BYLAWS OF THE MEDICAL STAFF. Scott & White Long Term Acute Care Hospital Temple, Texas

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1 BYLAWS OF THE MEDICAL STAFF Scott & White Long Term Acute Care Hospital Temple, Texas

2 TABLE OF CONTENTS PREAMBLE...5 DEFINITIONS...5 ARTICLE ONE PURPOSES AND RESPONSIBILITIES OF THE MEDICAL STAFF Section Purposes...7 Section Responsibilities...7 ARTICLE TWO CATEGORIES OF THE MEDICAL STAFF Section The Medical Staff...8 Section The Honorary/Emeritus Medical Staff...8 Section The Active Medical Staff...9 Section The Courtesy Medical Staff...9 Section The Consulting Medical Staff...9 Section Provisional Status...10 ARTICLE THREE - ALLIED HEALTH PROFESSIONALS Section Qualifications...10 Section 3.2 Procedure for Specification of Privileges...11 ARTICLE FOUR - MEDICAL STAFF APPOINTMENT Section Nature of Medical Staff Appointment Section Specific Qualifications Section No Entitlement to Appointment...13 Section Non-Discrimination Policy...13 Section Ethical Directives...13 Section Duties of Appointees...13 ARTICLE FIVE PROCEDURE FOR APPOINTMENT AND REAPPOINTMENT Section Application for Medical Staff Membership...14 Section Appointment Process...15 Section Reappointment Process...17 Section 5.4 Expedited Credentialing...18 Section 5.5 Leave of Absence...18 ARTICLE SIX - CLINICAL PRIVILEGES Section Application for Clinical Privileges...19 Section Temporary Privileges...20 Section Emergency Privileges...21 Section Special Temporary Privileges...22 Section Procedures for Requesting an Increase in Clinical Privileges

3 ARTICLE SEVEN - CORRECTIVE ACTION Section Professional Conduct and Clinical Privileges...23 Section Precautionary Suspension...24 Section 7.3 Automatic Suspension...24 Section 7.4 Delinquent Medical Records...24 ARTICLE EIGHT - IMMUNITY AND CONFIDENTIALITY Section 8.1 Acceptance of Conditions...25 Section Immunity...25 Section 8.3 Authorization to Obtain Information...26 Section 8.4 Authorization to Release Information...26 Section 8.5 Definitions...27 Section 8.6 Confidentiality and Reporting...27 Section 8.7 Peer Review Protection...27 ARTICLE NINE HEARING AND APPELLATE REVIEW PROCEDURE Section Right to Hearing Procedure...28 Section Request for Hearing...28 Section Notice of Hearing...29 Section Format of Hearing...29 Section Conduct of Hearing...30 Section 9.6 Appeal to Governing Body...32 Section 9.7 Final Decision of the Governing Body...33 Section 9.8 Right to One Appeal Only...33 ARTICLE TEN - OFFICERS Section Officers of the Medical Staff...33 Section Qualifications of Officers...34 Section Appointment of Officers...34 Section Term of Office...34 Section Removal from Office...34 Section Vacancies in Office...34 Section Duties of Officers...34 ARTICLE ELEVEN - COMMITTEES AND FUNCTIONS Section Types of Committees...35 Section Medical Executive Committee...37 Section 11.3 Credentials Committee...38 Section 11.4 Peer Review Committee...39 Section 11.5 Pharmacy and Therapeutics Committee...40 Section 11.6 Infection Control Committee...41 Section 11.7 Quality and Patient Safety Committee...42 ARTICLE TWELVE - COMMITTEE MEETINGS Section Regular Meetings...43 Section Special Meetings

4 Section Notice of Meetings...43 Section Quorum...43 Section Manner of Action...43 Section Rights of Ex-Officio Members...43 Section Minutes...44 Section Attendance Requirements...44 ARTICLE THIRTEEN - MEDICAL STAFF MEETINGS Section The Annual Meeting...44 Section General Medical Staff Meetings...45 Section Special Meetings...45 Section Quorum...45 Section Attendance Requirements...45 Section Agenda...46 ARTICLE FOURTEEN - RULES AND REGULATIONS...46 ARTICLE FIFTEEN - AMENDMENTS...46 ARTICLE SIXTEEN - ADOPTION

5 PREAMBLE WHEREAS Scott & White Long-Term Acute Care Hospital, d/b/a Scott & White Continuing Care Hospital, is authorized to do business in the State of Texas to operate a long term acute care hospital providing care to patients with long term acute care needs; and WHEREAS the laws, regulations, customs and generally recognized professional standards that govern hospitals require that all practitioners practicing at a hospital be formally organized into a collegial body of professionals, providing for its members mutual education, consultation and clinical support, constituting the hospital's medical staff; and WHEREAS a hospital's medical staff is the organizational component to which a hospital's board of directors must delegate responsibility relating to the quality and appropriateness of professional performance; and WHEREAS a hospital's board and management require a source of collective advice from the professionals practicing at the hospital in aid of institutional policy formulation and enforcement, planning, coordination of services and governance; and WHEREAS dedication to this purpose requires a cooperative effort among the professional peers practicing in the hospital and between them and the hospital board and management, with well-defined lines of communication, responsibility and authority throughout the organizational structure; THEREFORE the practitioners practicing in the Hospital hereby organize themselves into a Medical Staff in conformity with these Bylaws, Rules and Regulations, the Articles of Incorporation, Corporate Bylaws, policies and procedures, and philosophy of the Hospital. DEFINITIONS Allied Health Professional or AHP means an Advanced Practice Nurse or Physician Assistant who exercises independent judgment within the areas of his/her professional competence and who is qualified to render medical or surgical care under the supervision of a Practitioner who has been accorded privileges to provide such care in the Hospital. (See Rules and Regulations for further rules regulating these individuals.) Allied Health Professionals shall not be members of the Medical Staff. 5

