HomeMy WebLinkAboutMINUTES - 03112003 - C65 TO: BOARD OF SU?k",VISORS �
Contra Costa Count
FROM: William Walker, M.I3.
DATE: Feb. 10, 2003
SUBJECT: Revised Medical Staff Bylaws
SPECIFIC REQUEST(S)OR RECOMMENDATION(S)&BACKGROUND ANIS JUSnFICATION
APPROVE
The active members of the Medical staff of Contra Costa Regional Medical Center and Health Centers have
approved revised Bylaws. The following is a summary of the changes.
Nur 'tin to==' ts. JCAHO and state law state that Allied Health Practitioners such as
nurse practitioners and optometrists cannot be members of the Medical Staff,but must have privileges. We
have worked closely with Jan Wasko,ENP,and others to make the required changes while causing as little
change as possible to how nurse practitioners and optometrists function under the new Bylaws and Rules
and Regulations. For the most part,we have used language from the CMA Model Bylaws. The changes
should have little effect on how nurse practitoners function in our system. (Bylaws,.Allied Health
Practitioners,Article 4,Page 5.)
SkmMM Suspensia summary suspension of privileges(meaning a Medical Staff member is not allowed
to work until an investigation is carried out)should happen only in extremely rare situations,such as
obvious substance abuse,severe marital illness or another situation which causes immediate danger to
patients. This change in the Bylaws makes it more difficult to summarily suspend a Medical Staff member
and specifies the process that must occur, We have used language from the CME Model Medical Staff
Bylaws,(Bylaws,Article 11,2,Page 19.)
CONTINUED ON ATTACHMENT: YES SIGNATURE:
RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE
APPROVE OTHER
SIGNATURE(S):
ACTION OF BOARD ON March Il 2003 APPROVED AS RECOMMENDED X OTHER
VOTE OF SUPERVISORS I HEREBY CERTIFY THAT THIS IS A TRUE AND CORRECT
X UNANIMOUS COPY OF AN ACTION TAKEN AND ENTERED ON THE;
(ABSENT ) MINUTES Of THE BOARD OF SUPERVISORS ON TIME
AYES: NOES: DATE SHOWN.
ABSENT: ABSTAIN:
DIS'T'RICT III SEAT VACANT ATTESTED Bch 11, 2003
JOHN SWEETEN,CLERK OF THE BOARD OF
CONTACT: David Hearst, M.D. SUPERVISORS AND COUNTY
CC: .Jeff Smith, M.D. ADMIMTRATOR
Steven C, Tremain, M*D*
BY '�` I' LL:rTy
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Medical Staff Bylaws
- .
Table of Contents
Defindtioos . , .. . . . . . . . . . . . . . . . . . . ' . . . , . . . . 1 General Provisions . . . . . . . . . . . , . . . . . 14
Article Appointment of Members . . . . . . . . . . . 14
Name and Porpnauo . . . . . . . . . . . . . . . . . . . .. . % Medical Executive Cmomoittee . . . . . . . . 15
Article 2 Article 10
Membership . . . ,. .. . . '. . . .. . ... . ... .. . . 2 Meetings . . ' . .. . . . .. . .. . , . . . . . . . . . . . . 15
Nature . ... . . . . . . ... . . . . . . . .. . .. .. 2 Medical Staff Meetings . . . . . . . .. . .. . 15
Qualifications . . . . . . . . . . . . . . . .. . . . . . 2 Clinical mmdConooittee
Specific Qualifications. .. . . . . . . . . . . . . 2 Meetings . .. . . . . . . . . . .. . . . . . . . . . . t8
Requirements . . . . . .,. . . . . . . . . . . .. . . 3 Quorum . .` . . . . . . . . . . . . . . . . . . . . . . 16
Effect nfOther AtfiDmbnoo . . . . . . . . . . . 3 Manner ufAction. . . . .. . . . . . . . . . . . . . 16
Nondiscrimination . .. .. . . . . . . .' . .. . . 3 Notice of Meetings ' . . . . .. . . . . . . . . . 16
Responsibilities '. . .'.. .. . .. .. '... . . 3 Minutes ... .. ' . . ., .. .. .. . . . . . . . . . 17
Harassment Prohibited . '.. . . . . . . . .. . . 4 Agenda . . .',... . .. . . .' .. . . . . ..... 17
Article Attendance Requirements . .. . . . . . . . . 17
Categories wythe Medical Staff . . . .. . .. .' . . 5 Conduct of Meetings . . . . .. . . . . . . . . . 17
Categories . ..... . . . . . . . .. . . . .. . . . . 5 Article I1
General Prohibitions . .. ... . . . . . . . .. . 5 Corrective Action . ... .^ . . . . . . . . . . . . . . . lO
Article � initimti«n.' . ,. . . . .' . . . .. . . . . . . . . . . 18
Allied Health Pmactitioners ...' . .. . .. . . .. .. 5 Formal Investigation .. . .. . .. . .. . . .. 18
Definitions .'., . . .'. .,^..... . . .'' . . 5 Medical Executive Committee Action .. 10
Categories . .. ... ... . . . . . . .. .. . .. . . 5 Subsequent Action . 19
Article 5 . 19
Procedures for Appointment and Reappointment 5 . . . . . . . . . . . . . 20
General. . . . . . .. . . . . . . . . . . . . . . . . . . . 5 Grounds for Suspension or Restrictions 20
Burden .' . .' . . . . . . .. .. . . G Article 12
Application ,. '.. . . . .. . . . . . . . . . . . . . 6 Hearings and Appellate Reviews . . . . . . . . . %l
Leave of Absence ... . . . . . `.-.. . .. .. 7 Grounds for Hearing . . . . .. ... . .. . . ' 21
Waiting Period after Adverse Action Requests for Hearing . '. . . . .'.. ... .. 22
. ,. ,,, ., . . . ., . . . ,.. . . . .' . . . .. . . . . 7 Procedure .. . . . ' . .. . . . . ' . . . 23
Col . '^ . ^ . .'. . . ,.. . .. . ,. . 7 Appeals . ... . . . . . `. . .. .,. . '. . . . . . 25
Article 6 Exceptions to Hearing Rights ' .. . . . . . 27
Privileges ,,. . . . .. . ..' . ' .. . . . '. . . . . . . .. 8 Article 13
Exercise of Privileges ,. .. ...'.' .. . .. 8 Confidentiality '. . .. .'.. . .. .. ... .. .. . . 27
Delineation of Privileges . ...''. . '' ... O Geoesal.. . .. . .. .. .. . . .. . . .. . .. .. . 27
Basis for Determinations . ... . . .. . .. .. O Breach of Confidentiality. . . . . . . '.... 27
Limitations for Certain Members. . . . . . . & Protection . . .. .. . .. . . . . .. . . . . . . . . . 28
Non-licensed Residents . . . . , . . . . . . . . . 8 Access 8vPersons Outside the Hospital 20
Teniporary Privileges . . ., . . . . . . . . . , . . 9 Access 8vPersons Within the Hospital . 29
Emergency Privileges . . . . . . . . . ' . . . . 10 Article 14
Proctoring . .' ... . ... . .. . .. . .. . '.. to General Provisions . . . .. . . . . . . .. . . . . . . . 30
