TABLE OF CONTENTS. 1. Purpose of Credentialing 2

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1 POLICY NAME: PROFESSIONAL STAFF APPOINTMENT AND CREDENTIALING POLICY APPROVING BODY: Board of Directors NUMBER: GOV-3-22 VERSION: 1.0 EFFECTIVE DATE: June 13, 2013 MANUAL: Governance LAST REVIEW DATE: NA SECTION: Ensure Program Quality & Effectiveness REVISION DATE: NA PAGES: 1 of 28 NEXT REVIEW DATE: May 2014 COMMITTEE OVERSIGHT: Medical Advisory Committee TABLE OF CONTENTS 1. Purpose of Credentialing 2 PART A GENERAL 2. Appointment Term 3 3. Qualification And Criteria For Appointment 3 4. Request For Application 4 PART B APPLICATION FOR APPOINTMENT 5. Application Submissions 5 6. Processing an Application 7 7. Impact Analysis 8 8. Approval and Appointment Process 8 PART C ANNUAL REAPPOINTMENT PROCESS 9. General Qualification and Criteria for Reappointment Distribution of Reapplications Return of Completed Applications Re-application Review and Approval Process Unreturned and/or Incomplete Re-Applications Requests for Change in Privileges or Appointment Category 12 PART D - MID-TERM ACTION 16. Suspension/Revocation Of Privileges Non-Immediate Mid-Term Action 15 APPENDIX A - DEFINITIONS 17 APPENDIX B - APPLICATION CHECKLIST 19 APPENDIX C - NEW APPLICANT PROCESS 21 APPENDIX D - REAPPOINTMENT PROCESS 22 APPENDIX E - APPEAL PROCESS 23 APPENDIX F - LACK OF VACANCY/RESOURCE NOTIFICATION 24 APPENDIX G - RE-APPLICATION FOR PRIVILEGES 25 File Location: O:\ADMIN Mgmt\Board\Policy & Procedure\Manual\3.0 - Ensure Program Quality & Effectiveness\Profesional Staff Appointment and Credentialing Policy GOV-3-22 v1.0.doc

2 1. PURPOSE OF CREDENTIALING Pursuant to the Corporations Act and the Public Hospitals Act, the Board of Directors of a public hospital is responsible for the governance of the hospital, including the management of risk and the quality of care. The implementation of a system to ensure and monitor the quality of care provided by physicians, dentists, midwives, oral and maxillofacial surgeons, and registered nurses in the extended class (RN(EC)s) in the hospital is one of the primary responsibilities of the Board. In exercising this responsibility, directors must: act honestly and in good faith with a view to the best interests of the hospital; and exercise the care, diligence and skill that a reasonably prudent director would exercise in comparable circumstances. This Policy outlines a clear and reasonable system that will allow the Board to consider an application for appointment to Muskoka Algonquin Healthcare (MAHC) s Professional Staff in a manner that permits the Board to reasonably ensure the quality of care offered in MAHC and minimize the attendant risks to patients. The Policy further recognizes the Board s responsibility to efficiently and effectively utilize the resources of MAHC in the provision of patient care. The Public Hospitals Act mandates at section 36 that the Board appoint physicians and grant privileges, and at section 35 that the Medical Advisory Committee (MAC) consider and make recommendations to the Board with regards to such appointments. While responsibility for the implementation of this Policy lies with the Board, the operation of this Policy is delegated by the Board to the MAC. Under the Public Hospitals Act, hospitals are required to review all physicians delivery of care on an annual basis as well as on an as-needed basis. Under this Policy, this requirement shall be equally applicable to all members of the Professional Staff. As such, the Policy puts in place a two part process to address recommendations to the Board by the MAC at the time of reappointment: a) A Re-Appointment Process which is conducted on an annual basis in the intervening years to serve as review of the Applicant s past year and to update any significant information in the Applicant s file. b) The Policy also addresses the process by which members of the Professional Staff may apply for a change in the nature or scope of their privileges. The appointment and credentialing process also sets out the procedures to be followed where complaints are lodged against appointed and privileged staff members regarding a serious problem in the diagnosis, care or treatment of a patient or outpatient and/or a serious issue with respect to the conduct or behaviour of such member. Policy Number: GOV-3-22 Version: 1.0 Page 2 of 28

