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Approved December 16, 2014
MEDICAL STAFF BYLAWS, POLICIES, AND
RULES AND REGULATIONS OF
ST. JOSEPH'S HOSPITAL
MEDICAL STAFF BYLAWS
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MEDICAL STAFF BYLAWS
TABLE OF CONTENTS
PAGE
ORGANIZATIONAL OVERVIEW ...................................................................................... 6
MISSION STATEMENT ........................................................................................................ 8
HIPPAA COMPLIANCE STATEMENT ............................................................................. 9
1. GENERAL .................................................................................................................. 10
1.A. DEFINITIONS ................................................................................................. 10
1.B. TIME LIMITS .................................................................................................. 11
1.C. DELEGATION OF FUNCTIONS ................................................................... 11
1.D. MEDICAL STAFF DUES ................................................................................ 11
2. CATEGORIES OF THE MEDICAL STAFF ......................................................... 12
2.A. ACTIVE STAFF ............................................................................................... 12
2.A.1. Qualifications ........................................................................................ 12
2.A.2. Prerogatives ........................................................................................... 12
2.A.3. Responsibilities ..................................................................................... 12
2.B. AFFILIATE STAFF ......................................................................................... 13
2.B.1. Qualifications ........................................................................................ 13
2.B.2. Prerogatives and Responsibilities .......................................................... 13
2.C. ASSOCIATE STAFF ....................................................................................... 14
2.C.1. Qualifications ........................................................................................ 14
2.C.2. Prerogatives ........................................................................................... 14
2.C.3. Responsibilities ..................................................................................... 14
2.D. CONSULTING STAFF .................................................................................... 14
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2.D.1. Qualifications ........................................................................................ 14
2.D.2. Prerogatives and Responsibilities .......................................................... 16
2.E. EMERITUS STAFF ......................................................................................... 15
2.E.1. Qualifications ........................................................................................ 15
2.E.2. Prerogatives and Responsibilities .......................................................... 15
2.F. SENIOR ACTIVE STAFF ............................................................................... 16
2.F.1. Qualifications ........................................................................................ 16
2.F.2. Responsibilities and Prerogatives .......................................................... 16
2.G. SPECIAL NEEDS ............................................................................................ 16
2.H. TELEMEDICINE ............................................................................................. 17
2.H.1. Qualifications ........................................................................................ 17
2.H.2. Responsibilities and Prerogatives .......................................................... 17
3. OFFICERS .................................................................................................................. 18
3.A. DESIGNATION ............................................................................................... 18
3.B. ELIGIBILITY CRITERIA ............................................................................... 18
3.C. DUTIES ............................................................................................................ 18
3.C.1. President of the Medical Staff ............................................................... 18
3.C.2. President-Elect ...................................................................................... 19
3.C.3. Immediate Past President of the Medical Staff ..................................... 19
3.D. NOMINATIONS .............................................................................................. 20
3.E. ELECTION ....................................................................................................... 20
3.F. TERM OF OFFICE .......................................................................................... 20
3.G. REMOVAL ....................................................................................................... 21
3.H. VACANCIES ................................................................................................... 21
4. STAFF DEPARTMENTS .......................................................................................... 22
4.A. ORGANIZATION ............................................................................................ 22
4.B. ASSIGNMENT TO DEPARTMENT .............................................................. 22
4.C. FUNCTIONS OF DEPARTMENTS ................................................................ 22
4.D. QUALIFICATIONS OF DEPARTMENT CHIEFS ........................................ 22
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4.E. APPOINTMENT AND REMOVAL OF DEPARTMENT CHIEFS ............... 23
4.F. DUTIES OF DEPARTMENT CHIEFS ........................................................... 24
4.G. DIVISIONS ...................................................................................................... 26
4.G.1. Functions of Divisions .......................................................................... 26
4.G.2. Qualifications and Appointment of Division Chiefs ............................. 26
4.G.3. Duties of Division Chiefs ...................................................................... 26
5. MEDICAL STAFF COMMITTEES AND
PERFORMANCE IMPROVEMENT FUNCTIONS .............................................. 28
5.A. EXECUTIVE COMMITTEES ......................................................................... 28
5.A.1. Composition .......................................................................................... 28
5.A.2. St. Joseph's Women's Hospital MEC Subcommittee Composition ....... 28
5.A.3. St. Joseph’s Children's Hospital MEC Subcommittee Composition ..... 29
5.A.4. St. Joseph’s Hospital – North MEC Subcommittee Composition ......... 29
5.A.5. St. Joseph’s Hospital – South MEC Subcommittee Composition ......... 30
5.A.6. Duties .................................................................................................... 30
5.A.7. Meetings ................................................................................................ 31
5.B. PERFORMANCE IMPROVEMENT FUNCTIONS ....................................... 31
5.C. APPOINTMENT OF COMMITTEE CHAIRS AND MEMBERS ................. 33
5.D. CREATION OF STANDING COMMITTEES................................................ 33
5.E. SPECIAL TASK FORCES .............................................................................. 33
6. MEETINGS ................................................................................................................ 34
6.A. MEDICAL STAFF YEAR ............................................................................... 34
6.B. MEDICAL STAFF MEETINGS ...................................................................... 34
6.B.1. Regular Meetings .................................................................................. 34
6.B.2. Special Meetings ................................................................................... 34
6.C. DEPARTMENT AND COMMITTEE MEETINGS ........................................ 34
6.C.1. Regular Meetings .................................................................................. 34
6.C.2. Special Meetings ................................................................................... 34
6.D. PROVISIONS COMMON TO ALL MEETINGS ........................................... 35
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6.D.1. Notice of Meetings ................................................................................ 35
6.D.2. Quorum and Voting ............................................................................... 35
6.D.3. Agenda .................................................................................................. 36
6.D.4. Rules of Order ....................................................................................... 36
6.D.5. Minutes, Reports, and Recommendations ............................................. 36
6.D.6. Confidentiality ....................................................................................... 37
6.D.7. Attendance Requirements ..................................................................... 37
7. CONFLICTS OF INTEREST ................................................................................... 38
8. BASIC STEPS AND DETAILS ................................................................................ 39
8.A. QUALIFICATIONS FOR APPOINTMENT ................................................... 39
8.B. PROCESS FOR PRIVILEGING ...................................................................... 39
8.C. PROCESS FOR CREDENTIALING ............................................................... 39
8.D. INDICATIONS AND PROCESS FOR AUTOMATIC RELINQUISHMENT OF
APPOINTMENT AND/OR PRIVILEGES ...................................................... 39
8.D.1. ................................................................................................................ 39
8.D.2. ................................................................................................................ 40
8.E. INDICATIONS AND PROCESS FOR PRECAUTIONARY SUSPENSION 40
8.F. INDICATIONS AND PROCESS FOR RECOMMENDING TERMINATION
OR SUSPENSION OF APPOINTMENT AND PRIVILEGES OR REDUCTION
IN PRIVILEGES .............................................................................................. 40
8.G. HEARING AND APPEAL PROCESS, INCLUDING PROCESS FOR
SCHEDULING AND CONDUCTING HEARINGS AND THE COMPOSITION
OF THE HEARING PANEL............................................................................ 41
9. AMENDMENTS ......................................................................................................... 43
9.A. MEDICAL STAFF BYLAWS ......................................................................... 43
9.B. OTHER MEDICAL STAFF DOCUMENTS ................................................... 44
9.C. CONFLICT MANAGEMENT PROCESS ....................................................... 46
10. INDEMNIFICATION ................................................................................................ 47
11. ADOPTION ................................................................................................................ 48
Appendix A: Medical History & Physical Examination .................................................... 49
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Organizational Overview
St. Joseph’s Hospital traces its roots to the Franciscan Sisters of Allegany, New York, which
were founded in 1859 by a Franciscan priest seeking to educate children in the southern part of
the Diocese of Buffalo. Today, the Franciscan Sisters practice their ministry throughout New
York, New Jersey, Florida, the Caribbean, and South America providing services in healthcare,
education, pastoral and social work, and housing. These are the founders and the sponsoring
congregation of St. Anthony’s Hospital, St. Petersburg founded in 1931 and St. Joseph’s
Hospital, Tampa founded in 1934.