Article Rules and Regulations . ... . .. ... .,. . 30
General Medical Staff Officers.. . . . . . . . . . 11 Dues wrassessments '. ..' .. .. . . . . . . 30
Identification . . . . . . . . . . . . . . . . . . . . . ll Construction ofTerms and Headings . . 30
Qualifications . . . . . . . . . . . . . . . . . . . . . 11 Authority toAct .. . . . . . . . . . .. . . . . . . 31
Attainment ofOffice . .. . . . . . ,. . .. . . 11 Division ofFees . . . . . . . . . . . . . . . . . .. 31
l/ecancbes . . . . . . . . . . . . . . . . . . . .' . . . 12 Special Notices . .. . . . . . . . . . . . . . . . . 91
Resignation and Removal . . .. .. . . . .. 12 Requirements for Elections . . . . . .' . . . 31
Duties . . . .. .. . .. . .. . .. .. . ... . ... . 12 Disclosure mfInterest .. ..... . . . .. . . . 31
Article Authorization,Immunity and Releases . 81
Departments and Divisions . . . . . . . . . . . . . . 19 Article 15
Organization . . . '. . . . . . . . . . . . . , . . . 13 Adoption and Amendment mfBylaws . . . . . . 32
Designation . . . . . . . . . . . .. . . . . . . . . . 13 ~ Annual Review . .. . . . . . . . . . . . . . .. . 32
Assignment taDepartments . . .. . . .. . . 14 Procedure . . . . . . . . . .' . . . . . . . . . . , .. 32
Functions .. . . . '.. . .. . . . . .. . ... . . . 14 Medical Staff Action .. . . . .. .. . .. . . . 32
Article Approval ..'. . . . . . '. . . ... .. ...... 32
Committees . . . . . . . . . . . . . . . . . . . . . .. . ., 14 Exclusivity . .. . ,. . .. . . . . . . .. .. . . . . 32
BnAws DRAFT 9/20/02
CONTRA COSTA REGIONAL MEDICAL CENTER&
HEALTH CENTERS
MEDICAL STAFF BYLAWS
DEFINITIONS
The following definitions apply to these Medical Staff Bylaws:
1. Administrator means the Executive Director of Contra Costa Regional Medical Center and Health
Centers or 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 and
psychiatric or psychological 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 the County of Contra Costa in California.
7. Department or Clinical Department means a clinical structure of the Medical Staff as further identified
in these Bylaws and the Rules and Regulations.
8. Department Head means the practitioner elected or appointed,pursuant to these Bylaws and the Rules,
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. Senior Medical Director of the Health Services Department means the physician appointed by the
Director of the Health Service 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 position heli and,unless
expressly provided,without voting rights.
12. Governing Body means the Board of Supervisors of the County of Contra Costa.
13. Hospital or Medical Center shall mean the Contra Costa Regional Medical Center.
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 12-month period commencing on the first of July of each year and
ending on the thirtieth 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 the appropriate portions of these Bylaws.
17. Member in Good Standing means a Member of the Medical Staff who is not under a full membership
suspension or other pertinent special 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.
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 Contra Costa Regional Medical Center and Health Centers.
21. Resident means a physician in training who is participating in the Family Medicine training program
based at Contra Costa Regional Medical Center and Health Centers.
22. Rules or Rules and Regulations means the Medical Staff Rules and Regulations that are contained
under separate cover and are adopted pursuant to these Bylaws.
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BILAws DRAFT 9/20102
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.
1.2.1 To assure that all patients treated by any of its members receive the best possible care.
1.2.2 To provide for professional performance that is consistent with the mission and goals of
the Hospital.
1.2.3 To maintain Rules for the Medical Staff to carry out its responsibilities for the
professional work performed in the Hospital.
1.2.4 To provide a means for the Medical Staff,Governing Body and Hospital Administration
to discuss issues of mutual concern.
1.2.5 To provide for accountability of the Medical Staff to the Governing Body.
ARTICLE 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 admit patients to the Hospital and provide medical care consistent with those Privileges
to patients in the Hospital and/or Health Centers.
2.2 Qualifications for Membership
2.2.1 General Qualifications
Membership on the Medical Staff and Privileges shall be extended only to Practitioners who are
professionally competent and continuously meet the qualifications,standards,and requirements
set forth in these Bylaws and the Rules. Medical Staff membership,except for Honorary and
Resident membership,shall be limited to Practitioners who are currently licensed and qualified to
practice medicine,podiatry,dentistry,and/or clinical psychology.
2.2.2 Specific Qualifications
In addition to meeting the basic standards as outlined above,a Practitioner must meet the
following requirements in order to qualify for Medical Staff Membership.
(a) Licensed Physicians. An applicant for physician membership in the Medical Staff must have
a valid M.D or D.O.degree(or the equivalent). The Practitioner must have a current and
valid license to practice medicine issued either by the Medical Board of California or the
Board of Osteopathic Examiner of the State of California.
(b) Resident Physicians. An applicant for Resident Physician memliership on the Medical Staff
must have a valid M.D.or D.O.degree(or the equivalent)conferred by an accredited medical
or osteopathic school. The applicant must have been accepted for training by the 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.