6 Board of Directors or Board means the Governing Body of Scott & White Long-Term Acute Care Hospital. "Chief Medical Officer" is that Practitioner appointed by the Board to act in cooperation with the Hospital Administrator, and who serves as a member, exofficio, without vote, on all Medical Staff committees and who acts in coordination with the Chief of Staff as defined in these Bylaws. The Chief Medical Officer reports directly to the Board and is responsible for all Medical Staff activities of the Hospital. "Credentials Committee" means the committee which takes primary responsibility to assure that the process for admission to the Medical Staff is complete and comprehensive and without discrimination. "Hospital" means a long term acute care hospital as defined by 42 CFR (e) that is operated by Scott & White Long-Term Acute Care Hospital. "Hospital Administrator" means the individual who reports directly to the Board, through whom all administrative authority over the Hospital flows, and who exercises control and surveillance over all administrative activities of the Hospital. "Medical Executive Committee" or MEC means the executive committee of the Medical Staff unless specific reference is made to the executive committee of the Board. "Medical Staff" or Staff means the formal organization of all Practitioners who are privileged to attend patients or to provide other diagnostic or therapeutic services in the Hospital and is named the Medical Staff of Scott & White Long- Term Acute Care Hospital. Medical Staff Year means calendar year. "Practitioner" means, unless otherwise expressly provided, a licensed medical physician as defined under Texas Statute; an osteopathic physician as defined under Texas Statute; a licensed dentist as defined under Texas Statute; a licensed psychologist as defined under Texas Statute; or a licensed podiatrist as defined under Texas Statute; applying for or exercising clinical privileges or providing other diagnostic or therapeutic services in the Hospital. 6

7 ARTICLE I PURPOSES AND RESPONSIBILITIES OF THE MEDICAL STAFF 1.1 PURPOSES The purposes of the Medical Staff are to: a. provide a mechanism for accounting to the Board as to the appropriateness and quality of health care services, the qualifications and competence of Practitioners and other individuals exercising clinical privileges at the Hospital, and the teaching and research activities at the Hospital; and b. provide for education related to patient care and research opportunities directed to the delivery of cost-effective, quality care; and c. provide and maintain rules for self-governance of the Medical Staff with the cooperation and approval of the Board; and d. assist the Board and the Corporate Officers in fulfilling relevant obligations. 1.2 RESPONSIBILITIES The responsibilities of the Medical Staff are to: a. make recommendations to the Board concerning: (1) participation in long range planning for the Hospital, including the development and implementation of appropriate policies and programs to meet community health needs; (2) particular services, clinical privileges associated with those services, and the Practitioners to exercise those clinical privileges that may be appropriate for patient care within the Hospital; (3) the appointment of Practitioners to the Staff and the delineation of clinical privileges for Practitioners and AHPs; (4) the establishment of professional ethics and standards of care and policies and procedures regarding healthcare services within the Hospital to help ensure patient safety and 7

8 satisfaction; (5) the list of acceptable Specialty Board certifications applicable to each Staff category. b. conduct peer review, quality improvement review, and utilization review on the services of all Practitioners and Allied Health Professionals in relation to standards of care the Medical Staff develops and maintains, and to report regularly to the Board concerning the observed quality of care rendered, quality improvement activities, and effective resource utilization by such Practitioners and Allied Health Professionals within the Hospital; c. initiate appropriate corrective action with respect to Practitioners and Allied Health Professionals whose services or other conduct are inconsistent with professional ethics, standards of care, with these Bylaws, the Rules and Regulations or with other policies of the Hospital and the Board; d. assist the Hospital and the Board in meeting its obligations and the policies of the Hospital and the Board regarding the provision of uncompensated services for patients unable to pay; e. develop and enforce, subject to Board approval, bylaws, rules and regulations consistent with accepted standards of practice, including requirements regarding the qualifications and practice of Practitioners; and f. perform such other duties as may be set forth in these Bylaws or actions in conjunction with the Board. 2.1 THE MEDICAL STAFF ARTICLE II CATEGORIES OF THE MEDICAL STAFF The Medical Staff shall be divided into Honorary/Emeritus, Active, Courtesy and Consulting categories. 2.2 THE HONORARY/EMERITUS MEDICAL STAFF The category of Honorary/Emeritus Medical Staff may consist of Practitioners who are not active in the Hospital. These may be Medical Staff members who have retired from active hospital practice or who are of outstanding reputation and not necessarily residing in the community. 8

