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Mount Sinai Hospital Medical/Dental By-Laws Reviewed and revised by the Medical Advisory Council – February 2007

MOUNT SINAI HOSPITAL

MEDICAL/DENTAL/MIDWIFE STAFF BY-LAWS


ARTICLE 1

INTERPRETATION AND DEFINITIONS STAFF APPOINTMENTS

1.01 Appointment Criteria a) Licensure b) Specialty Certification c) Family Medicine d) Professional Liability Insurance e) Skills and Qualifications f) Applicant Agreement g) Performance h) University Appointments i) Attitude j) Need for Appointment k) Conforming Department Practice Plan

1.02 Appointment 1.03 Term of Appointment 1.04 Scope of Privileges 1.05 Revocation / Suspensions 1.06 Hearing Before Board 1.07 Written Notice of Denial 1.08 By-Laws/Public Hospitals Act 1.09 Applications for Appointment 1.10 Application Process 1.11 Procedure

Page 1 Pages 2 – 6

ARTICLE 2

STAFF REAPPOINTMENT

2.01 Application 2.02 Department Chief Responsibilities 2.03 Reappointment Process 2.04 Criteria for Reappointment 2.05 Provisions of Reappointment

Pages 7 - 8

ARTICLE 3

STAFF RESPONSIBILITIES 3.01 Accountability

3.02 Responsibilities

Page 9

ARTICLE 4

STAFF CATEGORIES

4.01 Categories 4.02 Active Staff 4.03 Associate Staff

Pages 10 – 12


4.04 Associate and Assistant Scientific Staff 4.05 Consultant 4.06 Clinical Associate 4.07 Honorary Staff

ARTICLE 5

PRIVILEGES

5.01 Competence 5.02 Temporary Privileges 5.03 Admitting 5.04 Operating Room 5.05 NNVP 5.06 Obstetrical Privileges for Family Physicians 5.07 Other Invasive or Special Procedures 5.08 Application for Changes 5.09 Privileges in another Department or Division 5.10 Observers 5.11 Housestaff Temporary Operating Room Privileges 5.12 Monitoring of Privileges a) Staff Members’ Responsibility b) Department Chiefs’ Responsibility 5.13 Temporary Restriction or Suspension of Privileges 5.14 Refer to MAC for Recommendations re Temporary Restriction or Suspension of Privileges 5.15 Written Notice for Restrictions or Suspensions of Privileges 5.16 Health Records

Pages 13 – 18

ARTICLE 6

DEPARTMENTS AND DEPARTMENTAL MEETINGS

6.01 Clinical Departments 6.02 Minutes of Meetings

6.03 Notice 6.04 Attendance Requirements

Page 18 – 19

ARTICLE 7

REVIEW AND SEARCH COMMITTEES

7.01 Appointment of Chief 7.02 First Term Review 7.03 Second and Third Term Reviews 7.04 Search Exception 7.05 University Department Chair 7.06 Search/Review Committee 7.07 Appointment of Head of Division

Pages 19 – 22


7.08 First Term and Second Term Review 7.09 Head of Division Search Exceptions

ARTICLE 8

DEPARTMENT CHIEF, ASSOCIATE CHIEF AND DIVISION HEAD DUTIES

8.01 Department Chief Duties 8.02 Deputy Chief Duties 8.03 Division Head Duties

Pages 22 - 24

ARTICLE 9

MEDICAL STAFF ASSOCIATION

9.01 Composition and Responsibility 9.02 Quorum 9.03 General Meetings 9.04 Special Meetings 9.05 Election Procedure 9.06 Terms and Officers 9.07 Limitation on Eligibility 9.08 Limitation on Terms 9.09 Nomination 9.10 Vacancies 9.11 President’s Duties 9.12 Vice-President’s Duties 9.13 Secretary’s Duties 9.14 Treasurer’s Duties 9.15 Dues

Pages 24 - 27

ARTICLE 10

MEDICAL ADVISORY COUNCIL

10.01 Composition 10.02 Quorum 10.03 Alternatives 10.04 Voting 10.05 MAC Duties 10.06 Subcommittee Duties 10.07 Chair Appointment and Term 10.08 Chair and Vice-Chair Eligibility 10.09 Chair’s Duties 10.10 Vice-Chair’s Duties 10.11 Recording Secretary’s Duties 10.12 Nominations

Pages 27 - 31

ARTICLE 11

COMMITTEES OF MAC

11.01 MAC Standing Subcommittees Established by the Board

Pages 31 - 42


11.02 Acute Resuscitation Committee 11.03 Clinical Practice Committee 11.04 Credentials 11.05 Clinical Ethics Committee 11.06 Health Records Committee 11.07 Infection Control Committee 11.08 Pharmacy and Therapeutics Committee 11.09 Transfusion Committee 11.10 Professional Affairs Committee 11.11 Other Committees 11.12 Appointment 11.13 Duties and Powers

ARTICLE 12

MIDWIVES

12.01 Appointment Criteria 12.02 Process 12.03 Responsibilities

Pages 42 - 44

ARTICLE 13

BAYCREST CENTRE FOR GERIATRIC CARE

13.01 Affiliation 13.02 Appointments 13.03 13.04 Reporting

Page 44 - 45

ARTICLE 14

AMENDMENT OF BY-LAWS

14.01 Repeals 14.02 Amendments 14.03 Conflict with Acts

Page 45 - 46


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NTERPRETATION AND DEFINITIONS “Active Medical Staff” shall have the same meaning throughout ascribed to it in Article 4. “Affiliation Agreement” means the agreement between the Governing Council of the University of Toronto and of Mount Sinai Hospital. “Association” or “MSA” means the Medical Staff Association of Mount Sinai Hospital. “Baycrest” refers to the Baycrest Centre for Geriatric Care. “the Board” means the Board of Directors of Mount Sinai Hospital. “the College” or “CPSO” refers to the College of Physicians and Surgeons of Ontario. “the Committee” refers to the Credentials Committee of the Medical Advisory Council. “the Council” or “MAC” means the Medical Advisory Council which is the body referred to in the Public Hospitals Act as the “Medical Advisory Committee.” “the Hospital” refers to the Corporation or the premises of Mount Sinai Hospital. “Housestaff” shall mean physicians or dentists holding appointments as postgraduate trainees including residents and fellows at the Hospital. “the Institute” refers to the Samuel Lunenfeld Research Institute of Mount Sinai Hospital, which is the Department of Research of the Hospital. “Medical Staff” means medical and/or dental practitioners appointed from time to time by the Board to attend or perform services for patients, medical or dental teaching and/or carry out research. The Medical Staff also includes members of the Associate Scientific Staff. “Member” (whether capitalized or not) means a member of the Medical Staff. “President” and “Vice-President” and references to all other offices and titles of office refer to those of Mount Sinai Hospital, unless specifically noted otherwise. “University” means the University of Toronto. Words importing the singular shall include the plural and vice versa and words importing any gender shall include the other gender.


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MEDICAL/DENTAL STAFF BY-LAWS

ARTICLE 1 STAFF APPOINTMENT

Section 1.01 The criteria for appointment to the Staff shall include the following:

Appointment Criteria

a) Only an individual who is qualified to practice medicine and registered with the College of Physicians and Surgeons of Ontario, pursuant to the laws of Ontario, is eligible to apply for membership in the Medical Staff.

Only an individual who is qualified to practice dentistry and registered with the Royal College of Dental Surgeons of Ontario, pursuant to the laws of Ontario, is eligible to apply for membership in the Dental Staff. An applicant shall provide to the Hospital a signed consent permitting the Hospital to receive information concerning the applicant from any professional body or licensing body and other persons familiar with the applicant;

Licensure

b) Applicants for Active Medical Staff appointments must be certified by the Royal College of Physicians and Surgeons of Canada or with the Royal College of Dental Surgeons of Ontario in the specialty in which they have applied to practice.

Specialty Certification

c) Applicants to the Department of Family Medicine shall hold membership in the College of Family Physicians of Canada.

Family Medicine

d) Applicants shall maintain current membership in good standing of the Canadian Medical Protective Association (“CMPA”), the Royal College of Dental Surgeons of Ontario or other body providing appropriate professional liability insurance services and provide evidence of such as a condition of appointment and annual reappointment.