(c) Dentists. An applicant for dental membership in the Medical Staff must have a DDS or
equivalent degree. The Practitioner must have a current and valid license to practice dentistry
issued by the California Board of Dental Examiners.
(d) Podiatrists. An applicant for podiatric membership in the Medical Staff must have a D.P.M.
or equivalent degree. The Practitioner;gust have a current and valid license to practice
podiatry by the California Board of Podiatric Medicine.
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B YLA Ws DRAFT 9120102
(e) Clinical Psychologists. An applicant for Clinical Psychologist Membership of the Medical
Staff must have a degree in clinical psychology. The Practitioner must have a current and
valid license to practice clinical psychology by the California Board of Psychology and
Division of Allied Health Professions of the Medical Board of California
2.3 Membership Requirements
An applicant for Membership in the Medical Staff must document his or her adequate experience,
education,and training in the requested Privileges. The applicant 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 patent care at a level
recognized as appropriate to a similar professional within the community. The Medical Executive
Committee 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 described in these Bylaws and the Rules.
2.4 Effect of Other Affiliations
No Practitioner shall be 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.
2.5 Nondiscrimination
Medical Staff Membership or particular Privileges shall not be denied on the basis of age,gender,
sexual orientation,religion,race,creed,color,national origin or disability.
2.6 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:
2.6.1 Provide his or her patients with care meeting the professional standards of the Medical
Staff of this Hospital.
2.6.2 Abide by the Medical Staff Bylaws and the Rules and all other lawful standards,policies,
and rules of the Medical Staff and the Hospital.
2.6.3 Abide by all applicable laws and regulations of governmental agencies and comply with
applicable standard of the JCAHO.
2.6.4 Discharge such Medical Staff,department,division,committee,and service functions for
which he or she is responsible,by appointment,election,or otherwise.
2.6.5 Prepare and complete in a timely manner the medical and other required records for all
patients to whom the Practitioner in any way provides services in the Hospital.
2.6.6 Abide by the ethical principles of his or her profession.
2.6.7 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.
2.6.8 Aid in educational programs approved by the Medical Staff and designed to improve the
quality of patient care.
2.6.9 Decline to engage in any improper inducements for patient care referrals.
2.6.10 Make appropriate arrangements for coverage for his or her patients when an absence is
anticipated.
2.6.11 Complete continuing education programs that are required by the Medical Staff:
2.6.12 Participate in emergency service coverage and consultation(on-call)panels as may be
required by the Medical Staff.
2.6.13 Accept responsibility for participating in Medical Staff proctoring in accordance with the
Rules.
2.6.14 Pay Medical Staff dues and assessments within sixty days of invoice receipt.
2.6.15 Participate in the resident training program as requested by the Residency Director.
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2.6.16 Promptly notify the Medical Staff Office of any professional liability action the member
is involved iri as soon as the member becomes aware of his or her involvement.
2.6.17 Participate in quality assurance programs as determined by the Medical Staff:
2.6.18 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.
2.7 Harassment and Discrimination Prohibited
2.7.1 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.
2.7.2 Harassment Defined
Harassment is unwelcome verbal,visual,or physical conduct that creates an intimidating,
offensive or hostile working environment or that interferes with work performance. Such
conduct constitutes harassment when:
2.7.2.1 Submission to the conduct is made either an implicit or explicit condition of
employment;
2.7.2.2 Submission to or rejection of the conduct is used as the basis for an employment
decision;or
2.7.2.3 The harassment unreasonably interferes with work performance or creates an
intimidating,hostile or offensive work environment.
2.7.3 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
includes all of these prohibited actions as well as requests for sexual favors,conversation
containing sexual comments,and unwelcome sexual advances.
2.7.4 Investigation and Corrective Action
2.7.4.1 Every complaint of harassment made to the Medical Staff,will be investigated
thoroughly and promptly. The Medial Staff will attempt to protect the privacy of
individuals involved is 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.
2.7.4.2 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 bearing 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.
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Bnaws DRAFT 9/20/02
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,and resident. Each Medical Staff Member shall be
assigned to a Medical Staff category based upon the respective qualifications set forth in these
Bylaws and the Rules. Members of each Medical Staff category shall have the respective
prerogatives and responsibilities as set forth in these Bylaws and the Rules. Action may be
initiated to change the Medical staff category or terminate the membership of any Member who
fails to meet the qualifications or fulfill the responsibilities as described in these Bylaws and the
Rules. Changes in Medical Staff category shall not be grounds for hearing unless it affects the
Member's Clinical Privileges.
3.2 General Prohibitions
Members of the Medical Staff assigned to resident category may not hold any general Medical
Staff office.
ARTICLE 4 ALLIED HEALTH PRACTITIONERS
4.1 Definitions
4.1.1 Allied Health Practitioner means a health care professional,other than a Member of the
Medical Staff,who holds a license,as required by California law,to provide certain
professional services.
4.1.2 "AHP clinical privileges"or"service authorizations"means the permission granted to an
Allied Health Practitioner to provide specified patient care services within his or her
qualifications and scope of practice.
4.2 Categories of AHPs Eligible to Apply for"AHP clinical privileges"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. At a minimum,the AHPs include two categories;
4.2.1.1 Nurse Practitioners who are registered nurses with additional training,expertise,
certification and licensing that is recognized by the State of California and allows
them to provide specific diagnostic and therapeutic services.
4.2.1.2 Optometrists who are licensed to provide specific optometric services.
4.2.2 The Medical Staff Rules and Regulations shall describe the qualifications,prerogatives,
and responsibilities of the AHPs. The Rules and Regulations shall also describe the
procedures for granting"AHP clinical privileges"and procedures for termination,
suspension or restriction of such authorization,including the AHP's procedural rights.
ARTICLE 5 PROCEDURES FOR APPOINTMENT AND REAPPOINTMENT
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 and the Rules. The Medical Staff shall investigate each applicant
before recommending action by the Governing Body. The governing Body shall ultimately be
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
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BYLAws DRAFT 9/20/02
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. This
burden may include submission to a medical or psychological examination.
5.3 Application for Initial Appointment and Reappointment
Applicants for appointment and reappointment shall complete written application form provided
by the Medical Staff. These forms request information about the applicant and document the
applicant's agreement to abide by the Medical Staff Bylaws,Rules,and other terms. Once all
required information and agreements are provided by the applicant,the Medical Staff will
investigate and evaluated it. Thereafter,the Medical Executive Committee will make a
recommendation to the Governing Body whether or not to appoint,reappoint,or grant specific
Privileges.