9 Honorary/Emeritus Medical Staff members shall not be eligible to admit patients, vote, hold office, or serve on standing Medical Staff committees. 2.3 THE ACTIVE MEDICAL STAFF The category of Active Medical Staff may consist of Practitioners who are located close enough to the Hospital to provide for continuous care to their patients, and who assume all the functions and responsibilities of membership on the Active Medical Staff, including where appropriate, indigent patient, consultative, educational and teaching responsibilities. Members of the Active Medical Staff shall be eligible to vote, hold office, and serve on Medical Staff committees and should attend Medical Staff meetings. Active Medical Staff will be board certified in the field of medicine in which they are practicing by a recognized board of the American Board of Medical Specialties, or in the process of obtaining such board certification. Exceptions to this requirement may be made upon recommendation of the Section Chief and Chief of Staff. 2.4 THE COURTESY MEDICAL STAFF The category of Courtesy Medical Staff may consist of Practitioners qualified for Medical Staff membership who occasionally admit patients to the Hospital. Courtesy Medical Staff members shall be appointed to and hold clinical privileges determined by a specific section but shall not be eligible to vote or hold office in the Medical Staff organization. Resident/fellow physicians of the Texas A&M Health Science Center College of Medicine Scott & White Graduate Medical Education Program, who have an individual Texas license (as well as other appropriate licenses/registrations) and who are in good standing in their post-graduate training program may be appointed to the Courtesy Medical Staff upon recommendation of their program director and concurrence of the Section Chief. Members of the Courtesy Medical Staff shall be required, as delegated by the Section Chief, to participate with other members of the Medical Staff in handling the indigent patient, education and teaching responsibilities. Members of the Courtesy Medical Staff may serve on the various committees of the Medical Staff. They may attend Medical Staff meetings. Courtesy Medical Staff (excluding resident/fellow physicians) will be board certified in the field of medicine in which they are practicing by a recognized board of the American Board of Medical Specialties or in the process of obtaining such board certification. Exceptions to this requirement may be made upon recommendation of the Section Chief and Chief of Staff. 2.5 THE CONSULTING MEDICAL STAFF 9

10 The category of Consulting Medical Staff may consist of Practitioners who have been requested and are willing to serve in such capacity. Consulting Medical Staff may include PRN, Locum Tenens or Temporary Practitioners. Clinical privileges will be determined by the section to which they are appointed. Their duties shall be to provide services in the care of patients at the request of any member of the Active Medical Staff, or when consultation is required. Consulting Medical Staff, except PRN, Locum Tenens or Temporary Practitioners, shall not be eligible to admit patients, hold office, vote, or serve on standing Medical Staff committees. Consulting Medical Staff will be board certified in the field of medicine in which they are practicing by a recognized board of the American Board of Medical Specialties, or in the process of obtaining such board certification. Exceptions to this requirement may be made upon recommendation of the Section Chief and Chief of Staff. 2.6 PROVISIONAL STATUS All initial appointments to the Medical Staff shall be provisional. The appointment and clinical privileges for Active and Courtesy Staff will be provisionally granted for a period of six (6) months, during which time the Practitioner s performance will be monitored as outlined in Section 6.1(g). The provisional period may be extended for up to twelve months, if necessary, to permit the collection and analysis of data necessary to evaluate performance and grant full privileges. Provisional Medical Staff will be board certified in the field of medicine in which they are practicing by a recognized board of the American Board of Medical Specialties, or in the process of obtaining such board certification. Exceptions to this requirement may be made upon recommendation of the Section Chief and Chief of Staff. ARTICLE III ALLIED HEALTH PROFESSIONALS 3.1 QUALIFICATIONS Allied Health Professionals will not be appointed to the Medical Staff. However, Allied Health Professionals who meet the qualifications set forth in Articles 4.2(a), (c), (d), (f) and (h) shall be eligible to apply for clinical privileges at the Hospital. Where appropriate, the Medical Executive Committee may establish additional qualifications required of members of a specific category of Allied Health Professionals, provided that such qualifications are not founded on an arbitrary or discriminatory basis and are in conformity with applicable law. 10

11 3.2 PROCEDURE FOR SPECIFICATION OF PRIVILEGES Applications for privileges submitted by Allied Health Professionals shall be submitted and processed in the same manner as provided in Article 6 (clinical privileges for Medical Staff). They shall be subject in general to the same terms and conditions specified in Articles 4, 7.1 and 8 for Medical Staff appointments; provided, however, that corrective action with regard to Allied Health Professionals, including termination or suspension of services authorized, shall be accomplished in accordance with usual Hospital personnel practices or the Allied Health Professional's employment agreement, if any. ARTICLE IV MEDICAL STAFF APPOINTMENT 4.1 NATURE OF MEDICAL STAFF APPOINTMENT Appointment to the Medical Staff is a privilege, which shall be extended only to professionally competent individuals who continuously meet the qualifications, standards and requirements set forth in these Bylaws and whom the Governing Body appoints. All Practitioners practicing medicine in this Hospital must first have been appointed to the Medical Staff. Appointment to the Medical Staff shall be for a two (2) year term. Practitioners may seek reappointment as described in Article V. 4.2 SPECIFIC QUALIFICATIONS Only Practitioners who meet the credentialing criteria utilized by Medical Staff Services at Scott and White Memorial Hospital, including but not limited to the following conditions, may qualify for appointment to the Medical Staff: a. Licensure by the State of Texas is a prerequisite for Medical Staff membership. b. For the purposes of these Bylaws, a temporary permit issued by the appropriate State of Texas licensing board shall constitute a license to practice until the permanent license is issued. c. Medical Staff members must be committed to and capable of assuring continuous delivery of integrated medical and surgical services, and must document their background, experience, training, current competence, health status, adherence to the ethics of their profession, their good reputation, and ability to work with 11