3 PART A GENERAL 2. APPOINTMENT TERM 2.1 Each appointment to the Professional Staff shall be for a period of not more than one year. Provided that where, within the exiting appointment year, a member, other than a member appointed to the Term Staff, as described in Section 11.6 of the Professional Staff Bylaws, has applied for re-appointment, his or her appointment shall be deemed to continue, except where provided otherwise in the By-laws, until the re-appointment is granted; or where he or she is served with notice that the Board refuses to grant the reappointment, until the time for giving notice requiring a hearing by the Appeal Board has expired and, where a hearing is required, until the decision of the Appeal Board has become final. 3. QUALIFICATION AND CRITERIA FOR APPOINTMENT 3.1 Only an Applicant who is a registrant in good standing of the relevant College and qualified to practice medicine, dentistry, midwifery, or extended class nursing and licensed pursuant to the laws of Ontario, is eligible to be a member of and appointed to the Professional Staff of MAHC, except as otherwise provided for in the By-laws. 3.2 The Applicant must have the following qualifications: (c) (d) a current certificate of registration with the applicable College; a demonstrated ability to provide patient care at an appropriate level of quality and efficiency; a willingness to participate in the discharge of staff obligations appropriate to membership group, including without limitation, a demonstrated ability to communicate, work with, and relate to members of theprofessional and Hospital Staff, Senior Leadership Team, patients and patients families in a co-operative and professional manner; and adequate training and experience for the procedural privileges requested. 3.3 The Applicant must agree to participate in the on-call duty roster(s) as required by the Chief of Staff. 3.4 The Applicant must agree to undertake such duties in respect of those patients classed as emergency cases as may be specified by the Chief of Staff. 3.5 The Applicant must agree to govern himself/herself in accordance with the requirements set out in the Public Hospitals Act and regulations thereunder, the By-laws, the Professional Staff Rules and Regulations of MAHC, and all Hospital policies and procedures. Policy Number: GOV-3-22 Version: 1.0 Page 3 of 28

4 3.6 The Applicant must declare and indicate adequate control of any physical or behavioural impairment that affects skill, attitude or judgement relevant to the appointment and privileges requested. 3.7 There must be a demonstrated need for the services in the community and/or region and an appropriate Impact Analysis must have been completed which confirms MAHC s ability to provide those services. 3.8 The Applicant should meet the needs of the respective department as described in a Medical Human Resources Plan, and will be assessed on the basis of credentials and experience and such other factors as the Board may, from time to time, consider relevant, or as set out in the Professional Staff Rules and Regulations. 3.9 The Applicant must provide evidence of current immunization status as suggested in the Communicable Diseases Surveillance Protocols jointly published by the Ontario Hospital Association and the Ontario Medical Association. 4. REQUEST FOR APPLICATION 4.1 Upon receipt of a request for an application, the Medical Affairs Office will consult the Medical Human Resources Plan and any applicable current Impact Analysis to determine if a vacancy or needs exists. a) Should there be no vacancy clearly identified, the Chief Executive Officer and Chief of Staff will be advised accordingly immediately. If required, the applicant will be advised of the situation utilizing the Lack of Vacancy/Resource Notification - see Appendix F. 4.2 The Chief Executive Officer of MAHC shall provide an application package to every physician, dentist, midwife, oral and maxillofacial surgeon, and RN(EC) who requests the opportunity to apply to MAHC for Professional Staff appointment and privileges. 4.3 The initial application package provided to the Applicant shall consist of: a covering letter of instruction from the Chief Executive Officer; a copy of the Professional Staff Application Checklist; (c) an application form; (d) a copy of MAHC s By-laws and Professional Staff Rules and Regulations, as well as a copy of this Comprehensive Appointment and Credentialing Policy and other relevant Hospital policies; and (e) a request to provide a summary of the activities and procedures the applicant intends to utilize in hospital. This summary is in advance of the completion of the Impact Analysis as described in Section Where a completed application is not returned to the Chief Executive Officer within sixty (60) days following receipt of the application package, the application shall be deemed void and a new application required. Policy Number: GOV-3-22 Version: 1.0 Page 4 of 28

5 5. APPLICATION SUBMISSIONS PART B APPLICATION FOR APPOINTMENT 5.1 Each initial application provided to an Applicant for appointment to the Professional Staff of MAHC shall require that the application be submitted to the Chief Executive Officer and include the following information: (c) a statement by the Applicant that s/he has read MAHC s By-laws, the Professional Staff Rules and Regulations, a copy of this Appointment and Credentialing Policy and other relevant Hospital policies; an undertaking that, if the Applicant is appointed to the Professional Staff of MAHC, the Applicant will provide the services to MAHC (and will govern him/herself) as stipulated in the Application in accordance with the Public Hospitals Act and the Hospital Management Regulation thereunder; and with the By-laws, Rules and Regulations, and Hospital policies, as established or revised by MAHC from time to time; an acknowledgement by the Applicant that: (i) (ii) the failure of the Applicant to provide the services as stipulated in the Application in accordance with applicable legislation, the By-laws, the Rules and Regulations and Hospital policies will constitute a breach of his or her obligations to MAHC and MAHC may, upon consideration of the individual circumstances, remove access to any and all Hospital resources, including the limiting or restricting of operating room time, or take such actions as is reasonable, in accordance with the By-laws and Rules and Regulations; and MAHC may refuse to appoint an Applicant to the Professional Staff where the Applicant refuses to acknowledge the responsibility to abide by a commitment to provide services in accordance with the privileges granted by the Board, and in accordance with MAHC s By-laws, Rules and Regulations, and policies; (d) (e) (f) (g) a copy of the Applicant s current registration, certificate or license to practice in Ontario; a copy of the Applicant s professional school certificate; a record of eligibility for certification for specialty/sub-specialty certifications and for re-certification; a copy of fellowship/certification documentation for specialties/sub-specialties, including a speciality certificate from the Royal College of Dental Surgeons of Ontario authorizing practice in oral and maxillofacial surgery as applicable; Policy Number: GOV-3-22 Version: 1.0 Page 5 of 28