St. Joseph’s-Baptist Health Care
St. Joseph’s-Baptist Health Care (SJB) hospital consists of:
St. Joseph’s Hospital, Tampa
St. Joseph’s Women’s Hospital
St. Joseph’s Children’s Hospital of Tampa
St. Joseph’s Hospital – North
St. Joseph’s Hospital – South
The SJB responsible for the operation of the facilities located in Hillsborough County.
The facilities and operations of CHE in Hillsborough County and the facilities of South Florida
Baptist Hospital are now jointly operated through the Joint Operating Agreement (JOA) and
comprise the St. Joseph’s-Baptist Health Care Community Health Alliance.
BayCare Health System
In 1997 the Tampa Bay Area’s leading not-for-profit hospital organizations came together to
form BCHS through another JOA, which was approved and signed by the three member
organizations (“owners”) of the BayCare Health System, and is the document that determines
how BCHS is governed and managed. The three member organizations of BCHS are Morton
Plant Mease Health Care (MPM), Catholic Health East (CHE), and South Florida Baptist
Hospital (SFBH).
BCHS is the region’s only full-service, community-owned health care system, with nine
hospitals — plus additional outpatient and ancillary services — organized into three Community
Health Alliances. In addition to St. Joseph’s-Baptist Health Care, the two other CHAs are:
Morton Plant Mease Health Care, which includes:
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Morton Plant Hospital, Clearwater
Mease Dunedin Hospital, Dunedin
Mease Countryside Hospital, Safety Harbor
North Bay Hospital, New Port Richey
St. Anthony’s Health Care, which includes:
St. Anthony’s Hospital, St. Petersburg
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MISSION STATEMENT
MISSION
St. Joseph's-Baptist Health Care will improve the health of all we serve through community-
owned health care services that set the standard for high-quality, compassionate care.
VALUES
The values of St. Joseph's-Baptist Health Care are trust, respect and dignity and reflect our
responsibility to achieve health care excellence for our communities.
VISION
St. Joseph's-Baptist Health Care will be the regional leader in medical excellence by improving
the health of our community through accessible, compassionate and family-focused health care
services.
A Ministry of the Franciscan Sisters of Allegany
Guided by respect for
every individual’s dignity and worth,
our Franciscan values call us to have
reverence for human life,
compassion for those who suffer,
acceptance of each person and
hospitality to those who come to us.
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HIPAA COMPLIANCE STATEMENT
ORGANIZED HEALTH CARE ARRANGEMENT
FOR PURPOSES OF HEALTH INSURANCE PORTABILITY
AND ACCOUNTABILITY ACT OF 1996 ("HIPAA")
1. Each of the members of the Medical Staff of St. Joseph’s Hospitals shall participate
in St. Joseph’s Hospital's Organized Health Care Arrangement ("OHCA"), as that
OHCA is more particularly described in St. Joseph’s Hospital's Joint Notice of
Privacy Practices. As members of the OHCA, Medical Staff members shall: (i) abide
by the terms of the Joint Notice of Privacy Practices with respect to patient
information created or received by the Medical Staff member as part of his or her
participation in the OHCA, and (ii) use and disclose protected health information
("PHI") only as permitted (e.g., for treatment, payment and health care operations of
the OHCA) or required by HIPAA. The purpose of making this designation is solely
for more efficiently meeting certain administrative requirements of the regulations.
This designation is not intended to create a new legal entity nor limit or expand the
duties, obligations or liability in connection with any contract medical staff members
may have with the Hospital or any Hospital affiliate.
2. The Medical Staff and its individual members shall comply with applicable state and
federal laws, rules and regulations, as well as St. Joseph’s Hospital's policies and
procedures, including, but not limited to, policies and procedures regarding
confidentiality, privacy and security. Medical Staff members shall direct any
questions regarding the OHCA or permitted uses and disclosures of PHI to the Chief
Privacy Officer of BayCare Health System.
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ARTICLE 1
GENERAL
1.A. DEFINITIONS
The following definitions shall apply to terms used in these Bylaws and related policies
and manuals:
(1) "ALLIED HEALTH PROFESSIONALS" ("AHPs") are individuals other than
staff members who are authorized by law and by the Hospital to provide patient
care services.
(2) "BOARD" means the Board of Trustees of the Hospital which has the overall
responsibility for the Hospital or its designated committee.
(3) "BOARD CERTIFICATION" is the designation conferred by one of the
affiliated specialties of the American Board of Medical Specialties ("ABMS"),
the American Osteopathic Association ("AOA"), or the American Board of
Podiatric Surgery, as applicable, upon a physician, dentist or podiatrist who has
successfully completed an approved educational training program and an
evaluation process, including passing an examination, in the applicant's area of
clinical practice.
(4) "CHIEF EXECUTIVE OFFICER" ("CEO") means the individual who has the
responsibility of the overall management of the Hospital.
(5) "DAYS" means calendar days.
(6) "EXECUTIVE COMMITTEE" (“MEC”) means the Executive Committee of the
Medical Staff.
(7) "HOSPITAL" means St. Joseph's Hospital, Inc., d/b/a (i) St. Joseph's Hospital,
(ii) St. Joseph's Women's Hospital, (iii) St. Joseph's Children's Hospital or (iv)
St. Joseph’s Hospital – North.
(8) "MEDICAL STAFF" means all physicians, dentists and podiatrists who have
been appointed to the Medical Staff by the Board.
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(9) "NOTICE" means written communication by regular U.S. mail, e-mail,
facsimile, Hospital mail or hand delivery.
(10) "PATIENT CONTACTS" includes any admission, consultation, procedure,
response to emergency call, evaluation, treatment or service performed in any
facility operated by the Hospital or its outpatient facilities.
(11) “PRESIDENT” means the President (or Chief) of the Medical Staff, as described
in Article 3 of these Bylaws.
1.B. TIME LIMITS
Time limits referred to in these Bylaws are advisory only and are not mandatory, unless
it is expressly stated that a particular right is waived by failing to take action within a
specified period.
1.C. DELEGATION OF FUNCTIONS
When a function is to be carried out by a person or committee, the person, or the
committee through its chair, may delegate the performance of the function to one or
more qualified designees.
1.D. MEDICAL STAFF DUES
(1) Annual Medical Staff dues shall be as recommended by the Executive
Committee and approved by the Board of Trustees, and may vary by category.
(2) Dues shall be payable annually upon request. Failure to pay dues shall result in
ineligibility to apply for Medical Staff reappointment until all dues and
applicable fines have been paid.
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ARTICLE 2
CATEGORIES OF THE MEDICAL STAFF
Only those individuals who satisfy the qualifications and conditions for appointment to the
Medical Staff contained in the Credentials Policy are eligible to apply for appointment to one of
the following categories listed below. All optional changes in staff category must be made at the
time of reappointment.
2.A. ACTIVE STAFF
2.A.1. Qualifications:
The Active Staff shall consist of members who are involved in 24 or more patient
contacts annually.
