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CMMC Medical Staff By-Laws |
Bylaws of the Medical Staff
Central Maine Medical Center
Lewiston, Maine
With updates adopted by the Medical Staff on September 8, 2005
John Yindra, M.D. President
Approved by the Governing Body on September 26, 2005
Pauline V. Beale, O.D.Chair, CMMC Board of Trustees
PREAMBLE WHEREAS, the Central Maine Medical Center is a non-profit corporation organized under the laws of the State of Maine; and,WHEREAS, its purpose is to serve as a general hospital providing a uniform standard of patient care, education and research; consistent with the mission, vision and value statement as set forth in the corporate bylaws; and,WHEREAS, it is recognized that the Medical Staff, by delegation of the Governing Body, is responsible for actively participating in providing professional leadership for measuring, assessing and improving its performance in providing quality care in the hospital, and must accept and discharge this responsibility, subject to the ultimate authority of the hospital Governing Body, and that the cooperative efforts of the Medical Staff, the President of CMMC, and the Governing Body are necessary to fulfill the hospital's obligations to its patients;THEREFORE, the physicians practicing in this hospital hereby organize themselves into a Medical Staff in conformity with these Bylaws.
DEFINITIONS
1. The term "Medical Staff" includes all allopathic and osteopathic physicians licensed to practice medicine in Maine and licensed oral surgeons who are privileged to attend patients in the hospital and who are eligible participants in the governance of the Medical Staff.
2. The term "Governing Body" means the Board of Trustees of the hospital.
3. The term "Corporation" means Central Maine Medical Center.
4. The term "Executive Committee" means the Executive Committee of the Medical Staff unless specific reference is made to the Executive Committee of the Governing Body.
5. The term "President of CMMC" refers to the individual appointed by the Governing Body to act in its behalf with respect to the overall management of the hospital.
6. The term "President of Staff" refers to the individual elected by the Medical Staff to act on its behalf with respect to the overall governance of the Medical Staff.
7. The term "physician" means an appropriately licensed allopathic or osteopathic physician or an appropriately licensed oral surgeon.
8. The term "practitioner" refers to all categories of the Medical Staff, as well as Associate Professional Staff members.
9. The "Associate Professional Staff" includes all limited licensed practitioners who are specifically identified in Article IV, Section VI entitled "The Associate Professional Staff." The Associate Professional Staff may consist of other health care professionals active in the care of patients who are not eligible participants in the governance of the Medical Staff, so appointed by the Governing Body and practicing within the scope of their licenses.
ARTICLE I. NAME
The name of this organization shall be the Medical Staff of the Central Maine Medical Center.
ARTICLE II. PURPOSES
The purposes of this organization are:
1. To ensure that all patients admitted to or treated in any of the facilities, departments, or services of the hospital shall receive the best possible care within the resources of available Staff, equipment, and physical plant; and care that is consistent with applicable professional standards of quality and appropriateness.
2. To ensure a high level of professional performance of all practitioners authorized to practice in the hospital through the appropriate delineation of the clinical privileges that each practitioner may exercise in the hospital and through an on-going review and evaluation of each practitioner's performance in the hospital. ; . Personal or professional conflicts of interest shall be disclosed and where appropriate, prohibited, in fulfilling any of the functions of the Medical or Associate Professional Staffs and in the provision of patient care.
3. To provide an appropriate educational setting that will maintain scientific standards and that will lead to continuous advancement of professional knowledge and skill. This may include maintenance of any appropriate graduate medical education program;
4. To initiate and maintain rules and regulations for self-governance of the Medical Staff consistent with the ultimate authority of the Governing Body; and such rules and policies as are necessary to clearly define acceptable Medical Staff practices regarding provision of medical and surgical care, maintenance of medical records, conduct, and any other elements of medical staff function(s) within the Medical Center; and
5. To provide a means whereby issues concerning the Medical Staff and the hospital may be discussed by the Medical Staff with the Governing Body and the President of CMMC and to ensure that there will be Medical Staff representation and participation in any hospital deliberation affecting the discharge of Medical Staff responsibilities.
6. To provide input to the allocation of financial resources as it relates to the provision of patient care.
7. It is the intent of the Medical Staff and of these Bylaws that this organization is, and for all purposes should be considered, a constituent part of the Corporation, and is not intended to be a separate legal entity.
8. To provide for obligations of the Medical staff and Associate Professional Staff concerning peer review, ethical standards and quality improvement activities.
9. To provide methods for assuring accountability of its members to the Medical and Associate Professional Staff and its Bylaws, Rules and Regulations by stipulating disciplinary processes, including processes for enforcement and appeals.
ARTICLE III. MEDICAL STAFF MEMBERSHIP
Section I: Nature of Medical Staff Membership
Membership on the Medical Staff is a privilege, which shall be extended only to professionally competent physicians and Associate Professional Staff (as described in Article IV), who continuously meet the qualifications, standards and requirements set forth in these Bylaws, Rules and Regulations and in any Departmental Policy. All determinations about Medical Staff membership and clinical privileges will be made without regard to race, religion, gender, or national origin.
Section II: Qualifications for Membership
A) Only physicians licensed to practice in the State of Maine, who are geographically and otherwise available to meet the needs of patients and of the hospital, who can document their background, experience, training, (including the adequacy of training programs), demonstrated and continued competence, their adherence to the ethics of their profession, their good character and compliance with federal and state laws and regulations, including those governing the Medicare and Medicaid programs, and their ability to work with others with sufficient adequacy to assure the Medical Staff and the Governing Body that any patient treated by them in the hospital will be given a uniform standard of quality of medical care, shall be qualified for membership on the Medical Staff.
1. Whether a physician is “geographically and otherwise available” shall be determined, in each case, by the Governing Body, after consultation with or recommendation of the Executive Committee and/or the Credentials Committee, considering such factors as the distance from the physician’s home and office to the hospital, coverage arrangements, and the nature of the privileges being sought.
2. No physician shall be entitled to membership on the Medical Staff or to the exercise of particular clinical privileges in the hospital merely by virtue of the fact that he/she is duly licensed to practice in this or any other state, or that he/she is a member of any professional organization, or that he/she had in the past, or presently has, such privileges at another hospital.