6 (h) (i) (j) (k) (l) (m) (n) (o) (p) (q) (r) an up-to-date curriculum vitae, including a record of the Applicant s professional education and post-graduate training and a chronology of academic and professional career, organizational positions, and committee memberships; a current Certificate of Professional Conduct from the College of Physicians and Surgeons of Ontario, a current Certificate of Standing from the Royal College of Dental Surgeons of Ontario, a current Letter of Professional Standing from the College of Midwives of Ontario or an extended Certificate of Registration from the College of Nurses of Ontario (as applicable) and consent to the release of the information by the Registrar of the applicable College; for out-of-province applicants, a certificate from the licensing authority in their jurisdiction; a recital and description of pending or completed disciplinary actions, competency investigations, previous or ongoing performance reviews, and details with respect to prior privileges disputes with other hospitals regarding appointment, re-appointment, change of privileges, or mid-term suspension or revocation of privileges; a statement with respect to reduction in classification or voluntary or involuntary resignation of any professional license or certification, professional society membership or fellowship, professional academic appointment or privileges at any other hospital or health care institution; information regarding the Applicant s health, including any impairments, medical conditions, diseases or illnesses which may impact on the Applicant s practice relevant to the nature and scope of privileges requested; current treatments, the date of the Applicant s last examination, as well as the name of the treating health professional for those impairment(s)/condition(s)/disease(s) or illness(es); and an authorization to the treating health professional to release relevant information to MAHC; confirmation of professional liability insurance protection or membership in the Canadian Medical Protective Association satisfactory to the Board, including a record of the Applicant s past claims history; a record of any criminal convictions which may impact the Applicant s professional practice or responsibilities pursuant to their appointment; recital and description of completed civil liability actions that are related to the Applicant s professional practice or activities, including final judgements or settlements in which the applicant was involved; a declaration of compliance with MAHC s communicable diseases surveillance policies and practices, including proof of required immunization; information regarding any other appointments at other hospitals and any existing responsibilities regarding on-call coverage at any other hospital or practice; Policy Number: GOV-3-22 Version: 1.0 Page 6 of 28

7 (s) (t) (u) three completed and signed MAHC Confidential Reference Forms an authorization for release of information and release from harm for collecting and/or exchanging information and evaluation of the Applicant s credentials and suitability for the purposes of appointment to the Professional Staff; a statement indicating: (i) (ii) (iii) (iv) the type of application being made; the name of the Department or division to which the application is being made; the category of privileges requested; and the procedures requested; 6. PROCESSING AN APPLICATION 6.1 The application is to be returned to the Medical Affairs Office by the Applicant and stamped with the date of receipt. 6.2 The Medical Affairs Office reviews the application for completeness and inclusion of all items listed in section 5.1 above. The Medical Affairs Office will follow up with applicants regarding any requirements outlined in section 5.1 that have not been met. Following this follow up, should the requirements remain unmet; these will be clearly flagged on the application checklist by the Medical Affairs office. 6.3 Once all information is obtained, the application will be prepared and forwarded to the Chief of Staff for review. The Chief of Staff shall: investigate each application, with specific attention to the Applicant s qualifications, experience and his/her professional reputation; contact each reference listed on the application to obtain information relating to the past performance, experience and reputation of the Applicant, and make a detailed note to file regarding the time and substance of the conversation; (i) it is strongly recommended that the Chief of Staff also complete a verbal reference check with the Chief of Staff or Chief of Department from the place of last/current appointment. (c) (d) (e) review MAHC-approved MAHC Medical Human Resource Plan to confirm the availability of the position; confirm the completion of an Impact Analysis and support by the applicable Department/program/service(s); complete the Professional Staff Application Checklist. Policy Number: GOV-3-22 Version: 1.0 Page 7 of 28

8 7. IMPACT ANALYSIS 7.1 All professional staff applicants considered for appointment to the professional staff will require completion of an Impact Analysis as per the Impact Analysis Physician Recruitment Policy (currently under development). 7.2 Impact Analysis is also required for any requests for change in current privileges or appointment category. 8. APPROVAL AND APPOINTMENT PROCESS 8.1 The process for granting appointments and privileges to physicians is clearly set out in the Public Hospitals Act, MAHC Management Regulation thereto, and the By-laws. Pursuant to this Policy, the same process shall be used for physicians; dentists; including oral and maxillofacial surgeons; midwives; and RN(EC)s. 8.2 Every appointment shall be for a period of not more than one year. 8.3 The Chief of Staff shall ensure the Professional Staff Application Checklist is completed and forwarded along with the application to the MAC. 8.4 As appropriate, the Chief of Staff in consultation with the Chief Executive Officer, will initiate the development of a service agreement to ensure and formalize a common understanding of commitments and accountabilities. 8.5 The Medical Advisory Committee shall: (c) receive and consider the Application in the context of the Medical Human Resources Plan, and the completed Impact Analysis; make its recommendation in writing to the Board within 60 days from the date of the application; send notice of its recommendation to the Applicant pursuant to the Public Hospitals Act. In the case of a recommendation for appointment, the MAC shall specify its recommendation with respect to the privileges the Applicant should be granted and procedures the Applicant should be permitted to perform. 8.6 If the MAC s recommendation is against appointment or re-appointment, the MAC shall provide written notice to the Applicant which shall inform the Applicant that s/he is entitled to: written reasons for the recommendation if a request for reasons is received by the MAC within 7 days of the receipt of a notice of the recommendation by the Applicant; and a hearing before the Board if a written request is received by the Board and the MAC within 7 days of the Applicant s receipt of the written reasons. 8.7 The MAC may make its recommendation later than the 60 day period set out in the Public Hospitals Act and above if, prior to the expiry of the 60 day period, it indicates in Policy Number: GOV-3-22 Version: 1.0 Page 8 of 28