2.A.2. Prerogatives:
Active Staff members:
(a) may vote in all general and special meetings of the Medical Staff, and applicable
department and committee meetings; and
(b) may hold office, as per conditions of Article 3, serve as Department Chiefs and
serve on committees.
2.A.3. Responsibilities:
Active Staff members must:
(a) assume all the responsibilities of membership on the Active Medical Staff,
including committee service, emergency call, care for unassigned patients and
evaluation of Medical Staff members during the associate period;
(b) actively participate in the peer review and performance improvement process;
(c) accept consultations where applicable;
(d) attend applicable meetings;
(e) pay application fees, dues and assessments; and
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(f) perform assigned duties.
2.B. AFFILIATE STAFF
2.B.1. Qualifications:
(a) The Affiliate Staff shall consist of those members who desire to be associated
with, but who do not intend to establish a practice at this Hospital. The primary
purpose of the Affiliate Staff is to provide for professional and educational
opportunities, including continuing medical education, and to permit these
individuals to access Hospital services for their patients by referral of patients to
Medical Staff members for admission and care.
(b) Individuals requesting appointment to the Affiliate Staff must submit a pre-
application and application as prescribed in the Credentials Policy but are not
required to satisfy the following qualifications set forth in Section 2.A. and the
Credentials Policy.
2.B.2. Prerogatives and Responsibilities:
Affiliate Staff members:
(a) may visit their hospitalized patients and review their Hospital medical records
but may not admit patients, attend patients, exercise any clinical privileges, write
orders or progress notes, make notations in the medical record, or actively
participate in the provision or management of care to patients at the Hospital;
(b) may attend educational activities of the Medical Staff and the Hospital;
(c) may not vote, hold office, serve as a Department Chief or serve on Medical Staff
committees;
(d) may use the Hospital's diagnostic facilities; and
(e) must pay application fees, dues and assessments.
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2.C. ASSOCIATE STAFF
2.C.1. Qualifications:
The Associate Staff shall consist of: (1) new Medical Staff members who are in the
process of becoming eligible for appointment to the Active Staff and who meet all other
qualifications of Active Staff appointment or (2) Medical Staff members who have
greater than 5 but fewer than 24 patient contacts annually. Those Medical Staff members
who do not qualify for Associate Staff will have the ability to apply for Affiliate Staff
status or will have a voluntary relinquishment of their privileges. After completing one
year on the Associate Staff, new Medical Staff members are eligible for appointment to
the Active Staff. To move to the Active Staff Category, Associate Members must show
satisfactory demonstration of their ability to meet requirements, fulfill commitments
assigned to them, and have the written recommendation of their Department Chief.
2.C.2. Prerogatives:
Associate Staff members may serve on Medical Staff committees, but may not vote or
hold office.
2.C.3. Responsibilities:
Associate Staff members must meet all qualifications of Active Staff appointment,
except for the requisite number of patient contacts. Associate members who are not new
Medical Staff have the same qualifications as Active Staff appointment except
emergency on-call, depending on the Department requirements which will be
determined by the Department Chief and MEC.
2.D. CONSULTING STAFF
2.D.1. Qualifications:
The Consulting Staff shall consist of practitioners of recognized professional ability and
expertise who limit their practice to the specialty for which they seek privileges, and
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who are appointed to the Active Staff at another hospital where they are currently
practicing.
2.D.2. Prerogatives and Responsibilities:
Consulting Staff members:
(a) may treat (but not admit) patients in conjunction with another physician on the
Active Staff;
(b) may attend meetings of the Medical Staff, applicable department meetings and
applicable committee meetings (without vote);
(c) may not hold office or serve as Department Chiefs or committee chairmen; and
(d) shall pay application fees, dues and assessments.
2.E. EMERITUS STAFF
2.E.1. Qualifications:
The Emeritus Staff shall consist of practitioners who are recognized for outstanding or
noteworthy contributions to the medical sciences, have a record of previous
long-standing service to the Hospital, and have retired from the active practice of
medicine. Physicians wishing to be appointed to this staff category must apply to the
Medical Executive Committee.
2.E.2. Prerogatives and Responsibilities:
Emeritus Staff members may:
(a) not consult, admit or attend to patients;
(b) attend staff and Department meetings when invited to do so (without vote);
(c) be appointed to committees (without vote);
(d) not vote, hold office, serve as a Department Chief;
(e) not pay application fees, dues or assessments; and
(f) be nominated and recommended by the MEC at their September meeting.
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2.F. SENIOR ACTIVE STAFF
2.F.1. Qualifications:
The Senior Active Staff shall consist of those physicians who meet all qualifications for
Active Staff status and who have: (1) served on the Active Staff for 20 years, or (2)
reached the age of 50 and served on the Active Staff for 15 years, the last five years of
which have been continuous, and (3) who want to practice actively at the Hospital.
2.F.2. Responsibilities and Prerogatives:
Senior Active Staff members may vote and hold office and may (but are not required to)
serve on committees. They are excused from emergency service on-call responsibilities
(subject to a determination by the Executive Committee and Board that removal from
call would not cause a hardship to others who do serve on call the applicable specialty),
but must continue to take call in accordance with any previously published schedule for
up to six months after the date of transfer from the Active Staff.
2.G. SPECIAL NEEDS
The Executive Committee may recommend privileges for physicians who fulfill a
special need of the facility. The Special Needs Category shall consist of physicians who
have special expertise in the specialty for which they seek privileges that are not
currently provided by the Medical Staff. Physicians in this category may not meet all
requirements for Medical Staff membership but they shall:
(1) apply for privileges only at the request of the Chief of the department in which
they seek privileges;
(2) not have more than 24 patient encounters per year;
(3) seek renewal of their staff privileges on an annual basis;
(4) not be required to take call; and
(5) not be eligible to vote, hold office or serve on committees.
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2.G. TELEMEDICINE STAFF
2.G.1. Qualifications:
The Telemedicine Staff shall consist of those physicians who provide services, to
hospital patients solely by telemedicine link. These privileges, if granted in
conjunction with a contractual agreement shall be incident to and coterminous with
the agreement. These practitioners must hold a Florida license and are credentialed in
accordance with the processes described in these Bylaws and the Credentials Policy on
Appointment, Reappointment and Clinical Privileges.
2.G.2. Responsibilities and Prerogatives:
Physicians in this category may not meet all requirements for Medical Staff
membership but they shall:
(1) be granted privileges for a period of not more than two years;
(2) individuals granted telemedicine privileges shall be subject to the Hospital’s
peer review activities. The results of the peer review activities, including any
adverse events and complaints filed about the practitioner providing
telemedicine services from patients, other practitioners or staff, will be shared
with the hospital or entity providing telemedicine services.
(3) not be required to take in-person call;
(4) not have meeting requirements and
(5) not be eligible to vote, hold office or serve on committees.
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ARTICLE 3
OFFICERS
3.A. DESIGNATION
The officers of the Medical Staff shall be the President, President-Elect, and Immediate
Past President.
3.B. ELIGIBILITY CRITERIA
Only those members of the Active Staff who satisfy the following criteria initially and
continuously shall be eligible to serve as an officer of the Medical Staff. They must:
(1) be appointed in good standing to the Active Staff, and have served on the Active
Staff for at least five years;
(2) have no pending adverse recommendations concerning Medical Staff
appointment or clinical privileges;
(3) not presently be serving as a Medical Staff officer, Board Member or Department
Chief at any other hospital and shall not so serve during their term of office;
(4) be willing to faithfully discharge the duties and responsibilities of the position;
(5) have experience in a leadership position, or other involvement in performance
improvement functions for at least two years;
(6) attend continuing education relating to Medical Staff leadership and/or
credentialing functions prior to or during the initial term of the office; and
(7) have demonstrated an ability to work well with others.