B) Board Certification. Furthermore, the applicant must document:
1. Successful completion of the number of years in a specialty residency program approved by the Accreditation Council for Graduate Medical Education, American Osteopathic Association, the Canadian Medical Association or the Royal College of Physicians and Surgeons of Canada, or other postdoctoral medical training program; and other qualifications sufficient to satisfy the requirement in effect on the date of application for examination and subsequent certification in his/her approved medical specialty. Approved medical specialty shall mean approved by a specialty board recognized by the American Board of Medical Specialties and the council on Medical Education of the American Medical Association, American Osteopathic Association, or the Canadian Medical Association or the Royal College of Physicians and Surgeons of Canada.
a) Exceptions: The Governing Body may make an exception to the requirements of this paragraph, for a physician trained outside of the United States and Canada, on the recommendations of the Executive Committee and the Credentials Committee, if the Governing Body finds that it would promote enhanced quality of and access to patient care in the hospital if the physician were granted such privileges, and further finds that the education and training of the physician is substantially equivalent to the education and training otherwise required by this section.
2. Changes in Board Certification Requirements: A physician already certified in his/her approved medical specialty at the time of application shall not be affected by subsequent changes and requirements for the number of years in a residency program or other certification requirements.
3. Failure to Obtain Board Certification: Any physician or oral surgeon (who was not a member of the active Medical Staff as of April 14, 1989) who has failed to obtain board certification within 5 years of becoming eligible to sit for a specialty board examination for each area in which he/she has clinical privileges shall not be appointed or reappointed with respect to such clinical privileges.
a) Exceptions: The Governing Body may make an exception to this requirement, on the recommendations of the Executive Committee and the Credentials Committee, if the Governing Body finds that it would promote enhanced quality of and access to patient care in the hospital if the physician was granted or retained such privileges despite lack of certification. The Credentials Committee shall solicit the input of the appropriate Department Chair in considering such a request.
C) Ethics. Acceptance of membership on the Medical Staff shall constitute the Staff member's agreement that he/she will strictly abide by the Principles of Medical Ethics of the American Medical Association, of the American Osteopathic Association, or by the Principles of Ethics of the American Dental Association, whichever is applicable.
D) Coverage Responsibilities. All Staff members, except for Honorary and Associate Professional Staff, will be expected to respond or to arrange an appropriate response in a timely manner when a member of the Medical Staff requests assistance.
1. Primary Coverage Responsibilities:
a) All members of the Active, Senior Active, and Courtesy Staff and Locum Tenens Staff shall provide continuous coverage for both their inpatients and their private practices, if applicable.
b) This coverage must be by an appropriately privileged member of the Medical Staff at Central Maine Medical Center, and must be provided from within 30 minutes driving time of the hospital.
c) A statement confirming such an arrangement shall be submitted at the time of both initial appointment to the Staff and upon application for reappointment.
2. Service Coverage Responsibilities
a) All members of the Active Medical Staff shall participate in providing coverage for patients who are without an available local physician and who present to the Central Maine Medical Center needing services.
b) This coverage obligation includes both inpatient hospital care and outpatient follow-up care of acute illness and/or injuries, but does not require the provision of long term or ongoing comprehensive care.
c) Individual Departments and/or Sections will determine Service coverage policies, subject to approval of the Executive Committee.
d) Physicians will not be expected to provide coverage for problems outside their area of specialty or expertise.
e) Two or more physicians may establish a system of coverage for their sub-specialty, subject to approval by both their Department and by the Executive Committee.
Section III: Qualification for Privileges
A) Documentation of Qualifications for clinical privileges for physicians shall include submission of:
1. Application for Membership and Privileges. A completed Medical Staff application and clinical privilege delineation application appropriate to the department(s) in which physician is seeking privileges (for APS, see Article IV, Section 6).
2. Education. Graduation from a medical or dental school, which is approved by the Liaison Committee on Medical Education of the AAMC and the AMA or AOA.
3. Training. Completion of an approved residency program (as defined in Section II A above) in the specialty for which the physician is seeking privileges or other past residency academic or experiential training which is required.
4. Procedure Lists. Submission of appropriate procedure lists as defined by specific departments.
5. Letters of Reference and peer attestations regarding clinical skills and competence. Three letters of reference. Two out of three letters shall be from persons who have been immediately involved in the supervision of, training of, or in practice with the individual. Each reference shall be asked to comment specifically on the applicant's clinical skills and competence, judgment, knowledge base, and interpersonal relationships. These letters will be used as evidence of the applicant’s personal performance and conduct at other institutions. References may be confirmed by telephone by the appropriate Department/Section Chief or designee and the Chair of the Credentials Committee or his/her designee.
6. Liability Insurance. Proof of liability insurance in the amount required by the Governing Body's Bylaws.
7. Licensure. Proof of current Maine medical license (or dental license in the case of an oral surgeon) and DEA license (if applicable). Consideration of past licensure in Maine and other states or countries, and consideration of the history of sanctions by any licensing authority or disciplinary action by any professional association or specialty board in the immediate past five years will also be provided.
B) Primary Source Verification. The applicant’s licensure, board certification status, professional liability claims history (from the carrier), and professional sanctions (e.g. NPDB) shall be primary source verified at the time of initial appointment and reappointment for all Staff categories.
Section IV: Conditions and Duration of Appointment
A) The Governing Body shall make initial appointments and reappointments of physicians and Associate Professional Staff to the Medical Staff. The Governing Body shall act on appointments, reappointments, or revocation or restrictions of appointments only after there has been a recommendation from the Executive Committee of the Medical Staff as provided by these Bylaws.
B) Term. Initial appointment shall be for at least a one-year period. Reappointments to any category of the Medical Staff shall be for a period of not more than two (2) years. All initial appointments may provide for a period of supervision and any other conditions, which shall be determined by the Governing Body upon the recommendation of the Executive Committee.