Professional Liability Insurance

e) Applicants shall provide evidence of current certification in skills or other qualifications relevant to fulfilling their expected duties and privileges;

Skills and Qualifications

f) Applicants shall agree to: i) maintain a high ethical standard; ii) comply with the By-Laws and Policies and

Procedures of the Hospital as well as the

Applicant Agreement


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Hospital/University Affiliation Agreement and the relevant provisions set out in the applicable laws of Ontario, including without limitation the Public Hospitals Act and its Regulations, as amended from time to time;

iii) notify the President of any change in his or her license to practice medicine or dentistry as made by the College of Physicians and Surgeons of Ontario and the Royal College of Dentals Surgeons;

iv) inform the President of any findings of professional misconduct or professional negligence;

v) never to accept or receive any financial or other benefit because of the reference of any patient for the purchase of drugs, appliances, equipment or laboratory tests;

vi) never to pay to or receive from another practitioner, either directly or indirectly, any part of a fee received from any patient for professional services, unless the division of the fee is shown to the patients on the account form submitted and unless the professional services adjustment is made in accordance with a group practice arrangement within the Hospital;

vii) demonstrate an appropriate use of Hospital resources;

viii) be responsible to his or her Department Chief and the President for the discharge of all staff, department, committee and hospital functions for which he or she is responsible by staff category assignment, appointment, election or otherwise and attend Department and Medical Staff Association meetings as appropriate; and

ix) fulfill all of the responsibilities established in Section 3.01 and Section 3.02 of these By-Laws.

g) Applicants who shall participate in patient care will have demonstrated the ability to provide patient care at an appropriate level of quality and efficiency;

Performance

h) Applicants to the Active Medical/Dental Staff shall be eligible for and hold an appointment at the Faculty of Medicine or the Faculty of Dentistry of the University of Toronto. This by-law applies to the staff of all clinical departments and services, with the exception of Clinical Associates, and individuals in the Associate and Assistant Scientific Staff category and the non-teaching Associate Staff in the Department of Family Medicine.

University Appointments

i) Applicants will be judged by: i) their demonstrated ability to work with and relate to

Attitude


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others in a cooperative and professional manner; ii) their interest in and aptitude for scholarly activities;

and iii) their willingness to participate in the discharge of

staff obligations appropriate to the membership category.

j) All appointments to the Staff shall be subject to the Hospital’s

evolving mission, strategic, medical manpower, and resource plans. An impact analysis of the candidate’s appointment shall be done for each Staff appointment.

Need for Appointments

k) Active Medical/Dental Staff with full-time academic appointments must participate in the conforming departmental practice plan or equivalent.

Conforming Departmental Practice Plan

Section 1.02 The Board shall appoint annually a Medical and Dental Staff in accordance with the provisions of the Public Hospitals Act and these By-Laws.

Appointment

Section 1.03 Appointments to the Staff shall be for a period of up to one year beginning July 1st and terminating on or before June 30th of the following year. Appointments made at other times of the year shall terminate on or before the succeeding June 30th. The MAC shall make recommendations to the Board concerning all appointments including the Departments to which appointments shall be made and the privileges to be granted.

Term of Appointment

Section 1.04 A Staff appointment shall not automatically confer any specific access to Hospital resources such as office space, operating room time or admitting privileges. The privileges which accompany an appointment to the Medical Staff shall be based on the recommendation of the Medical Advisory Council having regard to the qualifications of the applicant and the needs and resources of the Hospital at the time of appointment or reappointment.

Scope of Privileges

Section 1.05 The Board, after consultation with the MAC, may, at any time and for stated cause, revoke, alter or suspend any appointment to the Staff.

Revocation / Suspensions

Section 1.06 Where the MAC recommends to the Board that an application for appointment or reappointment to the Medical/Dental Staff be denied,

Hearing Before Board


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the MAC shall give written notice of such recommendation to the applicant who may then request written reasons for the recommendation and a hearing by the Board pursuant to the Public Hospitals Act, as amended. Section 1.07 If the Board proposes to deny a favourable recommendation of the MAC regarding a physician’s or dentist’s application for appointment or reappointment or for a change in privileges, the Board shall give written notice to the applicant of such proposed denial.

Written Notice of Denial

Section 1.08 The Medical Affairs office shall, on behalf of the President, keep available a copy of the By-Laws and Policies of the Hospital and a copy of the Public Hospitals Act and its Regulations for review by each physician or dentist who expresses, in writing, intention to apply for membership on the Staff.

By-Laws/ Public Hospitals Act

Section 1.09 Applications for appointment to the Staff shall be made in writing and submitted to the President in care of the Medical Affairs office. Applicants shall state their qualifications and submit documented proof thereof, including two references from members of their profession. Applicants shall sign a statement that, if they are appointed, they will govern themselves in accordance with the requirements set out in the Public Hospitals Act and its Regulations, the By-Laws, the Hospital’s mission, the Policies and Procedures established by the Hospital and the University of Toronto Affiliation Agreement. The applicant shall also indicate agreement to abide by the Hospital policy on patents and inventions. No application shall go to the Credential Committee until all documentation is complete. Applicants may be required to visit the Hospital for interview(s) by appropriate members of the Staff.

Applications for Appointment

Section 1.10 Physicians or Dentists applying for an appointment to the Medical/Dental Staff shall provide the following: Completed application form; Notarized copy of Licence to Practise; Notarized copy of Medical School Certificate; Notarized copy of Fellowship Certificate; Notarized copy of current CMPA Membership (in the case of

Dentists, the Royal College of Dental Surgeons provides this information);

Curriculum Vitae;

Application Process


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University Status; Fully executed Release of Information Form; CPSO Certificate of Professional Conduct; Three letters of references.

Section 1.11 The procedure for processing applications shall be as follows:

(a) On behalf of the President, the Medical Affairs office shall process and keep a record of each appointment application received and refer the original forthwith to the MAC Credentials Committee if complete or to the Department Chief for completion as appropriate.

(b) The relevant Department Chief shall submit a written

recommendation concerning the appointment category, duties and privileges for each application received by the Medical Affairs office.

(c) The Medical Affairs office will ensure that an impact analysis is

completed for Active Staff appointments or appointments with resource implications and sent to the appropriate Planning Council.

(d) The MAC’s Credentials Committee shall investigate each

application submitted in accordance with the criteria for membership in the Staff set forth in Section 1.01 and shall make a written report thereon to the next regular meeting of the MAC.

(e) The MAC shall receive and consider the report of the

Credentials Committee and send its recommendation in writing to the Board and to the applicant, pursuant to the provisions of the Public Hospitals Act, not later than sixty (60) days after the date of receipt of the completed application by the Committee, unless, prior to the expiration of the sixty (60) day period, the MAC indicates in writing to the Board and the applicant that a final recommendation cannot yet be made and gives written reasons therefore.

Procedure

ARTICLE 2 STAFF REAPPOINTMENT


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Section 2.01 Applications for reappointment to the Staff shall be made on the prescribed form by the Staff member each year.

Application

Section 2.02 The Department Chief shall review and make a written recommendation to the MAC concerning each application for reappointment in his or her Department and any proposed amendment of privileges within the Department. In Departments divided into Divisions, the Division Head may review and have input into the recommendation of the Department Chief concerning each application for reappointment within the Division. Privileges may be subject to amendment to reflect any changes in the Hospital’s evolving mission, strategic and resource plans.

Department Chief Responsibilities

Section 2.03 Each year, each member of the Medical Staff shall make a written application for reappointment to a department of the Medical Staff of the Hospital in the prescribed form. The Chief of Department shall conduct a review of the applicant’s performance for the past year in accordance with the prescribed Hospital process which shall include:

(a) a review of the applicant’s performance and health during the past year;

(b) a discussion of the applicant’s plans for any changes in type or level of service provided or status of the appointment;

(c) a discussion of any other matter listed in section 2.04 All applications for reappointment to the Staff shall be processed through the Medical Affairs office. The applications and/or resulting reappointment recommendations shall be reviewed in turn by the Department Chief, the Credentials Committee, the MAC and the Board.

Reappointment Process

Section 2.04 The criteria for reappointment to the Staff shall include:

(a) the member continues to meet all of the criteria set out in Section 1.01;

(b) the member complies with the relevant provisions set out in the laws of Ontario, including but not limited to the Public Hospitals Act, the By-Laws and Policies and Procedures of the Hospital, and the Affiliation Agreement;

(c) the member attends Department and Medical Staff Association meetings as appropriate;

Criteria for Reappointment


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(d) the member maintains a high ethical standard and agrees i) to notify the President of any change in his or her

license to practice medicine or dentistry as made by the College of Physicians and Surgeons of Ontario, or the Royal College of Dental Surgeons of Ontario;

ii) never to accept or receive any financial or other benefit because of the reference of any patient for the purchase of drugs, appliances, equipment or laboratory tests; and

iii) never to pay to or receive from another practitioner, either directly or indirectly, any part of a fee received from any patient for professional services, unless the division of the fee is shown to the Patient on the account form submitted and unless the professional services adjustment is made in accordance with a group practice arrangement within the Hospital;

(e) the member continues to fulfill all of the responsibilities established in Section 3.01 and Section 3.02 of these By-Laws; and

(f) the member demonstrates an appropriate use of Hospital resources.

Section 2.05 All Medical/Dental reappointments are subject to the provisions of Section 1.05, Section 1.06 and Section 1.07 of these By-Laws.

Provisions of Reappointment


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ARTICLE 3 STAFF RESPONSIBILITIES

Section 3.01 Each member of the Staff is accountable to and shall recognize the authority of the Board through the relevant Department Chief and the President.