3.C. DUTIES
3.C.1. President of the Medical Staff:
The President of the Medical Staff shall:
(a) act in coordination and cooperation with Hospital management in matters of
mutual concern involving the care of patients in the Hospital;
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(b) represent and communicate the views, policies and needs, and report on the
activities of the Medical Staff to the CEO and the Board;
(c) call, preside at, and be responsible for the agenda of all meetings of the Medical
Staff and the Executive Committee;
(d) appoint all committee chairs and committee members, in consultation with the
Executive Committee;
(e) chair the Executive Committee (with vote, as necessary) and be a member of all
other Medical Staff committees, ex officio without vote;
(f) promote adherence to the Bylaws, policies, Rules and Regulations of the Medical
Staff and to the Policies and Procedures of the Hospital;
(g) recommend Medical Staff representatives to Hospital committees; and
(h) perform all functions authorized in all applicable policies, including those
outlined in the Credentials Policy.
3.C.2. President-Elect:
The President-Elect shall:
(a) assume all duties of the President of the Medical Staff in his or her absence,
acting with full authority as President;
(b) serve on the Executive Committee;
(c) chair the Quality and Safety Committee;
(d) assume all such additional duties as are assigned to him or her by the President of
the Medical Staff or the Executive Committee; and
(e) become President of the Medical Staff upon completion of his/her term.
3.C.3. Immediate Past President of the Medical Staff:
The Immediate Past President of the Medical Staff shall:
(a) serve on the Executive Committee;
(b) chair the Bylaws Committee;
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(c) serve as an advisor to other Medical Staff leaders; and
(d) assume all duties assigned by the President of the Medical Staff or the Executive
Committee.
3.D. NOMINATIONS
The President of the Medical Staff shall chair a Nominating Committee consisting of:
the President of the Medical Staff; a member of the Active or Senior Active Staff
appointed by the President; a member of the Active or Senior Active Staff appointed by
the Executive Committee; a member of the Active or Senior Active Staff from the
Department of Medicine and a member of the Active or Senior Active Staff from the
Department of Surgery, who are appointed by their respective Chiefs of their
departments. The CEO of the Hospital or his/her designee will serve on the Committee
as an ex officio member without vote. The Committee shall convene at least 60 days
prior to the election and shall report a slate of one or more qualified nominees for each
office. Notice of the nominees shall be provided in writing to the Medical Staff and
posted in the staff lounge(s) at least 30 days prior to the election. Nominations may also
be submitted in writing by petition signed by at least 150 Active Staff members at least
20 days prior to the election. In order for a nomination to be placed on the ballot, the
candidate must meet the qualifications in Section 3.B subject to the judgment of the
Nominating Committee, and be willing to serve, notifying the President of the Medical
Staff in writing of his or her willingness to serve and fulfill the necessary duties.
Nominations from the floor shall not be accepted.
3.E. ELECTION
Candidates receiving the majority of written votes cast shall be elected, subject to Board
confirmation.
3.F. TERM OF OFFICE
Officers shall serve for a term of two years, or until a successor is elected.
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3.G. REMOVAL
(1) Removal of an elected officer or an at-large member of the Executive Committee
may be effectuated by a two-thirds vote of the Executive Committee, subject to
Board approval, for:
(a) failure to comply with applicable policies, Bylaws, or Rules and
Regulations;
(b) failure to perform the duties of the position held;
(c) conduct detrimental to the interests of the Hospital and/or its Medical
Staff; or
(d) an infirmity that renders the individual incapable of fulfilling the duties of
that office.
(2) At least 10 days prior to the initiation of any removal action, the individual shall
be given written notice of the date of the meeting at which action is to be
considered. The individual shall be afforded an opportunity to speak to the
Executive Committee or the Board prior to a vote on removal.
3.H. VACANCIES
A vacancy in the office of President of the Medical Staff shall be filled by the
President-Elect, who shall serve until the end of the President's unexpired term. In the
event there is a vacancy in another office more than a year after the last election, the
Executive Committee shall appoint an individual at their discretion to fill the office for
the remainder of the term or until a special election can be held. If less than a year after
the election, the Executive Committee shall call for a special election to fill the vacancy
within three (3) months of declaring the vacancy.
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ARTICLE 4
STAFF DEPARTMENTS
4.A. ORGANIZATION
The Medical Staff shall be organized into the departments as listed in the Organization
Manual.
4.B. ASSIGNMENT TO DEPARTMENT
(1) Upon initial appointment to the Medical Staff, each member shall be assigned to
a clinical Department. Assignment to a particular Department does not preclude
an individual from seeking and being granted clinical privileges typically
associated with another Department.
(2) An individual may request a change in Department assignment to reflect a
change in the individual's clinical practice.
4.C. FUNCTIONS OF DEPARTMENTS
The departments shall be organized for the purpose of implementing processes (i) to
monitor and evaluate the quality and appropriateness of the care of patients served by the
departments, and (ii) to monitor the practice of all those with clinical privileges in a
given department. Each department shall assure emergency call coverage for all patients.
4.D. QUALIFICATIONS OF DEPARTMENT CHIEFS
Each Department Chief shall:
(1) be an Active Staff member;
(2) be certified by an appropriate specialty board or possess comparable competence,
as determined through the credentialing and privileging process; and
(3) satisfy the eligibility criteria in Section 3.B.
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4.E. APPOINTMENT AND REMOVAL OF DEPARTMENT CHIEFS
(1) Except as otherwise provided by contract, Department Chiefs shall be elected by
the department, subject to Board confirmation.
(2) A questionnaire shall be sent to all eligible Active and Senior Active Medical
Staff members who are members of any such departments to determine each
member's willingness to serve as Chief of the respective department. The
questionnaires shall be returned to the Medical Staff Services Office by the last
day of September in order to be tabulated. The results shall be confirmed by the
President of the Medical Staff. A ballot will then be prepared, listing all eligible
members of the department who indicated a willingness to stand for election.
(3) If only one eligible Medical Staff member indicates his or her willingness to
stand, this individual shall automatically become the Department Chief, subject
to Board confirmation, and no election will be held. Only Active and Senior
Active members of the department shall be eligible to vote.
(4) If an election is held, the Medical Staff Services Office shall send to every
eligible voting member of the department a voting instruction sheet, the ballot,
and an envelope addressed to the Medical Staff Services Office, by U.S. mail,
with certified return receipt requested. The return envelope shall have a line for
the signature of the voting member.
(5) Each member may cast a vote for one candidate, then enclose the ballot in the
envelope, sign at the designated space on the envelope and mail as addressed.
Only those ballots which are received in signed envelopes by the Medical Staff
Services Office within 30 days of the mailing of the ballot shall be accepted and
counted. The Administration shall verify that each envelope is signed by an
eligible voting member and thereafter the ballots shall be removed from the
envelopes. The President of the Medical Staff and/or their appointed designees
shall thereafter count the ballots without knowledge as to who cast each ballot.
Those who receive a majority of the votes cast shall be elected.
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(6) Any Department Chief may be removed by a two-thirds vote of the department
members, by a two-thirds vote of the Executive Committee subject to Board
confirmation, or by the Board after reasonable notice and the opportunity to be
heard. Grounds for removal shall be:
(a) failure to comply with applicable policies, Bylaws, or Rules and
Regulations;
(b) failure to perform the duties of the position held;
(c) conduct detrimental to the interests of the Hospital and/or its Medical
Staff; or
(d) an infirmity that renders the individual incapable of fulfilling the duties of
that office.