C) Provisional. All initial appointments to any category of the Medical Staff or applications for enhancement of privileges shall be provisional ("under supervision" of the Chief of Section and/or Department) for a period of at least six (6) months. Successive reappointments to provisional membership may not total more than three full years, at which time the failure to advance the appointee from provisional to regular Staff shall be deemed a termination of his/her Staff appointment. A provisional appointee whose membership is so terminated shall have the rights accorded by these Bylaws to a member of the Medical Staff who has failed to be reappointed.
D) Privileges. Appointments to the Medical Staff shall confer on the appointee only such clinical privileges as have been granted by the Governing Body after review by the Department or Section Chief, the Credentials Committee and Executive Committee of the Staff.
E) Every application for Staff appointment shall be signed by the applicant and shall contain appropriate references to the rules and regulations, Corporate Bylaws and departmental policies to ensure acceptance of committee assignments, and an agreement to accept consultation and service call assignments as specified in these Bylaws.
Section V: Dues and Assessments - Budget
A) All members of the Medical Staff shall pay dues and assessments as determined to be appropriate by the Medical Staff unless waived for hardship circumstances by the President of the Staff upon consent of the Executive Committee. The dues paid shall not be commingled with hospital funds and may be used only for Medical Staff purposes authorized by the Executive Committee or the Medical Staff.
1. If a member fails to pay dues or assessments within ninety (90) days after notification by the Staff Treasurer, then the member shall be provided with a second notice by certified mail. If dues remain unpaid thirty (30) days after receipt of the second notice, the member shall be subject to corrective action.
B) The amount of dues and assessments can be established at any meeting of the Medical Staff.
C) The Treasurer of the Medical Staff shall present a budget to the Medical Staff at the annual meeting. The budget shall reflect anticipated expenses and income for the coming year.
Section VI: Leaves of Absence (LOA)
A) Procedure. An application for a leave of absence is required for any absence from the Medical or Associate Professional Staff, which is greater than forty (40) days. The request shall include the reason for absence and the time period involved. The application shall be submitted to the Vice President for Medical Affairs who shall consult with the President of the Medical Staff, and provide notice to Active Staff members with privileges in the same department as the applicant. The Vice President for Medical Affairs may then grant or deny the application, or impose conditions on approval. The applicant may appeal a denial, or conditions imposed, to the Executive Committee, whose decision on the application shall be final.
B) Categories of Leaves of Absence
1. Medical Leave: A medical leave of absence may be granted for as long as is medically necessary. In the case of a medical LOA, before resuming regular Staff privileges, it is incumbent upon the applicant to provide documentation of health status sufficient to justify resumption of those privileges.
2. Educational Leave: An educational leave of absence may be granted for the duration of the educational program. Staff members on an educational LOA must submit verification of attendance as requested and determined by the Credentials Committee.
3. Personal Leave: A personal leave of absence may be granted for up to one year, as long as the Staff member is not actively engaged in medical practice in the hospital service area.
C) An absence greater than 40 days without a submitted written request shall be cause for termination of Staff membership, privileges, and prerogatives without right of hearing or appellate review. A subsequent request for Staff membership from a Staff member so terminated shall be submitted and processed in the manner specified for applications for initial appointment.
D) A leave of absence shall not operate to stay or preclude corrective action.
E) Upon return from any leave of absence and upon request of the Chief of the Department the member shall provide his/her department Chief with a written description of professional/medical activities in which he/she may have been involved during the period of leave, in order to assist the Chief in assessing maintenance of competency for the privileges the Staff member holds.
ARTICLE IV. CATEGORIES OF THE MEDICAL STAFF AND ASSOCIATE PROFESSIONAL STAFF
Section I: The Active Medical Staff
A) The Active Medical Staff shall consist of physicians who have been granted clinical privileges by the Governing Body, who regularly admit or care for hospital patients and who assume all the functions and responsibilities of membership on the Active Medical Staff, including, where appropriate, emergency and service call as well as consultation assignments. Members of the Active Medical Staff shall be appointed to a specific department, shall be eligible to vote, to hold office, and to serve on Medical Staff committees, and shall be required to attend Medical Staff meetings as specified in Article XII, Section IV. Active Staff members shall provide call services from an area within 30 minutes drive time from the hospital.
B) Transfers. Any applicant for transfer to the Active Medical Staff who is a member of a lesser category of Staff membership shall be subject to the same standards for review of applications as a non-member of the Staff.
C) Provisional Staff. Provisional Staff members shall be appointed to a specific department. They shall have all the above stated privileges, rights and responsibilities of Active Staff members, except that they may not hold office until their supervisory restrictions are lifted.
1. Before completion, or if not practicable soon after completion of the provisional period, the Chief or his/her designee of the appropriate department shall review all pertinent information available on each provisional appointee. Criteria for review of provisional status include assessment of quality of patient care, documentation skills, and interpersonal relationships affected by the physician during the probationary period established in Article III, Section IV C. The Chief of the Department or his/her designee will recommend to the Credentials Committee either regular Staff membership or continuation of provisional status, subject to the three-year limitation. This recommendation shall then be forwarded to the Executive Committee for review and recommendation to the Governing Body, which shall take final action.
2. Any provisional appointee shall be notified in writing in a timely manner of any adverse recommendation from the Credentials Committee or the Executive Committee. Nothing in this Section shall be construed as entitling a provisional appointee to a hearing in accordance with these Bylaws. However, upon serving the maximum number of provisional terms, the provisional appointee shall be given an opportunity to appear before the Credentials Committee prior to the Credentials Committee’s recommendation to the Executive Committee.
Section II: The Senior Active Staff
Members of the Active Medical Staff may be appointed to the Senior Active Staff after they have reached the age of 65 years (with a minimum of five years of Active Staff service) or have completed 25 years of Active service on this Staff. A member of the Senior Active Staff shall have admitting privileges and the option of holding office, serving on committees, and providing coverage in the Emergency Room if he/she so desires. Senior Active Staff are required to attend their Department/Section meetings. Members of the Senior Active Staff are not required to pay Staff dues.