9 writing to the Board and the Applicant that a final recommendation cannot yet be made, and gives the written reasons therefore. 8.8 Subject to the provisions of the Public Hospitals Act, where no hearing is requested, the Board shall either implement the recommendation of the MAC or it shall reject the MAC s recommendation. In either case, the Board shall cause the MAC and the Applicant to be informed of the Board s decision regarding the recommendation. 8.9 Where an Applicant requests a hearing before the Board within 7 days of the Applicant s receipt of the written reasons, the Board shall appoint a time for and hold the hearing and shall decide the matter within its authority. The parties to the proceedings before the Board are the Applicant, the MAC and such other persons as the Board may specify Where the Board is required to hold a hearing, the person requiring the hearing shall be afforded all of the rights set out in MAHC s By-laws and schedule thereto and specifically may examine any documentary evidence that will be produced or any report, the contents of which will be given orally in evidence at the hearing, prior to the hearing The Board may make a decision under certain conditions without holding a hearing, unless a hearing is required by or under the Public Hospitals Act Upon Board approval of the application, the Chief of Staff will: (c) ensure execution of the service agreement; assign a mentor for the applicant; ensure the applicant is sent a letter advising of the Board of Directors decision (prepared and distributed by Medical Affairs). Policy Number: GOV-3-22 Version: 1.0 Page 9 of 28

10 PART C ANNUAL REAPPOINTMENT PROCESS 9. GENERAL 9.1 The reappointment process is coordinated through the Medical Affairs Office on an annual basis. 9.2 Each year, each member of the Professional Staff is required to make a written application for reappointment to the Professional Staff of MAHC. 9.3 The reappointment year extends from January 1 to December QUALIFICATION AND CRITERIA FOR REAPPOINTMENT 10.1 In addition to meeting the qualifications and criteria set out in PART A - GENERAL, an Applicant for re-appointment shall also meet the following criteria: have conducted himself or herself in compliance with this Policy; and MAHC s mission, vision and values, Rules and Regulations, By-laws, policies and procedures; have demonstrated appropriate use of Hospital resources in accordance with the MAHC Medical Human Resources Plan and the Rules and Regulations and policies of MAHC. 11. DISTRIBUTION OF RE-APPLICATIONS FOR COMPLETION 11.1 Early September The re-application package will be sent out to all eligible privileges staff by Medical Affairs on behalf of the Chief Executive Officer in accordance with the Public Hospitals Act. The re-application package will contain the following information: (i) (ii) (iii) (iv) Covering letter from Chief of Staff Re-application Form populated with the existing data for each individual staff member. For a list of the required data, see the Re-Application in Appendix G. A checklist of required information The deadline for returning the complete re-application form, generally this is the end of September. 12. RETURN OF COMPLETED RE-APPLICATIONS 12.1 September 1 - October 15 Policy Number: GOV-3-22 Version: 1.0 Page 10 of 28

11 (c) (d) A series of informal reminder messages (general and targeted as required) and activities are carried out by Medical Affairs through-out and beyond this period. All re-applications that are returned to Medical Affairs are reviewed for completeness Re-applications will be considered complete if all requested documentation is included with the package. The official close for reappointment applications is the end of September October 15 - Formal notification from Medical Affairs on behalf of the Chief of Staff is sent to all privileged staff members who have not submitted a complete re-application. This notification will advise that should a complete re-application not be received by November 15 th, the privileged staff member will receive a final notification that failure to return a complete re-application will be deemed a resignation November 15 - In the absence of extenuating circumstances, final notification from Medical Affairs on behalf of the Chief of Staff is sent to all privileged staff indicating that failure to return a complete re-application within a defined period of time will be deemed a resignation. 13. REAPPLICATION REVIEW AND APPROVAL PROCESS 13.1 Medical Affairs reviews the completed re-application and enters all data changes into the professional staff database Medical Affairs will flag any areas of concern and/or any changes, other than demographic changes All re-applications for reappointment shall be forwarded to the Credentials Committee for review The Credentials Committee is responsible for ensuring that each applicant for reappointment meets the qualifications and criteria The Credentials Committee will review and consider recommendations to be forwarded to the MAC The MAC will consider the Credentials Committee recommendation and will make its recommendation to the Board of Directors If there is a delay in making the recommendation to the Board of Directors or the reapplication is denied, the applicant must be notified as per the Bylaws after the MAC meeting The Board of Directors will review the recommendation made by the MAC and approve or reject the recommendation The applicant is sent a letter advising of the Board of Directors decision (prepared and distributed by Medical Affairs). Policy Number: GOV-3-22 Version: 1.0 Page 11 of 28

