BYLAWS OF THE MEDICAL STAFF OF Hospital,, West Virginia PREAMBLE

Transcription

1 BYLAWS OF THE MEDICAL STAFF OF Hospital,, West Virginia PREAMBLE WHEREAS, Hospital., is a corporation organized under the laws of the State of West Virginia; and WHEREAS, its purpose is to serve as a general hospital providing patient care, education, and research; and WHEREAS, it is recognized that the medical staff is responsible for the quality of medical care in the hospital and must accept and discharge this responsibility, subject to the ultimate authority of the hospital governing body, and that the cooperative efforts of the medical staff, the chief executive officer and the governing body are necessary to fulfill the hospital's obligations to its patients; THEREFORE, the physicians and dentists practicing in this hospital hereby organize themselves into a medical staff in conformity with these bylaws. DEFINITIONS 1. The term "medical staff" means all medical physicians and osteopathic physicians holding unlimited licenses, and duly licensed dentists, who are privileged to attend patients in the hospital. 2. The term "governing body" means the board of directors of the hospital. 3. The term "executive committee" means the executive committee of the medical staff unless specific reference is made to the executive committee of the governing body. 4. The term "chief executive officer", administrator means the individual appointed by the governing body to act in its behalf in the overall management of the hospital. His title shall be "CEO" Administrator. 5. The term "practitioner" means an appropriately licensed medical physician, an osteopathic physician with an unlimited license or an appropriately licensed dentist. 6. The team health professional affiliate or affiliate means an individual, other than a licensed physician or dentist, whose patient care activities require that his or her authority to perform specified patient care services be approved through the usual medical credentialing process. 7. The term "service" means that group of practitioners who have clinical privileges in one of the general areas of medicine, surgery, obstetrics, and pediatrics. Page 1 of 44

2 8. The term "chief of service" means the medical staff member duly appointed or elected in accordance with these bylaws to serve as the head of a service. 9. Clinical Privileges or Privileges means the permission granted to a practitioner to render specific diagnostic, therapeutic, medical, dental or surgical services. 10. Dentist means an individual who has been awarded the degree of doctor of dentistry (D.D.S.) or doctor of dental medicine (D.D.M.). 11. EX-OFFICIO means service as a member of a body by virtue of an office or position held and, unless otherwise expressly provided, means without voting rights. 12. MEDICAL STAFF YEAR means the period from 1 through PHYSICIAN means an individual who has been awarded the degree of doctor of medicine (M.D.), or the degree of doctor of osteopathy (D.O.) licensed in West Virginia 14. (PRESIDENT, CEO, Administrator) means the individual appointed by the board to act on its behalf in overall administrative management of the hospital. 15. LIMITED HEALTH PRACTITIONER means an individual, other than a licensed physician or dentist whose patient care activities require that his authority to perform specified patient care services be processed through the medical staff channels or with involvement of medical staff representatives. 16. GOOD STANDING means the staff member has met the attendance requirements during the previous medical staff year, and is not under a suspension of his appointment or admitting privileges. 17. SPECIAL NOTICE means written notification sent by certified mail, return receipt requested. ARTICLE I: NAME The name of this organization shall be the Medical-Dental Staff of ARTICLE II: PURPOSES AND RESPONSIBILITIES The purposes of this organization are: 1. To ensure that all patients admitted to or treated in any of the facilities, departments, or services of the hospital shall receive quality medical care. Page 2 of 44

3 2. To ensure a high level of professional performance of all practitioners and limited health practitioners authorized to practice in the hospital through the appropriate delineation of the clinical privileges that each practitioner may exercise in the hospital and through an ongoing review and evaluation of each practitioner s performance in the hospital. 3. To provide an appropriate educational setting that will maintain scientific standards and that will lead to continuous advancement in professional knowledge and skill. 4. To initiate and maintain rules and regulations for self-government of the medical staff; and 5. To provide a means whereby issues concerning the medical staff and the hospital may be discussed by the medical staff with the governing body and the chief executive officer. 6. To be the formal organization structure through which: A. The benefits of membership on the staff may be obtained by individual practitioners, and B. The obligations of staff membership may be fulfilled. 7. To serve as the primary means for accountability to the board for the appropriateness of the professional performance and ethical conduct of its members and to strive toward assuring that the pattern of patient care in the hospital is consistently maintained at the level of quality and locally available. 8. To provide a means through which the staff may participate in the hospital's policy-making and planning process. The responsibilities of this organization are: The responsibilities of the staff, to be fulfilled through the actions of its officers, departments and committees, include: 1. To account for the quality and appropriateness of patient care rendered by all practitioners and limited health practitioners authorized to practice in the hospital through the following measures: A. A credentials program, including mechanisms for appointment and reappointment, and the matching of clinical privileges to be exercised or of specified services to be performed, with the verified credentials and current demonstrated performance of the applicant, staff member or limited health practitioner: B. A continuing education program. C. A utilization review program to allocate inpatient and outpatient medical and health services based upon patient specific determinations of individual medical needs. Page 3 of 44

