and
facilities for the applicant or Member.
A) Term of Appointment, Extensions, and Failure to File Reappointment Application
Except as otherwise provided in these Bylaws, initial appointments to the Medical Staff
shall be until the applicants’ second birthday after the initial provisional appointment.
Reappointments shall be for a period of two years.
Failure to file a complete and timely application for reappointment shall result in the
automatic termination of the Members’ membership Privileges and prerogatives at the
end of that term.
5.5 Application Procedure.
5.5.1 Application for Medical Staff membership must be submitted directly to the Credentials
Committee by the applicant in writing and on such form as approved by the MEC. Prior to
the application being submitted, the applicant will be provided access to a copy of the
Medical Staff Bylaws, the Rules and Regulations of the Staff and its Departments and
Divisions, and summaries of the policies and resolutions relating to clinical practice in the
Hospital and Health Centers. An applicant who does not meet the basic qualifications or
requirements as outlined in these Bylaws, related rules or policies, is not eligible or qualified
to apply for Medical Staff membership and the application shall not be accepted for review.
If, during any stage of the application process, it is discovered that the applicant does not
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meet the basic qualifications or requirements as outlined in these Bylaws, related rules or
policies, review of the application shall be discontinued.
An applicant who does not meet the basic qualifications or requirements in not entitled to
procedural hearing and appellate review rights.
5.5.2 Application Content
Every applicant, except Resident staff applicants, must furnish a complete application
providing all supporting documentation and an accurate and complete response to each
query including but not limited to the following:
1) The applicant’s undergraduate, medical school, and postgraduate training, including the
name of each institution, degrees granted program completed, and dates attended;
2) All currently valid medical, dental, podiatric and other professional licensures or
certifications, and Drug Enforcement Administration registration (with exceptions
determined by Credentials Committee action when the applicant will not be prescribing
medication) and any other controlled substances registration, with the date and number
of each;
3) Specialty or sub-specialty board certifications and/or recertification;
4) Health impairments (including alcohol and drug dependencies), hospitalizations, and
institutionalizations, if any, which may affect the applicant’s ability in terms of skill,
attitude and judgment to perform professional and Medical Staff duties;
5) Applicant’s statement that his or her health status is such that he or she has the ability
to perform the privileges requested;
6) Applicant’s statement that he or she will consent to and cooperate with any required
physical or mental health evaluations and provide the results from the evaluations to
enable a full assessment of the applicant’s fitness, as described in Section 5.2,
‘Applicant’s Burden’;
7) Evidence of applicant’s current Professional Liability Insurance coverage, or if not
currently insured, evidence of past Professional Liability Coverage;
8) Whether there are any pending or completed actions involving denial, revocation,
suspension, reduction, limitation, probation, non-renewal or voluntary relinquishment
(by resignation or expiration) of the applicant’s license or certificate to practice any
profession in any state or country; Drug Enforcement Administration or other controlled
substances registration; membership of fellowship in local, state or national professional
organizations; or faculty membership at any medical or other professional school;
9) The location of offices, names and addresses of other practitioners with whom the
applicant is associated and inclusive dates of such association; names and locations of
any other hospital, clinic or health care institution where the applicant provides or
provided clinical services with the inclusive dates of each affiliation, status held, and
general scope of clinical privileges, for the last five years;
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10) Requests for department assignment(s), staff category after conclusion of provisional
status, and specific Clinical Privileges;
11) Whether the applicant has ever been charged with or convicted of a crime, other than
minor traffic violations, or whether a criminal action is now pending;
12) Whether there are any pending or completed actions involving denial, revocation,
suspension, reduction, limitation, probation, non-renewal or voluntary relinquishment
(by resignation or expiration) of Medical Staff membership, or privileges at another
hospital, clinic or health care facility of institution;
13) References as required below;
14) An acknowledgement that the applicant has read the Medical Staff Bylaws of the Contra
Costa Regional Medical Center and Health Centers, that he/she understands said
Bylaws, and that he/she agrees to be bound by the terms thereof, as they may be
amended from time to time, if he/she is granted membership or Clinical Privileges, and
to be bound by the terms thereof, without regard to whether or not he/she is granted
membership and/or clinical privileges in all matters relating to consideration of this
application;
15) Any and all continuing medical education classes attended by applicant in the last
twenty-four (24) months;
16) Whether the applicant has had any notification of, or involvement in, a professional
liability action, the applicant’s complete malpractice claims history, including all
information regarding lawsuits, or settlements made, concluded and pending;
17) Whether the applicant has been excluded from federal health care program in the past,
or is subject to a pending or current exclusion from a federal health care program;
18) The applicant’s consent to the release and inspection of all records and documents as
may be necessary for a thorough evaluation of the applicant’s professional
qualifications, background and health status;
19) The applicant’s consent to provide release and a release from liability for all individuals
requesting and all individuals providing information related to the applicant’s
professional qualifications, background, or health, or evaluating and making judgments
regarding the applicant’s professionalism qualifications, background, or health;
20) A valid photo identification issued by a state federal agency;
Applicants to the Resident Staff must furnish the information and/or documentation
listed in (1), (2), (5), (6), (8), (11), (12), (14), (18), (19) and (20) above, and may do so by
submitting their residency application form, updated as necessary to include these
required items, in lieu of submitting the standard application form described herein.
Furthermore, each applicant will be assessed an application fee as determined by
policies set forth by the Medical Executive Committee. The application will not be
processed without receipt of this fee.
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5.5.3 References
The applicant must include the names of at least three (3) professionals currently licensed
and practicing in the same discipline as the applicant, not currently or about to become
corporate or business partners with the applicant in professional practice or personally
related to him, who have personal knowledge of the applicant’s current clinical ability,
competence, ethical character, health status and ability to work cooperatively with others
and who will provide specific written comments on these matters, and letters of
recommendation for staff membership.
The named individuals must have acquired the requisite knowledge through recent
observation of the applicant’s professional performance over a reasonable period of time
and at least one must have had organizational responsibility for supervision of his/her
performance (e.g., Department Chairperson, Service Chief, Training Program Director). The
applicant is responsible for submitting three (3) letters of recommendation from the named
professional references to the Credentials Committee Chairperson.
At the discretion of the Credentials Committee, the requirement of receipt of all three
letters of reference may be reduced to two (2).
5.5.4 Effect of Application
The applicant must sign the application and in so doing:
1) Attests to the correctness and completeness of all information furnished and
acknowledges that any significant misstatement in or omission from the application
constitutes grounds for denial of appointment or revocation of Medical Staff
membership;
2) Signifies his/her willingness to appear for interviews in connection with his/her
application;
3) Agrees to abide by the terms of the Bylaws, Rules, and policies and procedures manuals
of the Medical Staff if granted membership and/or Clinical Privileges, and to abide by
the terms thereof in all matters relating to consideration of the application without
regard to whether membership and/or privileges are granted;
4) Agrees to maintain an ethical practice and to provide continuous care to his or her
patients;
5) Agrees to keep Medical Staff representatives up to date on any change made or
proposed in the status of his/her professional license to practice, DEA or other
controlled substances registration, malpractice insurance coverage, and membership or
clinical privileges at other institutions;
6) Authorizes and consents to Medical Staff representative consulting with prior associates
or others who may have information bearing on professional or ethical qualifications
and competence and consents to Medical Staff representatives inspecting all records
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and documents that may be material to evaluation of said qualifications and
competence;
7) Releases from any liability all those who, in good faith and without malice, review, act
upon or provide information regarding the applicant’s competence, professional ethics,
utilization practice patterns, character, health status, and other qualifications for staff
appointment and clinical privileges.
5.5.5 Processing the Application
1) Verification of Information
After the application is submitted to the Credentials Committee Coordinator, the
Credentials Committee Coordinator shall seek to verify the references, licensure status,
and other qualification evidence submitted in support of the application, and to obtain
the supporting information relevant to the application. The Coordinator shall verify in
writing and from the primary source whenever feasible. The Credentials Committee
Coordinator shall also query the National Practitioner Databank, and shall promptly
notify the applicant of any problems in obtaining any of the information required. Upon
such notification, it shall be the applicant’s obligation to obtain the required
information.
Verification shall include sending a copy of the list of Clinical Privileges requested by the
applicant to at least his/her most recent affiliations and a request for specific
information regarding his/her competence in exercising those privileges.
When the application is complete as defined in subsection (b), the Credentials
Committee Coordinator transmits the application and all supporting materials to the
Head of each Department in which the applicant seeks Privileges.
2) Definition of Completed Application
A completed application shall consist of all pertinent material including receipt in the
Medical Staff office of all correspondence from references and other medical staffs as
required.
3) Incomplete Applications
Incomplete applications will not be accepted for review. In addition to applications
which are incomplete as described by Section 5.3, ‘Application for Initial Appointment
and Reappointment for Medical Staff Membership’, applications may be deemed
incomplete as follows.
If the MEC, the Medical Staff office, or Credentials Committee, Administrator or
Governing Body review the application requests additional information, documentation,
or clarification from the applicant, and/or an interview with the applicant, the applicant
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will be promptly notified and the application process will be suspended, and the
application shall be deemed incomplete, until the requested information,
documentation, or clarification has been provided and/or the requested interview has
been conducted. No application shall be considered complete until it has been
reviewed by the Department Head or designee for each department for which the
applicant seeks privileges, the Credentials Committee or designee and the Medical
Executive Committee, and all have determined that no further documentation or
information is required to permit consideration of the application.
The Medical Staff shall promptly inform the applicant of the specific request(s) made,
the time period within which the applicant must satisfy the request and the effect on
the application process if the request is not satisfied within that time period.
4) Department Evaluations
The Head of each Department in which the applicant seeks privileges reviews the
application and its supporting documentation and forwards to the Credentials
Committee a written report as required evaluating the evidence of the applicant’s
training, experience and demonstrated ability and stating how the applicant’s skills are
expected to contribute to the activities of the Department.
The Department Head or his/her designee shall conduct an interview with the applicant.
If a Department Head requires further information, he/she may defer transmitting
his/her report, but overall the combined deferral time generally should not exceed
thirty (30) days. In case of a deferral, the Department Head must notify the Chairperson
of the Credentials Committee in writing of the deferral and the grounds. If the applicant
is to provide additional information or a specific release/authorization to allow Medical
Staff’s representative to obtain information, the notice to him/her must so state, must
be a special notice, and must include a request for the specific data/explanation or
release/authorization required and the time frame for response. Failure, without good
cause, to respond in a satisfactory manner by that date is deemed a voluntary
withdrawal of the application.
5) Credentials Committee Evaluation
The Chairperson of the Credentials Committee or a designated committee member may
conduct an interview with the applicant. Following the interview, the Credentials
Committee reviews the application, the supporting documentation, the reports from the
Department Heads, and any other relevant information available to it. The Credentials
Committee then transmits to the Medical Executive Committee (MEC) its written report
and recommendations as required. If the Credentials Committee requires further
information, it may defer transmitting its report, but generally for not more than thirty
(30) days. If the applicant is to provide the additional information or specific
release/authorization to allow Medical Staff representatives to obtain information, the
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notice to him/her must so state, must be a special notice, and must include a request
for the specific data/explanation or release/authorization required and the time frame
for response. Failure, without good cause, to respond in a satisfactory manner by the
date is deemed a voluntary withdrawal of the application.
The Credential Committee’s written report, as required, is transmitted with all
supporting documentation to the MEC.
6) The MEC, at its next regular meeting after receiving the Credentials Committee
recommendation, reviews the application, the supporting documentation, the reports
and recommendations from the Department Heads and Credentials Committee, and any
other relevant information available to it. The MEC is responsible for determining staff
status. The MEC defers action on the application, or prepares a written report with
recommendations as required.
7) Effect of Medical Executive Committee Action
A. Deferral. Action by the MEC to defer the application for further consideration must,
except for good cause, be followed up within forty-five (45) days with its report and
recommendations. The Medical Staff President promptly sends the applicant a
special notice of an action to defer, including a request for the specific
data/explanation or release/authorization, if any, required from the applicant and
the time frame for response. Failure, without good cause, to respond in a
satisfactory manner by that date is deemed voluntary withdrawal of the application.
B. Favorable Recommendation. When the MEC’s recommendation is favorable to the
applicant in all respects, the Medical Staff President promptly forwards it, together
with all supporting documentation, to the Administrator. All supporting
documentation means the application form and its accompanying information, the
reports and recommendations of the Division and Department Heads, Credentials
Committee and MEC, and dissenting views.
C. Adverse Recommendation. When the MEC’s recommendation is adverse to the
applicant, the Medical Staff President promptly forwards it, together with all
supporting documentation, to the Administrator, and the Administrator
immediately informs the applicant by special notice, and the applicant is entitled to
the procedural rights provided in the Bylaws.
8) Administrator Action
A. On MEC recommendation the Administrator may adopt or reject, in whole or in
part, a favorable recommendation or refer the recommendation back to the MEC
for further consideration stating the reasons for such referral and setting a time
limit within which a subsequent recommendation must be made to the
Administrator.
B. If the Administrator’s action is favorable to the applicant, this action is forwarded to
the Governing Body for final approval. If the Administrator’s action, after complying
with the applicable requirements, is adverse to the applicant in any respect, the
25
Administrator promptly informs the applicant by special notice, and the applicant is
then entitled to the procedural rights provided in the Bylaws.
C. If the Governing Body, upon receiving a report from the Administrator for favorable
action, disagrees with the Administrator, it must comply with the requirements
below concerning Conflict Resolution. If, after such compliance, the decision is
adverse to the applicant in any respect, the Administrator shall promptly inform the
applicant by mailing a special notice to the applicant. The applicant is then entitled
to the procedural rights provided in the Bylaws and the applicant shall be so
informed by the special notice.
9) Content of Reports and Bases for Recommendations and Actions. The report of each
individual or group, including the Administrator, required to act on an application must
include recommendations as to approval or denial of, and any special limitations on,
staff appointment, category of staff membership and prerogatives, Department
affiliation(s) and scope of Clinical Privileges.
10) Conflict Resolution. Whenever the Administrator or Governing Body disagrees with the
recommendation of the MEC, the matter will be submitted for review and
recommendation to a joint conference composed of two members each from the
Medical Staff and the Governing Body, appointed by the President of the Medical Staff
and the Chairperson of the Governing Body, respectively, before the Governing Body
makes its decision.
11) Notice of Final Decision
A. The Administrator shall mail notice of the Governing Body‘s final decision to the
applicant, with copies to the Medical Staff President and the applicable Department
Head(s).
B. A decision and notice to appoint included:
1) The Staff category to which the applicant is appointed;
2) The Department(s) to which he/she is assigned;
3) The Clinical Privileges he/she may exercise; and
4) Any special conditions attached to the appointment.
12) Time Periods for Processing
Individual/Group
A. Applicant. Ninety (90) days.
1) If the fully completed application is not received by the Medical Staff Office as
defined, within ninety (90) days, the application will be returned and
reapplication will not be allowed for a period of ninety (90) days and any
temporary privileges granted are immediately terminated.
2) If, after receipt of the fully completed application, the need for additional
information arises at any stage in the review process, the application is deemed
incomplete and further review will be suspended. A letter or email will be sent
to the applicant asking for the required information. If the applicant does not
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respond within thirty (30) days it will be deemed a voluntary withdrawal, and
reapplication will not be allowed for a period of ninety (90) days. Any
temporary privileges granted are immediately terminated.
B. Credentials Committee Coordinator. Thirty (30) days.
C. Department Heads. Thirty (30) days after receiving material from Credentials
Committee Coordinator.
D. Credentials Committee. Thirty (30) days after receiving reports from the Credentials
Committee Coordinator and Department Head.
E. Medical Executive Committee. At the next regular meeting after receiving report
from the Credentials Committee.
F. Administrator. Fifteen (15) days after receiving report from the Medical Executive
Committee.
G. Governing Board. At the next regular meeting after receiving report from the
Administrator.
H. The time periods set forth are guidelines, not directives, and do not create any
rights in any application to have his or her application processed within the time
periods provided.
5.5.6 Staff Category upon Appointment
Except for applicants to the Resident Staff, all appointments to the Staff shall be to the
Provisional Staff. After successful completion of the provisional term, as defined, the
Medical Executive Committee, after recommendation from the Credentials Committee, shall
assign the appropriate staff category.
5.6 Reappointment and Requests for Modifications of Staff Status or Privileges
Applications for reappointment are due one hundred and fifty (150) days prior to the expiration of
a Member’s term. Applications that are not complete at ninety (90) days prior to the expiration of
a term are not processed and the membership automatically expires at the end of the term.
Applications completed between one hundred and fifty (150) and ninety (90) days from the end of
a term are charged a late fee as noted in the Rules.
At least one hundred and eighty (180) days prior to the expiration date of the current staff
appointment (except for temporary appointments), a reappointment form developed by the
Medical Executive Committee shall be mailed or delivered to the Member. The completed
application form and Medical Staff dues are due one hundred and fifty (150) days prior to the
expiration date. The department Chair will be notified if the member is delinquent. Each Medical
Staff Member shall submit to the Credentials Committee the completed application form for
renewal of appointment to the staff and for renewal or modification of clinical privileges. The
reapplication form shall include all information necessary to update and evaluate the
qualifications of the applicant including, but not limited to, the matters set forth in these Bylaws
as well as other relevant matters.
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The results of performance monitoring, evaluation, and identified opportunities to improve care
and service are printed and included in the reappointment file. Ongoing Professional Practice
Evaluation (OPPE) data are collected and provided as evidence of the practitioner’s current
competence. A reappointment may be deferred if more information is needed.
Upon receipt of the application, the information shall be processed as set forth commencing at
Section 5.4. In addition, the Department Head will review the applicants’ QA profile if there is
one.
A Medical Staff Member who seeks a modification of Clinical Privileges may submit such a request
at any time upon a form developed by the Medical Executive Committee, except that such
application may not be filed within one year of the time similar request has been denied.
5.6.1 Effect of Application
The effect of an application for reappointment or modification of staff status or privileges is
the same as that set forth in Section 5.4.
5.6.2 Standards and Procedures for Review
When a staff Member submits the first application for reappointment, and every two (2)
years thereafter, or when the Member submits an application for modification of staff
status or Clinical Privileges, the Member shall be subject to an in-depth review generally
following the procedures set forth in Section 5.4.
5.7 Leave of Absence from the Medical Staff
A Member may request a leave of absence not to exceed two (2) years. No leave is effective
unless and until approved by the Medical Executive Committee. At the end of the leave the
Member must apply for reinstatement. The Member must provide information regarding his or
her relevant activities during the leave of absence if the MEC so requests. During the period of
leave, the Member shall not exercise Privileges at the Hospital, and membership rights and
responsibilities shall be inactive. The obligation to pay dues, if any, shall continue during the
leave unless waived by the Medical Executive Committee.