Section III: The Courtesy Medical Staff
A) The Courtesy Medical Staff shall consist of physicians qualified for Staff membership as outlined in Article III, Section III (Qualification for Privileges). Courtesy Staff members shall not be eligible to vote or hold office, nor are they required to participate in Medical Staff Committees. The physician must have an Active Staff appointment in another licensed hospital to be eligible for Courtesy Staff appointment and to maintain eligibility. All applications for transfer from Courtesy to Active Staff shall be handled in the same manner as an initial appointment to Active Staff.
B) It is expected that the use of hospital facilities by the Courtesy Staff shall be minimal. Specific guidelines for inpatient admissions, consultations, day hospital procedures, and outpatient procedures shall be recommended for each Department or Section, by that Department or Section Chief, when necessary. In the event that issues arise that cannot be settled in a timely manner at a Departmental or Sectional level, they shall be resolved by the Executive Committee of the Medical Staff.
C) A member of the Courtesy Staff who is responsible for the call coverage of an inpatient in the hospital shall be available within 30 minutes time to attend to the patient.
Section IV: The Consulting Medical Staff
Consulting Medical Staff appointments may be made for those physicians who have expressed a desire to participate in the teaching and consulting activities of the hospital. They shall act as consultants when requested by members of the Medical Staff. They shall not be accorded admitting privileges and shall not be eligible to vote or hold office in this Medical Staff organization.
Section V: The Honorary Medical Staff
The Honorary Medical Staff shall consist of physicians and dentists who have retired from active hospital practice and who are of outstanding reputation, not necessarily residing in the community. Honorary Staff members shall not be eligible to admit patients, to vote, hold office, nor shall they be required to serve on Medical Staff committees or to pay dues.
Section VI: The Associate Professional Staff (APS)
A) General Information. An Associate Professional Staff category is maintained by the Medical Staff for the purpose of improving patient care. Applicants to the APS shall meet the qualifications for privileges as set forth in Article III, Section III, and Article V, Section I, as appropriate to their discipline. When required by law, applicants shall be fully licensed, registered or certified. In addition, applicants must have the competence, training and experience for the credentials for which they are applying. Applicants must submit letters of reference. APS Staff applicants will be in good standing in their professional fields. Applicants shall provide proof of professional liability insurance coverage to cover the scope of privileges requested and in an amount to be determined by the Governing Body’s Bylaws and shall abide by the ethical principles established by their respective professional associations. Applications for membership and delineation of privileges of practice shall be reviewed and voted upon in the manner designated for Medical Staff applications. Associate Professional Staff membership is limited to persons with acceptable credentials in the categories outlined in the table below:
CATEGORY |
RESPONSIBLE TO CHIEF OF |
Certified Registered Nurse Anesthetist |
Anesthesiology |
Audiologist
Speech Therapist
Speech Pathologist |
Otolaryngology |
Physicist (Masters level and above) |
Radiology and Medical Imaging |
Psychologist
Veterinarian |
Internal Medicine
|
Dentist |
Oral Surgery |
Certified Nurse Midwife
Certified Nurse Practitioner
Physician Assistant
Procedural Technicians |
Appropriate Department Chief or designee |
Podiatrist |
General Surgery Section |
B) Dependent Practitioners. Certain Associate Professional Staff members are considered dependent upon the supervision of an Active Medical Staff physician. These shall include certified registered nurse anesthetists, licensed nurse practitioners, certified nurse midwives, and physician assistants. Dependent practitioners must be under the active supervision of a member of the Active Medical Staff and must act only at the direction of said member or another Active Staff member designated by the primary supervising physician. The following provisions apply to any dependent practitioner:
1. The supervising physician must accept full responsibility and accountability for the conduct of the practitioner within the hospital.
2. The supervising physician must accept responsibility to acquaint the practitioner with the applicable Medical Staff Bylaws and Rules and Regulations and the department to which the practitioner is assigned.
3. The privileges accorded the practitioner shall automatically be restricted, suspended, or terminated in the same manner, immediately upon restriction, suspension, or termination of the clinical privileges of the supervising physician.
4. When specific clinical privileges of the supervising physician are curtailed, the privileges of the dependent practitioner shall be similarly curtailed.
5. The privileges accorded the practitioner shall terminate automatically upon the loss of license by the supervising physician, or by action of the Executive Committee.
6. The practitioner shall indicate to the Medical Affairs Office the name of the primary supervising physician, alternative physician as appropriate, and shall notify Medical Affairs of any changes in status.
7. Any supervising physician shall provide the Office of Medical Affairs with a letter attesting to the supervisory relationship. A Physician may resign from such a relationship at his/her discretion, and must notify the office of Medical Affairs.
C) Independent Practitioners. Those members of the Associate Professional Staff who are not considered dependent practitioners shall be supervised by the Chief of a specified Department of the Medical Staff (through a Section Chief when applicable) or his/her designee. Dentists and podiatrists may provide care to patients admitted by a member of the Active or Courtesy Staff, who shall be responsible for the medical aspects of the patient’s care throughout the hospital stay and shall complete the relevant components of the History and Physical.
1. Podiatrists
a) In order to be granted podiatric privileges, podiatrists must meet the following standards:
i) Non Surgical
(a) Basic education: Doctor of Podiatric Medicine (DPM)
(b) Minimum formal training: The applicant must demonstrate successful completion of a one-year surgical residency, a one-year postgraduate training program in primary podiatric orthopedics, or a one-year postgraduate training program in primary podiatric medicine. The Council on Podiatric Medical Education (CPME) must approve both the surgical residency and the postgraduate training programs.
ii) Surgical. In order to be granted surgical privileges, podiatrists must meet the following standards:
(a) Items (a) and (b) above, plus:
(b) Required previous experience: The applicant must demonstrate prior competent performance of each requested procedure and submit thirty (30) operative reports reflecting procedures performed during residency or during prior experience for each of the podiatric groupings in which he or she request privileges:
(c) Class I - digital and forefoot
(d) Class II - forefoot and simple hind foot.
(e) Board certification by the American Board of Podiatric Surgery (ABPS) within five (5) years of eligibility for that Board examination shall be an additional requirement for any podiatrist requesting surgical privileges.
b) Podiatrists shall be responsible to the Chief of the Department of Surgery and shall be reappointed in accordance with standard reappointment practices for the Associate Professional Staff.
c) Note: Rules and Regulations, VI F 9), provides that podiatrists are responsible for that part of the patient’s history and physical which relates to podiatry, and that podiatrists may admit patients in collaboration with a member of the Active or Courtesy Staff who shall be responsible for the medical aspects of the patient’s care throughout the hospital stay.