4 D. Review and evaluation of the quality of patient care through a valid and reliable quality assessment procedure. 2. To recommend to the board action with respect to appointments, reappointments, staff category, clinical privileges, and corrective action. 3. To account to the board for the quality and efficiency of patient care rendered to patients in the hospital through regular reports and recommendations concerning the implementation, operation and results of the quality/utilization management activities. 4. To develop, administer and seek compliance with these bylaws, the rules and regulations of the staff, and other patient care related hospital policies. 5. To assist in identifying community health needs. 6. To exercise the authority granted by these bylaws as necessary to adequately fulfill the foregoing responsibilities. ARTICLE III: MEDICAL STAFF MEMBERSHIP Section 1. Nature of Medical Staff Membership Membership on the medical staff of is a privilege which shall be extended only to professionally competent physicians and dentists who continuously meet the qualifications, standards, and requirements set forth in these bylaws. No person shall be denied membership on the medical staff on the basis of sex, race, creed, color or national origin. Section 2. Qualifications for Membership a. Only physicians and dentists licensed to practice in the State of West Virginia, who can document their background, experience, training, and demonstrate competence, their physical and/or mental health status, evidence of professional liability insurance coverage as required herein, their adherence to the ethics of their profession, their good reputation, and their ability to work with others, with sufficient adequacy to assure the medical staff and the governing body that any patient treated by them in the hospital will be given high quality medical care in an economically efficient manner, taking into account patient needs, the available hospital facilities and resources, and utilization standards in effect at the hospital, shall be qualified for membership on the medical staff. No physician or dentist shall be entitled to membership on the medical staff or to the exercise of particular clinical privileges in the hospital merely by virtue of the fact that he is duly licensed to practice medicine or dentistry in this or in any other state, or that he is a member of any professional organization, or that he had in the past, or presently has, such privileges at another hospital. Page 4 of 44

5 b. Acceptance of membership on the medical staff shall constitute the staff member s agreement that he will strictly abide by the Principles of Medical Ethics of the American Medical Association or by the Code of Ethics of the American Dental Association, whichever is applicable, (as the same are appended to and made a part of these bylaws.) c. All members of the medical staff shall at all times be required to provide and maintain a current certificate of insurance from an insurance company licensed or approved to do business in West Virginia to verify malpractice liability coverage. The amount of coverage required shall be in accordance with the minimum requirements of the hospital s professional liability insurance carrier as it now exists and as it may hereinafter be amended. All members of the medical staff shall be required to report involvement in a professional liability action. At a minimum, final judgments or settlements. d. All members of the medical staff shall at all times be required to adhere to any and all information practices and procedures as required for HIPAA compliance involving protected health information (PHI). Section 3. Conditions and Duration of Appointment a. Initial appointments and reappointments to the medical staff shall be made by the governing body. The governing body shall act on appointments, reappointments, or revocations of appointments only after there has been a recommendation from the medical staff as provided in these bylaws; provided that in the event of unwarranted delay on the part of the medical staff (1 20 days from the date the application, supporting materials and all other materials and information deemed pertinent have been received), the governing body may act without such recommendation on the basis of documented evidence of the applicant s or staff member s professional and ethical qualification obtained from reliable sources other than the medical staff. b. Initial appointments shall be for a period of six months. Reappointments shall be for a period of not more than every two years. For the purposes of these bylaws the medical staff commences on the 1st day 30th day of of each year, which coincides with the fiscal year of the hospital. c. Appointment to the medical staff shall confer on the appointee only such clinical privileges as have been granted by the governing body, in accordance with these bylaws, and rules and regulations of the medical staff. d. Every application for the staff appointment shall be signed by the applicant and shall contain the applicant s specific acknowledgment of every medical staff member s obligations to provide continuous care and supervision of his patients, to abide by the medical staff bylaws, rules and regulations, to accept committee assignments and to accept consultation assignments and to participate in staffing the emergency service area and other special care units of the hospital. Page 5 of 44