(7) Prior to the initiation of any removal action, the individual shall be given written
notice of the date of the meeting at which such action shall be taken at least 10
days prior to the date of the meeting. The individual shall be afforded an
opportunity to speak to the department or Executive Committee or the Board, as
applicable, prior to a vote on such removal.
(8) Should removal occur, a new nomination and election shall be held within 30
days. If more than one year has been served, the elected individual shall fill the
term plus two years.
(9) Department Chiefs shall serve a term of two years.
4.F. DUTIES OF DEPARTMENT CHIEFS
Each Department Chief is accountable for the following:
(1) all clinically related activities of the department;
(2) all administratively related activities of the department, unless otherwise
provided for by the Hospital;
(3) continuing surveillance of the professional performance of all individuals in the
department who have delineated clinical privileges;
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(4) recommending criteria for clinical privileges that are relevant to the care
provided in the department;
(5) evaluating requests for clinical privileges for each member of the department;
(6) assessing and recommending off-site sources for needed patient care services not
provided by the department or the Hospital;
(7) the integration of the department into the primary functions of the Hospital;
(8) the coordination and integration of interdepartmental and intradepartmental
services;
(9) the development and implementation of policies and procedures that guide and
support the provision of services;
(10) recommendations for a sufficient number of qualified and competent persons to
provide care or service;
(11) recommendation of the qualifications and competence of department personnel
who provide patient care services;
(12) continuous assessment and improvement of the quality of care and services
provided;
(13) maintenance of quality monitoring programs, as appropriate;
(14) the orientation and continuing education of all persons in the department;
(15) recommendations for space and other resources needed by the department;
(16) performing all functions authorized in the Credentials Policy including collegial
intervention;
(17) appointing one or more Vice Chiefs as deemed necessary;
(18) attending, in person or through a representative, 70% of the Executive
Committee meetings in order to be eligible for reelection;
(19) establishing and enforcing departmental policies and procedures, as well as
Medical Staff Bylaws, policies and Rules and Regulations; and
(20) presiding at all meetings of the department.
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4.G. DIVISIONS
4.G.1. Functions of Divisions:
(a) Divisions may perform any of the following activities:
(1) continuing education;
(2) discussion of policy;
(3) discussion of equipment needs;
(4) development of recommendations to the Department Chief or the
Executive Committee;
(5) participation in the development of criteria for clinical privileges (when
requested by the Department Chief); and
(6) discussion of a specific issue at the special request of a Department Chief
or the Executive Committee.
(b) No minutes or reports will be required reflecting the activities of divisions,
except when a division is making a formal recommendation to a department,
Department Chief, Credentials Committee, or Executive Committee.
(c) Divisions shall not be required to hold any number of regularly scheduled
meetings.
4.G.2. Qualifications and Appointment of Division Chiefs:
Division Chiefs shall meet the same qualifications, and shall be subject to the same
appointment and removal provisions as Department Chiefs. Members of a Division may
vote for the Chief of their respective Division, but are not eligible to run for Chief of the
Department.
4.G.3. Duties of Division Chiefs:
The Division Chief shall carry out the duties requested by the Department Chief. These
duties may include:
(a) review and reporting on applications for initial appointment and clinical
privileges, including interviewing applicants;
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(b) review and reporting on applications for reappointment and renewal of clinical
privileges;
(c) evaluation of individuals during the provisional period;
(d) participation in the development of criteria for clinical privileges;
(e) review and reporting on the professional performance of individuals practicing
within the division; and
(f) delegation to a vice Chief such duties as appropriate, including, but not limited
to, the review of applications for appointment, reappointment, or clinical
privileges or questions that may arise if the Division Chief has a conflict of
interest with the individual under review.
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ARTICLE 5
MEDICAL STAFF COMMITTEES AND
PERFORMANCE IMPROVEMENT FUNCTIONS
5.A. EXECUTIVE COMMITTEE
5.A.1. Composition:
(a) The Executive Committee shall include the officers of the Medical Staff, the
Department Chiefs, the Chair of SJH-N and the Chair of SJH-S.
(b) The President of the Medical Staff will chair the Executive Committee.
(c) The CEO and designees shall be ex officio members of the Executive Committee,
without vote.
5.A.2. St. Joseph's Women's Hospital Subcommittee Composition:
(a) The Subcommittee shall consist of the Department Chief (past chief and vice-
chief, if applicable), the chairs (or designee) of the Women's Hospital Quality
and Safety Committee, and the Surgical Suite Committee; the St. Joseph’s
Women’s Hospital (SJWH) Medical Directors (or designee) of Anesthesia,
Pathology, Perinatology, Nursery, Neonatology and Imaging; and the SJWH
representative on the Credentials Committee.
(b) The CEO or his/her designee and the Administrative Director/Nursing Director
shall be ex officio members of the Executive Committee, without vote.
(c) The Chief of the St. Joseph's Women's Hospital Department of Obstetrics and
Gynecology shall serve as chair of the Subcommittee.
(d) The St. Joseph’s Women’s Hospital Executive Committee shall function as a
sub-committee of the overall St. Joseph's Hospital Executive Committee and
shall forward a report of its recommendations to the St. Joseph's Hospital
Executive Committee.
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5.A.3. St. Joseph's Children's Hospital Subcommittee Composition:
(a) The Subcommittee shall be comprised of the chairperson (the Chief of the
Pediatric Department), chairperson of the SJCH Quality and Safety Committee,
the St Joseph’s Children’s Hospital (SJCH) Medical Directors (or designee) of
Anesthesia, Cardiac Services, Emergency Medicine, Neonatology, Oncology,
Pediatric Intensive Care Unit, Pediatric Surgery and the Chief of the section of
Pediatric Medicine the Medical Director of SJCH, one (1) at large member and
the President or designee.
(b) The St. Joseph’s Children’s Hospital Executive Committee shall function as a
sub-committee of the overall St. Joseph's Hospital Executive Committee and
shall forward a report of its recommendations to the St. Joseph's Hospital
Executive Committee.
5.A.4. St. Joseph's Hospital - North Subcommittee Composition:
(a) The Subcommittee shall consist of the Department Chiefs of Medicine (SJH-N),
Surgery (SJH-N), Ob/Gyn (SJH-N), Emergency Medicine (SJH-N) and Radiology
(SJH-N), and two (2) at-large members.
(b) The Chair of the St. Joseph’s Hospital – North Executive Committee will
be determined by the SJH-N MEC.
(c) The CEO and/or his/her designee(s) shall be ex officio member(s) of the
Executive Committee, without vote.
(d) The St. Joseph’s Hospital - North Executive Committee shall function as a
sub-committee of the overall St. Joseph's Hospital Executive Committee and
shall forward a report of its recommendations to the St. Joseph's Hospital
Executive Committee.
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5.A.5. St. Joseph's Hospital - South Subcommittee Composition:
(a) The Subcommittee shall consist of the Department Chiefs of Medicine (SJH-S),
Surgery (SJH-S), Ob/Gyn (SJH-S), Emergency Medicine (SJH-S) and Radiology
(SJH-S), and two (2) at-large members.
(b) The initial executive committee will be appointed by the Board of Trustees.
(c) The Chair of the St. Joseph’s Hospital – South Executive Committee will
be determined by the SJH-S MEC.
(c) The CEO and/or his/her designee(s) shall be ex officio member(s) of the
Executive Committee, without vote.
(d) The St. Joseph’s Hospital - South Executive Committee shall function as a sub-
committee of the overall St. Joseph's Hospital Executive Committee and shall forward a
report of its recommendations to the St. Joseph's Hospital Executive Committee.