Accountability

Section 3.02 Each member of the Staff shall:

(a) attend and treat Patients within the limits of such member’s Privileges;

(b) be responsible to his or her Department Chief and to the President for the discharge of all staff, department, committee and Hospital functions for which he or she is responsible by staff category assignment, appointment, election or otherwise;

(c) prepare and complete in a timely fashion the required records for all patients to whom he or she in any way provides care in the Hospital;

(d) participate in Hospital peer review activities for credentialing, quality management, utilization review and other such functions of Department meetings or MAC committees;

(e) abide by the ethical principles of his or her profession; (f) remain competent in every area in which he or she is granted

privileges; (g) abide by the Hospital’s By-Laws and Policies as well as the

Public Hospitals Act and its regulations and all other legislated requirements;

(h) maintain current membership in good standing of the Canadian Medical Protective Association, the Royal College of Dental Surgeons of Ontario or other body providing appropriate professional liability insurance services and provide evidence of such as a condition of appointment and reappointment;

(i) Active Staff (excluding Dentists) with full-time academic appointments must maintain membership in the relevant conforming Departmental practice plan or equivalent;

(j) perform such other duties as may be prescribed from time to time by the Board, the MAC, the President or Department Chief; and

(k) Maintain collegial and respectful relations with all Hospital staff, patients and members of the public in the discharge of his or her duties.

Responsibilities


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ARTICLE 4 STAFF CATEGORIES

Section 4.01 The Staff shall be divided into the following groups:

(a) Active (b) Associate (c) Associate and Assistant Scientific Staff (d) Clinical Associate (e) Consultant (f) Honorary

Categories

Section 4.02 The Active Staff shall consist of those physicians or dentists whose principal responsibilities are with the Hospital. This status shall be subject to the annual reappointment process. Active Staff may be eligible to be granted privileges to admit and direct the treatment of patients. Every member of the Active Staff shall:

(a) be a member of the MSA, pay annual dues thereto, have a vote at MSA meetings and be eligible to hold elected or appointed offices therein;

(b) be bound by the attendance requirements for Department and MSA meetings and shall be subject to penalties provided for inadequate attendance; and

(c) be responsible to the Chief of the Department to which such member is assigned and to the President for all aspects of patient care, research and teaching and performed by or for him or her in the Hospital, for administrative responsibilities where assigned, and for the performance of research activities in accordance with Hospital and University policies.

Active Staff

Section 4.03 Associate Staff appointments are comprised of individuals whose principal professional activities are outside of the Hospital. Members of the Associate Staff may be eligible to be granted privileges by the Chief of the Department, to admit and direct treatment of patients. This status shall be subject to the annual reappointment process. Every member of the Associate Staff:

(a) is eligible to be a non-voting member of the MSA, is not required to pay MSA dues, and is not eligible to vote or hold office;

(b) may be bound by the attendance requirements for Department meetings and be subject to penalties provided for inadequate attendance; and

(c) will be responsible to the Chief of the Department to which

Associate Staff


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such member is assigned and to the President for all aspects of patient care, research and teaching performed by or for him or her in the Hospital, administrative responsibilities where assigned, and for the performance of research activities in accordance with Hospital and University policies.

Section 4.04 Members of the Associate Scientific Staff:

(a) shall hold a doctoral or masters level qualification or the equivalent as is acceptable to the Board;

(b) may be cross-appointed to the University Faculty or staff; (c) shall not have admitting privileges; (d) may work independently in research, teaching or patient care

without the direct supervision of a staff physician; (e) shall be responsible to the Chief for the performance of all

activities in accordance with Hospital and University policy. Members of the Assistant Scientific Staff:

(a) shall not have admitting or patient care privileges; (b) shall have a designated role in research, teaching, or patient

care under the supervision of a staff physician; (c) shall be responsible to the Chief for the performance of all

activities in accordance with Hospital and University policy.

Associate and Assistant Scientific Staff

Section 4.05 A Consultant shall consist of physicians or dentists appointed by the Board who:

(a) are a Chairman of a University Department and are not otherwise a member of the Medical Staff;

or (b) have specific experience which is of value to the Hospital; Consultants: shall not have admitting and patient care privileges; shall consult with Members when requested by the Chief of a

Department or his designate; shall not have a vote at Association meetings not be eligible to

hold elected or appointed offices; shall not be bound by attendance requirements of the

Department or Association meetings; shall be responsible to the Chief of the Department to which

the physician or dentist is assigned for all aspects of patient care and teaching performed by or for him in the hospital; shall be responsible to the Chief for the performance of research activities in accordance with Hospital and University policy.

Consultant


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No person may apply for an appointment as a Consultant. Consultant privileges must be requested by the Chief-of-Service who will provide reasons for this appointment as well as the curriculum vitae of the candidate. Section 4.06 Clinical Associate Staff shall consist of physicians or dentists whose application with the Hospital may be temporary but require privileges during their appointment.

(a) shall not have admitting privileges but may have patient care privileges as specified in their appointment or as designated by the Chief of the relevant Department;

(b) shall not have a vote at Association Meetings nor be eligible to hold elected or appointed offices;

(c) may serve on Medical Staff Committees; (d) may be assigned such duties as are determined by the Chief

of the relevant Department; (e) shall be responsible to the Chief of the Department to which

the Clinical Associate is assigned for all aspects of patient care and teaching performed by the Clinical Associate in the Hospital and for the performance of research activities in accordance with Hospital and University policy.

Clinical Associate

Section 4.07 Honorary Staff are individuals who have retired from the Hospital’s Active or Associate Staff and/or those who have an emeritus University appointment. The Honorary Staff shall consist of physicians or dentists recognized for their outstanding reputations, their noteworthy contribution to the health and medical sciences and/or their previous long standing service to the Hospital. Members of the Honorary Staff:

(a) are not eligible to admit Patients to the Hospital; (b) are not assigned regular duties or responsibilities; (c) are not required to attend Department meetings; and (d) are not eligible for membership in the MSA.

Honorary Staff


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ARTICLE 5 PRIVILEGES

Section 5.01 An individual appointed to the Medical or Dental Staff who requests privileges may be granted privileges allowing him or her to perform all those procedures normally within the competence of a trained and certified specialist in his or her particular specialty. It is recognized that, because of advancing technology, an individual may request privileges for procedures which are not included in the program of training for his or her particular specialty. The privileges-granting process requires the recommendation and approval of the appropriate Department Chief and the Medical Advisory Council who may recommend specific restrictions if for any reason the individual’s capability, training or experience warrant such restrictions or may advise on additional training to be taken, or competence to be demonstrated, prior to the granting of privileges.

Competence

Section 5.02 The following privileges may be requested: The President, upon the recommendation of a Chief of a Department, may allow a medical practitioner or dentist to practice in the Hospital upon such terms and for such period as the President determines after the Medical Affairs office has verified that the practitioner is duly registered with the appropriate licensing body in the Province of Ontario, and is in good standing with the Canadian Medical Protective Association, the Royal College of Dental Surgeons or other body providing appropriate professional liability insurance services and provide evidence in the form of a photocopy of the membership such as a condition of appointment. An up-to-date curriculum vitae shall also be provided. Such temporary privileges may be granted in cases where:

i) an application for appointment is pending; ii) the applicant is a nationally or internationally

recognized authority in his or her field; iii) the immediate needs of the Department or the

Hospital make such temporary privileges desirable; or

iv) in other circumstances when deemed appropriate.

The extent and duration of such privileges shall be clearly stated, and the applicant shall be accountable to the Department Chief.

Temporary Privileges


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Temporary privileges may range from one day to a maximum of one year, terminating on June 30 of each year. Notwithstanding the foregoing, all such privileges will be presented to the Board of Trustees for approval at the first Board meeting following the granting thereof. The Board may, on the recommendation of MAC, extend, terminate or amend the privileges granted in such manner as it deems appropriate. Temporary privileges can be renewed for a maximum of an additional year. The Board, upon receiving a recommendation, if any, of the Medical Advisory Council, may approve the recommendation of the said Committee with respect to the granting of temporary privileges or make such other determination as it considers desirable.

Section 5.03 Admitting Privileges to allow the individual to admit patients to the Hospital, attend to and direct the treatment of these patients as the designated Responsible Physician.

Admitting

Section 5.04 Operating Room Privileges to allow the physician or dentist to perform surgical procedures within the competence of a specialist in the particular specialty. Operating room privileges will also be granted to Anaesthesiologists in the Department of Anesthesia unless a request to the contrary is made by the Chief.

Operating Room

Section 5.05 Newborn Nursery Visiting Privileges (NNVP) are granted to paediatricians or family physicians who:

(a) are recommended for this privilege by the Paediatrician-in-Chief or the Family Physician-in-Chief in consultation with the Paediatrician-in-Chief in the case of family physicians;

(b) are limited to the care of infants in Level I nurseries; (c) may attend deliveries of these infants but resuscitation, if

necessary, remains the responsibility of the full-time neonatal staff;

(d) shall be responsible to the Chief of the Department of Paediatrics/Neonatology, for the performance of all activities in accordance with Departmental, Hospital and University policies;

(e) in the case of family physicians, shall meet specific requirements which are delineated in the Department of Family Medicine policies and procedures.