6 Section 4: Non-discrimination The Hospital will not discriminate in granting medical staff appointments/clinical privileges on the basis of age, gender, creed, national origin, pregnancy, religion, disability, or any other status characteristic protected by law. Section 1. The Medical Staff ARTICLE IV: CATEGORIES OF THE MEDICAL STAFF The medical staff shall be divided into active, honorary, associate, courtesy, and consulting categories. Section 2. The Honorary Medical Staff The honorary medical staff shall consist of physicians and dentists who are not active in the hospital or who are honored by emeritus positions. These may be physicians and dentists who have retired from active hospital practice or who are of outstanding reputation, not necessarily residing in the community. Honorary staff members shall not be eligible to admit patients, to vote, hold office or to serve on standing medical staff committees. Section 3. The Active Medical Staff The active medical staff shall consist of physicians and dentists who regularly admit patients to the hospital, who are located closely enough to the hospital to provide continuous care to their patients, and who assume all the functions and responsibilities of membership on the active medical staff, including, where appropriate, emergency service care and consultation assignments. Members of the active medical staff shall be appointed to a specific service, shall be eligible to vote, to hold office and to serve on medical staff committees, and shall be required to attend medical staff meetings. Section 4. The Associate Medical Staff The associate medical staff shall consist of physicians and dentists who are being considered for advancement to membership on the active staff. They shall be appointed to a specific service and shall be eligible to serve on service committees and to vote on matters before such committees. They shall be ineligible to vote or hold office in this medical staff organization. They shall be required to attend medical staff meetings. Section 5. The Courtesy Medical Staff The courtesy medical staff shall consist of physicians and dentists qualified for staff membership but who only occasionally admit patients to the hospital or who act only as consultants. Courtesy medical staff members shall be appointed to a specific department but shall not be eligible to vote or hold office in this medical staff organization. They may be appointed to serve on service committees and to vote on Page 6 of 44

7 matters before such committees to which they are appointed. They may admit no more than four patients per year. Section 6. The Consulting Medical Staff The consulting medical staff shall consist of recognized specialists who are active in the hospital or who have signified a willingness to accept such appointment. Normally, members of this category are physicians or dentists who desire this rank and who come to the hospital only occasionally, either on schedule or by call and who serve only in a consulting capacity. Members of this class shall be ineligible to vote or hold office in this medical staff organization. They may be eligible to serve on medical staff committees and to vote on matters coming before the committees on which they do serve. Section 7. Appointments Provisional a. All initial appointments to any category of the medical staff shall be for a period of six months. Reappointments to provisional membership may not exceed one full medical staff year, at which time the failure to advance an appointee from provisional to regular staff status shall be deemed a termination of his staff appointment. A provisional appointee whose membership is so terminated shall have the rights accorded to these bylaws to a member of the medical staff who has failed to be reappointed. b. Provisional staff members shall be assigned to a department where their performance shall be observed by the chairman of the department or his representative to determine the eligibility of such provisional members for regular staff membership and for exercising the clinical privileges provisionally granted to them. c. Provisional medical staff members are ineligible to hold office in this medical staff organization. They shall be eligible to serve on medical staff committees and to vote on matters before such committees. They shall be required to attend medical staff meetings but shall not be allowed to vote at such meetings. Section 8. Affiliate Staff Membership It is recognized that other healthcare professionals may provide definitive and beneficial care to the hospitalized patient and these healthcare professionals merit a position in the healthcare organization. For these circumstances, the status of Affiliate is developed. These healthcare professionals might include podiatrists, psychologists, physician assistants, nurse practitioners, audiologists, speech pathologists, prosthetics and orthotics, and other affiliates. All affiliate, accorded hospital privileges, must comply with all applicable bylaws, rules and regulations governing the medical staff. Applications for affiliate status shall be submitted and processed in the same manner as applications for medical staff Page 7 of 44

8 membership. Members of the affiliate staff who have been accorded the privilege of admission shall exercise this privilege with the concept of dual responsibility; that is the affiliate staff member is responsible for rendering the care of the patient within his province while a member of the active or associate medical staff, with appropriate privileges is responsible for the overall care of the patient of the hospital stay. Dismissal of affiliate staff patients is a dual responsibility for the affiliate staff member and the member of the medical staff assuming overall medical responsibility for the patient. 8.1 Podiatrist affiliates The podiatrist accorded hospital privileges must comply with all applicable by laws, rules, and regulations governing the medical staff Provisions for keeping accurate and complete clinicial records, both podiatric and medical, must be made for all patients treated in the hospital and should be completed at the time of discharge. The podiatrist is responsible for his or her field and will write the podiatric history and physical; the physician, the medical history and the physical In this regard, under the concept of dual responsibility, the podiatrist is responsible for the podiatric care of the patient while a member of the active medical staff, with appropriate privileges, is responsible for the overall care of the patient during the hospital stay Dismissal of podiatric patients is a dual responsibility for the attending podiatrist and the member of the active medical staff assuming overall medical responsibility for the patient. When the case is primarily podiatric and no other medical complications are present, the member of the active medical staff may indicate on the patient s record that the patient is eligible for dismissal at the discretion of the attending podiatrist. This would be conversely applicable if the case were primarily medical. Each is responsible for his or her section of the patient s record, including final diagnosis and proper signature entered in the record Applicants for the podiatric staff of the hospital must meet the following minimum requirements: (a) Be graduate of Schools of Podiatry approved by the Council of Education of the American Podiatric Association and be legally licensed to practice podiatry in the state of West Virginia. (b) Must successfully complete a minimum of one (1) year postgraduate training approved by the Council on Education of the American Podiatric Association. (c) If requesting surgical privileges must successfully complete a minimum of one (1) year postgraduate training in surgery at an institution approved by the Council on Podiatric Medical Education and/or the American Podiatric Medical Association, with a minimum of five (5) years of current surgical practice experience in an accredited hospital with the United States. Page 8 of 44