12 others, with sufficient adequacy to assure the Medical Staff and Governing Body that any patient treated by them will receive quality health care. d. Continuing education of all Medical Staff members, resident physicians, medical students and support health care practitioners is intrinsic to the delivery of quality health care within the Hospital. Medical Staff are expected to participate in the educational activities of their respective sections. e. Establishment and maintenance of appointment to the faculty of the Texas A&M Health Science Center College of Medicine shall be a condition precedent to membership on the Hospital Medical Staff, except for Honorary/Emeritus, Consulting and Scott & White resident/fellow physicians in good standing at programs by Scott and White Memorial hospital who are Courtesy Staff. When a Practitioner ceases to be a member of the faculty of the Texas A&M Health Science Center College of Medicine, appointment to the Medical Staff at the Hospital shall terminate simultaneously with the termination of that faculty status and with concurrence of the Governing Body. f. Acceptance of membership on the Medical Staff shall constitute the Medical Staff member s pledge to make every reasonable effort to strictly abide by the principles and code of ethics of the Medical Staff member s professional association, as well as the Bylaws and Rules and Regulations governing this Hospital. g. Each member of the Active Medical Staff shall maintain at all times medical malpractice insurance coverage or liability coverage under an actuarially sound and funded self-insurance program of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) aggregate or be covered by the Scott and White Corporate Insurance Plan. Members of the Courtesy and Consulting Medical Staff in high-risk practice areas, as determined by the Risk Management Department of Scott and White Memorial Hospital, shall maintain professional malpractice insurance coverage of one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) aggregate or be covered by the Scott and White Corporate Insurance Plan, and all others a minimum of two hundred thousand dollars ($200,000) per occurrence and six hundred thousand dollars ($600,000) aggregate by a carrier acceptable to Hospital or be covered by the Scott and White Corporate Insurance Plan. h. Medical Staff members shall conduct themselves in a professional, 12

13 cooperative, courteous and reasonable manner and refrain from disruptive behavior or acting in a manner unbecoming of Practitioners or in a manner which threatens a safe, cooperative and professional healthcare environment. 4.3 NO ENTITLEMENT TO APPOINTMENT No Practitioner shall be entitled to appointment to the Medical Staff or to the exercise of particular clinical privileges in the Hospital merely by virtue of the fact that such individual (a) is licensed to practice medicine in this or any other State, (b) is a member of any particular professional organization, (c) is certified by any clinical board, (d) has had in the past, or currently has, Medical Staff appointment or privileges at this or any other hospital or healthcare organization, or (e) resides in the geographic service area of the Hospital as defined by the Board. All appointees to the Medical Staff are subject to the credentialing process. 4.4 NON-DISCRIMINATION POLICY Medical Staff membership or particular clinical privileges shall not be denied on the basis of gender, race, creed, religion, color or national origin. 4.5 ETHICAL DIRECTIVES All Medical Staff appointees and others exercising clinical privileges in the Hospital shall abide by the terms of the Hospital s ethical directives with respect to their practice at the Hospital. No activity prohibited by said directives shall be engaged in by any Medical Staff appointee or other person exercising clinical privileges at the Hospital. 4.6 DUTIES OF APPOINTEES Appointment to the Medical Staff shall require that each appointee assume such reasonable duties and responsibilities as the Board, or the Medical Staff, shall require. Such duties and responsibilities include, but are not limited to: a. Provide his/her patients with care of the generally professionally recognized level of quality and efficiency; b. Adhere to the ethics of their profession, these Medical Staff Bylaws, Rules and Regulations, and the standards and ethical principles described in such policies and procedures as are adopted by the Hospital; 13