NNVP


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Section 5.06 The Family Physician-in-Chief, in consultation with the Obstetrician & Gynaecologist-in-Chief, may recommend members of the Department of Family Medicine for obstetrical privileges. To be eligible for recommendation of obstetrical privileges, the physician would be required to:

(a) maintain malpractice insurance for obstetrics; (b) perform a specified minimum number of deliveries; (c) document a minimum number of hours of continuing

education in obstetrics; (d) be assessed as satisfactory by an annual peer review

committee.

Obstetrical Privileges for Family Physicians

Section 5.07 Special privileges may be given to allow an individual to perform specified invasive or other specialized procedures not normally considered within the competence of a trained and certified specialist in the particular specialty. Specific details of the privileges are to be outlined by the Department Chief. Special procedures include:

i) pacemaker implants; ii) the use of lasers in the operating room; iii) the performance of endoscopic procedures not

normally part of the Fellowship training program; iv) the performance of E.R.C.P.; v) the performance of trans-esophageal

echocardiography; vi) other procedures as defined from time to time by

the Chief of the Department. The process for obtaining these privileges is available through the Medical Affairs office.

Other Invasive or Special Procedures

Section 5.08 Where a Medical or Dental Staff member wishes to apply for or amend his or her privileges, an application shall be submitted listing the privileges or amendments requested and evidence of appropriate Division Head(s) and Department Chief(s) review and then in turn to the MAC’s Credentials Committee, the MAC and the Board.

Application for Changes

Section 5.09 A Medical or Dental Staff member may apply for privileges in more than one Department or Division. In such cases, one

Privileges in Another Department or


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Department/Division shall be designated as the Department/Division of Primary Appointment, and the individual will hold Associate Staff privileges in the other department. Recommendations to the MAC for the granting or amendment of privileges in a Department/Division which is not the Department/Division of Primary Appointment must be made by the Chiefs of both the primary and secondary Departments.

Division

Section 5.10 Staff Physicians or the Department Chief may request the presence of observers for periods not in excess of four (4) weeks. The Credentials Committee must approve any extension beyond this period. Observers shall not have any patient care responsibilities. The individual or Chief of Service requesting observer privileges shall complete the prescribed form and send it to the Vice-President Medical Affairs for approval. Observer privileges will come into effect only after the Vice-President Medical Affairs has signed the prescribed form.

Observers

Section 5.11 Temporary operating room privileges may be awarded to selected final year surgical postgraduate trainees and fellows upon the recommendation of the Chief. These temporary privileges are subject to the following conditions. The resident/fellow:

(a) will personally obtain the signed consent form from the patient;

(b) will make a signed and dated notation in the doctor’s order that permission from the patient to perform the surgery was obtained;

(c) will make a signed notation in the doctor’s order indicating that authorization to perform the surgery has been obtained from the attending surgeon (who should countersign this at some future time).

Housestaff Temporary Operating Room Privileges

Section 5.12 Privileges will be monitored, controlled and/or restricted as set out below:

Monitoring of Privileges

Staff Members’ Responsibility (a) Every member of the Medical and Dental Staff shall discuss

his or her level of competence with the Division Head or Department Chief as part of his or her annual review; and


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Department Chiefs’ Responsibility (b) In exercising his or her overall responsibility for the quality of

care in his or her Department, the Division Head and/or Department Chief shall only approve those applications for privileges which he or she has reason to believe are within the competence of the applicant and recommend specific exclusions if he or she has reason to do so. The Department Chief has a statutory duty under the Public Hospitals Act to take action if there is a serious problem in diagnosis, care or treatment of Patients.

Section 5.13 A member of the Medical or Dental Staff may have any or all privileges temporarily or permanently, restricted or suspended for failure to comply with the Public Hospitals Act and its Regulations, the Hospital By-Laws, mission or Policies and Procedures. Any incident giving rise to a possible restriction or suspension of privileges shall be discussed between the Chief of the Department of which the individual is a member, the President and the Vice-President Medical Affairs, prior to the making of a recommendation for restriction or suspension.

Temporary Restriction or Suspension of Privileges

Section 5.14 The Chief of the Department of which the individual is a member shall promptly submit to the MAC a written report on the restriction or suspension of privileges with all relevant materials or information. A copy of the report and materials shall be provided to the Member at the same time. The MAC shall, on reasonable notice to the Member, then conduct a review of the decision, at which the Member may make submissions. At the review the MAC may:

(a) set aside the restriction or suspension of privileges; or (b) recommend to the Board such restriction or

suspension of privileges be continued on such terms as it deems appropriate.

Notwithstanding the above, the MAC may also refer the matter to the Professional Affairs Committee of the MAC for investigation.

Refer to MAC for Recommendations re Temporary Restriction or Suspension of Privileges

Section 5.15 If the MAC recommends the continuation of the restriction or suspension of privileges and/or makes further recommendations concerning discipline, the MAC shall give written notice to the member of the Medical and Dental Staff and to the Board of its

Written Notice for Restrictions or Suspensions of Privileges


18

recommendation, in accordance with the Public Hospitals Act. Section 5.16 In addition to the power conferred by Section 5.9, the President or Vice-President Medical Affairs may, by written notice to a Medical or Dental Staff member, temporarily restrict or suspend any or all privileges of that member, if, in the opinion of the President or Vice-President Medical Affairs, the member has failed to comply with such Policies as have been approved from time to time by the MAC relating to the maintenance of health records. Upon the correction of any such deficiencies and in the time frame delineated by the Health Records Committee, the restriction or suspension shall be lifted by the President or Vice-President Medical Affairs.

Health Records

ARTICLE 6 DEPARTMENTS AND DEPARTMENTAL MEETINGS

Section 6.01 The Clinical Departments of the Staff currently include those listed below:

(a) Anaesthesia (b) Dentistry (c) Family Medicine (d) Medical Imaging (e) Medicine (f) Microbiology (g) Obstetrics/Gynaecology (h) Ophthalmology (i) Otolaryngology (j) Paediatrics (k) Pathology and Laboratory Medicine (l) Psychiatry (m) Surgery

When warranted by the professional resources of the Staff, the Board, with the advice of the MAC, may establish or disband Departments of the Staff at any time. In accordance with Article 7 of these By-Laws, the Board shall appoint a Chief of each Department.

Clinical Departments


19

Each Department or Division shall function in accordance with these By-Laws and the Regulations. When the Board appoints a member of the Staff, the individual shall be assigned to the Department(s)/Division(s) for which he or she is qualified. Every member of Staff shall have a Department/Division of primary appointment and may have cross-appointments to other Departments/Divisions in accordance with 5.09.

Section 6.02 Each Department shall hold a minimum of ten (10) regular meetings during the fiscal year and the minutes of each meeting shall be properly recorded and a copy sent to the Vice-President, Medical Affairs office.

Minutes of Meetings

Section 6.03 All Departments meetings shall be called by the Department Chief or his or her Associate Chief, by giving at least forty-eight (48) hours written notice.

Notice

Section 6.04 Each Member of the Active Staff must attend, at the discretion of the Chief, 50% or more of the departmental meetings. Attendance shall be a consideration in regard to reappointment.

Attendance Requirements

ARTICLE 7 REVIEW AND SEARCH COMMITTEES

Section 7.01

(a) The appointment of a Chief of a Medical or Dental Department shall be made jointly by the Board and by the Board of Governors of the University of Toronto after consideration of the recommendation(s) of a Joint Search Committee of the Hospital and the University of Toronto in accordance with the Affiliation Agreement.

(b) Pursuant to the University policy regarding the term of

office for Chiefs of Service, the following conditions shall apply to appointments of Chiefs of Service:

The Chief of a Department shall be appointed by the Board for a one year term, and may be reappointed for four subsequent one year terms with each such term to commence on July 1 or on or about the

Appointment of Chief


20

termination date of the previous Chief of the Department.

Section 7.02 Prior to the reappointment of any Chief of a Department who has served in that capacity for five one year terms, there shall be a major performance review in accordance with the Affiliation Agreement.

First Term Review

Section 7.03 Prior to the appointment of a Chief of a Department which has been served by the same Chief for ten one year terms, there shall be a formal open search to which the existing Chief may apply. In extraordinary circumstances, after ten one year terms, the incumbent may be given consideration for an additional appointment and the Search Committee may recommend to the President and Chief Executive Officer that the incumbent should be appointed without going through a more extensive search process. In such cases the Search Committee may be required by the President and Chief Executive Officer to document the reasons for this recommendation with the understanding that the Hospital President may then decide whether to accept the recommendation, or to ask the Search Committee to conduct a broader search with the understanding that the incumbent may be a candidate if he/she chooses to submit his/her name. After three consecutive five-year terms, a broad search will be conducted even if the incumbent is a candidate for the position.