5.7.1 Reinstatement after a Leave
Failure, without good cause, to request reinstatement of Membership at least thirty (30)
days prior to the end of an approved leave shall be deemed voluntary resignation from
the Medical Staff. The MEC shall make recommendations concerning reinstatement of
the Member’s Membership and Privileges to the Governing Body for final action.
5.8 Waiting Period after Adverse Action
An applicant, Member, or prior Member is not eligible for Membership in the Medical Staff and/or
granting of Privileges for twenty-four (24) months after an adverse action regarding his or her
Membership or Privileges.
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5.8.1 An Adverse Action occurs when any of the following occur:
A. A final adverse decision regarding appointment or privileges is made by the Governing
Body, or an applicant withdraws his or her application or request for Privileges following
an adverse recommendation by the Medical Executive Committee to the Governing
Body.
B. A final adverse decision resulting in termination of a Member’s membership or
Privileges is made by the Governing Body, or if the Member resigns Membership or
relinquishes Privileges while an investigation and resolution is pending concerning
her/his membership and/or relevant Privileges.,
C. A final adverse decision resulting in termination or restriction of Privileges or denial of a
request for additional Privileges is made by the Governing Body
5.8.2 The Medical Staff may, as part of an adverse action, waive the twenty-four (24) month
ineligibility period or limit it in some way including but not limited to require proctoring or
supervision.
5.8.3 An action is considered final on the date the application was withdrawn, a Member’s
resignation became effective, or upon completion of all hearings and appellate reviews
described in the Bylaws pertinent to the action. After an ineligibility period, the individual
may reapply for Membership or re-request Privileges. The application will be treated as an
initial application or request, except that the individual must document to the satisfaction of
the Medical Staff that the basis for the adverse action no longer exists and that sufficient
measures have been taken to assure that it will not occur again. With regard to the subject
of the adverse action, the Medical Staff may impose more stringent conditions and
requirements for evaluation, documentation, and monitoring than it might in an application
de novo or it may deny the request outright.
5.9 Confidentiality and Impartiality
To maintain confidentiality and to assure the unbiased performance of appointment and
reappointment functions, participants in the credentialing process shall limit their discussion of
the matters involved to the formal avenues provided in the Bylaws for processing applications and
for appointment and reappointment.
ARTICLE 6
PRIVILEGES
6.1 Exercise of Privileges
Except as otherwise provided in these Bylaws, every Member providing direct clinical services at
this Hospital shall be entitled to exercise only those Privileges specifically granted to him or her.
Clinical privileges may be granted, continued, modified, or terminated by the Governing Body only
upon the recommendation of the Medical Staff as outlined in these Bylaws.
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6.2 Delineation of Privileges in General
6.2.1 Requests
A. Each applicant for appointment and reappointment to the Medical Staff must contain a
request for the specific Privileges desired by the applicant. A request for modification of
Privileges must be supported by documentation of training and/or experience
supportive of the request. A Member may make requests for modifications of Privileges
at any time.
B. Each department is responsible for developing written criteria for granting Privileges.
These criteria take effect only after approval by the Medical Executive Committee
(MEC.)
6.2.2 Basis for Privilege Determinations
Requests for Privileges shall be evaluated upon the basis of the Member’s education,
training, experience, demonstrated professional competence and judgment, clinical
performances, and the documented results of patient care. Privilege determinations shall
also be based upon pertinent information concerning clinic performance obtained from
other sources, especially other institutions and health care setting where an individual
exercises Privileges.
6.2.3 Privileges for Department Heads
Privileges for Department Heads will be acted upon by the Medical Staff President. If a
Department Head is also the Medical Staff President, privileges will be acted upon by the
Past President. In no event will a Department Head approve his/her own privileges.
6.2.4 Admissions
Dentists, oral surgeons, podiatrists and clinical psychologist Members are non-Physician
members. They may admit patients only if a Physician Member assumes responsibility for
the care of the Patient’s medical problems during the hospitalization. These non-physician
members may participate in the patient’s care to the extent allowed by the responsible
Physician Member and the Medical Staff Bylaws and Rules.
6.2.5 Medical Appraisal
A Physician Practitioner shall provide ongoing medical evaluation of all patients receiving
some care from a non-physician Member. The Physician shall also provide appropriate
supervision and control of the patient care provided by the non-physician Member.
6.3 Non-licensed Resident Physicians
By virtue of their enrollment in an accredited training program, non-licensed Residents hold
Privileges to admit patients and provide services as assigned under the supervision of the various
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Department Chairpersons and the Residency Director. A Physician Member who has Privileges for
the patient care being rendered must supervise non-licensed Residents.
6.4 Temporary Privileges
6.4.1 Circumstances
The Administrator (or his/her designee), with the written concurrence of the Medical Staff
President and the Chairperson of the Department where the Privileges will be exercised,
may grant temporary Privileges to a practitioner subject to the following conditions:
A. Pendency of Application:
After receipt of a completed application for appointment or reappointment (see Section
5.4, including a request for specific Privileges for an initial period of sixty (60) days while
the application is being processed. If the processing of the completed application by the
Medical Staff requires more than sixty (60) days, the temporary Privilege may be
extended for up to an additional sixty (60) days at the discretion of the Medical Staff
President or his/her designee. Temporary Privileges shall automatically terminate at the
end of a maximum of one hundred and twenty (120) days, unless earlier terminated in
accordance with the Bylaws.
B. Important Patient Care, Treatment and Service Need.
After receipt of an application for appointment or reappointment, including a request
for specific Privileges, an applicant may be granted temporary privileges for the
purposes of important patient care, treatment or service need, for an initial period of
sixty (60) days while the application is being processed. The Medical Staff must be able
to verify the applicant’s current licensure and competence, or temporary Privileges are
denied. The National Provider Data Bank will be queried. If the processing of the
application by the Medical staff requires more than sixty (60) days, the temporary
Privileges may be extended for up to an additional sixty (60) days at the discretion of the
Medical Staff President or his/her designee. Temporary Privileges shall automatically
terminate at the end of a maximum of one hundred and twenty (120) days, unless
earlier terminated in accordance with the Medical Staff Bylaws.
6.4.2 Conditions
Temporary Privileges may be granted only after the practitioner has submitted a written
application for appointment and a request for temporary Privileges and the information
available reasonably supports a favorable determination regarding the requesting
practitioner’s licensure, qualifications, ability, and judgment to exercise the Privileges
requested, and only after the practitioner has satisfied the requirement regarding
professional liability insurance. The chairperson of the department to which the
practitioner is assigned shall be responsible for supervising the performance of the
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practitioner granted temporary Privileges, or for designating a department member who
shall assume this responsibility. That Chairperson may impose special requirements of
consultation and reporting. Before temporary Privileges are granted, the practitioner must
acknowledge in writing that he/she has received a copy of the Bylaws and Rules and that
he/she agrees to be bound by the terms thereof in all matters relating to his/her temporary
Privileges.
6.4.3 Termination
The Administrator or the President of the Medical Staff may terminate any or all of a
practitioner’s temporary Privileges:
A. Upon discovery of any information or the occurrence of any event of a nature which
raises question about a practitioner’s professional qualifications or ability to exercise
any or all of the temporary Privileges granted by the Administrator or President of the
Medical Staff;
B. If the life or well-being of a patient is endangered in the opinion of the grantor of the
temporary Privilege;
C. In addition, any person entitled under these Bylaws to impose summary suspensions
may terminate temporary Privileges if the well-being of a patient is endangered or
thought to be endangered by the person termination the temporary Privilege. Any such
termination shall be reviewed at the next scheduled meeting of the Medical Executive
Committee. In the event of any such termination, the Department will assign the
practitioner’s patients then in the Hospital to another practitioner(s) or Division Head
responsible for supervision. The wishes of the patient will be considered, where
feasible, in choosing a substitute practitioner.
6.4.4 Rights of the Practitioner
A practitioner shall not be entitled to the procedural rights afforded by these Bylaws merely
because his/her request for temporary Privileges is denied. However, if all or any portion of
his/her temporary Privileges are terminated or suspended, the practitioner shall be entitled
to those procedural rights.
6.5 Emergency Privileges
In the event of an emergency, any Member of the Medical Staff is permitted to do everything
reasonably possible to save the life of a patient or to save a patient from serious harm. The
Member shall promptly enlist assistance from and yield patient care to a qualified Member as
soon as one becomes available.
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6.6 Focused Professional Practice Evaluation (FPPE)
A. General Requirements
All initial appointments to the Medical Staff and all Members granted new Privileges
shall be subject to Focused Professional Practice Evaluation (FPPE). Information used
for evaluation may be obtained through, but is not limited to the following:
1) Concurrent or targeted medical record review.
2) Direct observation.
3) Monitoring/proctoring of diagnostic, procedural, and/or treatment techniques.
4) Discussion with other practitioners involved in the care of specific patients.
5) Interviews with the physician involved in the patient’s care.
6) Sentinel event data.
7) Any applicable peer review data.
8) Review of data from other institutions with applicant/member’s permission.
B. Each appointee or recipient of new Clinical Privileges shall be assigned to a department
(or departments) where performance on an appropriate number of cases as established
by the Medical Executive Committee shall be observed by the chair of the department
or the chair’s designee, to determine suitability to continue to exercise the Clinical
Privileges granted in that department.
C. The Member shall remain subject to FPPE until the Credentials Committee has been
furnished with a report signed by the chair of the department(s) to which the member is
assigned describing the types and numbers of cases observed and the evaluation of the
applicant’s performance, a statement that the applicant appears to meet all of the
qualifications for unsupervised practice in that department. The MEC may allow
Department Heads to remove proctoring requirements for individual Privileges before
the end of the proctoring period.
D. FPPE may be implemented whenever the Medical Executive Committee or its designee
determines that additional information is needed to assess a Member’s performance.
E. FPPE is not an adverse action or a disciplinary measure. It is a means of gathering
information regarding a Members’ skills. Therefore, the requirements of proctoring
does not itself give rise to the hearing rights triggered by an adverse action.
F. During FPPE, the Member must demonstrate the requisite competence required to
exercise the Clinical Privileges.
6.6.1 Completion of FPPE
FPPE shall be deemed successfully completed when the Credentials Committee has received
sufficient information about the applicant’s competency.
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6.6.2 Requirements to Provide FPPE
Members of the Medical Staff shall serve in a manner consistent with FPPE requirements.
Refusal to serve in this capacity, without good cause, as determined by the Medical
Executive Committee, is grounds for corrective action.
6.6.3 Failure to Complete FPPE
A Member who fails to complete the required FPPE within one year shall be deemed to have
voluntarily withdrawn his or her request for those Privileges. The Medical Executive
Committee may extend the time for completion of FPPE in appropriate cases. If a Member
completes the necessary FPPE but fails to perform competently he or she may have the
relevant Privileges revoked or involuntarily modified in order to assure quality patient care.
Failure to successfully complete proctoring may, in certain situations, be adequate grounds
for revocation, suspension, or other involuntary modification of membership and/or
privileges. Such actions regarding Privileges and Membership qualify as adverse actions
entitling the practitioner to appropriate procedural hearings.
6.7 Disaster Privileges
In the event of a disaster of sufficient magnitude to require use of resources beyond those
available to the Hospital and Medical Staff, privileges may be granted to volunteers on an
emergent basis to handle immediate patient care needs.
6.7.1 Declaration of Disaster
The Hospital disaster plan must be implemented prior to consideration of grating disaster
Privileges.
6.7.2 Individuals Responsible for Granting Disaster Privileges
The Medical Staff President or his/her designee, or the Administrator or his/her designee(s)
are responsible for granting disaster Privileges. Under the disaster plan, and in the absence
of the above persons or designees, the incident commander, or his/her designee(s), is the
individual responsible for granting disaster Privileges until the above person or designees
are present to carry out the function of granting Disaster Privileges.
A. Responsibilities of Individuals Granting Disaster Privileges.
Disaster Privileges may be granted on a case-by-case basis, and the responsible
individual, at his or her discretion, is not required to grant Privileges to any individual.
6.7.3 Identification Requirements for Disaster Privileges
Disaster Privileges may be granted upon the presentation of a valid photo identification
issued by a state or federal agency, and at least one of the following items;
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A. A current hospital ID card that clearly identifies professional designation.
B. A current license to practice and a valid photo ID issued by a state or primary source
verification of the license.
C. Identification indicating that the individual is a member of a Disaster Medical Assistance
Team (DMAT) or MRC, ESAR-VHP, or other recognized state or federal organization or
group.
D. Identification indicating that the individual has been granted authority to render patient
care, treatment, and services in disaster circumstances (such authority having been
granted by a federal, state, or municipal entity.)
E. Verification of identity and qualifications by current Hospital or Medical Staff Member(s)
with personal knowledge of the practitioner’s identity and qualifications.
6.7.4 Disaster Identification
Practitioners granted disaster Privileges shall be identifiable to other staff by the wearing of
a Disaster Identification Badge.
6.7.5 Management of Persons Granted Disaster Privileges
Persons granted disaster Privileges will be assigned duties either by the grating authorities
as defined in Section 6.6.2, ‘Individuals Responsible for Granting Disaster Privileges,’ or
assigned to a specific department, by the Department Chair or his/her designee. In the
absence of these persons, the incident commander may assign duties or delegate this
responsibility to person(s), identified in the disaster plan, who are responsible for
designation of duties.
The Medical Staff oversees the professional practice of volunteer licensed independent
practitioners by direct observation and clinical record review.
Disaster Privileges are automatically terminated when the disaster plan is deactivated.
Disaster Privileges may be revoked at any time or for any reason by the Medical Staff
President, Administrator, Department Chair, or their designee(s).
The Hospital must make a decision (based on information obtained regarding the
professional practice of the volunteer) within seventy-two (72) hours related to the
continuation of disaster Privileges initially granted.
6.7.6 Verification Process
Verification:
Primary source verification of licensure begins as soon as the immediate situation is under
control and is usually completed within seventy-two (72) hours from the time the volunteer
practitioner presents to the organization. In extraordinary circumstances, when primary
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source verification cannot be completed in seventy-two (72) hours, there must be
documentation of the following:
Why the Primary source verification could not be performed;
Evidence of demonstrated ability to continue to provide adequate care, treatment
and services.
Primary source verification must still be done as soon as possible.
ARTCLE 7
GENERAL MEDICAL STAFF OFFICERS
7.1 Identification
The general officers of the Medical Staff are the President, the President-Elect, and the Past
President.
7.2 Qualifications
Each general officer must:
7.2.1 Be a member of the Active Staff at the time of nomination and election and remain a
Member in good standing during his/her term of office;
7.2.2 Be licensed as a physician and surgeon.
7.2.3 Willingly and faithfully discharge the duties of the office; and
7.2.4 Exercise the authority of the office held, working with the other general and Department
officers of the Medical Staff.
7.3 Attainment of Office
7.3.1 The election for the office of President-Elect shall take place in January of odd-numbered
years. The person who receives the majority of the votes cast is the President-Elect and
shall immediately assume the office. On July 1 of that same year, the President-elect shall
assume the office of the President.
7.3.2 Term of Office
The President shall serve a two-year term, and may serve a maximum of four consecutive
terms. If nonconsecutive,l the number of terms a President may serve is not submit to limit.
At the conclusion of the President’s term(s) of office, the President shall assume the office
of Past-President.
7.3.3 Should the incumbent President be reelected, the office of President-Elect shall remain
vacant until the next January election for President.
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7.3.4 Nomination
The MEC shall nominate qualified candidates for the office of President-Elect. Each nominee
must be an M.D. or a D.O. Nominations may also be made from the floor at the October
quarterly meeting by a Member of the Active Staff in good standing. Any such floor
nomination must be seconded by a Member of the Active Staff in good standing and
accompanied by evidence of the nominee’s willingness to be nominated.
7.3.5 Election
The President-Elect is chosen from among the nominated candidates by election as defined
in these Bylaws. Candidates for Medical Staff President-Elect may submit a written
statement not to exceed two pages to the Medical Staff Office no later than close of
business on December 3rd. On or before December 7th, the Medical Staff Office shall mail
to all active Members of the Medical Staff a list of the candidates for Medical Staff
President-Elect, accompanied by the candidates’ statements, if any. Approximately thirty
(30) days, but no less than twenty-five (25) days, before the January meeting of the Medical
Executive Committee, the Medical Staff Office shall mail ballots to all active Members of the
Medical Staff.
7.3.6 In order for a ballot to be counted, it must be returned to the Medical Staff Office no later
than close of business on the 11th day before the January meeting of the Medical Executive
Committee. The Medical Staff President and at least one other member of the MEC shall
count the ballots, unless the Medical Staff President is a candidate. In that event, the MEC
shall designate a second member of the MEC to count ballots. As soon thereafter as
possible, the MEC shall notify all candidates of the election results. Thereafter, but at least
seven (7) calendar days before the January meeting of the MEC, the MEC shall post, or
otherwise disclose the election results to the Medical Staff.
7.4 Vacancies
7.4.1 A vacancy in the office of President is filled by succession of the President-Elect who serves
the remainder of the unexpired term and his/her own full term as President. If the office of
President-Elect is vacant, the Past President serves as the Acting President pending the
outcome of a special election for the office of President to be conducted as expeditiously as
possible and generally in the same manner as provided in this Article. The MEC may
determine, however, not to call a special election if a regular election for the office is to be
held within ninety (90) days.
7.4.2 In the event of a vacancy in the office of Past President, the MEC shall appoint a Member of
the MEC to serve out the remainder of the vacated term.
7.4.3 Vacancy in the office of President-Elect shall be filled by the appointment of an acting officer
by the Medical Executive Committee. The acting officer serves pending the outcome of a
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special election to be conducted as expeditiously as possible and generally in the same
manner as provided in this Article.
7.5 Resignation and Removal from office
7.5.1 Resignation
Any general Medical Staff officer may resign at any time by giving written notice to the
Medical Executive Committee. Such resignation, which may or may not be made contingent
upon formal acceptance, takes effect on the date specified in the resignation or, if no date is
specified, on the date of receipt.
7.5.2 Removal
A. Authority and Mechanism:
1) Removal of a general staff officer may be effected by two-thirds majority vote by
secret ballot of the members of the Active Staff in good standing.
B. Grounds:
1) Permissible grounds for removal of a general staff officer include, without
limitation;
C. Failure to perform the duties of the position held in a timely and appropriate manner;
D. Failure to continuously meet the qualifications for the position;
E. Physical or mental infirmity that renders the office incapable of fulfilling the duties of
his/her office.