14 c. Immediately notify the Chief Medical Officer or Chief of Staff of any change in required health status, conviction of any felony criminal charges, any disciplinary proceeding against him by any licensing authority, the Texas Board of Medical Examiners or its counterpart in any other state, the loss or restriction of privileges at any hospital or health care institution, and any change or pending change in the Practitioner s ability to participate in a federal healthcare program (including but not limited to Medicare, Medicaid or Champus); and d. Complete all medical and other records in a manner consistent with the Rules and Regulations adopted by the Hospital. ARTICLE V PROCEDURE FOR APPOINTMENT AND REAPPOINTMENT 5.1 APPLICATION FOR MEDICAL STAFF MEMBERSHIP a. All applications for appointment to the Medical Staff shall be in writing, shall be signed by the applicant, and shall be submitted on the Texas Standardized Credentialing application form and other requested forms. The applicant shall provide sufficient information to document competency, background, character, professional training, experience, graduate medical education, board certification, malpractice insurance, claims, and other relevant information as requested, including a consent to release such information. The applicant shall list full and complete details regarding recommended psychiatric therapy for any conditions which may affect the applicant s ability to practice medicine or abide by these Bylaws. b. The applicant shall have the burden of producing adequate information for a proper evaluation of competence, character, ethics, health status, and other qualifications by providing sufficient documentation and providing the number of procedures and outcomes, and for resolving any doubt about such qualifications. No applicant shall be eligible for Medical Staff membership who has been convicted of a crime of the grade of felony or a crime of a lesser degree that involves moral turpitude. c. The completed application shall be submitted to Medical Staff Services at Scott and White Memorial Hospital. After collecting the references and other materials deemed pertinent, the application 14

15 will be transmitted with all supporting materials to the Credentials Committee for evaluation. d. By applying for appointment to the Medical Staff, each applicant thereby signifies a willingness to appear for interviews in regard to the application; authorizes the Hospital to consult with members of Medical Staffs of other hospitals with which the applicant has been associated and who may have information bearing on the applicant s competence and character, including mental and emotional stability and ethical qualifications; consents to the Hospital s inspection of all records and documents that may be material to the evaluation of professional qualifications and competence to carry out the clinical privileges requested, as well as moral and ethical qualifications for Medical Staff membership; releases from any liability the Governing Body, the Chief of Staff, the employees and agents of Medical Staff Services at Scott and White Memorial Hospital, all officers, directors and employees of Scott and White Memorial Hospital, their authorized agents or representatives, and all members of the Medical Staff and Hospital Staff who have committee or other responsibility for collecting and/or evaluating the applicant s credentials and/or acting upon the application for their acts performed in connection with evaluating the applicant s credentials; and releases from liability all individuals and organizations who provided information to the Hospital concerning the applicant s competence, background training, experience, health, reputation, ethics, character and other qualifications for Medical Staff membership and clinical privileges, including otherwise privileged or confidential information. This is an absolute release of liability, including, but not limited to, any alleged damages related to breach of confidentiality, defamation, slander, interference with contract or business, invasion of privacy, mental anguish, and all other damages. e. The application form shall include a statement that the applicant has received a copy of these Bylaws and the Rules and Regulations of the Medical Staff, and by signing the statement, the applicant agrees to be bound by the terms thereof without regard to whether or not membership and/or clinical privileges are granted in all matters relating to consideration of the application. 5.2 APPOINTMENT PROCESS a. Within ninety (90) days after receipt of the completed application for membership, the Credentials Committee shall make a written report of its investigation to the Medical Executive Committee. Prior to making this report, the Credentials Committee shall examine the 15

16 evidence of the character, professional competence, qualifications, and ethical standing of the applicant and shall determine whether the applicant has established and meets all necessary qualifications for the category of Medical Staff membership and the clinical privileges requested. The information to be examined may include, but not limited to, references given by the applicant, other sources such as peer review, and appraisal from the section in which privileges are sought. Every section in which the applicant seeks clinical privileges shall provide the Credentials Committee with specific written recommendations for delineating the applicant s clinical privileges, and these recommendations shall be made part of the report. The Credentials Committee shall transmit the completed application and its report to the Medical Executive Committee with one of three (3) recommendations; for provisional appointment to the Medical Staff; against the application for appointment to the Medical Staff; or the deferral of the application for further consideration b. Following its next regular meeting after receipt of the application and the Credentials Committee report and recommendation, the Medical Executive Committee shall consider the application and recommend to the Governing Body one of three (3) actions; provisional appointment of the applicant to the Medical Staff; rejection of the application for Medical Staff membership; or deferral of the application for further consideration. All recommendations for appointment to the Medical Staff must specifically recommend the clinical privileges to be granted. Privileges may be qualified by special requirements of supervision and reporting relating to such clinical privileges. c. When the Medical Executive Committee recommends that the applicant be deferred for further consideration, it must be followed up within sixty (60) days with a subsequent recommendation for either provisional appointment with specified clinical privileges, or for rejection of Medical Staff membership. d. When the recommendation of the Medical Executive Committee is favorable to the applicant, the Chief of Staff shall promptly forward the application, together with all supporting documentation, to the Governing Body. e. When the recommendation of the Medical Executive Committee is adverse to the applicant, either in respect to appointment or clinical privileges, the Chief of Staff or designee shall promptly notify the applicant in writing of the action, including a reason for the denial or 16