5.3.1 Basis for Appointment and Reappointment
Recommendations for appointment and reappointment to the Medical Staff and for
granting and renewal of Privileges shall be based upon:(a)the applicant's or Member's
professional performance at this Hospital and in other settings;(b)whether the applicant
or Member meets the qualifications and is able to carry out all of the responsibilities
specified in these Bylaws and the Rules;and(c)the Hospital's patient care needs and
ability to provide adequate support services and facilities for the applicant or Member.
5.3.2 Tema of Appointment,Extensions,and Failure to File Reappointment Application
The terra of appointment to the Medical Staff'is set forth in the Rules. Failure to file a
complete and timely application for reappointment shall result in the automatic
termination of the Member's Membership Privileges and prerogatives at the end of that
term,unless Membership is extended by the Medical Executive Committee. An
extension of the Membership term may occur solely at the discretion of the Medical
Executive Committee ifit finds that there is good cause to allow a grace period for the
Member to complete his or her application and for the Medical Staff to process the
application. Only one extension to a date certain that is no more than twelve months
from the end of the original term is allowed. If the application process is not complete by
the end of the extension,or if the Medical Executive Committee decides not to grant an
extension,the Member shall be deemed to have voluntarily xesigned Membership in the
Medical Staff. In the event that Membership terminates in such a manner,the Member
shall not be entitled to any hearing or review
5.3.3 Extension of Appointment
If it appears that an application for reappointment will not be fully processed by the
expiration date of the member's appointment,for reasons other than due to the
reapplicant's failure to return documents or otherwise timely cooperate in the
reappointment process,the Medical Executive Committee and the Board of Supervisors
shall approve a time-and member-specific extension of the member's status and clinical
privileges. With respect to such delays not caused by the staff member,if for any reasons
the Medical Executive Committee and/or Board of Supervisors fails to approve an
extension or the extension time rims out prior to completion of the reappointment
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BYLAws DRAFT 9/20/02
procedures,the member's membership and privileges shall nonetheless continue until
processing of the reapplication is completed. Any extension of an appointment pursuant
to this section does not create a vested right in the member for continued appointment
through the entire next term but only until such time as processing of the application is
concluded. The member shall continue to be subject to the reapplication review process
as outlined in sections 5.1 through 5.3. Failure by the member to timely complete and
return the reappointment application form or provide other documentation or cooperation
will result in termination of the member's appointment.
5.4 Leave of Absence
A Member may request a leave of absence not to exceed two 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 in accordance with the standards and procedures set forth in the
Rules. The Member must provide information regarding his or her professional activities during
the leave of absence. 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.
5.5 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 24 months after an adverse action regarding his or her
Membership or Privileges.
5.5.1 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 Board.
(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.
5.5.2 The Medical Staff may,as part of an adverse action,waive the 24-month ineligibility
period or limit it in some way including but not limited to require proctoring or
supervision.
5.5.3 An action is considered final on the date the application was withdrawn,a Member's
resignation became effective,or upon completion of all administrative hearings and
appellate reviews and all judicial reviews pertinent to the action served within 2 years
after completion of the Hospital proceedings.
5.5.4 After an ineligibility period,the individual may reapply for Membership or re-request
Privileges. That 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 nova or it may deny request
outright.
5.6 Confidentiality and Impartiality
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To maintain cpnfiden4ality and to assure the unbiased performance of appointment and
reappointment functions,participants in the credentialing process shall limit their discussions of
the matters involved to the formal avenues provided in the Bylaws and the Rules for processing
applications and for appointment and reappointment.
ARTICLE 6 PRIVILEGES
6.1 Exercise of Privileges
Except as otherwise provided in these Bylaws or the Rules,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 and the rules.
6.2 Delineation of Privileges in General
6.2.1 Requests
6.2.1.1 Each application 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
modification of Privileges at any time.
6.2.1.2 Each department is responsible for developing written criteria for granting
Privileges. These criteria take effect only after approval by the Medical Executive
Committee.
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
performance,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 settings where an individual
exercises Privileges.
6.2.3 Privileges for Department Heads
Privilege requests by Department Heads are governed by specific procedures in the
Rules.
6.3 Specific Limitations upon Privileges for certain Members
6.3.1 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.
6.3.2 Surgery
Surgical procedures.performed by non-physician Members shall be supervised as
designated in the Rules. X
6.3.3 Medical Appraisal
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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.
6.4 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
Department Chairpersons and the Residency Director. A physician Member who has Privileges
for the patient care being rendered must supervise non-licensed Residents.
6.5 Temporary Privileges
6.5.1 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:
6.5.1.1 Pendency of Application:After receipt of an application for appointment,including a
request for speck temporary privileges,an applicant may be granted temporary
privileges for an initial period of 90 days while the application is being processed. if
the processing of the application by the Medical Staff requires more than 90 days,
the temporary privileges may be extended for an additional-90-day sequential„grace
period 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
year of sequential grace periods,unless earlier terminated in accordance with the
Medical Staff Bylaws and/or the Rules.
6.5.1.2 Care of Specific Patients:Upon receipt of a written application for specific
temporary privileges,a practitioner who is not an applicant for membership may be
granted temporary privileges for the care of one or more specific patients. The
administrator(or his/her designee)may waive the requirement for written application
for specific temporary privileges upon recommendation of the Chairperson of the
Department(or his/her designee)in urgent situations. In such urgent situations,the
grantor of such privileges shall notify the Medical Executive Committee as specified
in the Rules. Such privileges shall be restricted to the treatment of not more than
four patients in any one-year by any practitioner. Practitioners requesting permission
to attend more than four patients in any one year shall be required to apply for active
membership in the Medical Staff.
6.5.2 Conditions
Temporary privileges may be granted only after the practitioner has submitted a written
application for appointment or a written request for temporary privileges(except as noted
above)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,if any;regarding professional liability insurance. The chairperson of the
department to which the practitioner is assigned shall be responsible for supervising the
performance of the 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 Medical Staff Bylaws and Rules and Regulations and that lie/she agrees to be bound
by the terms thereof in all matters relating to his/her temporary privileges.