5.A.6. Duties of the SJH Medical Executive Committee:
The Executive Committee is delegated the primary authority over activities related to the
functions of the Medical Staff and performance improvement activities regarding the
professional services provided by individuals with clinical privileges. The Executive
Committee is responsible for the following:
(a) acting on behalf of the Medical Staff without requirement of subsequent approval
by the staff (the officers are empowered to act in urgent situations between
Executive Committee meetings);
(b) recommending to the Board on at least the following:
(1) the Medical Staff's structure;
(2) the mechanism used to review credentials and to delineate individual
clinical privileges;
(3) recommendations of individuals for Medical Staff appointment;
(4) recommendations for delineated clinical privileges for each eligible
individual;
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(5) participation of the Medical Staff in Hospital performance improvement
activities;
(6) the mechanism by which Medical Staff appointment may be terminated;
and
(7) hearing procedures.
(c) consulting with administration on quality related aspects of contracts for patient
care services with entities outside the Hospital;
(d) receiving and acting on reports and recommendations from Medical Staff
committees, departments, and other groups as appropriate;
(e) reviewing, on an ongoing basis, and at a minimum every three years, the Bylaws,
policies, Rules and Regulations, and associated documents of the Medical Staff
and recommending such changes as may be necessary or desirable; and
(f) performing such other functions as are assigned to it by these Bylaws, the
Credentials Policy or other applicable policies.
5.A.7. Meetings:
The Executive Committee shall meet as often as necessary to fulfill its responsibilities
but at least ten times a year and maintain a permanent record of its proceedings and
actions.
5.B. PERFORMANCE IMPROVEMENT FUNCTIONS
(1) The Medical Staff is actively involved in the measurement, assessment and
improvement of the following:
(a) medical assessment and treatment of patients;
(b) use of information about adverse privileging decisions for any
practitioner privileged through the Medical Staff process;
(c) medication usage;
(d) the use of blood and blood components;
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(e) operative and other procedures;
(f) appropriateness of clinical practice patterns;
(g) significant departures from established patterns of clinical practice;
(h) the use of developed criteria for autopsies;
(i) sentinel event data;
(j) patient safety data;
(k) the Hospital’s and individual practitioners’ performance on Joint
Commission and Centers for Medicare & Medicaid Services (“CMS”)
core measures; and
(l) the required content and quality of history and physical examinations, as
well as the time frames required for completion, all of which are set forth
in Appendix A and Section 5 of the Medical Staff Rules and Regulations.
(2) The Medical Staff participates in the following activities:
(a) education of patients and families;
(b) coordination of care, treatment and services with other practitioners and
Hospital personnel;
(c) accurate, timely and legible completion of patient’s medical records;
(d) review of findings of the assessment process that are relevant to an
individual’s performance. The medical staff is responsible for
determining the use of this information in the ongoing evaluations of a
practitioner’s competence; and
(e) communication of findings, conclusions, recommendations and actions to
improve performance to appropriate staff members and the governing
body.
5.C. APPOINTMENT OF COMMITTEE CHAIRS AND MEMBERS
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(1) All committee chairs and members shall be appointed by the President of the
Medical Staff. The Chair of SJCH, the Chair of SJH-N and the Chief of the
Department of OB/GYN shall submit their recommendations for all committee
chairs and members of their respective Hospitals. Committee chairs shall be
selected based on the criteria set forth in Section 3.B of these Bylaws.
(2) Committee chairs and members shall be appointed for initial terms of two years,
but may be reappointed for additional terms.
(3) The President of the Medical Staff and the CEO, or their respective designees,
shall be members, ex officio, without vote, on all committees, unless otherwise
stated.
5.D. CREATION OF STANDING COMMITTEES
In accordance with the amendment provisions in the Organization Manuals, the
Executive Committee may, by resolution and upon approval of the Board and without
amendment of these Bylaws, establish additional committees to perform one or more
staff functions. In the same manner, the Executive Committee may dissolve or rearrange
committee structure, duties, or composition as needed to better accomplish Medical Staff
functions. Any function required to be performed by these Bylaws which is not assigned
to an individual, a standing committee or special task force shall be performed by the
Executive Committee.
5.E. SPECIAL TASK FORCES
Special task forces shall be created and their members and chairmen shall be appointed
by the President of the Medical Staff. Such task forces shall confine their activities to the
purpose for which they were appointed and shall report to the Executive Committee.
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ARTICLE 6
MEETINGS
6.A. MEDICAL STAFF YEAR
The Medical Staff year is January 1 to December 31.
6.B. MEDICAL STAFF MEETINGS
6.B.1. Regular Meetings:
The Medical Staff shall meet at least once a year.
6.B.2. Special Meetings:
Special meetings of the Medical Staff may be called by the President of the Medical
Staff, the Executive Committee, the Board, CEO, or by a petition signed by not less than
one-fourth of the Active Staff.
6.C. DEPARTMENT AND COMMITTEE MEETINGS
6.C.1. Regular Meetings:
Except as otherwise provided in these Bylaws or in the Medical Staff Organization
Manual, each department and committee shall meet at least quarterly at times set by the
presiding officer. If a department does not meet at least quarterly, the Department Chief
must provide reasons to the Executive Committee as to why meetings are not being held.
If, after two years, the department has not met quarterly, the Executive Committee shall
reevaluate the need for the department.
6.C.2. Special Meetings:
A special meeting of any department or committee may be called by or at the request of
the presiding officer or the President of the Medical Staff.
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6.D. PROVISIONS COMMON TO ALL MEETINGS
6.D.1. Notice of Meetings:
(a) Medical Staff members shall be provided notice of all regular meetings of the
Medical Staff and regular meetings of departments, divisions, and committees at
least two weeks in advance of the meetings. Notice may also be provided by
posting in a designated location at least two weeks prior to the meetings. All
notices shall state the date, time, and place of the meetings.
(b) When a special meeting of the Medical Staff, a department and/or a committee is
called, all of the provisions in paragraph (a) shall apply except that the notice
period shall be reduced to 72 hours (i.e., must be given at least 72 hours prior to
the special meeting). Posting may not be the sole mechanism used for providing
notice; notices must also be mailed, faxed or e-mailed, depending on the amount
of time before the meeting.
(c) The attendance of any individual at any meeting shall constitute a waiver of that
individual's objection to the notice given for the meeting.
6.D.2. Quorum and Voting:
(a) For any regular or special meeting of the Medical Staff, department, division, or
committee, those voting members present shall constitute a quorum. For
meetings of the Executive Committee, the presence of at least 50% of the total
Committee shall constitute a quorum.
(b) For any General Staff meeting, an absentee ballot, when requested in writing one
week prior to the meeting, will be available in the Medical
Staff Office. If this option is approved by the President of the Medical Staff, the
Medical Staff Office shall provide a voting instruction sheet, the ballot, and an
envelope. This envelope shall have a line for the signature of the voting member.
36
(c) Recommendations and actions of the Medical Staff, departments, divisions, and
committees shall be by consensus. In the event it is necessary to vote on an issue,
that issue will be determined by a majority vote of those individuals present.
(d) Any matter to be presented must be included in the notice, and votes are to be
returned to the Presiding Officer by the method designated in the notice. A
quorum shall be the number of ballots returned. The question raised shall be
determined in the affirmative if a majority of the ballots returned have so
indicated.
(e) Meetings may be conducted by telephone and/or video conference at the
discretion of the presiding officer.
6.D.3. Agenda:
The presiding officer for the meeting shall set the agenda for any regular or special
meeting of the Medical Staff, department, division or committee.