9 8.1-5 Scope of privileges will be determined by review of application by the Credentialing and Ethics Committee and those privileges may not exceed the West Virginia law governing podiatrists. 8.2 Clinical psychologists All psychologists shall possess the appropriate West Virginia state licensure. In cooperation with the attending physician, the psychologist may perform psychological evaluations; group, individual, and family psychotherapy; and other functions within the province of their licensure. 8.3 Physician s Assistants In order to be classified as a physician s assistant a person must have successfully completed an accredited course in the specific field of endeavor; he or she must be eligible to take the certifying examination of the appropriate accrediting agencies and must meet the requirements for such field of endeavor as established by the West Virginia State Board of Medicine or other agency of proper jurisdiction in West Virginia A qualified physician s assistant may: (a) Make entries in the progress notes of medical records (b) Write on the physician s order sheet, orders dictated by a member of the active medical staff in the same manner as does a registered nurse with the orders to be countersigned by the physician so ordering. (c) Carry out the orders of the employing physician The employing physician will assume full responsibility for the Assistant All duties to be performed by a physician s assistant must be submitted in writing and approved by the Credentialing and Ethics Committee. These privileges shall be renewed annually by the Credentialing and Ethics Committee. 8.4 Nurse Practitioners In order to be classified as a registered nurse practitioner, a person must have successfully completed an accredited course in the specific field of endeavor; must be eligible to take the Certifying Examination of the appropriate accrediting agencies established in the specific field; and must meet the requirements for such field of endeavor as established by the West Virginia State Board of Medicine or other agency of the proper jurisdiction in West Virginia A qualified registered nurse practitioner may: (a) Make entries in the progress notes of medical records of patients. (b) Write on the physician s order sheet, orders dictated by members of the active medical staff in the same manner as does the staff nurse with the orders to be countersigned by the physician so ordering. (c) Carry out orders as designated by the physician in charge Page 9 of 44

10 8.4-3 The employing physician will assume full responsibility for the registered nurse practitioners All duties to be performed by the registered nurse practitioner must be submitted in writing to and approved by the Credentialing and Ethics Committee. These privileges shall be renewed annually by the Credentialing and Ethics Committee. 8.5 Audiologists All audiologists shall be graduates of recognized speech and hearing programs as defined by the American Speech, Language and Hearing Association or their equivalent. Audiologists shall possess a state license in audiology and hold the Certificate of Clinical Competence from the American Speech, Language, and Hearing Association When requested by an attending physician, the audiologist may perform hearing evaluations, special diagnostic testing and other functions within the province of their licensure. 8.6 Speech Pathologists In order to be classified as a speech/language pathologist, a person must have successfully completed a Master s degree program in the specific field of endeavor; must have passed the certifying examination of the appropriate accrediting agencies established in the specific field; and must be licensed as a speech/language pathologists by the West Virginia Board of Examiners for Speech/Language Pathology and Audiology A qualified Speech/Language pathologist my: (a) Provide evaluation and therapy services for communication disorders (b) May carry out the orders of the attending physician (c) Make entries in the progress notes of the medical record. 8.7 Prosthetics and Orthotics In order to be classified as a certified Prosthetist/Orthotist, an individual must be certified by the American Board for Certification in Orthotics and Prosthetics, Inc. Currently, the minimum qualifications require a candidate to possess a Bachelors degree in any field and also to have successfully completed an ABC accredited long-term (certificate) educational program in Prosthetics and/or Orthotics and have acquired a minimum of one (1) year acceptable experience in each discipline, ( i.e. prosthetics or orthotics) after successful completion of the certificate program A certified Prosthetist/Orthotist may Page 10 of 44