6.5.3 Termination
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The Administrator or the President of the Medical Staff may terminate any or all of a
practitioner's temporary privileges:
6.5.3.1 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
6.5.3.2 Or if the life or well being of a patient is endangered in the opinion of the grantor of
the temporary privilege.
6.5.3.3 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
though to be endangered by the person terminating the temporary privileges. 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.
6.5.4 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.
6.6 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.
6.7 Proctoring
6.7.1 General Proctoring Requirements
6.7.1.1 Except as otherwise determined by the Medical Executive Committee and the
Governing Body,all initial appointees to the Medical Staff and all Members granted
new Privileges shall be subject to a period of proctoring in accordance with standards
and procedures set forth in the Rules.
6.7.1.2 Proctoring may be implemented whenever the Medical Executive Committee or its
designee determines that additional information is needed to assess a Member's
performance.
6.7.1.3 Proctoring is not an adverse action or a disciplinary measure. It is a means of
gathering information regarding a Member's skills: Therefore,the requirement of
proctoring does not itself give rise to the hearing rights triggered by an adverse
action.
6.7.1.4 During the proctoring,the Member must demonstrate the requisite competence
required to exercise the clinical privileges.
6.7.2 Completion of Proctoring
Proctoring shall be deemed successfully completed when the Member competently
completes the required number of proctored cases.
6.7.3 Requirement to Provide Proctoring
Members of the Medical Staff shall serve as proctors in a manner consistent with these
.Bylaws and the Rules. Refusal to serve as a'proctor,without good cause,as determined
by the Medical Executive Committee,is grounds for corrective action.
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6.7.4 Failure to Complete Proctoring
6.7.4.1 A Member who fails to complete the required number of proctored cases within the
time fame established in the Bylaws and the Rules 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 proctoring in appropriate cases.
6.7.4.2 If a Member completes the necessary number of proctored cases but fails to perforin
competently during the proctoring,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 entitle the practitioner to appropriate procedural hearings.
ARTICLE 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 Willingly and faithfully discharge the duties of the office;
7.2.3 And,exercise the authority of the office held,working with the other general and
Department offices of the Medical Staff,
7.3 Attainment of Office
7.3.1 Term of Office:The election for the office of President-Elect shall take place in April.
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 President. The President shall serve one one-year term,but may be
reelected to a second consecutive one-year term. At the conclusion of the President's
term(s)of office,the President shall assume the office of Past-President.
7.3.2 Should the incumbent President be nominated for,and choose to seek,a second one-year
term,the incumbent President will be listed on the ballot in the annual April election
along with all other nominated candidates. Should the incumbent President be reelected,
the office of President-Elect shall remain vacant until the next April election.
7.3.3 Nomination:The Medical Executive Committee shall nominate qualified candidates for
the office of President-Elect as specified in the Rules. Each nominee must be an M.D.or
a D.O. Nominations may also be made from the floor at the January 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
7.3.4 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
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than close of business on March 3rd. On or before March 7th,the Medical Staff Office
shall trail 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
30 days,but no less than 25 days,before the April meeting of the Medical Executive
Committee,the Medical Staff Office shall mail ballots to all active members of the
Medical Staff.
7.3.5 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 1 Ith 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 Con ntittee 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 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 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 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 vacatedterm.
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'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 and takes effect on the date specified in the
resignation or,if no date is specified,on the date of receipt.
7.5.2 Removal
7.5.2.1 Authority and Mechanism:Removal of a general Staff Officer may be effected by a
two-thirds majority vote by secret ballot of the members of the Active Staff'in good
standing,such vote being taken at a special meeting called for that purpose.
7.5.2.2 Grounds: Permissible ground for removal of a general Staff officer include,without
limitation:
7.5.2.2.1 Failure to perform the duties of the position held in a timely and appropriate
manner;
7.5.2.2.2Failure to continuously meet the qualifications for the position-,
7.5.2.2.3 Physical or mental infirmity that renders the officer incapable of fulfilling the
duties of his office.
7.6 Duties of General Staff Officers
7.6.1 Medical Staff`President
The Medical Staff'President shall.serve as the chief officer of the Medical Staff. The
duties of the Medical Staff President shall include,but not be limited to:
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7.6.1.1 Enforcing the Medical Staff Bylaws and Rules and Regulations,implementing
sanctions where indicated,and enforcing procedural safeguards where corrective
action has been requested or initiated;
7.6.1.2 Calling,presiding at,and being responsible for the agenda of all meetings of the
Medical Staff;
7.6.1.3 Serving as the chair of the Medical Executive Committee;
7.6.1.4 Serving as an ex officio member of all other Medical staff committees;
7.6.1.5 Interacting with the Administrator and the Governing Body in all matters concerning
the hospital;
7.6.1.6 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;
7.6.1.7 Representing the views and policies of the Medical Staff to the Governing Body and
to the Administrator;
7.6.1.8 Being a spokesperson for the Medical Staff in external professional and public
relations;
7.6.19 Performing such other duties as may be required by these Bylaws,the Medical Staff,
or by the Medical Executive Committee;
7.6.1.10 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 DEPARTMENTS 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
and a vice chair. The authority,duties,method of selection and responsibilities of these
department officers is set forth in the Rules. Each department may appoint°a department
committee and such other standing or ad hoc committees as it deems:appropriate to perform its
required functions. The composition and responsibilities of department standing committees is set
forth in the Rules. Departments may also form divisions as described below.
8.2 Designation
The current departments and divisions are set forth in the Rules. The Medical Executive
Committee may periodically review the designation of departments and divisions;and create,
eliminate,and/or combine departments or divisions for better organizational efficiency and
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improved patient care. Any action to modify the current departments and/or divisions becomes
effective upon appropriate modification of the Rules.
8.3 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.
8.4 Functions of Departments
The departments shall fulfill the clinical,administrative,quality improvement/risk management/
utilization management,and educational functions set forth in the Rules. When the department or
any of its committees meet to carry out the duties described below,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 duties.
ARTICLE 9 COMMITTEES
9.1 General Provisions
9.1.1 Designation
9.1.1.1 The Medical Executive Committee and the other committees described in these
Bylaws and the Rules shall be standing committees of the Medical Staff unless
otherwise indicated.