6.D.4. Rules of Order:
The latest edition of Robert's Rules of Order Revised may be used for reference at all
meetings and elections. Specific provisions of these Bylaws, and Medical Staff,
department or committee custom shall prevail at all meetings, and the Department Chief
or Committee Chair shall have the authority to rule definitively on all matters of
procedure.
6.D.5. Minutes, Reports, and Recommendations:
(a) Minutes of all meetings of the Medical Staff, departments and committees (and
applicable division meetings) shall be prepared and shall include a record of the
attendance of members and the recommendations made and the votes taken on
each matter. The minutes shall be authenticated by the presiding officer.
37
(b) A summary of all recommendations and actions of the Medical Staff,
departments, divisions and committees shall be transmitted to the Executive
Committee and CEO.
(c) A permanent file of the minutes of all meetings shall be maintained by the
Hospital.
6.D.6. Confidentiality:
Members of the Medical Staff who have access to credentialing and/or peer review
information agree to maintain the confidentiality of this information. Credentialing and
peer review documents, and information contained therein, must not be disclosed to any
individual not involved in the credentialing or peer review processes. A breach of
confidentiality may result in the imposition of disciplinary action.
6.D.7. Attendance Requirements:
(a) Each Active, Senior Active and Provisional Associate Staff member is expected
to attend and participate in at least 50% of the General Staff meetings and any
applicable Department and Division meetings each year.
(b) Members who are absent from meetings must submit excuses for the absence to
the relevant Department Chief.
(c) Failure to meet the 50% attendance requirement shall result in an increase in
renewal dues as determined by the MEC.
(d) An individual whose Medical Staff appointment has been revoked due to failure
to complete the renewal process shall be charged an initial application fee.
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ARTICLE 7
CONFLICTS OF INTEREST
(a) When performing a function outlined in these Bylaws or other applicable policy or
Rules and Regulations, if any Medical Staff member has, or reasonably could be
perceived as having, a conflict of interest or a bias in any matter involving another
individual, the he or she shall not participate in the discussion or vote on the matter,
and shall be excused from the meeting. However, the individual may be asked, and
may answer, any questions concerning the matter before leaving.
(b) The existence of a potential conflict of interest or bias on the part of any member
may be called to the attention of the President of the Medical Staff or applicable
Committee Chair or Department Chief by any other member with knowledge of it.
(c) The fact that a Department Chief or staff member is in the same specialty as a
member whose performance is being reviewed does not automatically create a
conflict. The evaluation of whether a conflict of interest exists shall be interpreted
reasonably by the persons involved, taking into consideration common sense and
objective principles of fairness. No staff member has a right to compel a
determination that a conflict exists.
(d) The fact that a committee member or Medical Staff leader chooses to refrain from
participation, or is excused from participation, shall not be interpreted as a finding of
actual conflict.
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ARTICLE 8
BASIC STEPS AND DETAILS
The details associated with the following Basic Steps are contained in the Credentials Policy
and the Policy on Allied Health Professionals.
8.A. QUALIFICATIONS FOR APPOINTMENT
To be eligible to apply for initial appointment or reappointment to the Medical Staff or
for the grant of clinical privileges, an applicant must demonstrate appropriate education,
training, experience, current clinical competence, professional conduct and ability to
safely and competently perform the clinical privileges requested as set forth in the
Credentials Policy.
8.B. PROCESS FOR PRIVILEGING
Complete applications are transmitted to the applicable Department Chief, who prepares
a written report to the Credentials Committee, Executive Committee and Board.
8.C. PROCESS FOR CREDENTIALING (APPOINTMENT AND REAPPOINTMENT)
Complete applications are transmitted to the applicable Department Chief, who prepares
a written report to the Credentials Committee, Executive Committee and Board.
8.D. INDICATIONS AND PROCESS FOR AUTOMATIC RELINQUISHMENT OF
APPOINTMENT AND/OR PRIVILEGES
8.D.1. Appointment and clinical privileges will be automatically relinquished if an individual:
(a) fails to do any of the following:
(i) timely complete medical records;
(ii) satisfy threshold eligibility criteria;
(iii) provide requested information;
(iv) attend a special conference to discuss issues or concerns;
40
(b) is involved in criminal activity as defined in the credentialing notebook;
(c) makes a misstatement or omission on an application form.
8.D.2. Automatic relinquishment shall take effect immediately and shall continue until the
matter is resolved, if applicable.
8.E. INDICATIONS AND PROCESS FOR PRECAUTIONARY SUSPENSION
(1) Whenever failure to take action may result in imminent danger to the health
and/or safety of any individual, the President of the Medical Staff, the chief of
the relevant clinical department, the chair of the Quality Committee or the
CEO is authorized to suspend or restrict all or any portion of an individual’s
clinical privileges pending an investigation.
(2) A precautionary suspension is effective immediately and will remain in effect
unless it is modified by the CEO or Executive Committee.
(3) The individual shall be provided a brief written description of the reason(s)
for the precautionary suspension.
(4) The Executive Committee will review the reasons for the suspension within a
reasonable time.
(5) Prior to, or as part of, this review, the individual will be given an opportunity
to meet with the Executive Committee.
8.F. INDICATIONS AND PROCESS FOR RECOMMENDING TERMINATION OR
SUSPENSION OF APPOINTMENT AND PRIVILEGES OR REDUCTION OF
PRIVILEGES
Following an investigation, the Executive Committee may recommend suspension or
revocation of appointment or clinical privileges based on concerns about:
(a) clinical competence or practice;
41
(b) violation of ethical standards or the bylaws, policies, Rules and Regulations of
the Hospital or the Medical Staff; or
(c) conduct that is considered lower than the standards of the Hospital or
disruptive to the orderly operation of the Hospital or its Medical Staff.
8.G. HEARING AND APPEAL PROCESS, INCLUDING THE PROCESS FOR
SCHEDULING AND CONDUCTING HEARINGS AND THE COMPOSITION OF
THE HEARING PANEL
(1) The hearing will begin no sooner than 30 days after the notice of the hearing,
unless an earlier date is agreed upon by the parties.
(2) The Hearing Panel will consist of at least three members and there may be a
Hearing Officer.
(3) The hearing process will be conducted in an informal manner; formal rules of
evidence or procedure will not apply.
(4) A stenographic reporter will be present to make a record of the hearing.
(5) Both sides will have the following rights, subject to reasonable limits
determined by the Presiding Officer:
(a) to call and examine witnesses, to the extent they are available and
willing to testify;
(b) to introduce exhibits;
(c) to cross-examine any witness on any matter relevant to the issues;
(d) to have representation by counsel; and
(e) to submit a written statement to the Hearing Panel within five (5) days
of the close of the hearing.
(6) The personal presence of the affected individual is mandatory. If the
individual who requested the hearing does not testify, he or she may be called
and questioned.
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(7) The Hearing Panel may question witnesses, request the presence of additional
witnesses, and/or request documentary evidence.
(8) The affected individual and the Executive Committee may request an appeal
of the recommendations of the Hearing Panel to the Board.
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ARTICLE 9
AMENDMENTS
9.A. MEDICAL STAFF BYLAWS
(1) Amendments to these Bylaws may be proposed by a petition signed by 25% of the
voting members of the Medical Staff, by the Bylaws Committee, or by the Executive
Committee. All proposed amendments must be reviewed by the Executive
Committee prior to a vote by the Medical Staff. The Executive Committee shall
report on the proposed amendments either favorably or unfavorably at the next
regular meeting of the Medical Staff, or at a special meeting called for such
purpose. The proposed amendments may be voted upon at any meeting if notice
has been provided at least 14 days prior to the meeting. To be adopted, the
amendment must receive a majority of the votes cast by the voting staff at the
meeting.