Second and Third Term Reviews

Section 7.04 Notwithstanding the above, in the case of a very small Department, it may be impractical to appoint a new Chief based on a ten year rotation policy. Hence, in cases where Departments have five or less Active Staff, the Hospital and the University may agree to waive the turnover policy.

Search Exception

Section 7.05 When the Departmental Chief to be selected or reappointed is also to be appointed a Chair of a University Department, the search and review procedures outlined in these bylaws and the Hospital policies shall be expanded as required to accommodate the requirements of both the Hospital and University.

University Department Chair

Section 7.06 Search/Review Committees will be chaired by a Board Member

Search/Review Committee


21

and/or the President and Chief Executive Officer and have representation from the Dean of the Faculty of Medicine or Dentistry or representative, the Chair of the University Department or representative, the Hospital Department, the President, Vice-President Nursing, Vice-President Medical Affairs, a representative from the staff of the pertinent department, a representative(s) from related department(s), and other members as needed. Minutes from search committees shall be considered confidential. Recommendations shall be transmitted to the Board for consideration. The Board will make the final decision. Section 7.07 Each Head shall be appointed by the Board following the recommendation of the Chief of the Department after consultation with the Chairman of the University Department and subsequent MAC and Board approval. The Head shall be appointed for one year terms, each such term to commence on July 1.

Appointment of Head of Division

Section 7.08 (a) Prior to the reappointment of any Division Head who has

served in that capacity for five one year terms there shall be a formal review of the performance of the Division Head.

(b) Reappointment of a Division Head shall be based on the

outcome of the five year review. A Division Head shall not normally serve in that capacity for more than ten one year terms. It is understood that at the end of a ten year tenure of such Division Head, a Search Committee shall be struck by the Chief of the Hospital department for the purpose of selecting an individual to head the Division, with the understanding that the incumbent may be a candidate if he/she chooses to submit his/her name.

First Term and Second Term Review

Section 7.09 (a) In extraordinary circumstances, after ten one year terms,

the Search Committee may recommend to the Hospital Chief that the incumbent should be reappointed without going through a broader search process involving the interview of other candidates. Documentation of the reasons supporting this recommendation must be submitted to the Hospital Chief, and the Chief may then decide whether to accept this recommendation or to ask the Search Committee to conduct a broader search involving other candidates, with the understanding that the

Head of Division Search Exceptions


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incumbent may choose to submit his/her name if he/she so desires.

(b) Notwithstanding the above, in the case of the very small

division it may be impractical to appoint a new Division Head based on a ten year rotation policy. Hence, in cases where divisions have five or fewer physicians, the Hospital and the University may agree to waive the turnover policy.

ARTICLE 8 DEPARTMENT CHIEF, ASSOCIATE CHIEF AND

DIVISION HEAD DUTIES Section 8.01 A Department Chief, in addition to fulfilling the requirements of the Public Hospitals Act and regulations hereunder shall:

(a) Be responsible to the President for the academic, clinical, research and administrative activities of his or her Department;

(b) Be accountable to the MAC for the quality of medical diagnosis, care and treatment provided to patients of his or her Department;

(c) Ensure that all Patients assigned to the care of his or her Department have a clearly defined Responsible Physician (Physician most responsible for the care of the patient) at all times;

(d) Prepare and keep current a Medical Human Resources Plan based on the Hospital’s evolving mission, strategic plan and resources;

(e) Present the Medical Human Resources Plan on an annual basis to MAC to support a Hospital-wide Medical Human Resources Plan based on the Hospital’s evolving mission, strategic plan and resources;

(f) Where necessary nominate a Deputy Chief and appoint Division Heads for his or her Department;

(g) Be responsible for the development of performance criteria for Members of the Department. The criteria shall include standards of clinical, academic and research excellence as well as collegial relationship building and maintenance. Each member shall undergo periodic performance evaluation by the Chief or designate, who will meet with the Member to discuss the evaluation and record the

Department Chief Duties


23

substance of the meeting in writing with a copy to the Member;

(h) Be responsible for the supervision and direction of Housestaff and for the education of medical students while they are assigned to his or her Department;

(i) Be responsible for the management and administration of his or her Department including participation in the development of the Hospital’s major planning processes; and

(j) Take action as required under Hospital policy and the Public Hospitals Act when he or she becomes aware of a serious problem in the diagnosis, care or treatment of a patient assigned to his/her Department. Such action is to inform the MAC Chair and the President and reassign patient care duties, following procedures in the Public Hospitals Act.

Section 8.02 The Department Chief may nominate a Deputy Chief who shall:

(a) Have responsibilities as clearly delegated by the Department Chief; and

(b) Assume the duties and responsibilities of the Department Chief during the Chief’s absence or inability to attend to his or her duties as Chief.

Deputy Chief Duties

Section 8.03 The Division Head shall be responsible to the Department Chief for:

(a) The organization of the Division; (b) Establishing such Division-specific rules as are necessary; (c) The quality of professional care provided in the Division

and making recommendations to the Department Chief for improvements thereof as deemed necessary;

(d) The discipline within the Division including issues related to timely completion of health records;

(e) The teaching and research within the Division; (f) The management and administration of the Division

including participation in the development of the Hospital’s major planning processes;

(g) The annual recommendation to the Department Chief of the privileges to be granted to the members of the Division; and

(h) Such other responsibilities as may be delegated to him or

Division Head Duties


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her by the Department Chief.

ARTICLE 9 MEDICAL STAFF ASSOCIATION (MSA)

Section 9.01 The MSA is the organization which represents the interests of Staff. The MSA is composed of the physicians and dentists who hold an appointment on the staff. Members of Staff who are Active Staff members and have paid their dues are eligible to vote or hold office in the MSA. Members of Staff who are Associate Staff members are not eligible to vote or hold office in the MSA. The MSA shall:

(a) Be concerned with matters relating to the Staff and provide a forum for discussion of such matters;

(b) Reflect, as best it can, the overall opinion of the Staff to the appropriate individuals, such as Department Chiefs and to bodies, such as the MAC and the Board.

Composition and Responsibility

Section 9.02 The quorum at any meeting of the MSA shall be no less than twenty (20) of all voting members at the time of said meeting.

Quorum

Section 9.03 (a) The MSA shall meet at least three (3) times a year, in addition to the Annual Meeting, to discuss medical and scientific topics and for the purpose of receiving various reports from the Council. A quorum for Medical Staff meetings shall be twenty (20). All such meetings shall be arranged by the Executive who shall also arrange such special meetings, as it may consider advisable. A record of the proceedings and attendance at such meetings will be maintained. (b) Each Member of the Active Staff should attend at least 50% of the quarterly Medical Staff meetings. Attendance at such conferences and meetings shall be taken into consideration in regard to reappointment.

General Meetings

Section 9.04 The President of the MSA or the Secretary of the MSA may call a special general meeting at any time on his or her own initiative, and shall call such a meeting if requested to do so by:

(a) the Board;

Special Meetings


25

(b) the President; (c) the MAC Chair; or (d) any fifteen (15) Active Staff members, in writing.

Section 9.05

(a) In the notices for the June meeting, prior to an election year, the Executive shall present to the membership of the Association the list of names who were nominated to stand for the offices of the Executive.

(b) Any further nominations may be made by members of the Association by writing to the President with fourteen (14) days after the distribution of the names referred to in Section (a).

(c) Further nominations may be accepted from the floor at that meeting by a majority vote of those present who are entitled to vote.

(d) Voting will then take place for each position on the Executive Committee by an open ballot.

(e) A closed ballot may be requested by a majority vote of those present at the meeting.

(f) The new Executive shall be installed at the meeting and shall hold office until the next election.

Election Procedure

Section 9.06 Subject to annual reappointment to the Staff, the elected officers of the MSA shall be elected for a two (2) year term and shall include:

(a) a President (b) a Vice President (c) a Secretary (d) a Treasurer

Terms and Officers

Section 9.07 The President of the MSA shall not be eligible to be elected as an officer of the MSA immediately following the two (2) year term as President.

Limitation on Eligibility

Section 9.08 No officer can be re-elected to the same office on completion of a two (2) year term but remains eligible for another office of the MSA Executive, subject to Section 9.07 and annual re-appointment to the Staff.

Limitation on Terms

Section 9.09 Nomination


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A Nomination Committee composed of members of Staff shall be appointed by the President of the MSA at least six (6) weeks prior to the Annual Meeting to prepare nominations for election of officers of the MSA as prescribed in Hospital policies. Section 9.10 Vacancies among elected officers of the MSA which occur between Annual Meetings shall be filled by members of the staff elected at a duly called meeting of the Medical Staff Association at which a quorum is present.

Vacancies

Section 9.11 The President of the MSA shall:

(a) be an ex-officio member of the Board and the MAC and represent the views of the MSA to the Board and MAC;

(b) chair the general meetings of the MSA; (c) appoint the Nominating Committee (usually the members

of the Executive Committee of the Medical Staff Association) to prepare nominations for the election of officers of the MSA;

(d) appoint such committees as may be required to assist in carrying out the business of the Medical Staff Association, provided that any such committee shall report through the President of the MSA or his or her designate; and

(e) report minutes of general meetings of the MSA and of appointed committee meetings to the next meeting of the MAC for comment and consideration and subsequent submission to the Board for approval.