7.6 Duties of General Staff Officers
7.6.1 Medical Staff President
The Medical Staff President shall serve as the Chief Office of the Medical Staff. The duties of
the Medical Staff President shall include, but are not limited to:
A. Enforcing the Bylaws and Rules, implementing sanctions where indicated, and enforcing
procedural safeguards where corrective action has been requested or initiated;
B. Calling, presiding at, and being responsible for the agenda of all meetings of the Medical
Staff;
C. Serving as the chair of the Medical Executive Committee;
D. Serving as an ex-officio member of all other Medical Staff Committees;
E. Interacting with the Administrator and the Governing Body in all matters concerning the
Hospital;
F. Appointing, in consultation with the Medical Executive Committee, committee members
for all standing and special medical Staff, liaison, and multi-disciplinary committees,
except where otherwise provided by these Bylaws and, except where otherwise
indicated, designating the chairpersons of these committees;
G. Representing the views and policies of the Medical Staff to the Governing Body and to
the Administrator;
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H. Being a spokesperson for the Medical Staff in external professional and public relations;
I. Performing such other duties as may be required by the Bylaws, the Medical Staff, or by
the Medical Executive Committee;
J. Serving as an ex-officio member on liaison committees with the Governing Body and
Administration and with outside licensing and accreditation agencies.
7.6.2 President-Elect
The President-Elect shall assume all duties and authority of the Medical Staff President in
the absence of the Medical Staff President. The President-Elect shall also be a member of
the Medical Executive Committee and an ex-officio member of the Joint Conference
Committee. The President-Elect shall perform such other duties as the Medical Staff
President may assign or delegate to the President-Elect.
7.6.3 Past President
The Past President shall have the same duties and responsibilities as the President-Elect in
the absence of the President-Elect.
ARTICLE 8
DEPARTMENT AND DIVISIONS
8.1 Organization of Departments
Each Department shall be organized as an integral unit of the Medical Staff and shall have a chair.
The authority, duties, method of selection and responsibilities of theses Department officers is set
forth below. Each Department may appoint such standing or ad-hoc committees as it deems
appropriate to perform its required functions. A Department may be further divided, as
appropriate, into divisions which shall be directly responsible to the Department within which
they function, and each of which shall have a division chief selected and entrusted with the
authority, duties and responsibilities specified in Section 8.7. When appropriate, the Medical
Executive Committee may recommend to the Medical Staff the creation, elimination,
modification, or combination of Departments of division.
8.1.1 Current Clinical Departments and Division
The current Clinical Departments and Division are:
A. Family Medicine
1. Divisions
(a) Antioch-Brentwood
(b) Pittsburg-Bay Point
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(c) Concord
(d) Martinez
(e) West County
(f) Inpatient
B. Anesthesia
C. Emergency Medicine
D. Surgery
E. Pediatrics
F. Psychiatry/Psychology
G. Internal Medicine
1. Divisions
(a) Inpatient
(b) Outpatient
H. Obstetrics & Gynecology
I. Intensive Care Unit
J. Diagnostic Imaging
K. Pathology
L. Dental
8.2 Assignment to Departments
Each Member shall be assigned membership in at least one Department, but may also be granted
membership and/or Privileges in other Departments.
8.3 Functions of Departments
The functions of each Department shall include:
1) Conducting patient care reviews for the purpose of analyzing and evaluating the quality and
appropriateness of care and treatment provided to patients within the Department. The
Department shall routinely collect information about important aspects of patient care
provided in the Department, periodically asses this information, and develop objective criteria
for use in evaluating patient care. Patient care reviews shall include all clinical work
performed under the jurisdiction of the Department;
2) Recommending to the Medical Executive Committee guidelines for the granting of Clinical
Privileges and the performance of specified services within the Department;
3) Evaluating and making appropriate recommendations regarding the qualification of applicants
seeking appointment or reappointment and Clinical Privileges within that Department;
4) Conducting, participating and making recommendations regarding continuing education
programs pertinent to departmental clinical practice;
5) Reviewing and evaluating departmental adherence to (1) Medical Staff policies and
procedures and (2) sound principles of clinical practice;
6) Coordinating patient care provided by the Department’s Members with nursing and ancillary
patient care services;
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7) Submitting written reports to the Medical Executive Committee concerning: (1) the
Department’s review and evaluation activities, actions taken thereon and the results of such
action; and (2) recommendations for maintaining and improving the quality of care provided
in the Department and Hospital;
8) Meeting regularly for the purpose of considering patient care review findings and the results
of the Department’s review and evaluation activities, as well as reports on other Department
and staff functions;
9) Establishing such committees or other mechanisms as are necessary and desirable to perform
properly the functions assigned to it, including proctoring protocols;
10) Taking appropriate action when important problems in patient care and clinical performance
or opportunities to improve care are identified;
11) Accounting to the Medical Executive Committee for all professional and Medical Staff
administrative activities within the Department;
12) Appointing such committees as may be necessary or appropriate to conduct Department
functions;
13) Formulating recommendations for departmental rules and regulation reasonably necessary
for the proper discharge of its responsibilities subject to the approval by the Medical Executive
Committee and the Medical Staff;
When the department or any of its committees meet to carry out the duties described above, the
meeting body shall constitute a peer review body, which is subject to the standards and entitled
to the protections and immunities afforded by federal and state law for peer review bodies and/or
committees. Each department and/or its committees, if any, must meet regularly to carry out
its/their duties.
8.4 Department Heads
Each Department shall have a Department Head who shall be a Member of the active
provisional Medical Staff and shall be certified by an appropriate specialty board, or
affirmatively establish, through the Privilege delineation process, that the person possesses
comparable competence in at least one of the clinical areas covered by the Department.
Each Department Head shall have the following authority, duties and responsibilities:
1) Act as presiding Officer (Chairperson) at departmental meetings;
2) Report to the Medical Executive Committee and the Medical Staff President regarding all
professional and administrative activities within the Department;
3) Generally monitor the quality of patient care and professional performance rendered by
Members with Clinical Privileges in the Department through a planned and systematic
process; oversee the effective conduct of the patient care, evaluation, and monitoring
functions delegated to the department by the Medical Executive Committee;
4) Prepare and transmit to the appropriate authorities, as required by these Bylaws,
recommendations concerning appointment, reappointment, delineation of Clinical
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Privileges, and corrective action with respect to practitioners holding membership of
exercising privileges or services in the Department;
5) Annually review, and amend as necessary, Department policies and procedures;
6) Participate in managing the Department through cooperation and coordination with nursing
and other patient care services and with Administration on all matters affecting patient
care, including personnel, equipment, facilities, services, and budget;
7) Endeavor to enforce the Bylaws, Rules and policies and regulations with the Department;
8) Appoint an acting Department Head (Vice-Chairperson) during any absence;
9) Assure all Department functions are performed;
10) Perform such other duties commensurate with the office as may from time to time be
reasonably requested by the Medical Staff President or the Medical Executive Committee;
11) Plan and conduct, as requested by and in cooperation with the Residency Director, a
program of instruction, supervision, and evaluation of Residents’
12) Assess and recommend to the relevant hospital authority off-site sources for needed patient
care services not provided by the department or organization;
13) Recommend a sufficient number of qualified and competent persons to provide care,
treatment and services;
14) Determine the qualifications and competence of Department or service personnel who are
not licensed independent practitioners and who provide patient care, treatment and
service;
15) Continually asses and improve the quality of care, treatment and services;
16) Maintain quality control programs, as appropriate;
17) Oversee the orientation and continuing education of all persons in the Department or
service;
18) Recommend space and other resources needed by the Department or service;
19) Recommend to the Medical Staff the criteria for Clinical Privileges that are relevant to the
care provided in the Department;
20) Integrate the Department or service into the primary functions of the organization and
coordinate and integrate interdepartmental and intradepartmental services;
21) Develop and implement policies and procedures that guide and support the provision of
care, treatment and services.
8.5 Election of Department Heads
8.5.1 In April of each election year, the active Medical Staff of the applicable Department shall
elect a Department Head.
8.5.2 The following Departments shall elect a Department Head in odd-numbered years: Family
Medicine, Anesthesia, Pediatrics, Internal Medicine, Pathology and Dentistry.
The following Departments shall elect a Department Head in even-numbered years:
Emergency Medicine, Surgery, Psychiatry/Psychology, Diagnostic Imaging, Obstetrics &
Gynecology and Intensive Care.
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8.5.3 The Medical Staff President shall request nominations for Department Head at the
January Quarterly Medical Staff meeting and at the applicable Department meeting.
Nominations may be submitted by any department member within the nominating
department regardless of status (e.g. active; courtesy, etc.). Nominations may be made
only to the current Department Head or to the Medical Staff President.
The last day to nominate a candidate for Department Head is March first. Candidates may
submit a written statement not to exceed two pages to the Medical Staff office no later
than close of business on March 3rd. The Medical Staff Office shall mail a list of candidates
to all active Members of the Medical Staff in the affected Department no later than March
7th. The candidates’ statements, if any, shall accompany the list.
8.5.4 Approximately thirty (30) days, but no less than twenty-five (25) days, before the April
meeting of the Medical Executive Committee, the Medical Staff office shall mail ballots to
all the active Medical Staff Members within the affected Department.
In order for a ballot to be counted, it must be returned to the Medical Staff Office no later
than close of business on the 11th day before the April meeting of the Medical Executive
Committee. The Medical Staff President and at least one other member of the Medical
Executive Committee shall count the ballots, unless the Medical Staff President is a
candidate. In that event, the Medical Executive Committee shall designate a second
member of the Medical Executive Committee to count ballots. As soon thereafter as
possible, the Medical Executive Committee shall notify all candidates of the election
results. Thereafter, but at least seven (7) calendar days before the April meeting of the
medical Executive Committee, the Medical Executive Committee shall post, or otherwise
disclose to the Medical Staff, the election results.
8.5.5 The Medical Executive Committee shall review the newly elected Department Heads for
approval at its April meeting. The elected Department Head is thereafter subject to the
approval of the Chief Medical Office. In the event that the elected Department Head is
not approved by either the Medical Executive Committee or the Chief Medical Officer, a
new election shall be conducted as soon as possible. If the Chief Medical Officer does not
approve a Department Head, she/he will discuss the reasons for disapproval at the next
Medical Executive Committee meeting.
8.5.6 Department Members shall fill vacancies due to any reason for the unexpired term by
election as soon as possible. The Medical Staff President can appoint an acting
Department Head, subject to MEC approval, to carry out the duties of Department Head
until this election is possible.
8.5.7 Term of Office
The term of office of Department Heads is two Medical Staff years. Each assumes office
on the first day of the Medical Staff year, except that a Department Head appointed to fill
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a vacancy assumes office immediately upon appointment. Each Department Head serves
until the end of his or her term until a successor is elected, unless he/she resigns sooner
or is removed from office. A Department Head is eligible to succeed himself/herself.
8.5.8 Removal
After election and ratification, removal of a Department Head from office may occur for
cause by two-thirds vote of the Medical Executive Committee or a two-thirds vote of the
Department Members on active staff.
8.6 Functions of Divisions
Subject to approval of the Medical Executive Committee, each division shall perform the functions
assigned to it by the Department Chairperson. Such functions may include, without limitation,
retrospective patient care reviews, evaluation of patient care practices, credentials review and
privileges delineation, and continuing education programs. The division shall transmit regular
reports to the Department Head on the conduct of its assigned functions.
Each Division head shall:
1) Act as presiding officer at division meetings;
2) Assist in the development and implementation, in cooperation with the Department Head, of
programs to carry out the quality review and evaluation and monitoring functions assigned to
the division;
3) Continually review the patient care and the professional performance of Division members,
and report to the Department Head patterns or situations affecting patient care within the
Division;
4) As requested by and in cooperation with the Department Head, conduct investigations and
submit reports and recommendations to the Department Head regarding the Clinical
Privileges to be exercised within his/her division by members of or applicants to the Medical
Staff;
5) Manage the Division through cooperation and coordination with nursing and other patient
care services and with Administration on all matters affecting patient care, including
personnel, equipment, facilities, services, and budget;
6) Assure all Division functions are performed;
7) Perform such other duties commensurate with the office as may from time to time be
reasonably requested by the Department Head, the Medical Staff President, or the Medical
Executive Committee.
8.7 Division Heads
Each division shall have a Division Head who shall be a Member of the active or provisional Staff
and a Member of the division which he/she heads, and shall be certified by an appropriate
specialty board, or affirmatively establish through the privilege delineation process that he/she
possesses comparable competence in at least one of the clinical areas covered by the division.
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Each Division Head shall:
1) Act as providing officer at division meetings;
2) Assist in the development and implementation, in cooperation with the Department Head, of
programs to carry out the quality review and monitoring functions assigned to the division;
3) Continually review the patient care and the professional performance of Division members,
and report to the Department Head patterns or situations affecting patient care within the
Division;
4) As requested by and in cooperation with the Department Head, conduct investigations and
submit reports and recommendations to the Department Head regarding the Clinical
Privileges to be exercised within his/her division by Members of or applicants to the Medical
Staff;
5) Manage the Division through cooperation and coordination with nursing and other patient
care services and with Administration on all matters affecting patient care, including
personnel, equipment, facilities, services, and budget;
6) Assure all Division functions are performed;
7) Perform such other duties commensurate with the office as may from time to time be
reasonably requested by the Department Head, the Medical Staff President, or the Medical
Executive Committee.
8.8 Election of Division heads
8.8.1 In April of each election year, the active Medical Staff of the applicable division shall elect a
Division Head as set forth.
8.8.2 Family Medicine West County and Family Medicine Antioch-Brentwood, Inpatient Family
Medicine and Outpatient Internal Medicine Divisions shall elect Division heads in even-
numbered years; Family Medicine Central County, Family Medicine Pittsburg-Bay Point and
Inpatient Internal Medicine Divisions shall elect Division Heads in odd-number years.
8.8.3 The Medical Staff President shall request nominations for Division Head at the January
Quarterly Medical Staff meeting and at the applicable division meeting. Nominations may
be made only to the current Department Head or to the Medical Staff President.
The last day to nominate a candidate for Division Head is March 1st. Candidates may submit
a written statement not to exceed two pages to the Medical Staff Office no later than close
of business on March 3rd. The Medical Staff Office shall mail ballots to all the active
Medical Staff Members within the affected division no later than March 7th. The
candidates’ statements shall accompany the list, if any.
8.8.4 Approximately thirty (30) days, but no less than twenty-five (25) days, before April meeting
of the Medical Executive Committee, the Medical Staff Office shall mail ballots to all the
active Medical Staff Members within the affected division.
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In order for a ballot to be counted, it must be returned to the Medical Staff Office no later
than the close of business on the 11th day before the April meeting of the Medical Executive
Committee. The Medical Staff President and at least one other member of the Medical
Executive Committee shall count the ballots, unless the Medical Staff President is a
candidate. In that event, the Medical Executive Committee shall designate a second
member of the Medical Executive Committee to count ballots. As soon thereafter as
possible, the Medical Executive Committee shall notify all candidates of the election results.
Thereafter, but at least seven calendar days before the April meeting of the Medical
Executive Committee, the Medical Executive Committee shall post, or otherwise disclose to
the Medical Staff, the election results.
8.8.5 The newly elected Division Heads shall be reviewed for approval by the appropriate
Department Head prior to the April meeting of the Medical Executive Committee and by the
Medical Executive Committee at its April meeting. The elected Division Head is thereafter
subject to approval of the Chief Medical Officer. In the event that the elected Division Head
is not approved by the Department Head, the Medical Executive Committee or the Chief
Medical officer, a new election shall be conducted as soon as possible. If the Department
Head or the Chief Medical Officer does not approve a Division head, she/he will discuss the
reasons for disapproval at the next Medical Executive Committee meeting.
8.8.6 Division members shall fill vacancies due to any reason for the unexpired term by election as
soon as possible. The Department Head can appoint an acting Division head, subject to MEC
approval, to carry out the duties of Division Head until this election is possible.
8.8.7 Term of Office
The term of office of Division heads is two Medical Staff years. Each assumes office on the
first day of the Medical Staff year, except that a Division head elected to fill a vacancy
assumes office immediately upon election. Each Division head serves until the end of
his/her term and until a successor is elected, unless he/she sooner resigns or is removed
from office. A Division Head is eligible to succeed himself/herself.
8.8.8 Removal
After selection and ratification, a Division head may be removed for cause by the
Department Head, a two-thirds vote of the Division Members on active Staff, or by a two-
thirds vote of the MEC.
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ARTICLE 9
COMMITTEES
9.1 General Provisions
9.1.1 Designation
A. The Medical Executive Committee and the other committees described in these Bylaws
shall be standing committees of the Medical Staff unless otherwise indicated.
B. The Chairperson of the Medical Executive Committee, a standing committee, or a
Department may create subcommittees, or Ad-Hoc committees, in order to carry out
specified tasks. These specified tasks must be within the scope of authority of the
committee whose chairperson created the committee. Such committees terminate
once the specified task is completed and are not standing committees.
9.1.2 Appointment of Members to Committees
A. The Medical Staff President, with the approval of the MEC, shall appoint chairpersons
and members of standing committees unless otherwise specified in the Bylaws.
Committee members are appointed for a term of one Medical Staff year unless
otherwise specified by the Bylaws, and shall serve either until the end of this period,
until the member’s successor is appointed, or until the member resigns or is removed
from the committee.
B. Only Medical Staff in good standing may be voting members of any Medical Staff
Committee. Other individuals may be appointed to committee positions as either Ex-
officio or non-medical Staff members.
C. For committees that are not standing committees, the person creating the committee
shall appoint Chairpersons and Members.
9.1.3 Removal of Committees
Unless otherwise specified in the Bylaws, committee members may be removed by the
appointing authority without cause.
9.1.4 Vacancies
Vacancies on any committees shall be filled in the same manner as an original appointment
is made.
9.1.5 Conduct of Meeting of Committees
Committee meetings shall be conducted and documented in the manner specified in these
Bylaws.
9.1.6 Attendance of Non-Members
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Members in good standing of the Medical Staff who are not committee members my attend
committee meetings only with the permission of the Chair of the committee.
9.1.7 Accountability
All committees of the Medical Staff are accountable to the Medical Executive Committee.
9.2 Medical Executive Committee
9.2.1 Composition
The Medical Executive Committee (MEC) consists of the following Members of the Medical
Staff as voting members:
1) President of the Medical Staff;
2) President-Elect;
3) Past President;
4) Clinical Department Heads;
5) Division heads;
6) The Chairpersons of the following committees shall be voting members of the MEC:
A. Administrative Affairs
B. Ambulatory Policy
C. Credentials
D. Patient Safety and Performance Improvement
E. Patient Care Policy and Evaluation
7) Chief administrators may attend the meetings without voting rights. These include the
Director of Health Services, the Chief Executive Officer of Hospital and Clinics, the Chief
Medical Officer, the Chief Nursing Officer, the Ambulatory Care Medical Director, the
Residency Program Director and the Medical Director of the health plan. The
Chairperson of the MEC may invite other individuals to participate in the MEC meetings
as non-voting guests.