9.1.1.1 The chairperson of the Medical Executive Committee,a standing committee,or a
department may create subcommittees,special committees,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
9.1.2.1 The Medical Executive Committee,on the recommendation of its chairperson,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.
9.1.2.2 Only members in good standing of the Medical Staff may be voting members of any
Medical Staff Committee. Others individuals may be appointed to committee
positions as either Ex officio or non-medical Staff members.
9.1.2.3 For committees that are not standing committees,the person creating the committee
shall appoint chairpersons and members.
9.1.3 Removal from 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 committee shall be filled in the same manner as an original
appointment is made.
9.1.5 Conduct of Meetings of Committees
Committee meetings shall be conducted and documented in the manner specified in these
Bylaws and the Rules.
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9.1.6 Attendance of Non-Members
Members in good standing of the Medical Staff who are not committee members may
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:
President of the Medical Staff;
President-elect;
Past President;
Clinical Department Heads;
And those Division Heads and Standing Committee Chairpersons who are specifically
named as members of the MEC in the Rules.
Representatives from administration,nursing and the residency program,as specified in
the Rules,may attend MEC meetings without voting rights. 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:
9.2.2.1 Perform and/or delegate performance of all Medical Staff functions in a manner
consistent with the Bylaws and the Rules.
9.2.2.2 Coordinate and implement the activities of the committees and the departments.
9.2.2.3 Make recommendations regarding Medical Staff membership and privileges.
9.2.2.4 Initiate and pursue disciplinary or corrective actions when indicated.
9.2.2.5 Supervise the Medical Staffs compliance with the Medical Staff Bylaws,Rules,and
policies.
9.2.2.6 Supervise the Medical Staff s compliance with County laws,rules,policies and
procedures.
9.2.2.7 Supervise the Medical Staffs compliance with state and federal laws and
regulations.
9.2.2.8 Supervise the Medical Staff's compliance with JCAHO and other applicable
accreditation and certification rules.
9.2.2.9 Regularly report to the Governing Body regarding the status of Medical Staff issues.
9.2.2.10 Meet monthly to conduct Medical Staff business.
9.2.2.11 Adopt and modify Rules in the manner set forth in these Bylaws
9.2.2.12 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 these
Bylaws and the Rules.
ARTICLE 10 MEETINGS
10.1 Medical Staff Meetings
10.1.1 Regular Meetings
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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 timc 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 Staff President. A
special meeting must be held by the President at the written request of the Governing
Body,the Director of Medical Staff Affairs,the Administrator,the Medical Executive
Committee,or 25%of the Active Staff in good standing.
10.20inieal Department and Committee Meetings
10.2.1 Regular Meetings
Clinical Departments,Divisions,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 Chouperson°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 Director of Medical Staff Affairs,or 25%of the group's current
members in good standing.
10.2.3 Executive(Closed)Sessions
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.
10.3Quorum
10.3.1 Medical Staff Meetings
The presence of one-third 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
Medical Staff Officer. For a meeting considering the removal of a Medical Staff Officer,
the quorum shall be one half 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 percent of the members of a committee but
no fewer than two members. For department and division meetings,a quorum shall
consist of 25 percent of the members. Ex-officio members do not count for quorum
purposes.
10AManner 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 at least a majority of the required quorum for such
meeting,or such greater number as may be specifically required by these Bylaws.
10.5Notice 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
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each person entitled to attend at not less than 5 days nor more than 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 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.
10.6Minutes
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 of
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.
10.7Agenda
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:
(a)Reading and acceptance of the minutes of the last regular meeting and of all special meetings
held since the last regular meeting;
(b)Administrative reports from the Medical Staff President,departments,and committees,and the
Administrator;
(c)Election of officers when required by these Bylaws;
(d)Reports by responsible officers,committees and departments 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;
(e)Old business;and
(f) New business.
10.8Attendance Requirements
10.8.1 Medical Staff Meetings
The Medical Executive Committee may adopt,as Rules,attendance requirements for the
Medical Staff and Department meetings.
10.8.2 Special Attendance
At the discretion of the chairperson 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 7 days prior to the meeting
and shall include the 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.
10.9Conduct 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.
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ARTICLE I I CORRECTIVE ACTION
11.1 Corrective Action
11.1.1 Initiation
Any person may provide information to the Medical Staff about the conduct,
performance,or competence of its members. When reliable information indicates 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(4)below applicable professional standards,a
request for an investigation 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 of the Medical Stam`,the administrator,the Medical Executive
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
Medical Executive Committee,and shall be supported by reference to the specific
activities or conduct which constitute 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 practicable. The report may include recommendations for
appropriate corrective action. The member shall be promptly notified that an
investigation has been initiated. 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.
11.1.3 Medical Executive Committee Action
As soon as practicable 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:
11.1.3.1 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;
11.1.3.2 Deferring action for a reasonable time where circumstances warrant;
11.1.3.3 Issuing letters of admonition,,censure,reprimand,or warning. Nothing herein shall
preclude department heads from issuing written or oral warnings or counseling. In
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the event the MEC issues such letters,the affected member may make a written
response which shall be placed in the member's file;
11.1.3.4 Recommending the imposition of terms of probation or special limitation upon
continued Medical Staff membership or exercise of clinical privileges,including,
without limitation,requirements for co-admissions,mandatory consultation,or
monitoring;
11.1.3.5 Recommending reduction,modification,suspension or revocation of clinical
privileges;
1 l.1.3.6 Recommending reductions of membership status or limitation of any prerogatives
directly related to the member's delivery of patient care;
11.1.3.7 Recommending suspension,revocation or probation of Medical Staff membership;
11.1.3.8 Taking other actions that are appropriate under the circumstances.
11.1.4 Subsequent Action
11.1.4.1 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.
11.1.4.2 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 or 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 members)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.
11.2.1.1 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 reasonably result in an imminent danger to the health of
an individual. The statement 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 these Bylaws for further action of the MEC regarding issues
related to such a summary suspension.
11.2.2 Medical Executive Committee Action
As soon as practicable after a summary restriction or suspension has been imposed,but
no more than ten calendar days thereafter,a meeting of the Medical Executive Committee
shall be convened to review and consider the summary suspension or restriction. The
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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 the 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.