12 13.10 If the applicant s re-application is rejected, the privileged Staff member is entitled to a written response and a hearing before the Board as per the Public Hospitals Act and Bylaw Article UNRETURNED AND / OR INCOMPLETE REAPPLICATIONS 14.1 January - February (c) Incomplete or unreturned re-applications that are greater than 3 months overdue from the return date and 1 month overdue from the end of the reapplication year. These cases will have received informal and formal notification requesting full application completion within a defined period of time and that if their application was not received by the prescribed time, they will be deemed to have resigned from the MAHC privileged staff. In the absence of extenuating circumstances, individuals who have not submitted their completed application within the specified period will be deemed to have resigned and this change in privilege status will be processed as outlined in section 13. Once the resignation has been approved to the level of the Board, any individual who indicates their intention to return to MAHC privileged staff will be required to complete a full application package and will follow the new application process as outline in Part B. 15. REQUESTS FOR CHANGE IN PRIVILEGES 15.1 Application for Change in Privileges or Appointment Category A physician, dentist, midwife, oral and maxillofacial surgeon or RN(EC) that wishes to change his/her privileges or appointment category, must do so in writing to the Chief Executive Officer, identifying the changes that are requested, along with evidence of appropriate training, competence and professional liability protection and/or the reason(s) for the requested change in appointment category; (i) this request in writing may be made either by completing an original application, reapplication or by formal letter. (c) An application for change in privileges or appointment category shall be processed in accordance with the Public Hospitals Act, the By-laws, the Rules and Regulations and this Policy. The Chief Executive Officer shall immediately refer the application to the Chief of Staff, who, upon recording each application received: (i) (ii) reviews the Medical Human Resources Plan; shall ensure the completion of an Impact Analysis; (iii) shall refer the application and Impact Analysis forthwith to the Credentials Committee for review Policy Number: GOV-3-22 Version: 1.0 Page 12 of 28

13 (d) (e) (f) (g) The Credentials Committee will review the application, Medical Human Resources Plan and Impact Analysis to formulate a recommendation to be forwarded to the Medical Advisory Committee. The Medical Advisory Committee is entitled to request any additional information or evidence that it deems necessary for consideration of the application for alteration in privileges. The Medical Advisory Committee will make a recommendation to the Board of Directors. The Board of Directors will approve or reject the recommendation. The Board may refuse to support the change in privileges based on any of the following grounds: (i) (ii) (iii) the requested change is not consistent with the need for service, as determined by the Board from time to time; the Medical Staff Human Resources Plan and/or the Impact Analysis does not demonstrate sufficient resources to accommodate the change; or the change in privileges is not consistent with the strategic plan and mission, vision and values of the Corporation. (h) (i) The applicant will be sent a letter advising of the Board decision (prepared and distributed by the Medical Affairs Office). If the applicant s request is rejected, the privileged Staff member is entitled to a written response and a hearing before the Board as per the Public Hospitals Act and Bylaw Article 13. Policy Number: GOV-3-22 Version: 1.0 Page 13 of 28

14 PART D - MID-TERM ACTION 16. SUSPENSION/REVOCATION OF PRIVILEGES The Board or Chief of Staff may at any time in accordance with the Public Hospitals Act, the By-laws and this Policy revoke, suspend, restrict or otherwise alter the privileges of a member of the Professional Staff or elicit an undertaking from a member of the Professional Staff not to exercise his/her Hospital privileges Standing to Issue a Complaint (c) Any member of the Professional Staff or other person may advance a complaint concerning any alleged violation by a member of the Professional Staff (referred to as the Respondent ) of the By-laws, Rules or Regulations of MAHC or alleged professional misconduct, incompetence, or incapacity, unethical behaviour, or other unprofessional conduct giving reasonable cause for complaint to the Chief Executive Officer, and/or the Chief of Staff. Upon receipt of a complaint about the Respondent, Chief of Staff and/or MAHC Chief Executive Officer shall forthwith advise the Respondent as to the nature of the complaint and the manner in which the complaint is being handled. Where possible, the Chief of Staff or the Chief Executive Officer notified shall consult with at least two (2) other Committee Chairs regarding the most appropriate course of action as provided for by the Public Hospitals Act, Hospital By-law and this Policy, including whether the Respondent s privileges shall be immediately and temporarily suspended in accordance with Sections 16.2 below or whether the appropriate action is to commence a preliminary investigation in accordance with Section 17.2 below Immediate Mid-Term Action in an Emergency Situation If at any time it becomes apparent that a Professional Staff member s conduct, performance or competence is such that it exposes, or is reasonably likely to expose, patient(s), staff or others to harm or injury, or is reasonably likely to be detrimental to the safety of patient(s), staff or others or delivery of quality care, immediate suspension must be undertaken to protect the patient(s), staff or others to cause or to ensure the delivery of quality care. Where a Chief of Staff becomes aware that a serious problem exists in the diagnosis, care or treatment of a patient, such Chief of Staff shall forthwith discuss the condition, diagnosis, care and treatment of the patient with the attending Professional Staff member, and if satisfactory changes in diagnosis, care or treatment are not made promptly, such Chief of Staff shall assume forthwith the responsibility for any necessary investigation and diagnosis of, prescribing for and treatment of the patient, and shall notify the attending member of the Professional Staff, the Chief Executive Officer, and, if possible, the patient that Policy Number: GOV-3-22 Version: 1.0 Page 14 of 28