9.2.2 Duties
The Medical Executive Committee shall:
A. Perform and/or delegate performance of all Medical Staff functions in a manner
consistent with the Bylaws and the Rules;
B. Coordinate and implement the Activities of the committees and the Departments;
C. Make recommendations regarding Medical Staff membership and privileges;
D. Initiate and pursue disciplinary or corrective actions when indicated;
E. Supervise the Medical Staff’s compliance with the Medical Staff Bylaws, Rules and
policies;
F. Supervise the Medical Staff’s compliance with County laws, rules, policies and
procedures;
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G. Supervise the Medical Staff’s compliance with state and federal laws and regulations;
H. Supervise the Medical Staff’s compliance with TJC and other applicable accreditation
and certification rules;
I. Regularly report to the Governing Body regarding the status of Medical Staff issues;
J. Meet monthly to conduct Medical Staff business;
K. Represent and act on behalf of the Medical Staff in the intervals between Medical Staff
meetings, subject only to such specific limitations as may be imposed by those Bylaws.
9.3 Committees
In order to remain in good standing on a committee, a member must attend at least 50 percent of
the meetings.
9.3.1 Administrative Affairs Committee
A. Purpose and Meetings
The Administrative Affairs Committee (AAC) fulfills staff responsibilities relating to
review and revision of Medical Staff Bylaws and related manuals and forms and assumes
the responsibilities for investigating and providing recommendations on such other
administrative policy-making and planning matters and activities of concern to the Staff
as are referred by the MEC. The AAC oversees the Institutional Review Committee (IRC)
which reviews, approves or denies, monitors and evaluates research projects, protocols,
and clinical investigations to be conducted within the Medical Services, in compliance
with the regulations of the Food and Drug Administration and observing all
requirements of any other applicable regulatory authorities for any given study. The
AAC may overrule a positive recommendation of the IRC, but the AAC may not approve
a study or the use of an investigational agent if disapproved/denied by the IRC. The AAC
meets as needed, and reports to the MEC. When appropriate, it shares its monitoring
and evaluation findings from research projects with the Patient Safety and Performance
Improvement Committee and vice versa.
B. Composition
The Administrative Affairs Committee includes;
1) A Physician Chairperson, appointed by the Medical Staff President, subject to MEC
approval;
2) At least 4-6 additional Staff Members;
3) Administrator, with vote; and
4) Their members with special expertise as necessary on an ad-hoc basis, without vote.
9.3.2 Ambulatory Policy Committee
A. Purpose and Meetings
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The Ambulatory Policy Committee (APC) sets Medical Staff policy in the health centers
and acts as a liaison with Nursing and Administration for coordination of policies and
procedures under joint Medical Staff-Administration or Medical Staff-Nursing purview.
APC develops policies to resolve issues that affect more than one Medical Staff
Department and focuses on policies and projects that relate to quality of care, the
efficiency of the health centers and patients that relate to quality care, the regulatory
compliance. APC coordinates its activities with PSPIC and receives quality assurance
reports suggestive of or requiring changes in policies and procedures from individual
Medical Staff Departments and from the Ambulatory Subcommittee of PSPIC.
B. Composition
The Ambulatory Policy Committee includes:
1) A Physician Chairperson; appointed by the Medical Staff President, subject to MEC
approval
2) One Staff Member from each Region;
3) The Department Head of Family Medicine or his/her designee;
4) Representative of the Departments of Obstetrics & Gynecology, Surgery, Pediatrics
and Medicine, with vote;
5) Other members with special expertise as needed on an ad-hoc basis without cote;
6) Director of Health Information Management as needed on an ad-hoc basis without
vote
7) A representative of the Allied Health Professionals, without vote;;
8) Ambulatory Care Medical Director without vote;
9) Chief Nursing Officer without vote.
9.3.3 Bioethics Committee
A. Purpose and Meetings
The Bioethics Committee provides a multi-disciplinary forum for the development of
guidelines for consideration of cases and issues having bioethical implications;
development and implementation of procedures for the review of such cases;
development and/or review of institutional policies regarding care and treatment in
cases or issues having bioethical implications; consultation with concerned parties to
facilitate and education of the hospital staff regarding bioethical matters. The
committee will meet regularly (at least six (6) times yearly) and will also provide a
mechanism for other meetings as necessary to perform the case consultation functions.
The committee chair will report to the Medical Executive Committee.
B. Composition
The Bioethics Committee includes;
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1) A physician chairperson appointed by the Medical Staff President subject to Medical
Executive Committee approval;
2) Multi-disciplinary representation selected to represent the various clinical services
of the medical and nursing staff, ancillary support services (such as social workers,
chaplains, etc.) and lay members. At least a third of the committee membership will
be physicians;
3) A member representing hospital administration; and
4) The committee may invite other professional or community lay members to be
utilized when discussing issues involving their particular clinical, ethnic, religious or
other background.
9.3.4 Cancer Committee
A. Purpose and Meetings
The Cancer Committee is a multi-disciplinary committee that organizes, conducts and
evaluates hospital-wide oncology services and the cancer registry. The committee
assures that full oncology services including surgery, chemotherapy, radiation therapy,
as well as rehabilitation and hospice care are available to all patients. The committee
will develop and monitor annual goals and objectives for clinical care, community
outreach, quality improvement and programmatic endeavors related to cancer care.
The committee is responsible for establishing and monitoring the Cancer Conference
format, frequency and multi-disciplinary attendance. The committee will ascertain if
there is a need for specific educational programs both professional and public based on
survival and comparison data. The committee will also supervise the Cancer Registry for
quality control of case-funding, abstracting, staging, reporting and follow-up. The
committee will conduct a minimum of two patient care evaluation studies annually, one
to include survival data. The committee will meet at least quarterly or more often as
needed and communicate as necessary with the Patient Safety and Performance
Improvement Committee. The committee will designate one coordinator for each of
the four areas of Cancer Committee activity: Cancer Conference, quality control of the
cancer registry, quality improvement and community outreach.
B. Composition
The Cancer Committee includes:
1) A Physician chairperson appointed by the Medical Staff President, subject to
Medical Executive Committee approval;
2) At least five (5) additional Medical Staff Members including representation from
Surgery, Pathology, Hematology/Oncology, Family Practice, and Diagnostic Imaging;
3) Cancer Liaison Physician;
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4) Representation for Administration, Social Services, Nursing, and the American
Cancer Society all with vote; and
5) The Cancer Registrar, who will act as staff to the Cancer Committee, with vote.
52
9.3.5 Continuing Medical Education Committee
A. Purpose and Meetings
The Continuing Medical Education Committee (CMEC) directs the development of CME
programs for the Staff responsive to quality assurance findings and to developments
pertinent at the Hospital and apprises the Staff of outside education opportunities. It
coordinates the educational activities of the Departments and of the Staff and Hospital
Department. The CMEC also analyzes the status and needs of, and make
recommendations regarding, the medical library services. It meets at least quarterly
and more frequently if needed and reports on its activities to the MEC.
B. Composition
The CMEC included:
1) A Chairperson appointed by the Medical Staff President, subject to MEC approval;
2) At least two additional Staff Members; and
3) Medical Librarian, without vote.
9.3.6 Credentials Committee
A. Purpose and Meetings
The Credentials Committee coordinates the staff credentials function by receiving and
analyzing applications and recommendations for appointment, provisional period
conclusion or extension, reappointment, clinical privileges, and changes therein, and
recommending action therein, and by integrating quality assurance and utilization
review and monitoring, membership, and other relevant information into the individual
credentials files. It also assists in designing and participates in implementing the
credentialing procedures for Allied Health Practitioners. It meets monthly or more often
as necessary and reports to the MEC regarding the credentialing of Staff Members.
B. Composition
The Credential Committee includes:
1) A physician chairperson, appointed by the Medical Staff President, subject to MEC
approval; and
2) At least 4-6 additional Staff Members, selected to be representative of the
Departments and major clinical specialties.
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9.3.7 Critical Care Committee
A. Purpose and Meetings
The Critical Care Committee (CCC) is a multi-disciplinary committee that oversees the
quality, safety, and appropriateness of patient care services provided within the Critical
Care Unit (CCU) and Intermediate Medical Care Unit (IMCU). The CCC, in consultation
with the Patient Care Policy and Evaluation Committee, shall develop written policies
and procedures which shall guide the provision of patient care including, but not limited
to: criteria for patient admission to and discharge from the CCU and IMCU (including
priority determination); guidelines for providing specialized patient care to patients who
require such care but who, for pre-determined reason (e.g., contagious disease) or for
unforeseen reasons (e.g., when patient load exceeds optimal operational capacity)
cannot be cared for within the CCU and IMCU; guidelines for transferring and referring
patients who require services not provided by the CCU; guidelines for circumstances
under which consultations is required; the role of Resident Staff in these units; and
guidelines for appropriate orientation, in-service training, and continuing medical and
nursing education. As appropriate and as necessary, the CCC shares information with
the Patient Safety and Performance Improvement Committee and its subordinate
committees. The CCC shall meet at least quarterly and reports to the Patient Care Policy
and Evaluation Committee. The Chairperson (or his/her designee) shall serve as the
Director of the CCU and IMCU.
B. Composition
The CCC includes:
1) At least one Member each from the Departments of Anesthesia, Medicine, and
Surgery.
2) The Nursing Supervisor of the Critical Care Unit;
3) The Residency Director or his/her designee;
4) The Director of Cardiopulmonary Services, or his/her designee; and
5) A Member of the Resident Staff.
9.3.8 Hospital Leadership Committee
A. Purpose and Responsibilities
The Hospital Leadership Committee shall make those organizations decisions regarding
inpatient medical staff as necessary to improve patient care and teaching.
1) Development of standards for inpatient physicians and departments.
2) Make decisions regarding inpatient care as it relates to inpatient physician staffing
and organization.
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3) Institute staffing and process changes as needed for the improvement of patient
care and safety, hospital flow, teaching, oversight of resident physicians, and staff
sustainability.
4) Address inter-departmental hospital-based issues as needed.
5) Meet with the residency program director as needed to ensure that the patient-care
and educational goals are met.
6) Develop processes and policies to implement among the inpatient departments:
Nursing, OB, ED, Surgery, Psych and with Administration.
B. Membership
1) Chair: Hospital Medical Director
2) Voting Members:
(a) Inpatient Division Head, Department of Family Medicine (DFM)
(b) DFM Assistant Inpatient Division Head or designee
(c) Inpatient Internal Medicine Division Head
(d) Internal Medicine Department Head or designee
(e) Critical Care Unit Chair
(f) Assistant Residency Program Director or Residency Program Director or
designee
(g) Chief Resident
(h) Hospital Medical Director
3) Non-voting members: Director of Inpatient Nursing, Patient/Family representative,
Chair of the Surgery Department, Chair of the Emergency Department, Physicians
and Dentists of Contra Costa County President, Medical Director of Safety and
Quality, Department of Family Medicine Chair, Administrative representative,
Medical Staff President.
C. Reporting
1) The Hospital Medical Director will provide monthly administrative reports to the
MEC.
2) The Hospital Leadership Committee will submit an annual report to the MEC.
9.3.9 Informatics Advisory Committee
A. Purpose and Meetings
The Informatics Advisory Committee provides governance in informatics and
Information Technology (IT)-related clinical systems. It prioritizes issues, reports and
optimization and acts as a liaison between medical staff departments and IT/clinical
informatics.
A. Composition
1) Chief Medical Informatics Officer (CMI) who serves as Chair
2) Director of Nursing Informatics
3) Director of Medical Outpatient Informatics
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4) Director of Medical Inpatient Informatics
5) A representative of each department.
9.3.10 Institutional Review Committee
A. Purpose and Meetings
The Institutional Review Committee shall review and have authority to: approve,
require modification in (to secure approval), or disapprove all research activities
within the Hospital and Health Centers; approve, require modification in, or
disapprove the use of investigation drugs or devices in individuals (i.e.
“Compassionate use” cases); receive prompt notification of the emergency use of
investigational drugs or devices and approve, require modification in or, disapprove
their continued use; continue, require modifications in or terminate any ongoing
studies at intervals of not greater than twelve (12) months; immediately terminate or
suspend any research not conducted in accordance with the IRC’s requirements or
that has been associated with unexpected serious harm to subjects; ensure all
compliance with federal informed consent regulations regarding investigational use of
drugs and devices; and assure the protection of the rights and welfare of all human
subjects. The Institutional Review Committee shall meet semi-annually or more often
as necessary to fulfill its obligations. If the Institutional Review Committee
disapproves of any activity within its purview, that decision is final. The Institutional
Review Committee chairperson reports to the Administrative Affairs Committee.
B. Composition
The Institutional Review Committee includes:
1) A Chairperson appointed by the Chairperson of the Administrative Affairs
Committee, subject to Medical Executive Committee approval;
2) At least one member of each gender;
3) At least one member from outside the medical profession;
4) At least one non-scientist;
5) At least one member not affiliated with the Hospital and Health Centers; and
6) A total of at least five (5) members, including representative ethnic and cultural
backgrounds, of the community.
9.3.11 Inter-Disciplinary Practice Committee.
A. Purpose and Meetings
The Inter-Disciplinary Practice Committee (IPC) shall perform functions consistent with
the requirements of law and regulations (Title 22, Section 70706). The IPC shall
routinely report to the MEC; and, in addition, shall submit an annual report to the
MEC. The IPC shall meet at least annually, or more often as necessary.
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B. Composition
The IPC shall consist of:
1) A Physician Chairperson, appointed by the Medical Staff President, subject to MEC
approval;
2) The Chief Nursing Office;
3) The Administrator or designee;
4) The Ambulatory Care Medical Director, if not serving as the representative of
Administration;
5) Two (2) additional physicians, appointed by the Medical Executive Committee,
one of whom is the Chair of the Credentials Committee;
6) Two (2) additional Registered Nurses, appointed by the Chief Nursing Office;
7) An FNP representative selected by the MEC; and
8) One or more allied health professionals who are performing or will perform
functions requiring standardized procedures will be appointed by the IPC Chair on
a temporary basis when issues pertaining to their functions are discussed.
9.3.12 Joint Conference Committee
A. Purpose and Meetings
The Joint Conference Committee constitutes a forum between the Medical Staff, the
Administration and the Governing Body. Two members of the Medical Executive
Committee who serve at the will of the Medical Executive Committee represent the
Medical Staff. These members shall act as directed by the MEC in their capacity as
members of the Joint Conference Committee.
The Governing Body and the Administration shall have representation pursuant to
authority separate from these Bylaws.
9.3.13 Medical Errors and Adverse Outcome Committee
A. Purpose and Meetings
The Medical Error and Adverse Outcome Committee (MEAO) provides a multi-
disciplinary forum to develop and coordinate resources for education, case
consultation, and quality improvement with respect to possible medical error and/or
unanticipated adverse outcome. Its functions include:
1) Education: The committee develops and implements a system-wide educational
program addressing topics relevant to medical error.
2) Case consultation: The committee develops and provides consultative resource
services to assist with clinical management of cases involving clear of possible
medical error, unanticipated adverse outcome, or “near-miss”. Such services
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include assistance with patient/family communications, facilitation of prompt
medical case reviews, and initiation of debriefing and support services for staff.
3) Quality improvement: The committee works with other structures of the Medical
Staff and Administration to apply the lessons learned from case reviews toward
system-wide improvements.
An important part of the work of the MEAO Committee through its functions of
education, case management, and quality improvement is to de-sanitize error
and to nurture a culture in which clinicians are supported in their professional
responsibilities to acknowledge, constructively discuss, and prevent medical error.
The committee meets regularly (at least six (6) times yearly) and reports to the
Medical Executive Committee.
B. Composition
The MEAO Committee includes:
1) A Physician Chairperson, appointed by the Medical Staff President, subject to MEC
approval;
2) At least two (2)additional Staff Physicians;
3) At least two (2) Nurses;
4) One (1) Resident Physician
5) One (1) representative from Administration;
6) One community lay representative;
7) The Leader of the Staff Debriefing and Support Team; and
8) Other Members with special expertise as determined by the Chairperson.
9.3.14 Medical Staff Assistance Committee
A. Purpose and Meetings
In order to improve the quality of care and promote the well-being of the Medical
Staff, the Medical Staff Assistance Committee (MSAC) receives reports related to
health concerns, well-being, or impairment of Medical Staff Members, and other
Licensed Independent Practitioners (LIPs) and, as it deems appropriate, investigates
such reports. With respect to matters involving individual Medical Staff Members and
other LIPs, the committee may, on a voluntary basis, provide such advice, counseling,
or referrals as may seem appropriate. Such activities shall be confidential; however,
in the event information received by the committee clearly demonstrates that the
health or known impairment of a Medical Staff Member or LIP poses an unreasonable
risk of harm to patients, that information may be referred for corrective action.
The process that the MSAC uses to accomplish these goals includes:
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1) Education of the Medical Staff and other organization staff about illness and
impairment recognition issues specific to the Medical Staff Member or licensed
independent practitioners;
2) Self-referral by a physician or Licensed Independent Practitioner (LIP) and referral
by other organization staff;
3) Referral of the Physician, or the affected LIP to the appropriate professional
internal or external resources for diagnosis and treatment of the condition or
concern;
4) Maintenance of the confidentiality of the Physician, or LIP seeking referral or
referred for assistance except as limited by law, ethical obligation, or when the
safety of a patient is threatened;
5) Evaluation of the credibility of a complaint, allegation, or concern;
6) Monitoring of the Physician, or affected LIP and the safety of patients until the
rehabilitation or any disciplinary process is complete;
7) Reporting to the Medical Staff leadership instances in which a Physician or LIP is
providing unsafe treatment; and
8) Initiating appropriate action when a Physician or LIP fails to complete the required
rehabilitation program.
The committee shall also consider general matters related to the health and well-
being of the Medical Staff, and, with the approval of the Medical Executive
Committee, develop educational programs or related activities. The Medical Staff
Assistance Committee shall meet as often as necessary, but at least quarterly. It shall
maintain only such record of its proceedings as it deems advisable, but shall report on
its activities on a routine basis to the Medical Executive Committee.
B. Composition
The Medical Staff Assistance Committee includes;
1) A Physician Chairperson, appointed by the Medical Staff President, subject to
Medical Executive Committee approval;
2) At least two (2) additional practitioners; and
3) A Member of the Resident staff.
Except for the resident, who shall serve on the committee for one (1 ) year, each
member shall serve for a term of three (3) years, and the term shall be staggered as
deemed appropriate by the Medical Executive Committee to achieve continuity.