President’s Duties

Section 9.12 The Vice-President of the MSA shall be an ex-officio member of the Board and the MAC and shall act in the place of the President of the MSA when required to do so. The Vice-President shall perform such duties as may be assigned by the President of the MSA.

Vice-President’s Duties

Section 9.13 The Secretary of MSA shall:

(a) perform the duties of the President of the MSA in the absence or inability to act of the President and both Vice-Presidents of the MSA;

(b) keep the minutes of all general and annual meetings of the

Secretary’s Duties


27

MSA and of the Medical Staff Committee. A record will be maintained by name of each member in attendance at such meetings. An explanation in writing may be accepted for absence but does not give credit for attendance;

(c) where a quorum of the MSA is not present at the place named for any meeting within thirty (30) minutes of the scheduled start of the meeting, give those members present credit for attendance;

(d) perform such other duties as the Medical Staff Association may direct.

Section 9.14 The Treasurer shall be responsible for the annual collection of dues from the Medical Staff and for all financial matters pertaining to this office.

Treasurers Duties

Section 9.15 The amount of the dues shall be determined by a majority vote of the membership at the Annual Meeting in June. All active staff, with the exception of cross-appointments from other institutions, are required to maintain Medical Staff Association membership.

Dues

ARTICLE 10 MEDICAL ADVISORY COUNCIL

Section 10.01 The Medical Advisory Council shall be appointed by the Board for a period of one (1) year from July 1st and shall consist of:

(a) the Chief of Anaesthesia (b) the Head of the Division of Adult Critical Care; (c) the Chief of Dentistry; (d) the Chief of Family Medicine (e) the Chief of Medical Imaging; (f) the Chief of Medicine; (g) the Chief of Microbiology (h) the Chief of Obstetrics and Gynecology (i) the Chief of Ophthalmology; (j) the Chief of Otolaryngology; (k) the Chief of Paediatrics (l) the Chief of Pathology and Laboratory Medicine (m) the Chief of Psychiatry (n) the Chief of Surgery (o) the MSA President;

Composition


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(p) the MSA First Vice-President; (q) the President; (r) the Vice-President Nursing; (s) the Vice-President Medical Affairs; (t) the Vice-President of Research; (u) the Medical Director of Baycrest Hospital; (v) the Chair of the Research Ethics Board; (w) such other persons as the Board may designate.

Section 10.02 At any meeting of the MAC or its subcommittees, one half of the voting members shall constitute a quorum. For matters relating to Medical and Dental Staff Appointments and Privileges, voting privileges will be held only by those committee members who are members of the Medical and Dental Staff. For all other business, voting privileges will be held by each member of the MAC.

Quorum

Section 10.03 If unable to attend a meeting of the MAC, a member of the MAC shall notify the MAC Chair and the Vice-President Medical Affairs of the expected absence and request that an alternate attend to observe. The alternate will not have voting privileges unless these have been requested by the Departmental Chief in writing to the Chair of the MAC who shall inform the Chief of any reason this request is not granted.

Alternatives

Section 10.04 At any meeting of the MAC or its subcommittees, questions shall be decided by a majority of the votes cast thereon in person or by proxy, and in the case of a deadlock on any vote, the Chair shall be entitled to have a second or casting vote.

Voting

Section 10.05 The MAC shall be responsible to the Board:

(a) to carry out such functions as stipulated in the Public Hospitals Act and its Regulations as well as those functions the Board may direct;

(b) to meet at least ten (10) times per year; (c) to report in writing at each regularly scheduled meeting of

the Board respecting the practice of medicine in the Hospital;

(d) to make recommendations to the Board respecting: i) the quality of medical and dental care provided in

MAC Duties


29

the Hospital; ii) appointment or re-appointment to the Staff and

the privileges to be granted to each member of the Staff;

iii) the appointment of the Chairs of the Committee of the MAC;

iv) the dismissal, suspension or restriction of privileges of any member of the Staff;

v) clinical and general rules and regulations respecting the Staff as may be necessary in the circumstances;

vi) the Hospital’s patient care policies which require Board approval pursuant to the Public Hospitals Act or regulations hereunder; and

(e) to refer or delegate, as appropriate, any other matter to subcommittees of the MAC.

Section 10.06 A subcommittee of MAC is responsible to the MAC for matters referred or delegated to it by the MAC. Matters referred are for investigation and report back to the MAC with recommendations. Matters delegated require consideration by the MAC before recommendations are made to the Board. Functions of the MAC which may be referred to other MAC subcommittees for investigation and report back to MAC with recommendations include the following:

(a) after consultation with the relevant Department Chiefs, Division Heads, Department Heads or Vice-Presidents, development of acceptable standards of:

i) medical and dental care; ii) care provided by members of the other health

professional staff of the Hospital; iii) the admission and discharge of Patients and any

other matters of concern on which the Hospital administration may seek guidance;

(b) The regulation, discipline and instruction of medical students and residents with respect to their professional duties and responsibilities.

Subcommittee Duties

Section 10.07 The Board shall appoint a Chair of the MAC after consideration of recommendations from the President. The term of appointment shall be for two (2) years. The incumbent may be re-appointed and shall, in any case, hold office until a successor is appointed. The maximum number of consecutive terms shall be two (2). The Chair of the MAC will function as the Chief-of-Staff for the hospital.

Chair Appointment and Term


30

Section 10.08 All clinical Department Chiefs shall be eligible for nomination as MAC Chair or Vice-Chair. In April of each year, the past Chair, the President, and Vice-President Medical Affairs, will form a Nomination Committee to consider nominations for the position of MAC Chair and/or Vice-Chair.

Chair and Vice-Chair Eligibility

Section 10.09 The MAC Chair shall:

(a) chair meetings of the MAC; (b) be a member of the Board; (c) be an ex-officio member of all MAC subcommittees with

privileges to attend meetings and vote if he or she so wishes;

(d) advise the MAC and Board with respect to the quality of medical diagnosis, care and treatment provided to Patients and advise the Board with respect to standards of appropriate medical care;

(e) deliver such reports as the MAC is required to make under the Public Hospitals Act, the regulations hereunder or these By-Laws;

(f) perform such other duties as are described in the Hospital policies; and

(g) in consultation with the President or Vice-President Medical Affairs, designate an alternate to act during an absence of both the MAC Chair and Vice-Chair.

Chair’s Duties

Section 10.10 The Board shall appoint a Vice-Chair who shall act in the place of the MAC Chair if absent or unable to act, and shall be a non-voting member, ex-officio, of all subcommittees of the MAC.

Vice-Chair’s Duties

Section 10.11 As directed by the MAC Chair, the Recording Secretary shall:

(a) be responsible for notification of meetings, the agenda and the maintenance of accurate minutes of all meetings of the MAC;

(b) provide the President of the Hospital with a copy of the minutes and reports as required under these By-Laws;

(c) Call special meetings of the MAC when requested by the Board, the President of the Hospital, the MAC Chair or any three (3) members of the MAC.

Recording Secretary’s Duties


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Section 10.12 When the office of MAC Chair becomes vacant, the Board may request nominations from the Nominating Committee of MAC in order to appoint a new Chair to fill the vacancy.

Nominations

ARTICLE 11 COMMITTEES OF MAC

Section 11.01 Pursuant to the Public Hospitals Act and the regulation hereunder, the following MAC standing subcommittees are hereby established by the Board:

(a) Acute Resuscitation Committee (b) Clinical Practice Committee (c) Credentials Committee (d) Ethics Committee (e) Health Records Committee (f) Infection Control Committee (g) Pharmacy and Therapeutics Committee (h) Transfusion Committee (i) Professional Affairs Committee

MAC Standing Subcommittees

11.02 Purpose of the Acute Resuscitation Committee: To ensure that all adult or post-neonatal (> 1 month old) patients and visitors within Mount Sinai Hospital receive acute resuscitation when needed in accordance with best known practice by:

(a) establishing educational and training standards for all

Mount Sinai Hospital staff providing basic and advanced life support;

(b) determining and meeting educational needs related to resuscitation;

(c) develop and revise policies/procedures related to resuscitation practice within Mount Sinai Hospital;

(d) maintain continuing quality improvement programs related to Mount Sinai Hospital resuscitation practice;

(e) Provide expert advice and service where appropriate regarding resuscitation to other groups within the Mount Sinai Hospital community including Princess Margaret

Acute Resuscitation Committee


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Hospital; (f) Provide a forum for discussion of issues and problem

solving. Frequency of Meetings: Monthly at the discretion of the co-chairs.