15 the attending member of the Professional Staff shall cease forthwith to have any privileges as the attending. This may require immediate and temporary suspension of the privileges of the member of the Professional Staff. In all situations, the due process procedure set out in Section 17.2 through 17.3 must be followed. (c) (d) (e) (f) (g) Where the Chief of Staff is unable to discuss the problem with the attending Professional Staff member, s/he shall proceed with his/her duties under this section as if s/he had the discussion with the attending member. The Chief of Staff shall inform two members of the MAC within twenty-four (24) hours of any action taken under Section 16.2 and shall file a written report with the secretary of the MAC within forty-eight (48) hours of an action under Section The Chief of Staff responsible in Section 16.2 may delegate any or all of his/her responsibilities and duties hereunder to a member of the active Professional Staff in his/her department, but shall remain accountable to the MAC for the management of the patient by the Professional Staff member to whom any such responsibility or duty is delegated. In all instances other than those which are specific to a single patient as addressed in Section 16.2, where the professional conduct, performance or competence of a member is likely to expose patient(s) or Hospital staff to serious harm or injury such that immediate action must be taken to protect the patient(s) or staff, and there is no less restrictive measure available, the Chief of Staff or delegate, may with notice to the Chief Executive Officer or his/her delegate, immediately and temporarily suspend the Professional Staff member s privileges, until such time as a meeting or hearing can be arranged in accordance with MAHC By-laws and this Policy. Where immediate mid-term action is taken pursuant to this Section, the due process procedures established further to MAHC By-laws and Schedule A of the By-laws shall be followed in finally determining the appropriate mid-term action. 17. NON-IMMEDIATE MID-TERM ACTION 17.1 Where the professional conduct, performance or competence of a member of the Professional Staff: (c) (d) is, or is reasonably likely to be, detrimental to patient or staff safety or to the delivery of quality patient care within MAHC; results in the imposition of sanctions by the relevant professional College; is contrary to the By-laws, the Professional Staff Rules, policies of MAHC, the Public Hospitals Act or regulations made thereunder, or any other relevant law or legislated requirement; constitutes abuse; or Policy Number: GOV-3-22 Version: 1.0 Page 15 of 28

16 (e) (f) is, or is reasonably likely to be, detrimental to the operations of MAHC; the Chief of Staff, the Department Chief or their respective delegates, shall follow the due process procedures set out in the By-laws and Schedule A of the By-laws, respecting Non-Immediate Mid-Term Action Investigation/Complaint Process (c) (d) The Chief of Staff or the Chief Executive Officer or their respective delegates shall be responsible for undertaking and directing the preliminary investigation of a complaint, in such a manner as is determined reasonably necessary and in accordance with any applicable Hospital policies and procedures. Following preliminary investigation, the Chief of Staff and/or the Chief Executive Officer of MAHC, where deemed appropriate, shall place the complaint before the MAC and report upon the investigation of the complaint. In such circumstances the MAC shall follow the applicable due process procedures under Schedule A of the By-laws. Where the complaint and report of the preliminary investigation of the complaint is not placed before the MAC, the Respondent in question shall be informed of such decision. Where a complaint issued is not placed before the MAC, documentation of such complaint and any report created will not form part of the Professional Staff member s appointment record. Where the MAC has made a recommendation and the Professional Staff member (Respondent) requests a Board hearing, the matter shall be referred to the Board and a Board hearing shall be conducted in accordance with procedures under Schedule A of the By-laws Members of the Board holding a meeting shall not have taken part in investigation or consideration of the subject matter of the meeting before the meeting and shall not communicate directly or indirectly in relation to the subject matter of the meeting with any person or with any party or representative of a party. Policy Number: GOV-3-22 Version: 1.0 Page 16 of 28

17 APPENDIX A - DEFINITIONS In this Policy, the following terms shall have the following meanings: Chief Executive Officer means the person appointed by the Board of MAHC with direct and actual superintendence and charge of MAHC, as contemplated in MAHC Management Regulation and shall include the Chief of Staff/Chair of Medical Advisory Committee or delegate, and the Chief Executive Officer or delegate. Appeal Board means the Health Professions Appeal and Review Board established pursuant to the Ministry of Health Appeal and Review Boards Act, Applicant means the physician or other professional who is applying for appointment and privileges at MAHC in accordance with this policy. Board means the Board of Directors of MAHC. By-laws means the by-laws of MAHC as may be amended from time to time. College means a professional regulatory College under the Regulated Health Professions Act. Credentials Committee Report means the report of MAHC s Credentials Committee as described in section Error! Reference source not found. hereto. Dental Staff mean those members of the Royal College of Dental Surgeons of Ontario who have been granted privileges at MAHC. Department means a department of the Professional Staff comprised of the chief/head of the department and such other persons who may be designated authority to recommend granting privileges. Department Review Report means the report of the relevant Department(s) as described in section Error! Reference source not found. hereto. Extended Class Nursing Staff means those members of the College of Nurses of Ontario who are a registered nurse in the extended class (RN(EC)) to whom the Board has granted privileges. Hospital means Muskoka Algonquin Healthcare. Hospital Management Regulation means Regulation 965 Hospital Management passed pursuant to the Public Hospitals Act. Impact Analysis means a study conducted by the Chief Executive Officer or designate, in consultation with the Chief of Staff, Chairs of Department and Senior Medical Leaders to determine the impact upon the resources of MAHC of the proposed or continued appointment of any person to the Professional Staff. Impact Analysis Report means the report resulting from the Impact Analysis. Policy Number: GOV-3-22 Version: 1.0 Page 17 of 28