D) General Provisions Regarding All Associate Professional Staff. The members of the Associate Professional Staff:
1. Shall not be considered members of the regular Medical Staff, but may attend Medical Staff meetings;
2. Shall serve as members of Medical Staff committees when requested;
3. Shall not admit patients to the Medical Center;
4. Shall notify the Medical Affairs Office immediately upon restriction, suspension, non-renewal, or revocation of state license or certification;
5. Shall strictly adhere to the standards of ethics of the appropriate professional organization for their profession.
E) Clinical Privileges. Clinical Privileges. Clinical privileges of staff members shall be based on defined standards reflecting on their documented training, experience, demonstrated competence, judgment, and license, registration or certification. Periodic expansion or reduction of privileges based upon ongoing experience or changes in training, experience, proficiency, current clinical competence, and quality of care may occur at any time through appropriate requests to and action of the Credentials Committee, Executive Committee and the Governing Body. In the case of any expansion of privileges, the procedures to follow shall be the same as for an initial application for privileges as set forth in Article V, Section II.
F) Limitation. The Medical Staff shall limit its recommendations for appointment to membership on the Associate Professional Staff to that number of persons which it considers most advantageous in the rendering of quality medical care consistent with the hospital’s scope of services.
G) General Considerations. Appointment to the APS will not be determined solely by professional criteria such as certification, fellowship, licensure, or membership in a professional society or health care network; however, the use of any of these qualifications as specific requirements for appointment is not precluded.
Section VII: Allied Outpatient Staff
Qualifications: The Outpatient Staff shall consist of allied health professionals who meet the qualifications for membership under Article III, Section III and Article V, Section 1, as appropriate to their discipline and who do not admit to the facility and who do not provide care to inpatients of the institution.
General Provisions Regarding Allied Outpatient Staff. The members of Allied Outpatient Staff:
Shall not be considered members of regular Medical Staff, but may, by invitation only, attend Medical Staff meetings;
Shall serve as non-voting advisory members of Medical Staff committees when requested;
Shall strictly adhere to the standards of ethics of the appropriate professional organization for their profession.
Are not required to have orders co-signed by a physician.
For the purposes of this section, Allied health professionals shall include the categories of associate professional staff included in Article IV, Section VI A and licensed social workers.
Section VIII: Locum Tenens Staff
A) Qualifications. The Locum Tenens Staff shall consist of physicians or allied health professionals who meet the qualifications for membership under Article III, Section 2, or Section 3 and Article V Section 1, respectively, appointed for the specific purpose of providing temporary coverage in various disciplines where the number of appointed Staff is insufficient to meet patient care needs.
B) Term. Locum Tenens Staff shall be appointed for a specified term, no longer than necessary to meet the identified patient care needs, and in no event longer than two (2) years. There is no limit, other than those established by the appropriate state of Maine licensing board; to the number of times an individual may be appointed to this category. Appointment or reappointment as a Locum Tenens Staff member shall follow the appointment or reappointment provisions established elsewhere in these Bylaws.
C) Obligations. Physicians appointed to the Locum Tenens Staff shall not be required to meet the Medical Staff meeting attendance requirements, nor be required to pay dues and assessments (but shall pay any applicable application fees), nor be eligible to vote, to hold office, or to serve on standing committees, but may be appointed to special committees or assigned other responsibilities by Staff officers or the Department Chair. Locum Tenens Staff appointees are encouraged to attend educational conferences and appropriate Staff meetings.
D) Transfer. Physicians appointed to the Locum Tenens Staff may be changed to Active, Courtesy, or Consulting Staff providing they meet the requirements of that category. In such case, the applicant would be subject to the provisions of Article V, Secton III, regarding provisional appointment.
ARTICLE V. PROCEDURE FOR APPOINTMENT AND REAPPOINTMENT
Section I: Application for Appointment
A) All applications for appointment shall be in writing, signed by the applicant, and submitted on a form prescribed by the Governing Body after consultation with the Executive Committee. The application shall require detailed information concerning the applicant's professional qualifications, and shall include:
1. The names of at least three (3) persons who have had extensive experience in observing and working with the applicant and who can provide adequate references pertaining to the applicant's professional competence, training and experience, and ethical character, and
2. Information as to whether the applicant's membership status and/or clinical privileges have ever voluntarily or involuntarily been revoked, suspended, reduced or not renewed at any other hospital or institution, and as to whether his/her membership in local, state or national medical societies, or his/her license to practice any profession in any jurisdiction, has ever been voluntarily or involuntarily suspended, restricted, or terminated;
3. Information as to whether the applicant's narcotic license has ever been voluntarily or involuntarily suspended, restricted, or revoked;
4. Information concerning the applicant's malpractice experience, including all pending claims, settlements, and judgments, and including a consent to the release of information from his/her present and past professional liability insurance carrier(s) and proof of current liability insurance in the amounts required by the Governing Body’s Bylaws.
5. Information concerning the applicant’s history of sanctions or disciplinary action taken by his/her specialty board or professional society for the immediate past five (5) years.
6. Results of the National Practitioner Data Bank query.
B) The applicant shall have the burden of producing adequate information for processing the application to allow a proper evaluation of his/her competence, experience, character, ethics, mental and physical well-being, and other qualifications, and for resolving any doubts about such qualifications. Any material misrepresentation in, or omission from, the application and related documents, shall be grounds for denial of privileges or corrective action regardless of when the misrepresentation or omission is discovered.
C) The completed application shall be submitted to the Medical Affairs office. The Medical Affairs office will distribute the application for review by the appropriate committees and/or individuals.