11 (a) Consult with a licensed medical physician on the need for a new prosthesis and/or orthosis for the patient (b) Design, construct, and fit a new prosthesis and/or orthosis for a patient. (c) Modify and repair existing prostheses and/or orthoses. (d) Consult with physician and/or occupational therapists on the training for a patient wearing a prosthesis and/or orthosis. 8.8 Other Affiliates Other affiliate positions of the medical staff for non-physician professionals associated with the surgical or nonsurgical departments, as their special skills warrant, may be created by the medical staff and the composition, function, and limitations of such positions defined in writing and appendaged to these Medical Staff Bylaws Application for these positions must be supported by appropriate and specific training and licensure by state certification where applicable. Work of these applicants must be directed toward inpatient diagnostic or therapeutic procedures. ARTICLE V: PROCEDURE FOR APPOINTMENT AND REAPPOINTMENT Section 1. Application for Appointment a. All applications for appointment to the medical staff shall be in writing, shall be signed by the applicant, and shall be submitted on a form prescribed by the governing body after consultation with the executive committee. The applications shall require detailed information concerning the applicant s professional qualifications and physical and/or mental health status, shall include the name of at least two persons who have had extensive experience in observing and working with the applicant and who can provide adequate references pertaining to the applicant s professional competence and ethical character, and shall include information as to whether the applicant s membership status and/or clinical privileges have ever been revoked, suspended, reduced, or not renewed at any other hospital or institution, and as to whether his membership in local, state or national medical societies, or his license to practice any profession in any jurisdiction, has ever been suspended or terminated. The applicant shall also state whether the applicant s narcotic license has ever been suspended or revoked and information concerning an applicant s malpractice experience, including a consent to the release of information from his present and past malpractice insurance carriers; and require information confirming the applicant s compliance relating to malpractice liability coverage. Page 11 of 44

12 b. The applicant shall have the burden of producing adequate information for a proper evaluation of his competence, character, ethics and other qualifications, and for resolving any doubts about such qualifications. c. The completed application shall be submitted to the chief executive officer/ administrator. After collecting the reference and other materials deemed pertinent, he or she shall transmit the application and all supporting materials to the executive committee for evaluation. d. By applying for appointment to the medical staff, each applicant thereby signifies his or her willingness to appear for interviews in regard to his or her application, authorizes the hospital to consult with members of the medical staffs or other hospitals with which the applicant has been associated and with others who may have information bearing on his or her competence, character, and ethical qualifications, consents to the hospital s inspection of all records and documents that may be material to an evaluation of his or her professional qualifications and competence to carry out the clinical privileges he or she requests as well as of his or her moral and ethical qualifications for staff membership, releases from any liability all representatives of the hospital and its medical staff for their acts performed in good faith and without malice in connection with evaluating the applicant and his credentials, and release from any liability all individuals and organizations who provide information to the hospital in good faith and without malice concerning the applicant s competence, ethics, character and other qualifications for staff appointment and clinical privileges, including otherwise privileged or confidential information. e. The application form shall include a statement that the applicant has received and read the bylaws of the hospital governing body and the bylaws, rules and regulations of the medical staff and that he or she agrees to be bound by the terms thereof if he is granted membership and/or clinical privileges and to be bound by the terms thereof without regard to whether or not he or she is granted membership and/or clinical privileges in all matters relating to consideration of this application. Section 2. Appointment Process a. Within 60 days after receipt of the completed applications for membership, the executive committee shall make a written report of its investigation to the governing body, including its recommendation that the practitioner be provisionally appointed to the medical staff, or that he or she be rejected for medical staff membership, or that his or her application be deferred for further consideration. All recommendations to appoint must also specifically recommend the clinical privileges to be granted, which may, where appropriate, be qualified by probationary conditions. b. Prior to making this report and recommendation, the executive committee shall examine the evidence of the character, professional competence, qualifications and ethical standing of the practitioner and shall determine through information Page 12 of 44