(2) The Executive Committee may present proposed amendments to the voting staff
by mail ballot, returned to the Medical Staff Office by the date indicated by the
Executive Committee. Along with the proposed amendments, the Executive
Committee may, in its discretion, provide a written report on them either
favorably or unfavorably. To be adopted, an amendment must receive a majority
of the votes cast, so long as the amendment is voted on by at least 50% of the
staff eligible to vote.
(3) The Executive Committee shall have the power to adopt such amendments to
these Bylaws which are needed because of reorganization, renumbering, or
punctuation, spelling or other errors of grammar or expression.
44
(4) All amendments shall be effective only after approval by the Board.
(5) If the Board has determined not to accept a recommendation submitted to it by
the Executive Committee or the Medical Staff, the Executive Committee may
request a conference between the officers of the Board and the officers of the
Medical Staff. Such conference shall be for the purpose of further
communicating the Board's rationale for its contemplated action and permitting
the officers of the Medical Staff to discuss the rationale for the recommendation.
Such a conference will be scheduled by the CEO within two weeks after receipt
of a request for same submitted by the President of the Medical Staff.
9.B. OTHER MEDICAL STAFF DOCUMENTS
(1) In addition to the Medical Staff Bylaws, there shall be policies, procedures and
rules and regulations that shall be applicable to all members of the Medical Staff
and other individuals who have been granted clinical privileges or a scope of
practice.
(2) The Medical Staff Organization Manual will list the departments of the Medical
Staff. The Medical Staff Organization Manual will also contain a description of
the committees of the Medical Staff.
(3) The Executive Committee and the Board shall have the power to provisionally
adopt urgent amendments to the Rules and Regulations that are needed in order
to comply with a law or regulation, without providing prior notice of the
proposed amendments to the Medical Staff. Notice of all provisionally adopted
amendments shall be provided to each member of the Medical Staff as soon as
45
possible. The Medical Staff shall have fourteen (14) days to review and provide
comments on the provisional amendments to the Medical Executive Committee.
If there is no conflict between the Medical Staff and the Medical Executive
Committee, the provisional amendments shall stand. If there is conflict over the
provisional amendments, then the process for resolving conflicts set forth below
shall be implemented.
(4) An amendment to the Credentials Policy, Medical Staff Organization Manual,
Policy on Allied Health Professionals, or the Medical Staff Rules and
Regulations may be made by a majority vote of the members of the Executive
Committee present and voting at any meeting of that Committee where a quorum
exists. Notice of all proposed amendments to these documents shall be provided
to each Active Staff member of the Medical Staff at least fourteen (14) days prior
to the Executive Committee meeting when the vote is to take place, and any
Active Staff member may submit written comments on the amendments to the
Executive Committee.
(5) Amendments to Medical Staff policies and Rules and Regulations may also be
proposed by a petition signed by 25% of the voting members of the Medical
Staff. Any such proposed amendments will be reviewed by the Executive
Committee who will make a recommendation.
(6) All other policies of the Medical Staff may be adopted and amended by a
majority vote of the Medical Executive Committee. No prior notice is required.
(7) Adoption of and changes to the Credentials Policy, Medical Staff Organization
Manual, Policy on Allied Health Professionals, Medical Staff Rules and
46
Regulations, and other Medical Staff policies will become effective only when
approved by the Board.
(8) The present Medical Staff Rules and Regulations of the Hospital are hereby
readopted and placed into effect insofar as they are consistent with these Bylaws,
until such time as they are amended in accordance with the terms of these
Bylaws. To the extent any present Rule or Regulation is inconsistent with these
Bylaws, it is of no force or effect.
9.C. CONFLICT MANAGEMENT PROCESS
(1) When there is a conflict between the Medical Staff and the Executive Committee
with regard to:
(a) proposed amendments to the Medical Staff Rules and Regulations;
(b) a new policy proposed by the Executive Committee; or
(c) proposed amendments to an existing policy that is under the authority of
the Executive Committee,
a special meeting of the Medical Staff will be called. The agenda for that meeting
will be limited to the amendment(s) or policy at issue. The purpose of the meeting
is to resolve the differences that exist with respect to the Medical Staff Rules and
Regulations or policies.
(2) If the differences cannot be resolved, the Executive Committee shall forward its
recommendations, along with the proposed recommendations pertaining to the
Medical Staff Rules and Regulations or policies offered by the voting members of
the Medical Staff, to the Board for final action.
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ARTICLE 10
INDEMNIFICATION
All Medical Staff officers, Department Chiefs, committee chairs, committee members, and
authorized representatives shall be indemnified when acting in those capacities, to the fullest
extent permitted by law, in accordance with the Hospital's Bylaws.
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ARTICLE 11
ADOPTION
These Bylaws are adopted and made effective upon approval of the Board, superseding and
replacing any and all previous Medical Staff Bylaws, Rules and Regulations, policies, manuals
or Hospital policies pertaining to the subject matter thereof.
Adopted by the Medical Staff on:
Date: October 21, 2014
Jayendra Choksi, MD Jayendra Choksi, MD
President of the Medical Staff
Approved by the Board on:
Date: December 16, 2014
Eric Obeck Eric Obeck
Chairman, Board of Trustees
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APPENDIX A
Medical History & Physical Examination
The medical history and physical examination are completed and documented by a physician, an
oral maxillofacial surgeon, or other qualified licensed individual in accordance with State law and
hospital policy.
A complete history and physical examination appropriate for the patient's condition shall be
dictated, entered via PowerNote or on a transcribed/office EMR for all cases within 24 hours after
hospital admission (The definition of "appropriate" is defined by the H & P Policy with input from
appropriate medical staff specialties.) For those individuals in the Allied Health category, the
history and physical examination, progress note, consultation and/or ordered procedure must be
performed under the supervision of, or through appropriate delegation by, a specific qualified
physician who countersigns within 24 hours. The Physician retains accountability for the patient’s
medical history and physical. When such history and physical examination are not on the medical
record prior to a scheduled operation, the operation shall be canceled unless the attending physician
documents that such delay constitutes a hazard to the patient. A current, legible and thorough
history and physical examination must be on the medical record prior to the performance of surgery
and procedures requiring anesthesia/sedation services.
Even if the H&P was done within the 24 hours time frame of the patient’s scheduled surgery
or procedure requiring anesthesia/sedation services, an update must be done in the medical
record after seeing the patient prior to surgery or procedure requiring anesthesia services.
The only exception to performing an update would be if the surgeon completed the entire
H&P after seeing the patient the day of procedure or life-threatening emergency procedure.
If the H&P is greater than 30 days, a new H&P must be completed.
A patient admitted to the hospital prior to the day of surgery is not required to have the
History and Physical update completed, as the daily hospital progress note meets this
requirement.
This update must be completed 24 hours after inpatient admission or prior to procedure. (For
example, “the History and Physical was reviewed and the patient was examined and no change has
occurred in the patient’s condition since the H & P was completed.”) For patients undergoing
procedures, when the performing physician is not the ordering physician (i.e.; bone marrow
aspiration) where anesthesia is involved, the Anesthesia Assessment note on the day of
surgery/procedure satisfies the H & P update requirement. When patients are being evaluated by
Allied Health Practitioners, these patients must also be seen by the responsible supervising
physician within 24 hours.
The minimum requirements for documentation of appropriate history and physical examination
findings for outpatients shall also be defined by the H & P Policy with input from appropriate
medical staff specialties.