17 restriction of privileges, not later than the 20 th day after the date on which the action is taken. f. At its next regular meeting after receipt of a favorable recommendation, the Governing Body shall act in the matter. If the Governing Body s decision is adverse to the applicant with respect to either appointment or clinical privileges, the Chief of Staff or designee shall notify the applicant in writing of the action, including a reason for denial or restriction of privileges, not later than the 20 th day after the date on which the action is taken. 5.3 REAPPOINTMENT PROCESS a. At meetings prior to the scheduled Governing Body meetings in the Medical Staff year, the Credentials Committee shall review all pertinent information available on each Practitioner scheduled for biennial appraisal, to determine its recommendations for reappointment to the Medical Staff and for the granting of clinical privileges for the ensuing period, and shall transmit its recommendation in writing to the Medical Executive Committee. Where the recommendation is against reappointment, the reason for such recommendation shall be stated and documented. b. Each recommendation concerning the reappointment may be based upon the Quality Management Process utilized by Medical Staff Services at Scott and White Memorial Hospital and peer review, professional competence, Practitioner-specific data and clinical judgment in the treatment of patients, ethics, and conduct, professionalism, graduate medical education, board certification, reputation, health status, licensure status, attendance at Medical Staff meetings and participation in Medical Staff affairs, compliance with Medical Staff Bylaws, Rules and Regulations, cooperation with Hospital personnel, use of the Hospital s facilities for patients, relations with other Practitioners and AHPs, and general attitude toward patients, the Hospital, and the public, and any other factor appropriate for the furtherance of the purposes of the above criteria. A record of periodic reappointment will be kept in each Practitioner s credentials file. c. Prior to the scheduled Governing Body meetings in the Medical Staff year, the Medical Executive Committee shall make written recommendation to the Governing Body, through the Chief of Staff, concerning the recommendations for reappointment, recommendations against reappointment and/or recommendations for clinical privileges of Practitioners then scheduled for periodic appraisal. Where the Medical Executive Committee recommends 17

18 against reappointment, a reason for such recommendation shall be stated and documented. d. Thereafter, the procedure provided in Section 5.2, relating to recommendations on application for initial appointment, shall be followed. 5.4 EXPEDITED CREDENTIALING The Governing Body may delegate to a committee, consisting of at least two members of the Governing Board, action on appointment, reappointment, and clinical privileges if there has been a favorable recommendation from the Credentials Committee and the Medical Executive Committee and there is no evidence of the following: A current or previously successful challenge to any license or registration; An involuntary termination, limitation, reduction, denial, or loss of appointment of privileges at any other hospital or other entity; or A final adverse judgment in a professional liability action. Any decision reached by the Governing Body Committee to appoint shall be effective immediately and shall be forward to the Governing Body for ratification at its next meeting. Applications found to be ineligible for the expedited credentialing process will undergo full review by the Credentials Committee before being forwarded to the Medical Executive Committee, and subsequently to the Governing Body for final action. 5.5 LEAVE OF ABSENCE A Practitioner who wishes to obtain a voluntary leave of absence must provide written notice to the Chief of Staff. The notice must state the reasons for the leave and the approximate period of the time of the leave, which may not exceed six (6) months except for military service or upon express permission of the Governing Body. Requests for leave must be forwarded with a recommendation from the MEC and affirmed by the Governing Body. While on leave of absence, the Practitioner may not exercise clinical privileges or prerogatives and has no obligation to fulfill medical staff responsibilities. At least thirty (30) calendar days prior to the termination of the leave, or at any earlier time, the Practitioner may request reinstatement by sending a written notice to the Chief of Staff. The Practitioner must submit a written summary of relevant activities during the leave if the MEC or Governing Body so requests. The MEC will make a recommendation to the Governing Body concerning reinstatement, and the applicable procedures 18

19 concerning the granting of privileges are followed. If the Practitioner s most recent grant of staff membership and/or privileges expired during the leave of absence, the Practitioner must complete a reappointment application and have it acted on favorably in order to resume membership and/or privileges. ARTICLE VI CLINICAL PRIVILEGES 6.1 APPLICATION FOR CLINICAL PRIVILEGES a. Every Practitioner and Allied Health Professional 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 by the Governing Body, except as provided in Sections 6.2, 6.3 and 6.4. Individuals other than members of the Medical Staff or Allied Health Professionals who have responsibilities and provide patient care or services at the Hospital shall act within the scope of their licensure, registration, or certification. b. Every initial application for clinical privileges must delineate specific clinical privileges desired by the applicant. The evaluation of such requests shall be based on the Quality Management Process utilized by Medical Staff Services at Scott and White Memorial Hospital and peer review. These requests shall also be based on demonstrated Hospital need and availability of support facilities, the applicant s licensure, registration, certification, quality of education and continuing education, relevant training, experience, demonstrated and current competence, physical, intellectual, and emotional capacity, liability coverage, malpractice allegations, claims or suit history, ability to meet geographic requirements, references and other relevant information, including an appraisal by the section in which such privileges are sought. The applicant shall have the burden of establishing the qualifications by sufficient documentation and by providing information on the number of procedures performed, outcomes, and demonstrated competency in the privileges requested. Privileges for each section shall be maintained by Medical Staff Services at Scott and White Memorial Hospital. c. The scope and extent of procedures that each Practitioner and AHP may perform shall be specifically delineated and granted in the same manner as all other privileges. Procedures performed by all Practitioners shall be under the overall supervision of the 19