D) By applying for appointment to the Medical Staff, each applicant thereby signifies:
1. His/her willingness to appear for interviews in regard to his/her application;
2. Authorizes the hospital to consult with members of Medical Staffs of other hospitals/institutions with which the applicant has been associated, and with others who may have information bearing on his/her competence and character, including mental and emotional stability, and ethical qualifications;
3. Consents to the hospital's inspection of all records and documents that may be material to an evaluation of his/her professional qualifications and competence to carry out the clinical privileges he/she requests as well as of his/her moral and ethical qualifications for Staff membership; and,
4. Releases from any liability all representatives of the hospital and its Medical Staff for their acts performed in good faith.
5. Certifies that he/she does not have any physical or mental disability that might interfere with his/her ability to provide quality patient care consistent with the clinical privileges he/she has requested.
Section II: Appointment Process
A) The Credentials Committee shall examine evidence of character, including emotional stability, professional competence, qualifications, training and ethical standing of the applicant and shall determine, through information contained in references given by the applicant and other sources including an appraisal by the appropriate Chief, whether the practitioner meets all of the necessary qualifications for the category of Staff membership and the clinical privileges requested.
B) Department/Section Chief Review: Every department in which the practitioner seeks clinical privileges shall provide the Credentials Committee with specific, written recommendations for delineating the practitioner's clinical privileges, and these recommendations will be included in the Committee’s report.
C) Credentials Committee Review: Upon completion of the review of the application, the Credentials Committee shall submit to the Executive Committee the completed application and a recommendation that the practitioner be either provisionally appointed, rejected, or that the application be deferred for further consideration.
D) Medical Staff Executive Committee Review: After receipt of the application and the report and recommendation of the Credentials Committee, the Executive Committee shall recommend to the Governing Body either provisional appointment, rejection, or deferral for further consideration. All recommendations to appoint must also specifically recommend the clinical privileges to be granted, which may be qualified by probationary conditions relating to such clinical privileges. When the recommendation of the Executive Committee is to defer the application for further consideration, it must be followed up within a reasonable time with a subsequent recommendation for provisional appointment with specific clinical privileges, or for rejection for Staff membership.
E) Governing Body (Board) Review: The recommendations of the Executive Committee will be transmitted promptly to the Governing Body. Should the Governing Body take any action inconsistent with the recommendation of the Executive Committee the matter will be referred to the Board’s Joint Conference Committee for further deliberations and recommendations. The action of the Governing Body shall remain in effect, and shall not be stayed, pending a recommendation of the Joint Conference Committee.
Section III: Evaluation of Provisional Appointees
A) Before the expiration of any provisional appointment or reappointment, the Chief of the Department/Section to which the appointee was primarily assigned shall begin to review all pertinent information. Criteria for review of provisional status may include an assessment of patient care, documentation skills and interpersonal relationships demonstrated by the appointee during the probationary period. If the level of activity in the facility is low or non-existent, the burden is on the appointee to provide sufficient information from the institutions in which he/she has practiced or from his/her office practice to satisfy the above criteria.
B) Following review, the Chief of the Department/Section or his/her designee will make a written recommendation to the Credentials Committee. The Credentials Committee shall conduct such informal inquiry and review as it deems appropriate and then recommend to the Executive Committee that the provisional appointee should be advanced to the applicable category of Medical Staff, appointed to provisional status, or not appointed. A provisional appointee whose appointment is terminated shall not have the rights accorded by these bylaws to a member of the Medical Staff who has failed to be reappointed except as provided in Article IV, Section I, c)2. The Executive Committee shall consider the recommendation of the Credentials Committee and then forward its recommendation to the Governing Body for action. If the Board has not acted by the expiration date of a provisional appointment, the provisional appointment shall be deemed extended until the effective date of formal action by the Board
Section IV: Reappointment Process
A) The term of a regular appointment for any category of the Medical Staff shall be for two years. Each member shall be considered for reappointment at the end of each two-year period.
B) Chief’s Review: The Chiefs shall review the reappointments of all Department/Section members and transmit their comments to the Credentials Committee;
C) Credentials Committee Review: The Credentials Committee shall review all pertinent information available, for the purpose of determining its recommendations for reappointment and for the granting of clinical privileges for the ensuing period, and shall transmit its written recommendations to the Executive Committee. Where non-reappointment or a change in clinical privileges is recommended, the reason for such recommendation shall be documented.
D) Each recommendation concerning the reappointment of a Staff member and the clinical privileges to be granted upon reappointment shall be based upon such member's:
1. Professional qualifications, based on a peer evaluation of documented clinical competence; including review of any patient, staff or professional complaint concerning the applicant.
2. Clinical judgment in the treatment of patients as demonstrated by peer review;
3. Ethics and conduct;
4. Attendance at Medical Staff, meetings and committees;
5. Compliance with the Governing Body’s Bylaws and the Medical Staff Bylaws, Rules and Regulations;
6. Cooperation with hospital personnel;
7. Proper medical use of the hospital's facilities for his/her patients;
8. Relations with other practitioners;
9. General attitude toward patients, the hospital, and the public;
10. Evidence of professional liability coverage consonant with the requirements of the Governing Body;
11. Report of liability experience as requested;
12. Certification that he/she does not have any physical or mental disability which might interfere with his/her ability to provide quality patient care consistent with the clinical privileges he/she has requested;
13. Certification that he/she is not impaired by any form of substance abuse;
14. Information as to whether the applicant’s membership status and/or clinical privileges have ever voluntarily or involuntarily been revoked, suspended, reduced or not renewed at any other hospital or institution, and as to whether his/her membership in any local, state or national medical societies, or his/her license to practice any profession in any jurisdiction, or his/her narcotic license has ever been voluntarily or involuntarily suspended, restricted or revoked.
15. Certification that he or she has never been convicted of any Class A, B, or C criminal offense:
16. Certification that he/she has never voluntarily surrendered or modified his/her privileges or resigned from Staff membership while under or to avoid investigation or disciplinary action;
17. Record of professional performance and conduct at other institutions where the individual holds or has held privileges to practice
18. Results of the National Practitioner Data Bank query
19. Certification of coverage arrangements consistent with these Bylaws.
20. The information required in section b10 - 16 inclusive may be limited to experience since the date of the most recent reappointment.