Membership: Co-chair – M.D. from the Adult Critical Care Unit Co-chair – Nursing representative/Respiratory Therapy from

the Adult Critical Care Unit Departmental Representation: Medicine – Critical Care Medicine/Nursing – Cardiology Medicine – Anaesthesia Medicine – Emergency Medicine – Chief Medical Resident Medicine – Princess Margaret Hospital Nursing – ICU Nursing – Emergency Nursing – Surgery/PACU Nursing – Medicine Respiratory Therapy Nursing Administration Pharmacy Risk Management Infection Control

11.03 Purpose of the Clinical Practice Committee:

(a) The primary purpose of the Clinical Practice Committee is to recommend to the Medical Advisory Council the adoption of professional policies and procedures regarding hospital preprinted Physician’s order/order sets, medical directives and Delegated Controlled Acts;

(b) The Clinical Practice Committee shall be responsible for communication of the above mentioned policies/directives to all departments and teams;

(c) The Committee will collect the necessary data regarding quality and risk as applied to the above activities.

Objectives:

Clinical Practice Committee


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To provide a forum for members of clinical teams to present professional policies and procedures regarding preprinted Physician’s order/order sets, medical directives and Delegated Controlled Acts, to ensure that the process outlined in the policies and procedures for the development and approval of same, has been followed.

To recommend appropriate policies/directives to the Medical Advisory Council for approval.

To ensure that a process is in place to review all of the above. To maintain records, for quality and risk management, of what has been approved and the review process followed.

To maintain an inventory of approved preprinted Physician’s order/order sets, medical directives and Delegated Controlled Acts.

Membership: Membership is appointed by the Medical Advisory Council. The membership will be multidisciplinary with representation from:

- Anesthesia - Critical Care - NICU - ER - Laboratory Medicine - Medicine - Nurse Clinician - Nurse Practitioner - Nutrition - Pharmacy - Infection Control - Program Director, Nursing - Radiology - Rehabilitation - Respiratory Therapy - Quality and Risk Management - Health Records (Department or Committee link)

The Chairperson is appointed by the Medical Advisory Council. Meetings: The Chairperson shall call meetings as deemed necessary

but not less than six times per year.


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The position of Secretary will be rotated. 11.04 Purpose of the Credentials Committee:

a) Investigate the credentials submitted by the applicants for membership on the Medical Staff;

b) Evaluate the form completed by the Chief of the respective Service entitled “Information Regarding the Staff Appointments under Consideration” which has been reviewed initially by the President;

c) Submit its findings and recommendations in writing for Active Staff applications to the Medical Advisory Council for approval;

d) This Committee shall meet as required to consider Medical Staff changes.

This Committee shall include:

(a) Chairman and Vice-Chairman of the Council, the latter to act as Chairman of the Committee;

(b) President of Medical Staff Association; (c) President; (d) Vice-President Medical Affairs.

Credentials

11.05 Reporting Accountability: The primary reporting relationship of the Clinical Ethics Committee (CEC) shall be to the Medical Advisory Council (MAC). The committee also has a reporting link to Senior Management. Purpose of the Clinical Ethics Committee:

(a) (CEC) shall develop institutional policy on ethical issues (e.g. do not resuscitate orders) and shall be consulted by other committees developing policy which raises ethical issues (e.g. critical care interventions, access to scarce resources).

(b) The CEC shall organize and provide educational sessions on new policies and on ethical issues affecting staff, patients and their families at Mount Sinai Hospital.

(c) The CEC will collaborate with the hospital bioethicist in the bioethics case consultation process. The Ethics Committee

Clinical Ethics Committee


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will respond to policy issues arising from individual case consultations. The CEC shall also be a forum for case consultation and review. Any member of the MSH community may access the CEC for consultation and review.

(d) The committee will collect the necessary data regarding quality and risk as applied to the above activities.

Membership: The CEC shall have no less than 10 and no more than 15

members. The CEC shall have a representative from each of the

clinical councils (Women’s and Infants’, Medical and Surgical/Oncology) and the Board.

The CEC should have representation from the following groups: physician, nurse, social worker, bioethicist, lawyer, chaplain, patient representative, hospital administration, member of lay public. The REB may participate on an ad hoc basis.

The CEC may have a number of non-voting student members (eg. residents, graduate students).

If a member attends less than half of the Ethics Committee meetings during the course of a year, that member may be replaced.

Meetings: The chairperson shall call meetings as deemed necessary

but not less than six times per year. Quorum for the CEC shall be fifty percent of CEC members,

plus one. The agenda shall be set by the Chair in consultation with the

members of the CEC The bioethicist shall present a summary of case

consultations and other relevant activities to each meeting of the Ethics Committee.

Minutes of each meeting shall be kept and shall reflect the substance of the discussion and arguments put forth, including dissenting opinions, discussions, arguments and any decisions made. Minutes will be distributed to all CEC members, and forwarded to MAC.

The CEC shall, whenever possible, strive to achieve consensus on issues. When consensus cannot be achieved after a reasonable period of time, a majority vote of


36

members present shall rule. Dissenting views may be presented in writing, along with the recommendations for approval.

11.06 Purpose of the Health Records Committee: To assure that individual health records are a comprehensive, integrated reflection of clinical care provided at Mount Sinai Hospital and identify opportunities to improve the structures and processes related to the management of health records for patients and clinicians. The Health Records Committee (HRC) reports to the Medical Advisory Council (MAC). Each member is responsible to report to his or her respective program, department and/or team to:

(a) review and recommend to the Medical Advisory Council the Rules and Regulations governing the storage and retrieval of health records;

(b) set standards for the health record, and ensure these standards are maintained;

(c) review, and when appropriate, recommend to the Medical Advisory Council improvement opportunities to assure high quality health record keeping;

(d) monitor and ensure compliance with the requirements of the Public Hospitals Act and the By-laws and Rules and Regulations of the Medical Staff on the part of all persons having a responsibility for completing health records;

(e) develop and oversee a process for approval of forms pertaining to clinical care in the hospital;

(f) review and approve policies and procedures related to the access and management of health records, especially as Mount Sinai moves towards the Electronic Patient Record;

(g) address issues related to the integration of inpatient and outpatient records;

(h) review the format and integration of decision support rules and tools, maintain linkages with other Clinical committees;

(i) perform any other duties as prescribed by the Medical Advisory Council.

Membership: Representation from:

- Surgery

Health Records Committee


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- Medicine - Women’s and Infant Health Program - Emergency Department - Laboratory Medicine - Nursing - Pharmacy - Health Records Services - Risk Management - Radiology - Psychiatry - Corporate Privacy Office - Senior Hospital Administration

Meetings:

The Committee shall meet monthly (at least 8 times per

year) and at the call of the chairperson. The Manager of Health Records will hold the position of

secretary. 11.07 The purpose of the Infection Control Committee: The Infection Control Committee is responsible for assuring that infection control practices are comprehensive, reflected in hospital policy, and integrated into clinical practice provided at Mount Sinai Hospital and its affiliated sites. The Committee shall aid in the development and maintenance of the Infection Control Program. The Infection Control Committee is responsible for the identification of opportunities to improve structures and processes related to infection control practice. Goals/Functions:

(a) to monitor and develop policies, procedures, and processes for infection prevention and control within Mount Sinai Hospital and its sites. These shall apply to all patients, visitors, and personnel of the Hospital;

(b) to review and approve policies and procedures and ensure they comply with legislative requirements and provincial directives;

(c) to approve guidelines for the safe practice of patient care across the organization as it pertains to infection control;

Infection Control Committee


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(d) to establish and maintain a quality assurance program for all aspects of infection prevention, monitoring and control;

(e) to review and approve education plans and strategies regarding infection control and prevention;

(f) to function as a part of the Outbreak Management Team in times of suspected or actual outbreak;

(g) perform any other duties as designated by MAC.

Membership:

The membership is composed of representatives from the interdisciplinary health care team representing all three programs and supported by key departments:

- Department Head – Director of Infection Control - the Vice-President to whom Infection Control reports - One representative from Nursing Advisory Committee (NAC) from each of the following programs:

o Surgical Program o Clinical Specialties Program o Obstetrical/ Perinatology Program

- Physician representative - Medicine (1) - Physician representative - Surgery (1) - Physician representative - Obstetrics/ Perinatology (1) - Diagnostic Imaging (1) - Microbiology (1) - Respiratory Therapy (1) - Occupational Health and Safety (1) - Housekeeping (1) - Pharmacy (1) - Infection Control Practitioners (all) - Toronto Public Health (1) - Quality Assurance, Risk Management

The Committee may recommend additional members attend as needed. Members who are unable to attend are responsible for allocating an alternate representative at the meeting.

Reporting Relationship/ Accountability:

The Infection Control Committee is accountable to the

Medical Advisory Council (MAC) at Mount Sinai Hospital. The Infection Control Committee provides Nursing Advisory

Committee (NAC) with updated communications on its activities and recommendations.


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Frequency of Meetings:

The Committee will meet monthly at least 8 times per year.

Quorum: Major decisions related to the safe practice of infection

control and prevention will be made by the Infection Control Committee as necessary. Decisions will be made when there is a quorum of representatives present. Major decisions require input from 50% plus 1 of the membership.