18 Initial Department Report means the initial report of the relevant Department(s) as described in section Error! Reference source not found. hereto. MAC means the Medical Advisory Committee of MAHC. Medical Staff means those members of the College of Physicians and Surgeons of Ontario who have been granted privileges at MAHC. Midwifery Staff means those members of the College of Midwives of Ontario who have been granted privileges at MAHC. Professional Staff means those physicians, dentists, midwives, oral and maxillofacial surgeons, and registered nurses in the extended class who are appointed by the Board and who are granted specific privileges to practice in MAHC. Professional Staff Application Checklist means the checklist attached hereto as Appendix A. MAHC Medical Human Resources Plan means the plan developed by the Recruitment and Retention Committee in consultation with the Chief of Staff, Chiefs of Department, and Senior Medical Leaders based on the mission and strategic plan of MAHC and on the needs of the community, which provides information and future projections of this information with respect to the management and appointment of physicians, dentists, midwives, and RN(EC)s who are or may become members of the Professional Staff. Public Hospitals Act means the Ontario Public Hospitals Act, together with all regulations there under, as amended from time to time. Respondent for the purposes of this policy, means a member of the professional staff under Part V who is subject of a complaint under Part V of this policy. RN(EC) means a Registered Nurse in the Extended Class. Rules and Regulations means the Professional Staff rules and regulations of MAHC as may be amended from time to time. Senior Medical Leader(s) means Senior Leadership Team. Term Staff has the meaning ascribed thereto in the By-laws. Policy Number: GOV-3-22 Version: 1.0 Page 18 of 28

19 APPENDIX B CREDENTIALLING CHECKLIST Name: Category/Privileges Primary Site: Dates: Sponsoring Physician: Notification: COS CEO Send with Application: Hospital By-Laws Professional Staff Rules & Regulations Billing Forms (For Radiologists, Internist) Medical Directives Package (for ED Physicians Only) Required Documentation: Completed Application CV CPSO CPSO Website Print-Out Ontario License CMPA Certificate Medical Directives signed off (applicable to ED work) Certification/Re-certification Status ATLS (if applicable) Date: ACLS (if applicable) Date: PALS (if applicable) Date: Neonatal Resuscitation Date: Pre-placement Health Form Completion Reference Forms i. ii. iii. (3 required) Verbal Reference Check BY Whom: Policy Number: GOV-3-22 Version: 1.0 Page 19 of 28

20 Correspondence: Date Application Sent Date Application Rec d Impact Analysis Complete Letter Sent to Applicant Hospital Staff Notified Mentor Assigned: Presented at: Medical Advisory Committee Board of Directors Following Approval: Memo to all staff re: Privileges Advise physician and send out Policy Number: GOV-3-22 Version: 1.0 Page 20 of 28

21 APPENDIX C - NEW APPLICANT PROCESS Written notice to the CEO expressing interest in becoming a member of the Professional Staff Medical Affairs to supply appropriate application package YES Review of application by Chief of Staff Vacancy/ need exits? NO Written notice to applicant (see Appendix F) Application forwarded to appropriate Committee Chair/Senior Director and request completion of the Impact Analysis Chief of Staff to complete reference check Name/specialty kept on file in Medical Affairs Chief of Staff review of application, references Impact Analysis and MAHC Medical Human Resources Plan to formulate recommendation to Medical Advisory Committee Medical Advisory Committee reviews and considers recommendation to Board of Directors within 60 days from the date of application. Recommend granting privileges Applicant notified in writing (delivered via , courier or personally, and given the option to request reasons within 7 days of receipt of above notification. MAC Recommendation Board of Directors Do not recommend Applicant notified in writing (delivered via courier or personally, and given the option to request reasons within 7 days of receipt of above notification. Appointment process finalized with: Letter to applicant Execution of service agreement YES Grant Privileges? YES Receipt of request from applicant for reasons within 7 days. NO NO See Appeal Process PROCESS ENDS Effective Date: Revised Date: Version: I File Name: admin mgmt/manuals/nursing/debriefing

22 APPENDIX D - REAPPOINTMENT PROCESS Applications for reappointment are distributed to all members of the professional staff in September annually. Applicants complete application and provide all required documentation to Medical Affairs by end of September. Credentials Committee reviews applications and Report to Medical Advisory Committee Medical Advisory Committee makes recommendation to Board of Directors Board of Directors Note: If the Medical Advisory Committee does not recommend reappointment for a member, the member is informed in writing and, as with new applicant process, given seven days to request written reasons for its recommendation. Policy Number: Version: Page 22 of 28