13 contained in references given by the practitioner and from other sources available to the committee, including an appraisal from the clinical service in which privileges are sought, whether the practitioner has established and meets all of the necessary qualifications for the category of staff membership and the clinical privileges requested by him. Every service in which the practitioner seeks clinical privileges shall provide the executive committee with specific, written recommendations for delineating such clinical privileges, and these recommendations shall be made a part of the report. Together with its report, the executive committee shall transmit to the governing body the completed application and all other documentation considered in arriving at its recommendation. c. When the recommendation of the executive committee is to defer the application for further consideration, it must be followed up within 30 days with a subsequent recommendation for provisional appointment with specified clinical privileges, or for rejection for staff membership. d. When the recommendation of the executive committee is favorable to the practitioner, the chief executive officer shall promptly forward it, together with all supporting documentation, to the governing body. e. When the recommendation of the executive committee is adverse to the practitioner either in respect to the appointment or clinical privileges, the chief executive officer/administrator shall promptly so notify the practitioner by certified mail, return receipt requested. No such adverse recommendation need be forwarded to the governing body until after the practitioner has exercised or has been deemed to have waived his or her right to a hearing as provided in Article VIII of these bylaws. f. If, after the executive committee has considered the report and recommendations of the hearing committee and the hearing record, the executive committee s reconsidered recommendation is favorable to the practitioner, it shall be processed in accordance with subparagraph d. of this Section 2. If such recommendation continues to be adverse, the chief executive officer shall promptly so notify the practitioner, by certified mail, return receipt requested. The chief executive officer/administrator shall also forward such recommendation and documentation to the governing body, but the governing body shall not take any action thereon until after the practitioner has exercised or has been deemed to have waived his right to an appellate review as provided in Article VIII of these bylaws. g. At its next regular meeting after receipt of a favorable recommendation, the governing body or its executive committee shall act in the matter. If the governing body s decision is adverse to the practitioner in respect to either appointment or clinical privileges, the chief executive officer/administrator shall promptly notify him or her of such adverse decision by certified mail, return receipt requested, and such adverse decision shall be held in abeyance until the practitioner has exercised or has been deemed to have waived his right under Article VIII of these Page 13 of 44

14 bylaws and until there has been compliance with subparagraph 1 of this Section 2. The fact that the adverse decision is held in abeyance shall not be deemed to confer privileges where none existed before. h. At its next regular meeting after all the practitioner s rights under Article VIII have been exhausted or waived, the governing body or its duly authorized committee shall act in the matter. The governing body s decision shall be conclusive, except that the governing body may defer final determination by referring the matter back for further recommendation. Any such referral back shall state the reasons therefore, shall set a time limit within which a subsequent recommendation to the governing body shall be made, and may include a directive that an additional hearing be conducted to clarify issues which are in doubt. At its next regular meeting after receipt of such subsequent recommendation, and new evidence in the matter, if any, the governing body shall make a decision either to provisionally appoint the practitioner to the staff or to reject him for staff membership. All decisions to appoint shall include a delineation of the clinical privileges which the practitioner may exercise. i. Whenever the governing body s decision will be contrary to the recommendation of the medical staff executive committee, the governing body shall submit the matter to the joint conference committee for review and recommendation and shall consider such recommendation before making its decision final. j. When the governing body s decision is final, it shall send notice of such decision through the chief executive officer/administrator to the president of the medical staff, to the chairman of the executive committee, and to the chief of service concerned, and by certified mail, return receipt requested, to the practitioner. Section 3. Reappointment Process a. At least 30 days prior to the final scheduled governing body meeting in the medical staff year, the executive committee shall review all pertinent information available on each practitioner scheduled for periodic appraisal, for the purpose of determining its recommendations for reappointments to the medical staff and for the granting of clinical privileges for the ensuing period, and shall transmit its recommendations, in writing, to the governing body. Where non-reappointment or a change in clinical privileges is recommended, the reason for such recommendation shall be stated and documented. b. Each recommendation concerning the reappointment of a medical staff member, current licensure, and the clinical privileges to be granted upon reappointment shall be based upon such member s professional competence and clinical judgment in the treatment of patients, his or her ethics and conduct, his or her health status, his or her attendance at medical staff meetings and participation in staff affairs, his or her compliance with the hospital bylaws and the medical staff bylaws, rules and regulations, his or her cooperation with the hospital personnel, his or her use of the hospital s facilities for his or her patients, his or her relations Page 14 of 44

15 with other practitioners, and his or her general attitude towards patients, the hospital, and the public. c. Thereafter, the procedure provided in Section 2 of this Article V relating to recommendations on applications for initial appointment shall be followed. Section 1. Clinical Privileges Restricted ARTICLE VI: CLINICAL PRIVILEGES a. Every practitioner practicing at this hospital by virtue of medical staff membership or otherwise, shall, in connection with such practice, be entitled to exercise only those clinical privileges specifically granted to him or her by the governing body, except as provided in Sections 2 and 3 of this Article VI. b. Every initial application for staff appointment must contain a request for the specific clinical privileges desired by the applicant. The evaluation of such requests shall be based upon the applicant s education, training, experience, demonstrated competence, references and other relevant information, including an appraisal by the service in which such privileges are sought. The applicant shall have the burden of establishing his qualifications and competency in the clinical privileges he requests. Periodic redetermination of clinical privileges and the increase or curtailment of same shall be based upon the direct observation of care provided, review of the records of the patients treated in this or other hospitals and review of the records of the medical staff which document the evaluation of the member s participation in the delivery of medical care. c. Privileges granted to dentists shall be based on their training, experience, and demonstrated competence and judgment. The scope and extent of surgical procedures that each dentist may perform shall be specifically delineated and granted in the same manner as all other surgical privileges. Surgical procedures performed by dentists shall be under the overall supervision of the chief of surgery. All dental patients shall receive the same basic medical appraisal as patients admitted to other - surgical services. A physician member of the medical staff shall be responsible for the care of any medical problems that may be present at the time of admission or that may arise during the hospitalization. d. Applications for additional clinical privileges must be in writing. Such applications shall be processed in the same manner as applications for initial appointment. Section 2. Temporary Privileges a. Upon receipt of an application for medical staff membership from an appropriately, licensed practitioner, the chief executive officer/administrator may, upon the basis of information then available which may reasonably be relied upon as to the competence and ethical standing of the applicant, and with the written concurrence of the service chief and of the chairman of the executive Page 15 of 44