E) Executive Committee Review: After receipt of the application and the report and recommendation of the Credentials Committee, the Executive Committee shall determine whether to recommend to the Governing Body that the practitioner be reappointed to the Medical Staff, that he/she not be reappointed, or that his/her application be deferred for further consideration. All recommendations to reappoint must also specifically recommend the clinical privileges to be granted, which may be qualified by certain conditions.
F) Governing Body (Board) Review: After receipt of the application, and the report and recommendation of the Executive Committee, the Governing Body shall determine whether the practitioner be reappointed, to the Medical Staff, that he/she not be reappointed, or that his/her application be deferred for further consideration. All reappointments shall specify the clinical privileges being granted, which may be qualified by conditions relating to such clinical privileges.
1. Deferred Action: When the recommendation of the Executive Committee or the action of the Governing Body is to defer the application for further consideration, it must be followed up within a reasonable time with a subsequent recommendation for reappointment with specific clinical privileges, or for rejection for Staff membership.
2. Joint Conference Committee Review: The recommendations of the Executive Committee will be transmitted promptly to the Governing Body. Should the Governing Body take any action inconsistent with the recommendation of the Executive Committee, the matter will be referred to the Board’s Joint Conference Committee for further deliberations and recommendations. The action of the Governing Body shall remain in effect, and shall not be stayed, pending a recommendation of the Joint Conference Committee.
Section V: Continuing Medical Education
Reappointment by the above process will be dependent on the following educational requirements:
A) All members of the Medical Staff will participate in Continuing Medical Education.
B) All members of the Medical Staff shall meet the Continuing Medical Education requirements of the Maine Board of Licensure in Medicine or that agency responsible for their particular educational certification. Members of the Associate Professional Staff shall meet their Board or Organization’s requirements for continuing education. Meeting these requirements is considered necessary for continued active association with Central Maine Medical Center. At least fifty percent (50%) of the required educational hours shall be in the practitioner's special area of practice.
ARTICLE VI. CLINICAL PRIVILEGES
Section I: Delineation of Clinical Privileges
A) Only members of the Medical Staff and Associate Professional Staff shall be entitled to the exercise of clinical privileges in the hospital. Every practitioner shall be entitled to exercise only those clinical privileges specifically granted to him/her by the Governing Body, except as provided in Sections II and III of this Article VI (Temporary and Emergency Privileges).
B) Every application for Staff appointment must contain a request for the specific clinical privileges desired. The evaluation of such request shall be based upon the applicant's education, training, qualifications, experience, demonstrated competence, references, and other relevant information, including an appraisal by the Chief of every department in which privileges are sought. The applicant shall have the burden of producing documentation to establish his/her qualifications, training, education, experience and demonstrated competency in the clinical privileges he/she requests.
C) All Staff members will be reappointed, and their clinical privileges reviewed, as outlined in Article V, Section IV (Reappointment Process).
D) This article shall also apply to a member of the Medical Staff who requests additional clinical privileges other than during the reappointment process. The procedures to follow in such a case shall be the same as for an initial application for privileges as set forth in Article V, Section II (Appointment Process).
E) Any request for privileges that are new to the practitioner or new to the practitioner’s professional or medical discipline or the institution and might include investigational or unproved techniques shall be individually granted based on relevant criteria for competence, training, and experience.
F) Providing Care Via Telemedicine:
1. Description: Telemedicine involves the use of electronic communication or other communication technologies to provide or support clinical care at a distance. Diagnosis and treatment of a patient may be performed via telemedicine link (video conferencing). The Medical Staff shall determine which clinical services are appropriately delivered through this medium, according to commonly accepted quality standards.
2. If a practitioner prescribes, renders a diagnosis, or otherwise provides clinical treatment to a patient at CMMC via telemedicine, the practitioner shall be credentialed and privileged through the Medical Staff mechanisms set forth in these bylaws. The CMMC Medical Staff may use credentialing information from another licensed hospital, so long as the decision to delineate privileges is made at CMMC.
Section II: Temporary Privileges
A) General. Upon receipt of an application for Medical Staff membership from an appropriately licensed practitioner who meets the qualifications for privileges as set forth in Article III, Section 3 and Article V, Section 1, as appropriate to their discipline, the President of CMMC, or in his absence, the Chief Operating Officer may, upon verification of the active Maine licensure, current professional liability insurance and of past claims history, acceptable competence and training to perform the functions for which privileges are granted and results of the National Practitioner Data Bank query, and with the written concurrence of the Department Chief concerned and the Chairman of the Executive Committee, grant temporary admitting and clinical privileges to the applicant;; but, in exercising such privileges, the applicant shall act under the supervision of the Chief of the department to which he/she is assigned.
1. Not withstanding the above, the temporary privileges may not be granted until the approved number of reference phone calls have been completed and the Credentials Committee has reviewed the application.
B) Urgent Need. The President of the Medical Staff may make exceptions to grant temporary privileges absent completion of reference phone calls and Credentials Committee review only in the event of an urgent need for a practitioner to provide a service not otherwise available by other practitioners on Staff.
C) For Care of A Specific Patient. Temporary privileges for the care of a specific patient may also be granted by the President of CMMC, or in his absence, the Chief Operating Officer, to a practitioner who is not an applicant for membership in the same manner and upon the same conditions as set forth in subparagraph "A" of this Section II, provided that there shall first be obtained such practitioner's signed acknowledgment that he/she has received and read copies of the Medical Staff's Bylaws, Rules and Regulations, and that he/she agrees to be bound by the terms thereof in all matters relating to his/her temporary privileges.
D) Limited to 60 days. Such temporary privileges as described in paragraphs A through C above shall be restricted to not more than 60 days (with only one 60-day renewal, if needed), by which time a practitioner will either have applied for membership on the Medical Staff before being allowed to attend additional patients in the case of (C) above or in the case of an applicant, has been granted provisional membership.
E) Privileges and Rights. Receipt of temporary privileges by a practitioner includes only those privileges delineated with respect to patient care and does not confer any of the other privileges and rights associated with permanent Staff membership (including voting, holding office, and due process).
F) Supervision. The appropriate department Chief or his/her designee, who will perform concurrent review of care for appropriateness and quality and will report his/her findings to the Executive Committee, will supervise any practitioner receiving temporary privileges.