11.2.3 Procedural Rights
Unless the Medical Executive Committee terminates 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.
11.3.1 Licensure
11.3.1.1 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.
11.3.1.2 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.
11.3.1.3 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.
11.3.2 Controlled Substances
11.3.2.1 Whenever a member's DEA certificate is revoked,limited or suspended,the member
shall 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
11.3.2.2 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 probatiop„as of the date such action becomes effective and
throughout its term.
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11.3.3 Failure to Satisfy Special 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.
11.3.4 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.
11.3.5 Professional Liability Insurance
Failure to maintain professional liability insurance,if any is required,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 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 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 90 days,the Medical Executive Committee shall
mail written notice of the 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.
ARTICLE 12 HEARINGS AND APPELLATE REVIEWS
12.1 Grounds for Nearing
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);
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12.1.12 Any"other restriction(s)on Medical Staff membership or clinical privileges;
12.2 Requests for Hearing
12.2.1 Notice of Action or Proposed Action
In the event of proposed or actual adverse action against a member of the Medical Staff
or an applicant,the Administrator shall gave the member-
12.2.1.1
ember:12.2.1.1 Prompt notice of the recommendation or action,including a brief description of the
reasons for the recommendation or action;
12.2.1.2 Notice of the right to request a hearing;
12.2.1.3 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;
12.2.1.4 Notice regarding whether the proposed action,if adopted,is reportable pursuant to
Business&Professions Code Section 805 and following;
12.2.1.5 A summary of the rights the member will have at the hearing.
12.2.2 Requesting a Hearing
The affected Member must request a hearing within thirty-(3€1)calendar days after the
date of the notice of action or proposed action. The request for a hearing shall be in
writing and addressed to tate Administrator. Failure to make a tamely request and in the
manner described may result in the denial of a hearing at the discretion of the Medical
Executive Committee.
12.2.3 Time and Place for Hearing
Upon receipt of a request for hearing,the Administrator shall schedule a hearing and
provide Notice to the Member 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
the Notice of Hearing. When the member is under summary suspension,the hearing shall
commence not more than 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.
12.2.4 Notice of Charges
In the Notice of Hearing,the Administrator shall state the reasons for the adverse action
taken or recommended,including the acts or omissions with which the member is
charged and a list of the charts 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.
12.2.5 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. 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 Staff: The Judicial Review Committee shall include at
least one member with the same healing arts licensure as the affected member. All other
members shall have M.D.or D.O.degrees.
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12.2.6 Failure to Appear or Proceed
Failure,without good cause,of the member to personally attend and proceed at such a
hearing shall constitute voluntary acceptance of the recommendations or action at issue.
12.2.7 Postponements and Extensions
Once a hearing is requested,postponements and extensions 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.
12.3 Hearing Procedure
12.3.1 Pre-hearing Procedure
12.3.1.1 The Medical Executive Committee or its designee may request,in writing,a list of
the names and addresses of all persons the member anticipates calling to testify at the
hearing on the member's behalf. The member 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 with copies of all
documents upon which the adverse action is based. Upon written request,the
Member shall provide the Medical Executive Committee or its designee with copies
of all documents the Member expects to present at his/her hearing.
12.3.1.2 It is the duty of the Member 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 decisions concerning such matters may
be made in advance of the hearing. Objections to any preheating decisions may be
again made at the hearing.
12.3.2 Representation
The hearings provided for in these Bylaws are for the purposes of intraprofessional
resolution of matters bearing on professional conduct,professional competency,and/or
character. The Member shall be entitled to representation by legal counsel in 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 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 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 question.The Medical Executive Committee shall
only be represented by an attorney at law if the member is also represented by an
attorney.
12.3.3 The Hearing Officer
The Medical Executive Committee shall appoint a Hearing Officer(who may also be the
Chair 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
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any participant is not proceeding in an efficient*and expeditious manner,the Hearing
Officer may take such action as seems warranted by the circumstances.
12.3.4 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 may request,in
writing,a copy of the hearing record. The copy will be provided to the member upon
payment of the cost of preparing and copying the record.
12.3.5 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 shall have
testified orally on any matter relevant to the issues,and otherwise rebut evidence,as long
as these rights are exercised in an efficient and expeditious manner. The Member may be
called by the Medical Executive Committee or its designee and examined as if under
cross-examination. The Member may,at the beginning of the baring,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(requiring a
postponement if necessary)or proceed without removal. If the Medical Staff`President
chooses to proceed without removal,any challenge by the Member shall be made
succinctly in writing and shall be made part of the hearing record.
12.3.6 Miscellaneous Rules
Judicial rules of evidence and procedure relating to the conduct of the hearing,
exsarnination of witnesses,and presentation of evidence,do not apply to a baring
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.
12.3.7 Burden of Proof
When a hearing relates 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.
12.3.8 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.
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12.3.9 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 provisions of these
Bylaws.
12.3.10 Presence of Judicial Review Committee Members and Vote
A majority of the Judicial Review Committee must be present throughout the hearing and
deliberations. If a committee member is absent from any part of the proceedings,he/she
may not participate in the deliberations or the decision.
12.3.11 Decision of the Judicial Review Committee
12.3.11.1 The Judicial Review Committee shall make findings of fact.
12.3.11.2 The Judicial Review Committee may make one of the following decisions based
upon the findings of fact:
12.3.11.2.1 the action of the Medical Executive Committee is sustained;
12.3.11.2.2 the action of the Medical Executive Committee is overturned;or
12.3.11.2.3 The action of the Medical Executive Committee is modified. (The
modification may be less or more adverse to the member than the action of the
Medical Executive Committee.)
12.3.11.3 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.
12.3.11.4 Within 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 15
workdays. The original report and decision shall be delivered to the Medical
Executive Committee. Copies of the report and decision shall be forwarded to the
Administrator,the Professional Affairs Committee and the member 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 of appeal or review as set
forth in these Bylaws.
12.4 Appeals
12.4.1 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,either the Member 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.
12.4.2 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 facts in support of the appeal. The grounds for
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.
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12.4.3 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 30 nor more than 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 15 days from the date of the notice.
The time for appellate review may be extended by the appeal board for good cause.
12.4.4 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
prion 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.