Insofar as possible, members of this committee shall not serve as active participants
on other peer review or quality assurance committees while serving on this
committee.
The Chairperson may appoint additional individuals who are not members of the
Medical Staff, including non-physicians, when such appointment may materially
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increase the effectiveness of the work of the committee. These individuals shall serve
for a term that shall be determined by the Chairperson.
9.3.15 Informatics Clinical Communication Committee (ICCC)
A. Purpose and Meetings
The Informatics Clinical Communication Committee addresses clinical workflows in an
effort to enhance patient safety and maximize efficient care. The InBasket is the hub
of communication and information flow in the electronic health record. The
committee brings together provider, nursing, ancillary and technical representative to
design, build, and troubleshoot processes to allow providers, nurses, and ancillary
staff to care for patients safely and efficiently.
The committee will meet at least monthly and more frequently as needed.
B. Composition
1) A Chairperson appointed jointly by the Chief Medical Informatics Officer and the
Medical Staff President
2) DFM representative
3) Medicine Department Representative
4) Pediatrics Department Representative
5) Specialty Representative
6) At least one (1) representative from Nursing Administration
7) At least one (1) representative from Nursing Informatics
8) A representative from the Public Health Division
9) A representative from Information Technology Department
10) A representative from the Residency
In addition, the committee will seek representation from departments whose
workflows appear on the meeting agenda, including the various ancillary services
departments.
This ICCC Chair or his/her designee shall report to the Medical Executive Committee
on an annual basis. The ICCC will make recommendations to IAC and operations
leadership as appropriate.
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9.3.16 Patient Care Policy and Evaluation Committee
A. Purpose and Meetings
The Patient Care Policy and Evaluation Committee (PCP&EC) monitors, assesses and
recommends improvements to the MEC for:
1) The clinical and medical records policies and rules of the Medical Staff and of its
inpatient clinical units and diagnostic and therapeutic support services (including
OR/PAR, ER, CCU’s, etc.);
2) Medical-related aspects of infection control policies;
3) Pharmacy and therapeutics policies and practices; and
4) Blood and blood products usage policies and practices.
It also acts as liaison with Nursing and Administration for review and coordination of
policies, procedures, rules or regulations under joint Medical Staff-Administration or
Medical Staff-Nursing purview and coordinates its activities with those of the
Ambulatory Policy Committee. The PCP&EC receives quality assurance findings
suggestive of or requiring changes. It serves as a forum for identifying and discussing
problems in the delivery of patient care services and in the observance of patients’
rights. The PCP&EC meets monthly and reports to the MEC.
B. Composition
The Patient Care Policy and Evaluation Committee includes:
1) A Physician Chairperson appointed by the Medical Staff President, subject to MEC
approval;
2) At least 6-8 staff members selected to be representative of major clinical areas;
3) A representative of Nursing Service;
4) Director of Pharmacy ad-hoc for Pharmacy and Therapeutic function;
5) A representative from Pathology Department ad-hoc for blood and blood product
review function;
6) Manager of Infection Control and Prevention Committee of the Hospital;
7) A representative of Administration responsible for policy committee support
without vote;
8) A Nursing Supervisor/Coordinators for specialty units invited on an ad-hoc basis
without vote;
9) A representative of other clinical services and professional, technical,
administrative support staff participate as consultants in relevant areas of
expertise ad-hoc without vote; and
10) Director of Health Information management quarterly and as needed without
vote.
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9.3.17 Patient Safety and Performance Improvement Committee
A. Purpose and Meetings
The Patient Safety and Performance Improvement Committee (PSPIC) has the
authority and responsibility for implementing and directing the Quality Management
Program for the Hospital. It is responsible for setting the quality management
standards, determining criteria by which care will be measured, setting priorities for
which aspects of care will be monitored, and analyzing the quality of care studies,
indicators, utilization reports, grievances, survey data and risk management
information. A systematic, multi-disciplinary improvement process is followed. It
develops an annual plan for performance improvement activities (Quality
Management Plan).
B. Composition
The Patient Safety and Performance Improvement Committee include the following
members:
1) A Physician Chairperson, appointed by the Medical Staff President, subject to MEC
approval. The Physician Chair will serve for approximately three (3) years (in
addition to one (1) year as Chair Elect), with the term ending one (1) year after the
approximately triennial Joint Commission Survey;
2) A Physician Chair-Elect appointed by the Medical Staff President, subject to MEC
approval, will be appointed after the triennial “unannounced: Joint Commission
survey. He/she will take over as Chair one (1) year after the survey;
3) The Medical Staff President;
4) The CCRMC Chief Executive Officer;
5) The Director of Systems Redesign/Chief Medical Officer;
6) The Chief Nursing Officer;
7) The Ambulatory Care Medical Director;
8) The Chief Operating Officer;
9) The Chief Quality officer;
10) The Facilities manager;
11) The past Medical Staff President;
12) The Chair of the Patient Care Policy and Evaluation Committee; and
13) Two (2) Medical Staff Physician representatives, appointed by the Medical Staff
President, subject to MEC approval.
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9.3.18 Peer Review Oversight Committee
A. Purpose and Meetings
The Peer Review Oversight Committee will oversee the peer review that is carried out
by the departments. It will supervise the processes, help address systems issues and
review cases that involve more than one department.
B. Composition
1) The Medical Staff President shall serve as Chair of the Committee;
2) Each department will have at least one (1) representative. Large departments will
have two (2) representatives one from inpatient and the other from outpatient.
Large departments are: Family Medicine, Internal Medicine, Surgery, and
Psychiatry/Psychology.
9.3.19 Perinatal Morbidity and Mortality (PM&M) Committee.
A. Function
The Perinatal Morbidity and Mortality Committee (PM&C) is an inter-disciplinary
committee which monitors perinatal outcomes. It is intended to complement the
quality assurance activities of the Departments of Pediatrics and Obstetrics and
Gynecology by focusing on those cases whose management involves both obstetrical
and pediatric issues. The PM&M reports to the Departments of OB/GYN and
Pediatrics.
B. Composition.
The Perinatal Morbidity and Mortality Committee consist of:
1) All Members in good standing of the Departments of OB/GYN and Pediatrics. The
individual departments established attendance obligations;
2) Nurse Program manager for the Perinatal Unit, Clinical Nurse Specialists for
maternity and nursery and the RN Case Coordinator are members, all with voting
privileges; and
3) Regularly invited members, all without vote, including:
(a) Consultant Perinatologist;
(b) Consultant Neonatologist;
(c) Any Member of the Department of Ambulatory Medicine having obstetrical
privilege;
(d) Any Member of the Resident Staff presently assigned to the Pediatrics or
OB/GYN services or with a particular interest in a case being discussed; and
(e) Any member of the nursing staff with a particular interest in a case being
discussed. The Nurse Program Manager or his/her designee will maintain a
file of confidentiality agreements signed by a non-physician attendees.
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9.3.20 Professional Affairs Committee
A. Purpose of Meetings
The Professional Affairs Committee consists of the two members of the Governing
Body who sit on the Joint Conference Committee. The members of the Professional
Affairs Committee shall invite representatives from the Medical Staff and
Administration, as appropriate, to its meetings.
B. Composition
The Professional Affairs Committee consists of the two (2) members of the Governing
Body who sit on the Joint Conference Committee. The members of the Professional
Affairs Committee shall invite representative from the Medical Staff and
Administration, as appropriate to its meetings.
9.3.21 Utilization Management Committee
A. Purpose and Meetings
The Utilization Management Committee develops and oversees implementation and
operation of the utilization management plan relating to inpatient, ambulatory and
clinical support services, makes utilization decisions as required under the plan,
analyzes utilization profiles and evaluates the effectiveness of the UR program.
Physician members of the committee act as the physician advisors required by the UR
plan. The URC meets at least quarterly and reports to the Performance Improvement
Committee.
B. Composition
The Utilization Management Committee includes:
1) A Chairperson appointed by the Chairperson of the PSPIC, subject to MEC
approval;
2) At least 6-8 additional Medical Staff members, selected to provide broad
representation from the Medical Staff;
3) At least one (1) representative from Administration, without vote;
4) Director of Social Services, without vote;
5) Representative from Nursing, without vote;
6) Representative from Finance, without vote;
7) Representative from Quality Assurance Department, without vote; and
8) Director of Health Information Management, without vote.
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ARTICLE 10
MEETINGS
10.1 Medical Staff Meetings
10.1.1 Regular Meetings
General Staff meetings will be held quarterly. The Medical Executive Committee may
authorize additional regular general Staff meetings by resolution. The resolution
authorizing any such additional meeting shall require notice specifying the place, date,
and time for the meeting, and that the meeting can transact any business as may come
before it.
10.1.2 Special Meetings
A special meeting of the Medical Staff may be held by the Medical Executive Staff
President. A special meeting must be held by the President at the written request of the
Governing Body, the Chief Medical Officer, the Administrator, the Medical Executive
Committee, or 25% of the active staff in good standing.
10.2 Clinical Department and Committee Meetings
10.2.1 Regular Meetings
Clinical Departments, Division, and Committees may establish by resolution the time for
regular meetings. No additional notice is required.
10.2.2 Special Meetings
A special meeting of any Department, Division, or Committee may be held by the Head or
Chairperson thereof. A special meeting must be held by the Head or Chairperson at the
written request of the Administrator, the Medical Executive Committee, the Medical Staff
President, the Chief Medical Officer, or 25% of the group’s current members in good
standing.
10.2.3 Executive (Closed) Session
Any Committee, Department or Division may call itself into executive session at any time
during a regular or special meeting. All ex-officio members shall leave during the
executive session unless requested to remain by the Chairperson. Accurate and complete
minutes must be made and kept of any executive session.
10.3 Quorum
10.3.1 Medical Staff Meetings
The presence of one-third (1/3) of the active Medical Staff at a General or Special Medical
Staff meeting shall constitute a quorum for all appropriate actions except the removal of a
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Medical Staff Officer. For a meeting considering the removal of a Medical Staff Officer,
the quorum shall be one-half (1/2) of the active Medical Staff. Ex-officio members do not
count for quorum purposes.
10.3.2 Department and Committee Meetings
For committees, a quorum shall consist of 25% of the members of a committee by no
fewer than two (2) members. For Department and division meetings, a quorum shall
consist of 25% of the members. Ex-officio members do not count for quorum purposes.
10.4 Manner of Action
Except as otherwise specified, the action of a majority of the members present and voting at a
meeting at which a quorum is present shall be the action of the group. A meeting at which a
quorum is initially present may continue to transact business notwithstanding the withdrawal of
members, if any action taken is approved by a least a majority of the required quorum for such
meeting, or such greater number as may be specifically required by these Bylaws.
10.5 Notice of Meetings
Written notice of any regular general medical Staff meeting, or any regular committee or
Department meeting, not held pursuant to resolution, will be delivered personally or via mail to
each person entitled to attend at not less the five (5) days or more than fifteen (15) days before
the date of such meeting. Notice of any special meeting of the Medical Staff, a Department, or a
committee will be given orally or in writing at least seventy-two (72) hours prior to the meeting.
Personal attendance at a meeting constitutes a waiver of notice of such meeting, except when a
person attends a meeting for the express purpose of objecting, at the beginning of the meeting, to
the transaction of any business because of lack of notice. No business shall be transacted at any
special meeting except that listed in the meeting notice.
10.6 Minutes
Except as otherwise specified herein, minutes of all meetings will be prepared and retained. They
shall include, at a minimum, the date and time of the meeting, a record of the attendance or
members and the vote taken on all matters. A copy of the minutes shall be signed by the
presiding officer of the meeting and forwarded to the medical Executive Committee.
10.7 Agenda
The Medical Staff president and Medical Executive Committee shall determine the order of
business at a meeting of the Medical Staff. The agenda shall include, insofar as feasible:
1) Reading and acceptance of the minutes of the last regular meeting and of all special meetings
held since the last regular meeting;
2) Administrative reports from the Medical Staff president, Departments, Committees, and the
Administrator;
3) Election of officers when required by these Bylaws;
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4) Reports by responsible Officers, Committees and Department on the overall results of patient
care audits and other quality review, evaluation, and monitoring activities of the Staff and on
the fulfillment of other required Staff functions;
5) Old business; and
6) New business.
10.8 Attendance Requirements
10.8.1 Medical Staff Meetings
The Medical Executive Committee may adopt attendance requirements for the Medical
Staff and Department meetings.
10.8.2 Special Attendance
At the discretion of the Chairpersons or presiding Officer, when a Member’s practice or
conduct is scheduled for discussion at a regular Department, Division or Committee
meeting, the Member may be requested to attend. If a suspected deviation from
standard clinical practice is involved, the notice shall be given at least seven (7) days prior
to the meeting and shall include time and place of the meeting and a general indication of
the issue involved. Failure of a Member to appear at any meeting, with respect to which
he/she was given such notice, unless excused by the Medical Executive Committee upon a
showing of good cause, is grounds for corrective action.
10.9 Conduct of Meetings
Unless otherwise specified, meetings shall be conducted according to Robert’s Rules of Order;
however, technical or non-substantive departures from such rules shall not invalidate action taken
at such a meeting.
ARTICLE 11
CORRECTIVE ACTION
11.1 Corrective Action
11.1.1 Initiation
Any person may provide information to the Medical Executive Committee about the
conduct, performance, or competence of its Members. When reliable information
indicate a Member may have exhibited acts, demeanor, or conduct reasonably likely to be
(a) detrimental to patient safety, (b) unethical or illegal, (c) contrary to the Medical Staff
Bylaws and/or rules and regulations, or (d) below applicable professional standards, a
request for an investigative and/or corrective action against such Member may be
initiated. The President of the Medical Staff, a Department Chair, the Chair of any
standing Committee, or the Governing Body may initiate such a request. All requests for
corrective action and/or formal investigation shall be in writing, shall be made to the
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Medical Executive Committee, and shall be supported by reference to the specific
activities or conduct which constitutes the grounds for the request. If the Medical
Executive Committee initiates the request, it shall make an appropriate written record of
the reasons for the request.
11.1.2 Formal Investigation
If the Medical Executive Committee concludes a formal investigation is warranted, it may
conduct the investigation itself, or assign the task to an appropriate medical Staff Officer,
Department, or standing or ad-hoc committee of the Medical Staff. If the investigation is
delegated, the designee shall proceed with the investigation in a prompt manner and shall
provide a written report of the investigation to the Medical Executive Committee as soon
as practical. The report may include recommendation for appropriate corrective action.
The Member shall be given an opportunity to provide information in a manner and upon
such terms as the investigating body deems appropriate. The individual or body
investigating the matter may, but is not obligated to, conduct interviews with persons
involved; however, such investigation shall not constitute a hearing, nor shall the
procedural rules with respect to hearings or appeals apply. Despite the status of any
investigation, at all times the Medical Executive Committee shall retain authority and
discretion to take whatever action may be warranted by the circumstances, including the
imposition of summary suspension, termination of the investigative process, or other
action. Any reports that are made to the Medical Executive Committee must be shared
promptly with the Member under investigation.
The MEC may also require a medical or psychological exam. The examining physician shall
be chosen in the manner described in Section 5.2, however, the Member is not required
to pay for the exam.
11.1.3 Medical Executive Committee Action
As soon as practical after the conclusion of the formal investigation (or without a formal
investigation if deemed unwarranted), the Medical Executive Committee shall take action
that may include, without limitation:
A. Determining no corrective action is warranted and, if the Executive Committee
determines there was no credible evidence for the complaint in the first instance,
removing any adverse information from the Member’s file;
B. Deferring action for a reasonable time where circumstances warrant;
C. Issuing letters of admonition, censure, reprimand, or warning. Nothing herein shall
preclude Department Heads from issuing written or oral warnings or counseling. In
the event the MEC issues such letters, the affected Member may make a written
response which shall be placed in the Member’s file;
D. Recommending the imposition of terms of probation or special limitation upon
continued Medical Staff membership or exercise or clinical privileges including,
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without limitation, requirements for co-admissions, mandatory consultation, or
monitoring;
E. Recommending reduction, modification, suspension or revocation of clinical
privileges;
F. Recommending reductions of membership status or limitation of any prerogatives
directly related to the Member’s delivery of patient care;
G. Recommending suspension, revocation or probation of Medical Staff membership;
H. Taking other actions that are appropriate under the circumstances.
11.1.4 Subsequent Action
A. If corrective action as set forth above is recommended by the Medical Executive
Committee, the MEC shall notify the Administrator, the Governing Body, and the
affected member of the Medical Staff of the recommended action.
B. The recommendations of the Medical Executive Committee shall be final, unless the
affected member or the Governing Body requests a hearing to challenge the
recommendations.
11.2 Summary Restriction of Suspension
11.2.1 Criteria for Initiation
Whenever a Member’s conduct appears to require that immediate action be taken to
protect the life or well-being of patient(s) or to reduce a substantial and imminent
likelihood of significant impairment of the life, health, or safety of any patient, prospective
patient, or other person, the Governing body, the Administrator, the Medical Staff
President, the Medical Executive Committee, or the head of the Department in which the
Member holds privileges may summarily restrict or suspend the Medical Staff
membership or Clinical Privileges of such member. Unless otherwise stated, the summary
restriction or suspension shall become effective immediately, and the person or body
responsible shall promptly give written notice to the Member as described below, the
Governing Body, the Medical Executive Committee, and the Administrator. The summary
restriction or suspension may be limited in duration and shall remain in effect for the
period stated or until resolved as set forth herein. Unless otherwise indicated by the
terms of the summary restriction or suspension, the Member’s patients shall be promptly
assigned to another member(s) by the Department Chair or by the Medical Staff
President, considering, where feasible, the wishes of the patient in the choice of a
substitute Member.
11.2.2 Written Notice of Summary Suspension
Within one working day of imposition of a summary suspension, the affected Medical
Staff Member shall be provided with written notice of such suspension. This initial written
notice shall include a statement of facts demonstrating that the suspension was necessary
because failure to suspend or restrict the practitioner’s privileges summarily could
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reasonably result in an imminent danger to the health of an individual. The statements of
facts provided in this initial notice shall also include a summary of one or more particular
incidents giving rise to the assessment of imminent danger. This initial notice shall not
substitute for, but is in addition to, the notice required by theses Bylaws for further action
of the MEC regarding issues related to such a summary suspension.