23 APPENDIX E - APPEAL PROCESS Written reasons received by applicant indicating option for appeal if written request received within 7 days of receiving reasons Process ends. NO Applicant requests appeal? YES Board of Directors holds hearing; parties to include applicant, the MAC and others as deemed by Board. Decision of Board Uphold previous decision Grant privileges to applicant Applicant appeals? NO Process Ends Appointment process continues YES Health Professions Appeal & Review Board Policy Number: Version: Page 23 of 28

24 APPENDIX F - LACK OF VACANCY/RESOURCE NOTIFICATION Dear Applicant: Re: [INSERT REQUESTED PRIVILEGES] at Muskoka Algonquin Healthcare We are writing further to the application you have submitted for [XXX] privileges at Muskoka Algonquin Healthcare. We wish to inform you that based upon the most current impact analysis and the clinical human resources plan of the Corporation, there is currently no identified need for an additional [XXX] nor are there resources that could be dedicated to such a position. In these circumstances, and without prejudging your Application for Appointment, we would request your advice as to whether you wish the organization to continue to formally process your application further to the provisions of the Public Hospitals Act, Ontario and MAHC By-Laws, which will result in a recommendation by the Medical Advisory Committee and ultimately a decision by the Board. We would ask that you inform us of your decision in this respect within the next 30 days. Yours truly, Policy Number: Version: Page 24 of 28

25 APPENDIX G - RE-APPLICATION FOR PRIVILEGES FACILITIES Indicate all facilities to which you are re-applying. Collingwood General & Marine Hospital (CGMH) Muskoka Algonquin Healthcare Orillia Soldiers Memorial Hospital (OSMH) Mental Health Centre Penetanguishene (MHCP) Georgian Bay General Hospital (Midland) Royal Victoria Hospital (RVH) PRIVILEGE CATEGORY Indicate privilege category specific for each facility. Active: Modified Active: Associate: *Term: (Formerly Courtesy) With Admitting: Without Admitting Locum Tenens: Temporary: Honourary: *Regional Affiliate: (*Not applicable for all hospitals) Medicine RN (EC) Midwifery (NP) Dental DEPARTMENT / FACILITY PERSONAL N A M E SURNAME FIRST MIDDLE INITIAL H O M E A D D R E S S PROFESSIONAL E:MAIL: PHONE: CELL: O F F I C E A D D R E S S PHONE: FAX: (POSTAL CODE) PAGER: OHIP BILLING #: CMPA # or Proof of Current Insurance: CPSO LICENCE #: CNO LICENCE #: (Extended Class/NP) RCDSO LICENCE #: CMO LICENCE #: Policy Number: Version: Page 25 of 28

26 I. PRIVILEGE CHANGES Specify any requested changes to currently held privileges: II. IN THE PAST YEAR: I believe that I have exercised the requested privileges sufficiently in the past calendar year to maintain my clinical competence in each privilege requested. Yes No Provide information about your health and current treatments, any current impairments, medical conditions, diseases or illnesses that you objectively believe may affect your ability to practice. I remain free of TB * Refer to Policy on TB Surveillance Available through Medical Affairs Office Yes No Answer yes if you have an addiction or substance use problem (including alcohol) identified that may compromise your ability to practice medicine and you are not currently enrolled in the OMA s Physician Health Program. Yes Have your privileges in any hospital been suspended, restricted, terminated, curtailed, revoked, or not renewed by that hospital? Yes No Have you been found either unfit to practice and/or guilty of professional misconduct by your applicable College or any other medical licensing body? Yes No If yes, has the Chief of Staff been informed? Yes No III. Please attach details of your CME/CPD/Recertification for the past year. For applicants who belong to a Professional Society, downloading and attaching Proof of CME is sufficient. ACLS Date: ATLS Date: PALS Date: Neonatal Resuscitation Date: Number of CME Hours Policy Number: Version: Page 26 of 28

27 Other Courses Attended/Awards/Service: IV. Professional Societies Please indicate the applicable college that you have maintained registration with. *Attach Proof Royal College of Physicians & Surgeons of Canada (RCPSC) Yes No College of Family Physicians of Canada (CFPC) Yes No College of Midwives of Ontario (CMO) Yes No College of Nurses of Ontario (Extended Class) Yes No Royal College of Dental Surgeons of Ontario (RCDSO) Yes No V. If I am re-appointed to the Professional Staff, I agree to abide by and act in accordance with the requirements of the Public Hospitals Act and the Hospital s By-Laws, Mission, Vision, Values, Policies and Rules, as established or revised from time to time by the Hospital, as well as my profession s code of ethics. Signature: Date: Confidentiality of all re-application information is strictly maintained by Medical Staff Administration. Policy Number: Version: Page 27 of 28

28 FOR HOSPITAL USE ONLY ASSOCIATE STAFF PERFORMANCE REVIEW COMPLETED Yes No Date: CME Hrs Complaints ACLS ATLS PALS Neonatal Resuscitation APPROVED BY: CHIEF / DIRECTOR OF DEPARTMENT: (if applicable) CREDENTIALS COMMITTEE: Chair: Date: MEDICAL ADVISORY COMMITTEE: Chair: Date: Date: BOARD OF DIRECTORS: Meeting Date Privileges Approved On: Date: Not Approved: Reason: Policy Number: Version: Page 28 of 28