12.4.5 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 may allow each party
or representative to personally appear and make oral argument. 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.
12.4.6 Decision
12.4.6.1 Except as otherwise provided herein,within 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.
12.4.6.2 The Governing Body nay 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 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.
12.4.6.3 In the event the decision of 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
15 days to submit the matter to an ad-hoc committee. This ad-hoc committee shall
be composed of 2 members of the Governing Body(appointed by the chair of the
Governing Body)and 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.
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The decision of this committee shall be in writing within 34 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.
12.4.7 Right to One Hearing
No member shall be entitled to more than one evidentiary hearing and one appellate
review on any matter that shall have been the subject of adverse action or
recommendation.
12.5 Exceptions to Hearing Rights
12.5.1 Automatic Suspension or Limitation 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.
12.5.2 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,deliberations,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,
meetings of departments and divisions,meetings of committees,and meetings of special and ad
hoc committees and including information regarding any member or applicant to this Medical
Stall 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 conditions 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
13.2Breach of Confidentiality
Inasmuch as effective peer review and ponsideration of the qualifications of Medical Staff
members and applicants to perform specific procedures must be based on free and candid
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discussions, any breach of the confidentiality provisions of these Bylaws, except in conjunction
with other CCRMC & HC, professional society, or licensing authority duties, is unauthorized
conduct for any Medical Staff Member and is grounds for corrective action.
13.31'rotection
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 profile cabinets under the
custody of the Chairpersons of the Credentials Committee and the 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.
13.4Access 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,exercises 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 Surveyors/Investigators
Hospital surveyors/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
13.4.2.1 No originals or copies maybe removed from the premises,
13.4.2.2 Access is only with concurrence of the Administrator(or designee)and the Medical
Staff President'(or designee),and
13.4.2.3 The surveyor demonstrates the following to Hospital and Medical Staff
representatives:
13.4.2.3.1 'That the surveyor has specific statutory or regulatory authority to
review the requested materials;
13.4.2.3.2 That the materials sought are directly relevant to the matter being
investigated;
13.4.2.3.3 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;
13.4.2.3.4 That sufficient specificity is provided to allow for the production of
individualdocumentswithout undue burden to the Hospital or Medical Staff,
and
13.4.2.3.5 That the case of request for documents with physician identifiers,
documents the need for such identifiers.
13.4.2.4 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 formulating a response.
The Administrator shall notify the Medical Staff President when a subpoena for Medical
Staff records is,received
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13.4.4 Requests from Licensing Boards
Current law allows the California Medical Board,the Board of Osteopathic Examiners,and
the Board of Mental 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:
13.4.4.1 The Notice of Charges presented to the practitioner before the beginning of a
Medical Staff hearing;
13.4.4.2 Any document,medical record,or other exhibit received in evidence at the hearing;
and/or,
13.4.4.3 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 to the appropriate licensing
board upon the specific request of such board.
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
13.5.1.1 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 request shall include a statement of the basis for the
action requested. The request will be considered and acted upon in accordance with
the Rules and the Bylaws.
13.5.1.2 Except as noted above,no member of the Medical Staff,.other than those specified in
the Rules,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 and the Rules.The individual practitioner under review will be notified in
writing whenever this request occurs.
13.5.1.3 Quality Assurance profiles may be submitted as evidence during a fair hearing
conducted pursuant to these Bylaws.
13.5.2 Credentials Files
A Medical Staff member shall be granted access to his/her own credentials file,subject to
the following provisions:
13.5.2.1 The request shall give timely notice to the Medical Staff President or his/her
designee;
13.5.2.2 The member may review,and receive a copy of,only those documents provided by
or personally addressed 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
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the Medical Staff President or designee.Such summary shall disclose the substance,
but not the source,of the information summarized;
13.5.23 The review by the member shall take place in the Medical Staff Office,during
normal work 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
file. 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 nuke 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
Director of Medical Staff Affairs,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 Administration or the Governing Body will be given access
to a practitioner's credentials file;however,the Governing Body or its designee,
consistent with its ultimate responsibility to oversee quality of 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 shall adopt such Rules and Regulations as it may deem necessary for the proper
conduct of its work and may annually review and revise its Rules and Regulations.
Recommended changes to the Rules and Regulations shall be submitted to the Medical Executive
ConurAttee for review and evaluation prior to presentation to the Medical Staff at a General
Medical Staff Meeting. Following adoption by the Medical Staff at a properly scheduled General
Medical Staff Meeting,and approval by the Professional Affairs Committee,such Rules and
Regulations shall become effective. Such Rules and Regulations as are properly initiated and
adopted shall govern applicants and members of the Medical Staff. If there is a conflict between
the Bylaws and the Rules and Regulations,the Bylaws shall prevail.the mechanism described
herein shall be the sole method for the initiation,adoption,amendment,or repeal of the Medical
Staff Rules and Regulations.
14.2Dues 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
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The captions or headings in these Bylaws are for convenience only and are riot intended to limit or
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.
14.4Authority 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.
14.5Division of pees
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.
14.6Special 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 know 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.
14.7Requirements 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 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.
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.
14.8Disclosure of Interest
All nominees for election or appointment to Medical Staff offices,department chairs,or the
Medical Executive Committee shall,at least 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.
14.9Authorization,Immunity,and Releases
14.9.1 Authorization and Conditions
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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) Authorizes 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 are necessary to carry out the provisions of these Bylaws.
ARTICLE 15 ADOPTION AND AMENDMENT OF BYLAws
15.1 Annual Review
These Bylaws shall be reviewed annually by the Medical Executive Committee,
15.2Procedure
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.
15.3Medical Staff Action
These Bylaws 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 a copy of the
proposed documents or amendments was given or made available to each staff member
entitled to vote thereon 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 given to each staff
member entitled to vote thereon,and provided that no less than two 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 shall be conducted in accordance with these
Bylaws.
15AApproval
Bylaw changes adopted by the Medical Staff shall not become effective until approved by the
Governing Body.
15.5Exclusivity
The mechanism described herein shall be the sole method for the initiation,adoption,amendment,
and/or repeal of the Medical Staff Bylaws.
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Approved by the Medical Staff on Witnessed by the President of the
Medical Staff
Approved by the Governing Body on Witnessed by the Chairperson
of the Governing Body
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