11.2.3 Medical Executive Committee Action
As soon as practicable after a summary restriction or suspension has been imposed, but
no more than ten (10) calendar days thereafter, a meeting of the Medical Executive
Committee shall be convened to review and consider the summary suspension or
restriction. The Member may attend the meeting and make a statement concerning the
issues under investigation on such terms and conditions as the Medical Executive
Committee may impose. In no event shall any meeting of the Medical Executive
Committee, with or without the Member in attendance, constitute a hearing, nor shall any
procedural rules apply. A Member’s failure, without good cause, to attend a meeting of
the Medical Executive Committee after a written request to attend was mailed to the
Member by the Medical Executive Committee, shall constitute a waiver of the Member’s
right to appear and be heard. The request of the Medical Executive Committee for the
Member to attend the meeting shall be made in writing, mailed to Member’s last known
address by first class mail of the United States Postal Service at least five (5) calendar days
before the meeting, and shall inform the Member that his or her failure to attend said
meeting shall constitute a waiver of his or her rights to appear and be heard. The Medical
Executive Committee may postpone or reschedule the meeting on the written request of
the Member. The Medical Executive Committee may modify, continue, vacate, or
terminate the summary restriction or suspension. The Medical Executive Committee shall
mail the Member written notice of its decision that shall be effective upon deposit in the
United States Mail.
11.2.4 Procedural Rights
Unless the Medical Executive Committee terminated or vacates the summary restriction
or suspension, the Member is entitled to the procedural rights afforded by these Bylaws.
11.3 Grounds for Automatic Suspensions and/or Restrictions
In certain instances, the Member’s Privileges or membership may be suspended or limited as a
result of certain occurrences that disqualify the member from membership or the exercise of
certain Privileges. These grounds for automatic suspension do not require any action of the MEC
or the Governing Body prior to the suspension and/or restriction. If a Member requests a hearing
to challenge these automatic suspensions and/or restrictions, the scope of such a hearing is
limited. The only question before the Judicial Review Committee in these situations is whether
the grounds for automatic suspension have occurred.
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11.3.2 Licensure
A. Revocation and Suspension
Whenever a Member’s license or other legal credential authorizing practice in the
state is revoked or suspended by the applicable licensing or certifying authority,
Medical Staff membership and Clinical Privileges shall be automatically revoked as of
the date such action becomes effective.
B. Restriction
Whenever a Member’s license or other legal credential authorizing practice in this
state is limited or restricted by the applicable licensing or certifying authority, any
Clinical Privileges which the Member has been granted at the Hospital which are
within the scope of said limitation or restriction are automatically limited or restricted
in a similar manner, as of the date such action becomes effective and throughout its
term.
C. Probation
Whenever a Member is placed on probation by the applicable licensing or certifying
authority, his or her membership status and Clinical Privileges are automatically
subject to the same terms and conditions of the probation as of the date such action
becomes effective and throughout its term.
D. Suspension of Membership when a License is Not Renewed
Expiration:
Whenever a Member’s license or other credential authorizing practice in the state
expires, Medical Staff Membership and Clinical Privileges shall automatically
suspended. If the member renews his or her license and is effective retroactive, the
suspension will be vacated. If it is not renewed within six (6) months, Medical Staff
Membership and Privileges shall be automatically revoked.
11.3.3 Controlled Substances
Whenever a Member’s DEA certificate is revoked, limited or suspended, the Member
automatically and correspondingly be divested of the right to prescribe medications
covered by the certificate, as of the date such action becomes effective and throughout its
term.
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A. Probation
Whenever a Member’s DEA certificate is subject to probation, the Member’s right to
prescribe such medications shall automatically become subject to the same terms of
the probation, as of the date such action becomes effective and throughout its term.
11.3.4 Failure to Satisfy Appearance Requirement
Failure of a Member, without good cause, to appear at a Special Appearance is cause for
automatic suspension of membership and restriction of Privileges.
11.3.5 Medical Records
Members of the Medical Staff are required to complete medical records within such
reasonable time as may be prescribed by the Medical Executive Committee. Failure to
comply with the Medical Executive Committee policies regarding completion of medical
records is criteria for suspension or other corrective action. If a Member is automatically
suspended for incomplete records, his/her membership is automatically reinstated once
the medical records are completed. A prolonged period of automatic suspension or a
repeated pattern of automatic suspensions for incomplete medical records may be
grounds for further corrective action by the Medical Staff and may result in adverse
reports to governmental and licensing authorities.
11.3.6 Professional Liability Insurance
Failure to maintain professional liability insurance shall result in the immediate suspension
of the Member’s Clinical Privileges. Written notice of the suspension shall be mailed to
the member at his or her last known address. Said notice shall also state that the member
has ninety (90) days to provide proof of professional liability insurance, that the
suspension will continue until proof of insurance is provided, and that failure to provide
proof of insurance within ninety (90) days shall result in termination of Medical Staff
membership. If proof of professional liability insurance is not provided to the Medical
Executive Committee within ninety (90) days, the Medical Executive Committee shall mail
written notice of termination of Medical Staff membership to the Member at his or her
last known address, including the information that he or she is entitled to the procedural
rights set forth in these Bylaws.
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ARTICLE 12
HEARING AND APPELLATE REVIEWS
12.1 Grounds for Hearing
Except as otherwise specified in these Bylaws, any one or more of the following actions or
recommended actions shall be deemed actual or potential adverse action and constitute grounds
for a hearing:
12.1.1 Denial of Medical Staff Membership;
12.1.2 Denial of requested advancement in Staff Membership category;
12.1.3 Denial of Medical Staff reappointment;
12.1.4 Demotion to lower Medical Staff category;
12.1.5 Suspension of Staff Membership;
12.1.6 Revocation of Medical Staff Membership;
12.1.7 Denial of any requested Clinical Privilege(s) except temporary Privileges;
12.1.8 Involuntary reduction of current Clinical Privileges, including temporary Privileges;
12.1.9 Suspension of any Clinical Privileges, including temporary Privileges;
12.1.10 Termination of any or all Clinical Privileges, including temporary Privileges;
12.1.11 Involuntary imposition of significant consultation or monitoring requirements, excluding
monitoring incidental to provisional status;
12.1.12 Any other restriction(s) on Medical Staff membership or Clinical Privileges which is
reportable pursuant to Section 805 of the Business and Professions Code.
12.2 Exhaustion of Remedies
If adverse action described above is taken or recommended, the applicant of Member must
exhaust the remedies afforded by these Bylaws before resorting to legal action.
12.3 Requests for Hearing
12.3.1 Notice of Action or Proposed Action.
In the event of a proposed or actual action against a Member of the Medical Staff or an
applicant, the Administrator shall give the Member or applicant:
12.3.2 Prompt notice of the recommendation or action, including a brief description of the
reasons for the recommendation or action;
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12.3.3 Notice of the right to request a hearing;
12.3.4 Notice that failure to request a hearing within the prescribed time period and in the
proper manner constitutes a waiver of rights to a hearing and to an appellate review on
the matter that is the subject of the notice;
12.3.5 Notice regarding whether the proposed action, if adopted, is reportable pursuant to
Business & Professions Code Section 805 and following;
12.3.6 A summary of the rights the Member or applicant will have at the hearing.
12.3.7 Requesting a Hearing
The affected Member or applicant must request a hearing within thirty (30) calendar days
after the date of the notice of action or proposed action. The request for hearing shall be
in writing and address to the Administrator. Failure to make a timely request and in the
manner described may result in the denial of a hearing at the discretion of the Medical
Executive Committee.
12.3.8 Time and Place for Hearing
Upon receipt of a request for hearing, the Administrator shall schedule a hearing and
provide notice to the Member or applicant of the time, place and date of the hearing. The
hearing shall commence not less than thirty (30) days or more than ninety (90) days from
the date of the Notice of Hearing. When the Member is under summary suspension, the
hearing shall commence not more that forty-five (45) days from the date of the Notice of
the Hearing is mailed or otherwise delivered to the Member under summary suspension.
The Member may waive these time limits if he/she wishes.
12.3.9 Notice of Charges
In the Notice of Hearing, the Administrator shall state the reason(s) for the adverse action
taken or recommended, including the acts or omissions with which the Member or
applicant is charged and a list of the charges in question, where applicable. In addition,
the Administrator shall furnish a list of witnesses the Medical Executive Committee
expects will testify on its behalf at the hearing. This list may be amended at a later time
should new names emerge.
12.3.10 Judicial Review Committee
When a hearing is requested, the Medical Executive Committee shall appoint a Judicial
Review Committee which shall be composed of not less than five (5) Members of the
Medical Staff who have not actively participated in the consideration of the matter
leading up to the recommendation or action and who are not in direct economic
competition with the member charged. The Medical Executive Committee shall designate
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one of the five as Chair. Knowledge of the matter involved shall not preclude a Member
of the Medical Staff from serving as a member of the Judicial Review Committee. In the
event that it is not feasible to appoint a Judicial Review Committee from the Medical Staff,
the Medical Executive Committee may appoint practitioners who are not Members of the
Medical Stall. The Judicial Review Committee shall include at least one member with the
same healing arts licensures as the affected Member. All other members shall have M.D.
or D.O. degrees.
12.3.11 Failure to Appear or Proceed
Failure, without good cause, of the Member or applicant to personally attend and proceed
at such a hearing shall constitute voluntary acceptance of the recommendations or action
at issue.
12.3.12 Postponements and Extensions
Once a hearing is requested, postponements and extension of time beyond the times
permitted in these Bylaws may be permitted by the Administrator, the Judicial Review
Committee, or its Chairperson on a showing of good cause.
12.4 Hearing Procedure
12.4.1 Pre-hearing Procedure
A. The Medical Executive Committee or its designee may request, in writing, a list of
names and addresses of all persons the Member or applicant anticipates calling to
testify at the hearing on the Member’s or applicant’s behalf. The Member or
applicant shall furnish the witness list within seven (7) days of the date of the request.
Upon written request, the Medical Executive Committee or its designee shall provide
the Member or applicant with copies of all documents upon which the adverse action
is based. Upon written request, the Member or applicant shall provide the Medical
Executive Committee or its designee with copies of all documents the Member
applicant expects to present at his/her hearing.
B. It is the duty of the Member or applicant and the Medical Executive Committee or its
designee to exercise reasonable diligence in notifying the Chairperson of the Judicial
Review Committee of any pending or anticipated procedural disputes as far in
advance of the scheduled hearing as possible, in order that decision concerning such
matters may be made in advance of the hearing. Objections to any pre-hearing
decision may be again made at the hearing.
12.4.2 Representation
The hearings provided for in these Bylaws are for the purpose of intra-professional
resolution of matters bearing on professional conduct, professional competency, and/or
character. The Member or applicant shall be entitled to representation by legal counsel in
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any phase of the hearing and shall receive notice of the right to obtain representation by
an attorney at law. In the absence of legal counsel, the Member or applicant shall be
entitled to be accompanied by and represented at the hearing by a practitioner licensed
to practice in the State of California who is not also an attorney at law. If the Member or
applicant is not represented by an attorney, the Medical Executive Committee shall
appoint a representative who is not an attorney to represent its position, present the
supporting witnesses and material, examine witnesses, and respond to appropriate
questions. The Medical Executive Committee shall only be represented by an attorney at
law if the Member or applicant is also represented by an attorney.
12.4.3 The Hearing Officer
The Medical Executive Committee shall appoint a Hearing Officer (who may also be the
Chair of the Judicial Review Committee) to preside at the hearing. The Hearing Officer will
not act as a prosecuting officer or as an advocate. The Hearing Officer shall endeavor to
ensure that all participants in the hearing have a reasonable opportunity to be heard and
to present relevant oral and documentary evidence in an efficient and expeditious
manner, and that proper decorum is maintained. The Hearing Officer shall determine the
order of or procedure for presenting evidence and argument during the hearing and shall
have the authority and discretion to make all rulings on questions that pertain to matters
of law, procedure and/or the admissibility of evidence. If the Hearing Officer determines
that any participant is not proceeding in an efficient and expeditious manner, the Hearing
Officer may take actions as seems warranted by the circumstances.
12.4.4 Hearing Record
A record of the hearing shall be made that is of sufficient accuracy to permit review by any
appellate group that may later be called upon to review the matter. The Judicial Review
Committee may determine to make the record by use of (a) a court reporter or (b) by a
tape recording and minutes of the proceedings. The Member or applicant may request, in
writing, a copy of the hearing record. The copy will be provided to the Member or
applicant upon payment of the cost of preparing and copying the record.
12.4.5 Rights of the Parties
Both parties at the hearing may call and examine witnesses for relevant testimony,
introduce relevant documents, cross-examine and/or impeach witnesses who have
testified on any matter relevant to the issues, and otherwise rebut evidence, as long as
theses rights are exercised in an efficient and expeditious manner. The Member or
applicant may be called by the Medical Executive Committee or its designee and examined
as if under cross-examination. The Member or applicant may, at the beginning of the
hearing, challenge the membership of the Judicial Review Committee because of alleged
conflict of interest on the part of any committee member. Should such a challenge occur,
the Medical Staff President may choose to remove and replace the challenged member
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(requiring a postponement if necessary) or proceed without removal. If the Medical Staff
President chooses to proceed without removal, any challenge by the Member or applicant
shall be made succinctly in writing and shall be make part of the hearing record.
12.4.6 Miscellaneous Rules
Judicial rules of evidence and procedure relating to the conduct of the hearing,
examination of witnesses, and presentation of evidence, do not apply to a hearing
conducted under this Article. Any relevant evidence, including Quality Assurance profiles,
credentials files, and hearsay shall be admitted if it is the sort of evidence on which
responsible persons are accustomed to rely in the conduct of serious affairs, regardless of
the admissibility of such evidence in a court of law. However, no finding of fact may be
based solely on hearsay. The Judicial Review Committee may interrogate the witnesses
and/or call additional witnesses if it deems such action appropriate. At its discretion, the
Judicial Review Committee may request or permit both sides to file written arguments. A
Medical Staff Member does not have the right to view or use peer review information of
other practitioners as part of the fair hearing process.
12.4.7 Burden of Proof
When a hearing related to denial of initial appointment, denial of requested Department
or division membership, denial or restriction of Clinical Privileges, mandatory consultation
or supervision requirements as it pertains to an initial application for membership or
Privileges, or denial of a request to advance from courtesy to active Staff, or termination
due to inactivity, the practitioner has the burden of proving that the adverse action or
recommendation lacks a substantial factual basis or that the action is arbitrary,
unreasonable, or capricious. Otherwise, the Medical Executive Committee has the burden
of proving that the adverse action is warranted and has a substantial factual basis.
12.4.8 Adjournment and Conclusion
After the presentation of the oral and written evidence, oral closing arguments, or written
closing arguments, if requested by the Judicial Review Committee, the hearing shall be
closed.
12.4.9 Basis for Decision
The decision of the Judicial Review Committee shall be based on the evidence introduced
at the hearing, including all logical and reasonable inferences from the evidence and the
testimony, and shall be within the constraints of these Bylaws. The decision of the Judicial
Review Committee shall be final, subject to the Appeal provision of these Bylaws.
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12.4.10 Presence of Judicial Review Committee members and Vote
A majority of the Judicial Review Committee must be present throughout the hearing and
deliberations. If the committee member is absent from any part of the proceedings,
he/she may not participate in the deliberations or the decision.
12.4.11 Decision of the Judicial Review Committee
A. The Judicial Review Committee shall make findings of fact.
B. The Judicial Review Committee may make one of the following decisions based upon
the findings of fact:
1) The action of the Medical Executive Committee is sustained;
2) The action of the Medical Executive Committee is overturned; or
3) The action of the Medical Executive Committee is modified. (The modification
may be less or more adverse to the Member or applicant than the action of the
Medical Executive Committee.)
C. The Judicial Review Committee shall make its decision by simple majority vote. The
numerated results of the vote are not reported in the final report of the Judicial
Review Committee.
D. Within thirty (30) workdays after adjournment of the hearing, the Judicial Review
Committee shall render a decision, which shall be in writing. If the Member is
currently under suspension, however, the time for the decision and report shall be
fifteen (15) workdays. The original report and decision shall be forwarded to the
Administrator, the Professional Affairs Committee and the Member or applicant at his
or her last known address. The report shall contain the findings of fact, a statement of
the reasons in support of the decision, and the decision. The decision of the Judicial
Review Committee shall be final, subject to such rights or appeal as set forth in these
Bylaws.
12.5 Appeals
12.5.1 Time for Appeal
Within ten (10) calendar days of the date that the report/decision of the Judicial Review
Committee is mailed to the Member of applicant, either the Member or applicant or the
Medical Executive Committee may request an appellate review of the decision. The
written request for such review shall be delivered to the Administrator and mailed or
delivered to the other party to the hearing. If a request for appellate review is not made
within the specified time period, the decision of the Judicial Review Committee shall be
final.
12.5.2 Grounds for Appeal
A written request for an appeal shall include an identification of the grounds for appeal
and a clear and concise statement of the fact in support of the appeal. The grounds for
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appeal from the hearing shall be: (a) substantial non-compliance with the procedures
required by these Bylaws or applicable law which has created demonstrable prejudice;
(b) the decision was not supported by substantial evidence based upon the hearing
record or such additional information as may be permitted.
12.5.3 Time, Place and Notice
If an appellate review is to be conducted, the appeal board shall, within thirty (30) days
after receipt of notice of appeal, schedule a review date and cause each side to be given
notice of the time, place and date of the appellate review. The date of appellate review
shall not be less than thirty (30) nor more than sixty (60) days from the date of such
notice, provided, however, that when a request for appellate review concerns a
Member who is under suspension which is then in effect, the appellate review shall be
held as soon as the arrangements may reasonably be made, not to exceed fifteen (15)
days from the date of the notice. The time for appellate review may be extended by the
appeal board for good cause.
12.5.4 Appeal Board
The Governing Body, or an authorized committee of the Governing Body, shall sit as the
Appeal Board. Knowledge of the matter involved shall not preclude any person from
serving as a member of the Appeal Board, so long as that person did not take part in a
prior hearing on the same matter. The Appeal Board may select an attorney to assist it
in the proceeding, but that attorney shall not be entitled to vote with respect to the
appeal.
12.5.5 Appeal Procedure
The proceeding by the Appeal Board shall be in the nature of an appellate hearing based
upon the record of the hearing before the Judicial Review Committee, provided that the
Appeal Board may accept additional oral or written evidence, subject to a foundational
showing that such evidence could not have been made available to the Judicial Review
Committee in the exercise of reasonable diligence and subject to the same rights of
cross-examination or confrontation provided at the Judicial Review Hearing; or the
Appeal Board may remand the matter to the judicial Review Committee for the taking of
further evidence and for decision. Each party shall have the right to be represented by
legal counsel in connection with the appeal, to present a written statement in support
of his or her position on appeal and, in its sole discretion, the Appeal Board shall present
its written recommendations as to whether the Governing Body should affirm, modify,
or reverse the Judicial Review Committee decision, or remand the matter to the Judicial
Review Committee for further review and decision.
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12.5.6 Decision
A. Except as otherwise provided herein, within thirty (30) days after the conclusion of the
appellate review proceeding, the Governing Body shall render a decision in writing
and shall forward copies thereof to each side involved in the hearing.