20 Section Chief. Procedures performed by all AHPs shall be under the overall supervision of the sponsoring physician. d. Requests for clinical privileges shall be processed in a manner as described in Article V. e. Restrictions of clinical privileges may be based upon insufficient number of procedures, insufficient information on or documentation of poor outcomes, involvement in professional liability action, unethical or unprofessional conduct, current competence, physical, intellectual, and emotional capacity, failure to adhere to the Bylaws or Rules and Regulations, previous or current challenges to licensure, registration, or certification, or loss of clinical privileges or Medical Staff membership at another institution, or any item necessary for qualification for Medical Staff membership or performance of such duties. Consent to inspect relevant records will be required from the applicant. f. No one specific Practitioner, group of Practitioners, or section will have exclusive authority over any clinical service in the management of jurisdictional conflicts. g. Clinical privileges will be provisionally granted for a period of six (6) months during which time the Section Chief or designee (or, in the case of an AHP, the sponsoring physician) shall monitor the Practitioner s or AHP s performance. At the end of this provisional period, the Section Chief or designee (or, in the case of an AHP, the sponsoring physician) shall evaluate the Practitioner s or AHP s performance and make recommendation for continuation of the provisional period or for granting privileges. Privileges are granted for a period of no more than twenty-four (24) months. h. A physician member of the Medical Staff shall be responsible for the care of any medical problem that may be present at the time of admission or that may arise during hospitalization. 6.2 TEMPORARY PRIVILEGES a. Upon receipt of an application for Medical Staff membership from an appropriately licensed Practitioner, the Chief of Staff, as a representative of the Governing Body, may, upon recommendation of the Chair of the Credentials Committee and the written concurrence of the appropriate Section Chief, grant temporary admitting and clinical privileges to an applicant; but in exercising such privileges, the applicant shall act under the supervision of the Section Chief or designee to which the applicant is assigned. 20

21 b. Temporary clinical privileges may be granted by the Chief of Staff, upon recommendation of the Chair of the Credentials Committee, 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 Section 6.1., provided that there shall first be obtained such Practitioner s signed acknowledgment that a copy of the Medical Staff Bylaws and Rules and Regulations has been received and read by the Practitioner, and the Practitioner agrees to be bound by the terms thereof in all matters relating to temporary clinical privileges. c. The Chief of Staff, as a representative of the Governing Body, may permit a Practitioner to serve as temporary staff for a member of the Medical Staff to attend patients for a period not to exceed one hundred twenty (120) days, providing all credentials have first been approved by the Section Chief and the Chief of Staff. d. Special requirements of supervision and reporting may be imposed by the Section Chief on any Practitioner granted temporary privileges. Temporary privileges may be immediately terminated by the Chief of Staff upon notice to the Practitioner and to the Medical Executive Committee. e. The Chief of Staff may, at any time, upon the recommendation of either the chairperson of the Medical Executive Committee or the Section Chief, terminate a Practitioner s temporary privileges. 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 precautionary suspension pursuant to Section 7.2 of these Bylaws, and the same shall be immediately effective. The appropriate Section Chief or, if absent, the chairperson of the Medical Executive Committee, shall assign a member of the Medical Staff to assume responsibility for the care of such terminated practitioner s patient(s) until they are discharged from the Hospital. 6.3 EMERGENCY PRIVILEGES In case of emergency, any licensed physician or dentist, or appropriately license non-physician practitioner, to the degree permitted by license and regardless of service or staff status or lack of it, shall be permitted to provide necessary emergent care. 21

22 Licensed independent practitioners who are not members of the Medical Staff and/or who do not already possess clinical privileges at the Hospital may be assigned disaster responsibilities during an emergency so long as the following two conditions are present: The Emergency Management Plan has been activated, and The Hospital is unable to meet immediate patient needs. An emergency is defined as any occurrence that inflicts destruction, harm or distress, and that creates healthcare demands that exceed the capabilities of the Hospital and/or the Medical Staff. Such occurrence may be due to a natural disaster or a man-made disaster, and may be an officially declared emergency, whether it is local, state or national. Any Licensed Independent Practitioner providing patient care must be granted disaster responsibilities prior to providing patient care, even in a disaster situation. 6.4 SPECIAL TEMPORARY PRIVILEGES The Chief of Staff, as a representative of the Governing Body, or designee(s), may grant special temporary privileges to a qualified Practitioner(s), without the necessity of the Practitioner(s) making application for Medical Staff membership and/or clinical privileges. Such privileges may be granted to perform procedures such as, but not limited to, organ harvest(s), consultative surgery, and demonstration of new technology. 6.5 PROCEDURE FOR REQUESTING AN INCREASE IN CLINICAL PRIVILEGES a. Additional privileges may be requested at any time by memo to the Section Chief. The request shall be reviewed and, when approved by the Section Chief, forwarded to Medical Staff Services at Scott and White Memorial Hospital for inclusion in the Practitioner s or AHP s current clinical privileges list. b. Recommendations for an increase in clinical privileges made to the Board shall be based upon factors including but not limited to: (1) relevant recent training; (2) observation of patient care provided; (3) review of the records of patients treated in this or other 22