16 committee, grant temporary admitting and clinical privileges to the applicant; but in exercising such privileges, the applicant shall act under the supervision of the chief of the service to which he or she is assigned. b. Temporary clinical privileges may be granted by the chief executive officer/administrator with concurrence of chief of staff for the care of a specific patient to a practitioner who is not an applicant for membership in the same manner and upon the same conditions as set forth in subparagraph a. of this Section 2., provided that there shall first be obtained such practitioner s application for temporary clinical privileges, certification of current West Virginia licensure, appropriate malpractice coverage, signed acknowledgment that he or she has received and read copies of the medical staffs bylaws, rules and regulations and that he or she agrees to be bound by the terms thereof in all matters relating to his or her temporary clinical privileges. Such temporary privileges shall be restricted to the treatment of not more than 4 patients in any one year by any practitioner, after which such practitioner shall be required to apply for membership on the medical staff before being allowed to attend additional patients. c. The chief executive officer/administrator may permit a physician serving as a locum tenens for a member of the medical staff to attend patients without applying for membership on the medical staff for a period not to exceed 60 days, providing all his or her credentials have first been approved by the chief of service concerned and by the chairman of the executive committee, and that he or she signs an application for temporary privileges, provides verification of current West Virginia licensure, appropriate malpractice coverage, and signs an acknowledgment that he or she has received and read copies of the medical staff bylaws, rules and regulations and agrees to be bound by the terms thereof while attending patients in the hospital. d. Special requirements of supervision and reporting may be imposed by the chief of service concerned on any practitioner granted temporary privileges. Temporary privileges shall be immediately terminated by the chief executive officer/administrator, after consultation with the chief of staff, upon notice of any failure by the practitioner to comply with such special conditions. e. The chief executive officer/administrator may at any time, upon the recommendation of the chairman of the executive committee or the chief of service concerned, terminate a practitioner s temporary privileges effective as of the discharge from the hospital of the practitioner s patient(s) then under his or her care in the hospital. However, where it is determined that the life or health of such patient(s) would be endangered by continued treatment by the practitioner, the termination may be imposed by any person entitled to impose a summary suspension pursuant to Section 2a of Article VII of these bylaws, and the same shall be immediately effective. The appropriate chief of service or, in his or her absence, the chairman of the executive committee, shall assign a member of the medical staff to assume responsibility for the care of such terminated Page 16 of 44

17 practitioner s patient(s) until they are discharged from the hospital. The wishes of the patient(s) shall be considered where feasible. f. A practitioner shall not be entitled to the procedural rights offered by Article III because of his or her inability to obtain temporary privileges or because of any termination or suspension of temporary privileges. Section 3. Emergency Privileges In the case of an emergency, any physician or dentist member of the medical staff, to the degree permitted by his or her license and regardless of service or staff status or lack of it, shall be permitted and assisted to do everything possible to save the life of a patient, using every facility of the hospital necessary, including the calling for any consultation necessary or desirable. When an emergency situation no longer exists, such physician or dentist must request the privileges necessary to continue to treat the patient. In the event such privileges are denied or he or she does not desire to request privileges, the patient shall be assigned to an appropriate member of the medical staff. For the purpose of this section, an emergency is defined as a condition in which serious permanent harm would result to a patient or in which the life of a patient is in immediate danger and delay in administering treatment would add to that danger. Section 4. Special Conditions for House Staff Trainees in postgraduate training programs (i.e. residencies, fellowships) shall be permitted to perform those services set out in training protocols developed by the applicable program directors. They shall, in the performance of those services, be subject to all applicable rules and policies of the staff and hospital and of the department. Section 1. Procedure ARTICLE VII: CORRECTIVE ACTION a. Whenever the activities of professional conduct of any practitioner with clinical privileges are considered to be lower than the standards or aims of the medical staff or to be disruptive to the operations of the hospital, corrective action against such practitioner may be requested by any officer of the medical staff, by the chief of any service, by the chairman of any standing committee of the medical staff, by the chief executive officer/administrator, or by the governing body. All requests for corrective action shall be in writing, shall be made to the executive committee, and shall be supported by reference to the specific activities or conduct which constitute the grounds for the request. b. Whenever the corrective action could be a reduction or suspension of clinical privileges, the executive committee shall forward such request to the chief of the service wherein the practitioner has such privileges. Upon receipt of such Page 17 of 44