B. The Governing Body may affirm, modify, or reverse the decision of the Judicial Review
Committee or remand the matter to the Judicial Review Committee for
reconsideration. If the matter is remanded to the Judicial Review Committee for
further review and recommendation, said committee shall promptly conduct its
review and make its recommendations to the Governing Body. This further review
and the time required to report back shall not exceed thirty (30) days in duration
except as the parties may otherwise agree or for good cause as jointly determined by
the Chairpersons of the Governing Body and the Judicial Review Committee.
C. In the event the decision of the Governing Body is unfavorable to the applicant or
Member, that action shall become final. In the event the decision is favorable, that
action also shall become final unless the Medical Executive Committee elects within
fifteen (15) days to submit the matter to an ad-hoc committee. This ad-hoc
committee shall be composed of two (2) members of the Governing Body (appointed
by the Chair of the Governing Body) and two (2) Members of the Medical Staff (as
appointed by the Medical Staff President) and shall have access to the records from
the hearing and appeal. The decision of this committee shall be in writing within
thirty (30) days of receipt of the matter unless extended for good cause. The decision
of this committee shall specify the reasons for the action taken and shall be forwarded
to the Governing Body who shall reconsider its action, and then render a final
decision.
12.5.7 Right to One Hearing
No Member or applicant shall be entitled to more than one evidentiary hearing and one
appellate review on any matter that has been the subject of adverse action or
recommendation.
12.6 Exceptions to Hearing Rights
12.6.1 Automatic Suspension or Limitations of Practice Privileges.
In the circumstances set forth in these Bylaws causing Automatic Suspension, the issues
which may be considered at a hearing, if requested, shall not include evidence designed to
show that the determination by the licensing or credentialing authority was unwarranted,
but only (1) whether the revocation, suspension, restriction, or probation occurred, (2) the
terms of any restrictions, or probation, and (3) whether the Member may continue to
practice in the Hospital with the Limitations imposed by the licensing or credentialing
authority.
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12.6.2 Expunction of Disciplinary Action.
Upon petition, the Medical Executive Committee, in its sole discretion, may expunge
previous disciplinary action upon a showing of good cause or rehabilitation.
ARTICLE 13
CONFIDENTIALITY
13.1 General
Discussion, deliberation, records and proceedings of all meetings of all Medical Staff committees
having the responsibility of evaluation and improvement of quality care rendered in this Hospital,
including, but not limited to meetings of the Medical Staff meeting as a committee of the whole,
meeting of Departments and Division, meeting of Committees, and meetings of special and ad-hoc
committees and including information regarding any Member or applicant to the Medical Staff,
shall be confidential to the fullest extent permitted by law.
“Records” includes, but is not limited to, the credentials and quality assurance profiles of
individual practitioners and the records of all Medical Staff credentialing, peer review, and quality
review activities.
Records will be disclosed only in the furtherance of credentialing, peer review, and quality review
activities, and only as specifically permitted under the condition described in this Article, or
otherwise required by law.
Records that are disclosed to the Governing Body of the Hospital or its authorized representatives,
in order for the Governing Body to discharge its lawful obligations and responsibilities, shall be
maintained as confidential.
13.2 Breach of Confidentiality
Inasmuch as effective peer review and consideration of the qualifications of Medical Staff
Members and applicants to perform specific procedures must be based on free and candid
discussions, any breach of confidentiality provision of these Bylaws, except in conjunction with
other Hospital, professional society, or licensing authority duties, is unauthorized conduct for any
Medical Staff member and is grounds for corrective action.
13.3 Protection
All Medical Staff records shall be maintained in the Medical Staff Office and in the Quality
Assurance Department. Such records shall be maintained in locking cabinets under the custody of
the Chairpersons of the Credentials Committee and the Patient Safety and Performance
Improvement Committee or their designees. The profile cabinets will be locked except during
such times as these Chairpersons or their designees are able to monitor access to the records.
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13.4 Access by persons or Agencies Outside the Jurisdiction of the Hospital
13.4.1 Credentialing or Peer Review at Other Hospitals
The Medical Staff president, the Credentials Committee Chairperson or the designee of
either, may release information contained in a credentials profile in response to a
request from another hospital or its Medical Staff. That request must include
information that the practitioner is a member of the requesting hospital’s Medical Staff,
exercise privileges at the requesting hospital, or is an applicant for Medical Staff
membership or privileges at that hospital, and must include a release for such records
signed by the concerned practitioner.
13.4.2 Requests by Hospital Surveyor/Investigators
Hospital surveyor/investigators are entitled to inspect records (excluding quality
assurance profiles, which shall not be made available to any persons or agencies outside
the jurisdiction of the Hospital) covered by this Article on the hospital premises in the
presence of the Medical Staff President (or designee), provided that:
A. No originals or copies may be removed from the premises;
B. Access is only with concurrence of the Administrator (or designee) and the Medical
Staff President (or designee); and
C. The surveyor demonstrates the following to Hospital and Medical Staff
representatives;
1) That the surveyor has specific statutory or regulatory authority to review the
requested materials;
2) That the materials sought are directly relevant to the matter being investigated;
3) That the materials sought are the most direct and least intrusive means to carry
out the pending investigation or survey, bearing in mind that credentials profiles
regarding individual practitioners are confidential materials;
4) That sufficient specificity is provided to allow for the production of individual
documents without undue burden to the Hospital or Medical Staff; and
5) That in the case of a request for documents with physician identifiers, the need
for such identifiers is documented.
6) Additionally, at the discretion of the Medical Staff President and the
Administrator, the surveyor may be asked to sign a statement acknowledging
notification of the provisions of confidentiality. If he/she declines to sign, it will be
noted at the bottom of the prepared statement that the surveyor, identified by
name, has declined to sign but has been provided a copy of confidentiality
provisions.
13.4.3 Subpoenas
All subpoenas of Medical Staff records shall be referred to the Administrator, who shall
have the option of consulting legal counsel for the purpose of formulation a response.
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The Administrator shall notify the Medical Staff President when a subpoena for Medical
Staff records is received.
13.4.4 Requests from Licensing Boards
Current law allows the California Medical Board, the Board of Osteopathic Examiners, and
the Board of Dental Examiners to review certain materials pertaining to Medical Staff
hearings concerning corrective action recommendations or decisions. Given the current
requirements of law, copies of the following records of a Medical Staff disciplinary hearing
shall be made available to the appropriate licensing board upon the specific request of
such board:
A. The Notice of Charges presented to the practitioner before the beginning of a Medical
Staff hearing;
B. Any document, medical record, or other exhibit received in evidence at the hearing;
and/or,
C. Any written opinion, finding, or conclusions of the Medical Staff hearing committee
that were made available to the concerned practitioner.
In the event that the concerned practitioner did not request a hearing as per these
Bylaws, the Notice of Action or Proposed Action shall be made available
The Medical Staff President, or designee, must review and approve the disclosure
before it is made. Any request for documents other than those cited above shall be
disclosed only in accordance with this Article.
13.4.5 Other Requests
All other requests for information contained in the Medical Staff records shall be
forwarded to the Medical Staff President and the Administrator for an appropriate
response.
13.5 Access by Persons within the Jurisdiction of the Hospital
13.5.1 Quality Assurance Profiles
A. Any practitioner may review his/her Quality Assurance profiles and/or work folder
without cause and without approval by giving timely notice in writing to the designee
of the Medical Executive Committee. An observer shall be present when the
practitioner is reviewing his/her profile. When a Member has reviewed his/her profile
as provided under this section, he/she may request a correction or deletion of
information in his/her Quality Assurance profile by written request to the Medical
Executive Committee. Such a request shall include a statement of the basis for the
action requested. The request will be considered and acted upon in accordance with
the Bylaws.
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B. Except as noted above, no Member of the Medical Staff, other than those specified in
the Bylaws, may be provided with access to a practitioner’s Quality Assurance profile
and/or work folder. No member of the Hospital Administration or the Governing Body
may be provided with access to practitioner’s Quality Assurance profile or work folder,
except as required by the administrative hearing process in these Bylaws. The
individual practitioner under review will be notified in writing whenever this request
occurs.
C. Quality Assurance profiles may be submitted as evidence during a fair hearing
conducted pursuant to these Bylaws.
13.5.2 Credential Files
A Medical Staff Member shall be granted access to his/her own credentials files, subject to
the following provisions;
A. The request shall give timely notice to the Medical Staff President or his/her
designee;
B. The Member may review, and receive a copy of, only those documents provided
by or personally address to the Member. A summary of all other information,
including peer review committee findings, letters of reference, monitoring
reports, complaints, etc., shall be provided to the Member in a timely manner, in
writing, by the Medical Staff President or designee. Such summary shall disclose
the substance, but not the source, of the information summarized;
C. The review by the Member shall take place in the Medical Staff Office, during
normal working hours, in the presence of the Medical Staff President or designee.
13.5.3 When a Member has reviewed his/her file, he/she may address to the Medical Staff
President a written request for correction or deletion of information in his/her credentials
files. Such request shall include a statement of the basis for the action requested. The
Medical Staff President shall review such a request within a reasonable time and shall
recommend to the Medical Executive Committee after such review whether to make the
correction or deletion requested. The Medical Executive Committee, when so informed,
shall either grant or deny the request by a majority vote. The Member shall be notified
promptly, in writing, of the decision of the Medical Executive Committee. In any case, a
Member shall have the right to add to his/her own credentials profile a statement
responding to any information contained in the file.
13.5.4 The Medical Staff President, Department Chairpersons, committee chairpersons, the Chief
Medical Officer, and the Administrator shall have access to credentials files to the extent
necessary to perform their official duties. Medical Staff committee members shall have
access only to the records of committees on which they serve.
13.5.5 No members of the Hospital Administrator or the Governing Body will be given access to a
practitioner’s credentials file; however, the Governing Body or its designee, consistent
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with its ultimate responsibility to oversee quality or care, may wish to have an individual
practitioner’s credentials profile evaluated for specific reasons of concern. The individual
practitioner under review must be immediately notified in writing whenever this request
occurs.
ARTICLE 14
GENERAL PROVISIONS
14.1 Rules and Regulations
The Medical Staff must annually review the Rules. The procedure for adopting, amending, and
repealing the Rules is set forth in Article 15 of the Bylaws. Once a rule or regulations is adopted or
amended by the Governing Body, it is effective and governs applicants and Members of the
Medical Staff. If there is a conflict between the Bylaws and the Rules, the Bylaws prevail. The
process set forth in Article 15 of the Bylaws is the sole method for the initiation, adoption,
amendment, and repeal of medical Staff Rules.
14.2 Dues or Assessments
The Medical Executive Committee shall annually recommend the amount of annual dues or
assessments, if any, for each category of Medical Staff membership, subject to the approval of the
Medical Staff, and to determine the manner of expenditure of such funds.
14.3 Construction of Terms and Headings
The captions or headings in these Bylaws are for convenience only and are not intended to limit of
define the scope of or affect any of the substantive provisions of these Bylaws. These Bylaws
apply with equal force to both genders wherever either term is used.
14.4 Authority to Act
Any Member or Members who act in the name of this Medical Staff without proper authority shall
be subject to such disciplinary action, as the Medical Executive Committee may deem appropriate.
14.5 Division of Fees
Any division of fees by Members of the Medical Staff is forbidden and any such division of fees
shall be cause for exclusion or expulsion from the Medical Staff.
14.6 Special Notices
Except as otherwise provided in these Bylaws, all notices, demands and requests required or
permitted to be mailed shall be in writing addressed to the last known address provided by the
Member, sealed, with postage fully paid, and deposited in the United States Postal Service. In the
alternative, any notice, demand, or request that is required or permitted to be mailed may be
hand-delivered. If the official records of the Medical Staff and the Hospital contain different
addresses, the notice, request or demand shall be mailed to both addresses.
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14.7 Requirements for Elections of Medical Staff President, Department Heads, Division
heads and for Bylaws Amendments
14.7.1 Elections by Secret Ballot:
All elections shall be by secret ballot.
14.7.2 Eligibility to Vote:
Only active Members of the Medical Staff in Good Standing may vote in elections
governed by these Bylaws. An active Member of the Medical Staff is one who has been
approved for active status by the Governing Body at least seven (7) days before the day
ballots are mailed.
14.7.3 Mailing Address:
It is the responsibility of each Member of the Medical Staff to provide the Medical Staff
Office with his/her current mailing address. Ballots will be mailed to the last address
provided by the Medical Staff Member.
14.7.4 Runoff Elections:
A candidate shall be elected by a majority of the votes cast. If no candidate receives a
majority vote on the first ballot, a runoff election shall be conducted as soon as is practical
between the two candidates who received the highest pluralities. If the runoff election
results in a tie, the election shall be repeated. If there is still a tie, the Medical Staff
president will cast the deciding vote. If the election is for the Medical Staff President, the
Medical Executive Committee will decide.
14.7.5 Voting within Committees and Departments:
At the discretion of the Department Chair, ballots may be by voice, by hand, or by secret
ballot. However, at the request of any voting Member within that committee or
Department, that vote shall be by secret ballot. Voting Members are determined in
accordance with these Bylaws.
14.8 Disclosure of Interest.
All nominees for election or appointment to Medical Staff offices, Department Chairs, or the
Medical Executive Committee shall, at least twenty (20) days prior to the date of election or
appointment, disclose in writing to the Medical Executive Committee those personal, professional,
and financial affiliations and relationships of which they are reasonably aware that could
foreseeably result in a conflict of interest with their activities or responsibilities on behalf of the
Medical Staff.
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14.9 Authorization, Immunity, and Releases.
14.9.1 Authorization and Conditions.
By applying for or exercising clinical privileges within this hospital, an applicant;
A. Authorizes representatives of the hospital and the Medical Staff to solicit, provide,
and act upon information bearing upon, or reasonably believed to bear upon, the
applicant’s professional ability and qualifications;
B. Authorized persons and organizations to provide information concerning such
practitioner to the Medical Staff;
C. Agrees to be bound by the provisions of this Article and to waive all legal claims
against any representative of the Medical Staff or the hospital who acts in
accordance with the provisions of these Bylaws; and
D. Acknowledges that the provisions of these Bylaws are express conditions to an
application for Medical Staff membership, the continuation of such membership,
and to the exercise of clinical privileges at this hospital.
14.9.2 Releases.
Each applicant or Member shall, upon request of the Medical Staff or hospital, execute
general and specific releases as necessary to carry out the provision of these Bylaws.
14.10 Standards for History and Physical Examination.
14.10.1 The complete history and physical examination (H&P), as required for the patient’s
medical record, shall be completed within twenty-four (24) hours after admission of the
patient, and, in case a patient is admitted for surgery, shall be completed prior to the
time surgery is done. When the history and physical examination is dictated, a holding
note must be recorded in the medical record at the time of examination. A history and
physical may be performed up to thirty (30) days in advance provided a durable and
legible copy is inserted into the inpatient medical record no later than twenty (24) hours
after admission and is updated as appropriate.
14.10.2 Special Standards for Elective Surgery.
The following procedure is to be followed when scheduling a patient for either elective
outpatient surgery or elective surgery to be done on the day of admission (for general or
regional anesthesia.)
14.10.3 The scheduling surgeon must schedule the patient for a pre-op H&P to be done within
thirty (30) days prior to surgery. The surgeon must clearly enter in the medical record:
A. The procedure being scheduled and type of anesthesia;
B. The surgical indications;
C. Whether the patient is to be admitted following the surgery.
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10.10.4 It is the responsibility of the surgeon scheduling the procedure to obtain informed
consent from the patient at the time it is scheduled, having explained the risks and
benefits to the patient.
10.10.5 The pre-op H&P and all ordered tests will be reviewed by the anesthesiologist prior to
surgery. The provider performing the H&P and/or the primary care provider may be
consulted in evaluation of abnormal results prior to cancellation of surgery.
ARTICLE 15
ADOPTION AND AMENDMENT OF BYLAWS AND RULES
15.1 Annual Review.
These Bylaws and the Rules shall be reviewed annually by the Medical Executive Committee.
15.2 Procedure.
Upon the request of the Medical Staff President, the Medical Executive Committee, the
Administrative Affairs Committee, or upon timely written petition signed by at least 10% of the
Members of the Medical Staff in Good Standing who are entitled to vote, consideration shall be
given to the adoption, amendment or repeal of these Bylaws or Rules.
15.3 Medical Staff Action.
These Bylaws and Rules may be adopted, amended, or repealed by:
15.3.1 The affirmative vote of a majority of the active Staff Members in Good Standing present at
a regular or special Staff Meeting at which a quorum attends, provided that the proposed
documents or amendments are made available to Staff Members entitled to vote thereon
no less than two (2) weeks before balloting with or at the time of notice of the meeting; or
15.3.2 The affirmative vote of a majority of ballots returned by Members in Good Standing,
provided that a copy of the proposed documents or amendments are made available to
each Staff member entitled to vote thereon no less than two (2) weeks before balloting,
and provided that no less than two (2) weeks’ time interval exists between the date the
ballot was mailed to active Members and the due date of the ballot.
All elections to adopt amend or repeal the Bylaws or Rules and Regulations shall be
conducted in accordance with these Bylaws.
15.4 Approval.
By laws and Rules changes adopted by the Medical Staff shall not become effective until approved
by the Governing Body. Neither the Medical Staff nor the Governing Body may unilaterally amend
the Bylaws or Rules.
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15.5 Exclusivity.
The mechanism described herein shall be the sole method for the initiation, adoption,
amendment, and/or repeal of the Bylaws or Rules.
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Rules and Regulations
These Rules and Regulations are adopted pursuant to Article 15 of the Medical Staff Bylaws. These
Rules use the same Definitions as the ones described in the Bylaws. The Rules specifically include those
policies and procedures that are referenced herein.
1. General Rules
A. Admissions
1. All admissions of patients are subject to rules delineated in the Medical Staff Bylaws, specific
department policies and hospital policies.
B. Continuous Responsibility for Patients
1. Inpatient
a. The attending physician is responsible for the complete and continuing care of his/her
patients. He/she is required to keep appropriate personnel informed as to where
he/she can be reached in case of emergency and shall designate at least one physician
to render emergency or other necessary patient care if he/she is not available. Each
patient shall be reassessed daily.
2. Outpatient
a. Primary Care Providers are responsible for their panel of patients as described in the
Ambulatory Care Policies.
C. Medical Records
1. General Provisions
a. Abbreviations
i. An “Unacceptable Abbreviations List” is posted throughout the hospital and clinics.