23 hospitals; (4) results of the Hospital's quality assessment activities; and (5) other reasonable indicators of the individual s qualifications for the privileges in question. The recommendation for such increased privileges may carry with it such requirements for supervision or consultation or other conditions, for such periods of time as are thought necessary. ARTICLE VII CORRECTIVE ACTION 7.1 PROFESSIONAL CONDUCT AND CLINICAL PRIVILEGES a. Whenever the activities or professional conduct of any Practitioner with clinical privileges are considered to be lower than the standards or aims of the Medical Staff, or disruptive to the operation of the Hospital or the work of others, or detrimental to patient safety, or detrimental to quality patient care; corrective action against such Practitioner may be requested by an officer of the Medical Staff, by the chairperson of any standing Medical Staff committee, the Chief Medical Officer, the Chief of Staff, the Hospital Administrator, the Director of Nursing for the Hospital, or by the President of the Governing Body. All requests for corrective action shall be made to the Chief of Staff with notification of the specific activities or conduct which constitutes the grounds for the request. b. An adverse professional review action may be taken based on: (1) The reasonable belief that the adverse action was in the furtherance of quality health care or in the furtherance of upholding the requirements of the Medical Staff, and (2) After a reasonable effort to obtain the facts of the matter, and (3) After adequate notice and hearing procedures are afforded to the Practitioner involved or after such other procedures as are fair to the Practitioner under the circumstances, and (4) In the reasonable belief that the action was warranted by the facts known after such reasonable effort to obtain facts. 23

24 7.2 PRECAUTIONARY SUSPENSION a. The Chief of Staff, the Chief Medical Officer, or the President of the Governing Body shall each have the authority whenever action must be taken immediately in the best interest of patient care or the health of an individual; or whenever a Practitioner has demonstrated willful disregard of Bylaws, Rules and Regulations or Hospital policies; or whenever conduct may require immediate action to protect patients, employees or other persons; to precautionarily suspend all or any portion of the clinical privileges of a Practitioner, and such precautionary suspension shall be effective immediately. Subsequent notice will be provided to the Practitioner. b. A precautionary suspension will be reported to the Chief of Staff. If the Chief of Staff or the Governing Body s recommendation is not adverse to the Practitioner, there is no right to a hearing. If continued adverse professional review action is recommended, the hearing process will be followed as outlined in Article IX. c. Immediately upon the imposition of a precautionary suspension, the Chief of Staff or the appropriate Section Chief shall have authority to provide alternate medical coverage for hospitalized patients of the suspended Practitioner. 7.3 AUTOMATIC SUSPENSION Action by a state health agency to revoke or suspend a Practitioner s professional license, registration, or certification, without probation, or conviction of a felony, shall automatically suspend the Practitioner s clinical privileges. Such a suspension does not entitle the Practitioner to a hearing, as the Practitioner no longer meets the basic qualifications for Staff membership. If the state health agency places the Practitioner on probation, the Practitioner will evaluated as outlined in Article V and VI. 7.4 DELINQUENT MEDICAL RECORDS Any Practitioner with a delinquent record of 30 days (30 days post discharge) who has not made a good faith effort to resolve the delinquency will have his/her CME funding reduced by $500. For every 30 days the record continues to be delinquent, $500 will be deducted. Section Chiefs will continue to be appraised on a monthly basis of the delinquent record status of their Practitioners and will be notified one week in advance of any Practitioner approaching the 30-day delinquency limit. 24

25 8.1 ACCEPTANCE OF CONDITIONS ARTICLE VIII IMMUNITY AND CONFIDENTIALITY The following statements, which shall be included on the initial application and reappointment application forms and which form a part of these Bylaws, are express conditions applicable to any Medical Staff applicant, any appointee to the Medical Staff, and to all others having or seeking clinical privileges at the Hospital. By applying for appointment, reappointment or clinical privileges, the applicant expressly accepts these conditions during the processing and consideration of the application, whether or not appointment or clinical privileges is granted. This acceptance also applies during the time of any appointment or reappointment. 8.2 IMMUNITY As a condition to applying for Medical Staff membership and/or clinical privileges, every applicant shall agree and give express consent for release of any information regarding the applicant s professional credentials, licensure, registration, certification, previous clinical privileges and all previous professional activities, medical or psychiatric records impacting on the ability to practice medicine, and criminal or court records. Any act, communication, report, recommendation, or disclosure, with respect to any such applicant, performed or made at the request of an authorized representative of this or any other healthcare facility or other facility, for the purpose of achieving and maintaining quality patient care in this or any other healthcare facility, shall be privileged to the fullest extent permitted by law. Such privilege shall extend to all members of the Hospital s Medical Staff, Governing Body, and others acting on their behalf, and to third parties who supply such information. Third parties herein means both individuals and organizations from whom information has been requested by an authorized representative of the Governing Body of the Medical Staff or others acting on their behalf. There shall be absolute immunity, to the fullest extent permitted by law, from civil liability arising from any act, communication, report, recommendation, or disclosure; even where the information involved would otherwise be deemed privileged or confidential. Such immunity shall apply to all acts, communications, reports, recommendations, or disclosures performed or made in connection with this or any other healthcare institution s activities related, but not limited to: a. applications for appointment or clinical privileges, including temporary privileges; 25