18 request, the chief of the service shall immediately appoint an ad hoc committee to investigate the matter. c. Within 30 days, and sooner if possible, after the service s receipt of the request for correction action, the service shall make a report of its investigation to the executive committee. Prior to the making of such report, the practitioner against whom corrective action has been requested shall have an opportunity for an interview with the service ad hoc investigating committee. At such an interview, he or she shall be informed of the general nature of the charges against him or her, and shall be invited to discuss, explain, or refute them. This interview shall not constitute a hearing, shall be preliminary in nature, and none of the procedural rules provided in these bylaws with respect to hearings shall apply thereto. A record of such interview shall be made by the service and included with its report to the executive committee. d. Within 30 days, and sooner if possible, following the receipt of a request for corrective action, or following receipt of a report from a service following the service s investigation of a request for corrective action involving reduction or suspension of clinical privileges, the executive committee shall take action upon the request. If the corrective action could involve a reduction or suspension of clinical privileges, or a suspension or expulsion from the medical staff, the affected practitioner shall be permitted to make an appearance before the executive committee prior to its taking action on such request. This appearance shall not constitute a hearing, shall be preliminary in nature, and none of the procedural rules provided in these bylaws with respect to hearings shall apply thereto. A record of such appearance shall be made by the executive committee. e. The action of the executive committee on a request for corrective action may be to reject or modify the request for corrective action, to issue a warning, a letter of admonition, or a letter of reprimand, to impose terms of probation or a requirement for consultation, to recommend reduction, suspension or revocation of clinical privileges, to recommend that an already imposed summary suspension of clinical privileges be terminated, modified or sustained, or to recommend that the practitioner s staff membership be suspended or revoked. f. Any recommendation by the executive committee for reduction, suspension or revocation of clinical privileges, or for suspension or expulsion from the medical staff shall entitle the affected practitioner to the procedural rights provided in Article VIII of these bylaws. g. The chairman of the executive committee shall promptly notify the chief executive officer/administrator in writing of all requests for corrective action received by the executive committee and shall continue to keep the chief executive officer/administrator fully informed of all action taken in connection therewith. After the executive committee has made its recommendation in the matter, the procedure to be followed shall be as provided in Article V, Section 2, and in Article VIII if applicable, of these bylaws. Page 18 of 44

19 Section 2. Summary Suspension a. Any one of the following - the chairman of the executive committee, the president of the medical staff, a chief of service, the chief executive officer/administrator, and the executive committee of either the medical staff or the governing body shall each have authority, whenever action must be taken immediately in the best interest of patient care in the hospital, to summarily suspend all or any portion of the clinical privileges of a practitioner, and such summary suspension shall become effective immediately upon the imposition. b. A practitioner whose clinical privileges have been summarily suspended shall be entitled to request that the executive committee of the medical staff hold a hearing on the matter within such reasonable time period thereafter as the executive committee may be convened in the accordance with Article VIII of these bylaws. c. The executive committee may recommend modification, continuance or termination of the terms of the summary suspension. If, as a result of such hearing, the executive committee does not recommend immediate termination of the summary suspension, the affected practitioner shall, also in accordance with Article VIII, be entitled to request an appellate review by the governing body, but the terms of the summary suspension as sustained or as modified by the executive committee shall remain in effect pending a final decision thereon by the governing body. d. Immediately upon the imposition of a summary suspension, the chairman of the executive committee or responsible chief of service shall have authority to provide for alternative medical coverage for the patients of the suspended practitioner still in the hospital at the time of such suspension. The wishes of the patients shall be considered in the selection of such alternative practitioner. Section 3. Automatic Suspension a. A temporary suspension in the form of withdrawal of a practitioner s admitting privileges, effective until medical records are completed, shall be imposed automatically after warning of delinquency for failure to complete medical records within thirty (30) calendar days of a patient s discharge. In the case of adverse events or the death of a medical practitioner, all said medical records will revert to the Chief of Staff for completion. b. Action by the State Board of Medical Examiners revoking or suspending a practitioner s license, or placing him upon probation, shall automatically suspend all of his hospital privileges. c. It shall be the duty of the president of the medical staff to cooperate with the chief executive officer in enforcing all automatic suspensions. Page 19 of 44