Copies may be obtained from Medical Records.
b. Records Belonging to Health Services Department
i. Refer to Hospital Policy 705 – Removal, Retention and Destruction of Protected
Health Information. All medical records and other records relating to the admission,
care and discharge of a patient are the property of the Contra Costa County Health
Services Department and may be removed from the Health Services Department’s
jurisdiction and safekeeping only in accordance with a subpoena, court order or
other statute. In case of readmission of any patient, all previous records shall be
available to the attending physician.
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c. Electronic Signature
i. Approved electronic signature of medical records is acceptable for chart completion.
2. Completion of Records
a. Inpatient Records
i. Responsibilities of the Members of Medical Staff and General Provisions
b. Content of Staff Entry
i. The attending physician shall be responsible for preparing a complete medical
record for each patient as described in Hospital Policy 706 – Medical Record
Content. This record shall include at least the following minimum information.
ii. Patients shall be discharged only upon the order of the attending physician or
another physician acting as his/her representative. At the time the patient is
discharged, the attending physician shall complete the medical record, indicate the
reason for admission, state the final diagnosis, record treatment and/or procedures
performed, describe the condition of the patient on discharge, including specific
comparison with condition on admission and any specific instructions given the
patient and/or family (e.g., diet, medication, physical activity and follow-up care.)
When pre-printed instructions are given to the patient, the record should so
indicate and a sample of the instruction sheet in use at the time must be kept on file
in the Medical Records Department. All medical record entries must be signed and
dated.
iii. When a patient has been hospitalized a discharge summary is required.
iv. All surgery performed shall be fully described by the operating surgeon in the
patient’s medical record. Such description shall include a detailed account of the
technique used, identification of tissues and foreign material removed, if any, and a
description of the findings. Such description shall be done immediately after
surgery is concluded. A brief interim operative note shall be placed in the medical
record immediately after surgery is concluded if the complete note is not
immediately visible in the electronic health record.
v. At the discretion of the attending physician, tissues and foreign materials removed
in surgery shall be submitted, together with adequate clinical information, to the
pathologist on duty. The Pathology Department may establish appropriate
guidelines.
vi. In addition to the operating surgeon’s report, the record of every operation
involving use of an anesthetic other than local shall include a proper anesthetic
record and a post-anesthetic follow-up report.
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vii. Standards for History and Physical Examination. The complete history and physical
examination (H&P), as required for the patient’s medical record, shall be completed
within twenty-four (24) hours after admission of the patient, and, in case a patient is
admitted for surgery, shall be completed prior to the time surgery is done. When
the history and physical examination is done a holding note must be recorded in the
medical record at the time of examination. History and physical may be performed
up to thirty (30) days in advance provided a durable and legible copy is inserted into
the inpatient medical record no later than twenty-four (24) hours after admission of
the patient, and, in case a patient is admitted for surgery, shall be completed prior
to the time surgery is done. When the history and physical examination is done a
holding note must be recorded in the medical record at the time of examination,. A
history and physical may be performed up to thirty (30) days in advance provided a
durable and legible copy is inserted into the inpatient medical record no later than
twenty-four (24) hours after admission and is updated as appropriate. At a
minimum the H&P will include the following sections: HPI, Problem List, Allergies,
Medications, Physical Exam, and Assessment/Plan.
viii. Special Standards for Elective Surgery. The following procedure is to be followed
when scheduling a patient for either elective outpatient surgery or elective surgery
to be done on the day of admission (for general or regional anesthesia.)
1. The scheduling surgeon must schedule the patient for a pre-op H&P to be done
within thirty (30) days prior to the surgery. The surgeon must clearly enter in
the medical record:
a. The procedure being scheduled and type of anesthesia;
b. The surgical indications;
c. Whether the patient is to be admitted following the surgery.
2. It is the responsibility of the surgeon scheduling the procedure to obtain
informed consent from the patient at the time it is scheduled, having explained
the risks and benefits to the patient.
3. A History and Physical shall be done on all pre-op patients.
4. Pre-op lab work should be scheduled within two weeks prior to surgery.
5. The pre-op H&P and all ordered tests will be reviewed by the anesthesiologist
prior to surgery. The provider performing the H&P and/or the primary care
provider may be consulted in evaluating abnormal results prior to cancellation
of surgery.
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3. Delinquency
a. All charts must be complete by the 13th day post discharge and will be delinquent on the
14th day post discharge if not complete. A “complete medical record” is defined as one
that meets all criteria as set forth.
Document Time Delinquent
Discharge Summary…………………………………………. Thirteen (13) days post discharge
Inpatient History/Physical………………………………… Twenty-four (24) hours post admission
Operative Report……………………………………………… Immediately after surgery
Pre-anesthesia evaluation (timed note)…………… Must be completed prior to being placed
under anesthesia unless extreme
emergency
Post/PAR Anesthesia (timed note)
“Early” PAR note………………………………………….
6 hours after conclusion of anesthesia
“Complete” recovery note………………………….. Forty-eight (48) hours after conclusion of
anesthesia
Verbal orders……………………………………………… Authenticated by twenty-four (24) hours
for IV Fluid or IV drug orders; all others
within 48 hours
Other inpatient documentation as required by
law, including;
At hospital discharge
a) Diagnostic and therapeutic orders;
b) Clinical observations and results of therapy;
c) Reports of procedures, tests, and their
results;
Must be signed within thirteen (13) days
and are delinquent after the fourteenth
(14th) day.
d) Conclusions at the termination of care.
e) All inpatient dictations.
4. Disciplinary Proceedings
a. Process
i. Automatic initiation of disciplinary proceedings for the responsible practitioner will
occur as soon as a chart becomes delinquent.
ii. A letter will be sent to the practitioner responsible for the delinquent records, signed by
the Medical Staff President.
iii. The letter shall state:
A. The list of delinquent records;
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B. That failure to complete delinquencies within seven (7) days will result in
suspension of all Medical Staff Privileges and Staff Membership by the Medical Staff
President until the stated delinquent charts are completed.
iv. If delinquent records referred to in the letter are not completed with seven (7) days, the
Medical Staff President shall immediately suspend all Medical Staff Privileges and
Membership until the delinquent charts are properly completed. The Medical Staff
President will notify the appropriate Department Heads, the Executive Director of the
Hospital, Chief Medical Officer and the Residency Director as appropriate.
b. Further Sanctions
i. Any practitioner suspended for thirty (30) days or more during any calendar year may be
reported to the Medical Board of California by the Medical Staff President.
5. Outpatient Records
a. Providers are encouraged to chart as soon as possible after visit. At a minimum, the
diagnosis and treatment plan shall be charted at the time of the visit. The provider note
must be complete within twenty-four (24) hours.
b. If their only delinquent records are unsigned outpatient records members will not be
suspended until after fourteen (14) days.
6. Outpatient notes should contain the following elements:
a. Patient identification.
b. Date of visit.
c. Relevant history or pertinent update of the illness or injury.
d. Physical findings, if applicable.
e. Results of tests and other studies, if applicable.
f. Diagnostic assessment.
g. Treatment plan, including prescriptions.
h. Results of treatment rendered during the visit, if applicable.
i. Patient teaching, including instructions given to the patient and/or family and follow-up
care.
j. The primary care provider should acknowledge all consultations in the medical record.
D. Medical Orders
1. Inpatient
a. All orders must be reconciled when a patient is transferred into or out of the Critical
Care units (ICU and IMCU.)
i. Orders can be dictated or telephoned to a health professional listed below and later
signed by the attending physician, or, in case of treatment required in the absence
of the attending physician, by the physician then responsible for the patient’s care/
Verbal orders shall be accepted and entered by a licensed nurse, occupational
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therapist, physical therapist, licensed respiratory therapist or speech therapist,
registered pharmacist or registered dietician only and such action will be limited to
urgent circumstances.
ii. Verbal orders are not valid for orders to limit or remove lifesaving procedures.
iii. There are no routine or standing orders regarding patient care or ordering of
diagnostic tests.
2. Outpatient
a. Outpatient orders should be entered in the medical records. Any verbal orders must
be co-signed by the M.D. or FNP within twenty-four (24) hours.
E. CPR
1. Although a “Basic CPR” certificate is not required for Medical Staff membership, it is strongly
encouraged for all those physicians in patient care. Individual Departments may require it
for membership.
F. Disaster Assignments: Refer to Hospital Disaster Plan
1. Contra Costa Regional Health Center & Health Centers maintains a disaster plan based upon
the Hospital Emergency Incident Command System (HEICS) which delineates the
administrative structure for disaster responses. Each individual Department also has in
place disaster and evacuation plans.
2. Employed members of the Medical Staff are designated automatically as disaster workers in
the event of a disaster. Other members of the Medical Staff are eligible to participate in
disaster work, as is volunteer staff under the guidelines of disaster credentialing as
delineated in the Medical Staff Bylaws.
G. Consultation Policy
1. All providers are expected to seek consultation and advice whenever they encounter a
situation in the course of caring for a patient in whom they are not confident of their own
ability or knowledge. They should also seek consultation when it become evident that the
patient is not comfortable with the diagnosis or management of his or her problem.
Consultation may be obtained from Members of the Staff who are privileged to care for the
problem for which the advice is sought, and his or her report shall be included in the
medical record. The consultation report should be placed in the medical report.
2. Except where consultation is precluded by emergency circumstances, the attending
physician shall consult with another qualified physician in all of the following cases:
a. All major surgical cases in which the patient is not a good risk.
b. In all cases in which the diagnosis is obscure or in which there is doubt as to the best
therapeutic measures to be utilized.
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H. Operating Room Policies
1. Consents:
a. Except in cases of emergency, no surgery shall be performed except pursuant to written
informed consent from the patient or his/her legal representative, and all other
persons, if any, from whom consent is required.
i. History and physical examination;
ii. Pre-operative diagnosis;
iii. All necessary Laboratory and X-ray work;
iv. Pre-anesthetic evaluation in all cases receiving a general anesthetic;
b. If, in any surgical cases, the foregoing requirements are not met prior to the time
scheduled for surgery, the operation shall be canceled by the Operating Room
Supervisor or designee and rescheduled unless the attending physician documents that
such delay would be detrimental to the patient.
2. Prompt attendance of surgeon and attendants:
Surgeons and attendants must be in the operating room and ready to commence surgery at
the time scheduled.
I. Supervision of House Staff
1. House staff shall have appropriate supervision present at all times regardless of patient
complexity or house staff proficiency capabilities. This supervision shall be accessible and
available particularly when house staff capability is exceeded.
2. Inpatient Supervision
a. House staff shall identify a Medical Staff member as the attending or record on the
admission orders of all patients admitted to the hospital. All critically ill patients
admitted by the house staff shall be discussed with an attending physician. Teaching
rounds shall be held daily. Junior house staff shall receive close attending supervision,
proficiency monitoring and patient care responsibilities whenever possible. After hours
supervision shall be provided by either in-house Medical Staff coverage or Department-
dependent call mechanisms.
b. All “No CPR” orders entered by house staff shall document concurrent discussion with
Medical Staff.
c. Medical Staff co-signatories are needed for all resident physicians for the following
medical records and documents:
i. Inpatient History and Physical
ii. Pre-anesthesia Evaluation
iii. Consultative Reports
iv. Procedure Notes and Operative Reports
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3. Outpatient Supervision
a. More detailed and specific house staff supervision rules and policies are located in the
specific Department rules and regulations manual of Contra Costa Regional Medical
Center. A copy of these policies is also located in the residency office.
i. Prescriptions
A. All unlicensed residents must have all prescriptions co-signed.
ii. Family Medicine Clinics
A. All family medicine residents must have a Department of Family Medicine
member with appropriate privileges assigned to supervise and precept them.
This preceptor must be immediately available and have adequate time for
teaching.
B. All medical record entries by medical students must be co-signed by a provider
with privileges.
iii. Specialty Clinics
A. A staff physician will directly supervise all residents working in a specialty clinic.
First-year residents are expected to discuss all patients with their supervising
physician before the patient leaves. Second- and third-year residents should
discuss most cases with their supervising physician. The supervising physician
should be identified on the consultation.
B. All medical record entries by medical students must be co-signed by provider
with privileges.
J. On-Call Response Time
1. Departments shall determine and monitor appropriate on-call procedures for their specific
services.
K. Processing and Delivery of Ordered Blood Products
1. Blood products ordered by any physician shall be provided by the Blood Bank/Transfusion
Service without delay. If questionable indications for transfusion are felt to be present, the
pathologist, while processing of this order proceeds without delay, will attempt to discuss
this issue with the ordering physician. If, after discussion, the pathologist still believes the
request to be questionable, he/she will report this case to the appropriate Department or
committee for review.
2. The physician who has primary responsibility for the patient has the final say in decision
making, although we encourage a team approach utilizing dialogue between the clinician
and the transfusion service.
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L. Collection and Expenditures of Medical Staff Funds
1. Application Fees
a. Each application may be assessed an application processing fee. This fee shall be Three
Hundred Dollars ($300) and shall also be considered as payment of any dues, for which
the applicant shall be liable during the period of the initial appointment, should the
applicant be appointed to the staff.
b. In the event that the applicant is not accepted, no portion of this applications fee shall
be refunded. In special circumstances as defined by the Credentials Committee and the
Medical Executive Committee, this application fee may be waived.
2. Medical Staff Dues
a. The Medical Executive Committee shall have the power to determine the amount of
biennial reappointment dues. The following dues are currently in effect:
i. Active Staff:
Two Hundred Dollars ($200) for each two-year reappointment
ii. Courtesy Staff:
One Hundred Dollars ($100) for each two-year reappointment
3. Reappointment Late Processing Fees
a. Pursuant to the Bylaws and the Rules, the Medical Staff is authorized to collect late
processing fees. An application for reappointment is late when less than one hundred
fifty (150) calendar days remain until the end of Members’ term. In addition to the
regular reappointment fee, the following late processing fees are assessed:
i. At one hundred fifty (150) days from the end of a term – Fifty dollars ($50) – (may
be waived in extenuating circumstances, such as vacation);
ii. At one hundred twenty (120) days from the end of the term – Fifty dollars ($50)
more for a total penalty of one hundred dollars ($100) – (may not be waived);
iii. At ninety (90) days from the end of the term – Fifty dollars ($50) more for a total
penalty of one hundred fifty dollars ($150),
iv. At ninety (90) days, all fees must be paid in full and application must be complete or
reappointment application is not processed and the membership is deemed to have
expired automatically at the end of the term. If the member submits a new
application for membership in the medical staff within six (6) months of the
expiration of the appointment, he/she must pay the one hundred fifty dollar ($150)
penalty in addition to the application fee.
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4. Expenditure of Funds
a. The Medical Executive Committee shall determine the method of disbursement of
Medical Staff funds. The Medical Executive Committee may appoint a Medical Staff
Funds Advisory Committee to advise the Medical Executive Committee regarding such
expenditures.
b. If an Advisory Committee is appointed, it shall study the various possible uses for the
funds and recommend specific expenditures, including specific dollar amounts, to the
Medical Executive Committee on an annual basis or more often as appropriate.
c. The Medical Executive Committee shall retain ultimate control of these funds. The
Medical Executive Committee may deposit these funds in any accounts it deems
suitable.
i. Any account shall have the following co-signers:
A. The Medical Staff President
B. The Medical Staff President-Elect
C. The Immediate Past President of the Medical Staff
D. The Chair of the Administrative Affairs Committee
E. Two Medical Staff Coordinators as designated by the Medical Executive
Committee
ii. Any two (2) of these co-signers may distribute Medical Staff funds provided at least
one co-signer is a Member of the Medical Staff. Any disbursement of funds greater
than three hundred dollars (>$300) must be approved in advance by the Medical
Executive Committee. Any disbursement of funds of three hundred dollars or less
(<=$300) may be authorized by any two (2) of the cosigners listed above. Any such
disbursement of funds without the advance approval of the Medical Executive
Committee must be reported to the Medical Executive Committee by the Medical
Staff President at the next regularly scheduled Medical Executive Committee
meeting.
M. Medical Staff Evaluation and Development
1. Each Member of the active Medical Staff shall be reviewed no less often than every eleven
(11) months by his/her Department Head on a form approved by the Medical Executive
Committee. The purpose of this evaluation shall be to facilitate verbal and documented
communications between the Department Head and the Staff Member in an attempt to
acknowledge the Staff Member’s areas of excellence and to identify those areas which can
be improved.
2. The Medical Staff President shall evaluate the Department Heads in the same manner after
consultation with the Members of his/her department. If the Department Head is also the
Medical Staff President, an individual designated by the Credentials Committee shall
evaluate him or her.
3. Upon completion, the evaluator and the Medical Staff Member shall meet face to face and
each receives a copy of the evaluation, with additional copy to be placed in the individual’s
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credentials file. The copy in the credential’s file shall be used by the Credentials Committee
during the reappointment process. The Staff Member may request modification of this.
4. This evaluation shall be sent to the credentials file and the information in the credentials
files shall be used for Medical Staff purposes only.
N. Other Policy Manuals
1. From time to time, policies are legally created and adopted by the Governing Body, the
Administration, Nursing, and particular administrative departments. To the extent that
these policies are not in conflict with the Medical Staff Bylaws, the Rules, or Medical Staff
Policies, the Medical staff shall abide by the extraneous policy. If these extraneous policies
are in conflict with the Bylaws, the Rules, or Medical Staff Policies, the Medical Executive
Committee shall review the conflicting policies and recommend appropriate changes. When
the extraneous policies have a negative impact upon the quality of patient care, the Medical
Executive Committee shall also review the policy and make appropriate recommendation to
assure quality care. In all cases, the Medical Staff must abide by the requirements of the
Bylaws and the Rules.
Proposed Amendments to the 2014 Medical Staff Bylaws
and Rules & Regulations
1) 7.3.2 Term of Office (page 36)
Proposal: Change Medical Staff President term limits from 2 consecutive terms to 4
consecutive terms of office.
Reason for change: Current term limits described in the Bylaws on the election of Medical
Staff President are arbitrary and could serve to diminish effective and experienced
leadership of the Medical Staff.
Current: The President shall serve one two‐year term, but may be reelected to a second
consecutive term. At the conclusion of the President’s term(s) of office, the President shall
assume the office of Past‐President.
Proposed: 7.3.2 The President shall serve a two-year term, and may serve a maximum of
four consecutive terms. If nonconsecutive, the number of terms a President may serve is not
subject to limit. At the conclusion of the President’s term(s) of office, the President shall
assume the office of Past‐President.
2) 8.5 Election of Department Heads
Proposal: Clarify who can nominate for Department Head positions.
Reason: Current Bylaws with unspecified language
8.5.3 (clarification in bold/italics page 44)
8.5.3 The Medical Staff President shall request nominations for Department Head at the
January Quarterly Medical Staff meeting and at the applicable Department meeting.
Nominations may be submitted by any department member within the nominating
department regardless of status (e.g. active; courtesy; etc.). Nominations may be
made only to the current Department Head or to the Medical Staff President.