11.08 The purpose of the Pharmacy and Therapeutics Committee is as follows: As a standing committee of the MAC, the Pharmacy and Therapeutics Committee is advisory to the MAC with authority and responsibilities to include:

(a) serve in an advisory capacity to the Medical and Dental Staff and Administration in all matters pertaining to the use of drugs;

(b) serve in an advisory capacity to the Medical and Dental Staff and the Pharmacy Department in the selection or the choice of drugs which meet the most effective therapeutic quality standards;

(c) develop and modify a Formulary for use in the Hospital, and to minimize duplication of the included drugs: i) review policies regarding the safe use of drugs

including their administration; ii) study problems involved in the proper distribution of

medications to inpatients and outpatients; iii) monitor drug usage in terms of safety, efficacy and

costs; iv) review the recommendations of the University of

Toronto’s Human Experimentation Committee and give approval for use of investigation drugs in the Hospital;

v) plan suitable programs on the collection and distribution of drug information; and

vi) make recommendations on any of the above to the Medical Advisory Council.

Representation from:

- Administration

Pharmacy and Therapeutics Committee


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- Nursing - Selected Clinical Departments - Infection Control Officer - Director of Pharmacy - Chief Medical Resident - Other persons as designated by the Committee Chairman

This Committee shall meet as required. 11.09 The purpose of the Transfusion Committee is to:

(a) promote high standards of transfusion medicine practice; (b) develop specific standards of transfusion practice

appropriate for Mount Sinai Hospital; (c) develop policies and procedures relevant to the practice of

transfusion medicine; (d) review transfusion practice by comparison with

predetermined specific standards; and, (e) review the performance of the Hospital blood transfusion

service. This Committee shall include: Head, Blood Transfusion Services; Representation from:

- Administration - Blood Transfusion Services - Microbiology/Infectious Diseases - Surgical/Perioperative Council

o Surgery o Anesthesia o Nursing

- Women’s and Infant Health Council o Obstetrics and Gynaecology o Neonatology

- Medical/Community Health Council o Medicine o Nursing

Other persons as designated by the Chairman. This Committee shall meet as required.

Transfusion Committee

Section 11.10 The purpose of the Professional Affairs Committee is to:

(a) review grievances relating to the granting or reduction of

Professional Affairs Committee


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clinical privileges brought forward by a member of the Medical or Dental Staff;

(b) review recommendations for discipline concerning a member of the Medical or Dental Staff brought forward by the President or the Chief of the Department to which the member is appointed;

(c) review incidences of disruptive behaviour by a member of the Medical or Dental Staff;

(d) report in confidence to the Chair of MAC, to the President and Vice-President Medical Affairs. This report shall be available to the MAC, and after consideration of the matter, the MAC shall make such recommendations as it deems appropriate for the resolution of the;

(e) in appropriate cases, recommend to the MAC that disciplinary action involving restriction, suspension or removal of privileges be taken against any member of the Medical or Dental Staff.

The Professional Affairs Committee shall consist of the following members:

(a) the MAC Vice-Chair, as Chair; (b) a representative of the MSA named by the President of the

MSA; (c) a member of the MAC appointed by the MAC Chair or his or

her designate; (d) the President; (e) the Vice-President Medical Affairs; and (f) other individuals as needed

This Committee shall meet as required. Section 11.11 The MAC may recommend to the Board the establishment of other standing subcommittees of MAC. The MAC may also establish ad hoc subcommittees to fulfill specified tasks or investigations. Such ad hoc subcommittees shall be disbanded after making their recommendations to the MAC.

Other Committees

Section 11.12 The MAC shall appoint the Staff members of the MAC subcommittees which are established in accordance with these By-Laws. The MAC shall also appoint the Chair of each such subcommittee.

Appointment


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Section 11.13 The duties and powers of the committees listed in Section 11 are summarized in these By-Laws. Duties, powers, composition and procedures for all other subcommittees of the MAC are detailed in the Hospital policies.

Duties and Powers

ARTICLE 12 MIDWIVES

Section 12.01 Only an individual who is qualified to practice midwifery and registered with the College of Midwives is eligible to apply for membership for staff appointment. Applicants for Midwifery privileges must be certified by the College of Midwives. Applicants for midwifery shall carry proof of liability insurance of at least $10 million. Applicants for midwifery are subject to all articles in the Mount Sinai Hospital Medical/Dental Staff Bylaws.

Appointment Criteria

Section 12.02 Midwives applying for privileges at Mount Sinai Hospital shall: 1. Agree to notify the President of any changes in his/her license

to practice midwifery as made by the College of Midwives. 2. Agree to provide the following: Complete application form; Notarized copy of proof of registration with College of

Midwives; Notarized copy of current Certificate of Professional Conduct

from the College of Midwives; Fully executed Consent to release information from the

Registrar; Proof of Liability Insurance (not less than $10 million); Three letters of reference (one from the graduating school,

and two from former placements); Resume outlining training, qualifications and experience; Where the Midwife has completed the Ontario Midwifery

University program, the following must be provided: i) letter from faculty attesting to the ability of the

Process


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midwife to function in the Hospital as part of a team; and

ii) transcript of Pre-registration Program and copies of diplomas received from any Midwifery Education Program.

Where the midwife is registered with the College of Midwives on the basis of credentials other than Ontario Midwifery University Program, the following must be provided:

i) copy of diploma or proof of completion of recognized Midwifery Education Program; and

ii) a letter of reference outlining the midwife’s hospital experience.

Midwives shall apply for privileges through the Department of Family Medicine;

Based on the established number of deliveries and the clinical and economic resources of the Perinatology Program, a maximum of 10 midwives may be appointed at any one time.

Section 12.03 Each member of the Midwifery Staff:

(a) shall practice Midwifery as defined by core competencies outline in the “Core Competencies Document” of the Interim Regulatory Council on Midwifery;

(b) shall work with clear indications for mandatory consultation and transfer of care according to the Interim Regulatory Council on Midwifery;

(c) may write orders for therapies, drugs, routine nursing care, laboratory tests and diagnostic imaging in accordance with the Midwife’s Pharmacopoeia, suggested lab tests and imaging procedures;

(d) perform epidural top-up and monitoring as delegated to midwives.

Responsibilities

Midwives will follow a similar process for reappointment as that of the Medical Staff. They will receive a performance evaluation from the Chief of Family Medicine.

Reappointment

ARTICLE 13 BAYCREST CENTRE FOR GERIATRIC CARE


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BAYCREST CENTRE FOR GERIATRIC CARE Section 13.01 Baycrest is a medical affiliate of the Hospital and assignments of responsibility at that institution shall be of equal importance to comparable assignments at the Hospital. Section 13.02 The Chiefs of Service of Mount Sinai Hospital with corresponding departments at Baycrest which provide consultation services to Baycrest shall, upon appointment by Baycrest, serve as senior consultants at Baycrest in their respective specialties. Such senior consultants may submit nominations of consultants to the Chairman of Baycrest’s Medical Advisory Council indicating the period of time they should serve on the Consulting Medical Staff, not to exceed one year. Section 13.03 The Chief of the corresponding Department of Mount Sinai Hospital who is a senior consultant of the Centre, in conjunction with the Medical Advisory Committee of Baycrest, shall recommend to the Board of Directors of Baycrest the Heads of Departments at Baycrest.

Affiliation Appointments

Section 13.04 The Chairman of the Medical Advisory Committee of Baycrest shall report at regular intervals to the Council in regards to the activities of the Medical Staff at Baycrest.

Reporting

ARTICLE 14 AMENDMENT OF BY-LAWS

Section 14.01 All previous By-Laws are hereby repealed, provided that such repeal shall not affect the previous operation of any By-Law so repealed or affect the validity of any act done or right, privilege, obligation or liability acquired or occurred under, or the validity of any contract or agreement made pursuant to any such By-Law prior to its repeal. All persons acting under any By-Law so repealed shall continue to act as if appointed under the provisions of this By-Law and all resolutions of the Trustees or Board with continuing effect passed under any repeal By-Law shall continue in effect except to the extent inconsistent wit this By-Law and until

Repeals


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amended or appealed. Section 14.02 Subject to the Act of Incorporation and the Public Hospitals Act, the By-Laws of the Hospital may be altered, amended or repealed and new By-Laws may be enacted by the Board at a meeting thereof duly called for the purpose of considering any such alteration, amendment, repeal or new By-Laws, provided that two week’s notice of the proposed alteration, amendment, repeal or new By-Laws shall have been given in writing preceding such meeting and provided that the amendment receives the affirmative vote of at least two-thirds of the appointed Trustees present at a duly constituted meeting of the Board.

Amendments

Section 14.03 Notwithstanding anything herein contained, these By-Laws shall be subject to the provisions of the Public Hospitals Act and Regulations thereunder, as amended from time to time, and to all other applicable legislation, and shall be ineffective to the extent in conflict therewith.

Conflict with Acts

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