G) Termination. Notwithstanding any other provision of the Bylaws, the President of CMMC may immediately terminate the temporary privileges granted under this Article, at any time, if he/she believes that the practitioner has failed to comply with the Bylaws, Rules or Regulations, or has not provided or documented care of appropriate quality.
1. In such a case the practitioner shall be notified in writing of the action and shall be entitled to appear before the Medical Staff Executive Committee to respond to the notification in accordance with the provisions of these bylaws.
2. The temporary privileges, pending the Executive Committee decision, will remain revoked pending the hearing and any subsequent appeal.
3. The appropriate department Chief or, in his/her absence, the Chairman of the Executive Committee, shall assign a member of the Medical Staff to assume responsibility for the care of such terminated practitioner's patient(s) until they are discharged from the hospital.
H) Disaster Response Plan. In addition to the provisions for temporary privileges provided in subsections (a) through (e) above, temporary privileges may also be granted in connection with implementation of any disaster response plan approved by CMMC.
1. Such privileges may be granted to an appropriately licensed practitioner by the President of CMMC, the President of the Medical Staff or the Chief of any department, upon the basis of information then available which may reasonably be relied upon. Reasonable attempts shall be made to verify active Maine licensure, current professional liability insurance, and past claims history and to verify acceptable competence and training to perform the functions for which the privileges are requested.
2. The lack of such verification shall not preclude the individual granting the temporary privileges from acting on his/her present knowledge and belief and the granting or denial of such privileges in these specific circumstances shall be within the sole discretion of the individual. Said temporary privileges shall terminate upon revocation by any individual having the authority to grant the credentials, or in 72 hours, whichever occurs first.
3. Temporary privileges granted in connection with implementation of the Disaster Response Plan are not renewable.
Section III: Emergency Privileges
For the purpose of this section, an "emergency" is defined as a condition in which serious permanent harm would result to a patient or in which the life of a patient is in immediate danger and any delay in administering treatment would add to the danger and there is no reasonable or safe alternative to making such an emergency appointment in order to assure appropriate patient care.
A) In the case of emergency, any practitioner on the Medical Staff, and any resident in the hospital’s residency program, to the degree permitted by his/her license and regardless of Staff status or level of privileges, shall be permitted and assisted to do everything possible to save the life of a patient, or to save the patient from serious harm, using every facility of the hospital necessary, including the calling for any consultation necessary or desirable.
B) When an emergency situation no longer exists, and in any case, within 72 hours of the emergency appointment, such practitioner must request the privileges necessary to continue to treat the patient. An emergency appointment is not renewable. In the event such privileges are denied or he/she does not desire to request privileges, the patient shall be assigned to an appropriate member of the Staff. This section is to be construed to be consistent with the hospital’s policies on patient consent to treatment.
Section IV: Reduction or Surrender of Privileges; Resignation
A) At any time, a practitioner may voluntarily reduce his/her privileges or resign from the Medical Staff by submitting a written and signed request to the Vice President of Medical Affairs or to the President of the Medical Staff, and such reduction or resignation shall take effect immediately upon receipt, provided that no corrective action is pending.
B) Absence from the Medical Staff for greater than forty (40) days as provided in Article III, Section VI (Leaves of Absence), shall also constitute a voluntary surrender of privileges. If no corrective action is pending, such voluntary reduction or resignation shall not be considered disciplinary action for any purpose.
C) If corrective action is pending, such request or resignation shall be submitted to the Governing Body, which may accept or reject it.
ARTICLE VII. CORRECTIVE ACTION
Section I: Investigation
A) Whenever the conduct or competence of a practitioner may be inconsistent with good patient care or the effective operation of the hospital, whether such acts or omissions constitute a single serious incident or a pattern of behavior, an investigation may be requested by the President of the Medical Staff, the Chief of any department, the President of CMMC, the Executive Committee of the Staff, or by the Executive Committee of the Governing Body to determine whether corrective action should be recommended. Such requests shall be submitted to the Executive Committee; and the affected practitioner, wherever practicable, shall be notified promptly.
B) Grounds for initiating corrective action shall include, but not be limited to:
1. Material violation of these bylaws, rules and regulations, or hospital policy;
2. Providing substandard patient care;
3. Violations of ethical standards of the practitioner’s profession as set forth by a recognized national association or board of such profession;
4. Imposition of sanctions for violations of Medicare or Medicaid statutes or regulations;
5. Unprofessional conduct toward patients, other members of this Medical Staff, or hospital Staff; and,
6. Disciplinary action by the Maine Board of Licensure in Medicine, The Maine Board of Osteopathic Licensure and Registration, or the Maine Board of Dental Examiners.
C) Ad Hoc Committee. At the request of the practitioner, or on its own motion, prior to making its report, the Executive Committee may refer the matter to an ad hoc Committee, which shall exercise the authority and assume the responsibilities of the Executive Committee with respect to investigating the matter and shall then report its findings, conclusions, and recommendations to the Executive Committee.
1. The President of the Medical Staff shall appoint the members of the ad hoc Committee, and there shall be not less than three, nor more than five, voting members who shall be members of the Medical Staff.
2. The President may also appoint one or more persons who are not members of the Medical Staff to the Committee, to serve as non-voting advisors, consultants, or presiding officer.
D) After completing its investigation, or receiving a report from the ad hoc committee of its findings, conclusions, and recommendations, the Executive Committee may decide that no further action is warranted; it may warn, admonish, or reprimand the practitioner; it may impose a probation or requirement for consultation upon such terms and conditions as it deems appropriate; or it may recommend that the practitioner's privileges be restricted, reduced, suspended, or revoked; or that the practitioner's membership on the Medical Staff be suspended or terminated.
E) The Executive Committee shall notify the practitioner, the person or body who requested the investigation, (consistent with Article VII, Section I A.) and the Governing Body of its actions or recommendations.
F) Notwithstanding any other provision of this section, only the Governing Body shall have the authority to take action that constitutes a restriction, reduction, suspension, or revocation of privileges.
G) Except in cases of summary suspension, the practitioner shall be offered an opportunity to appear before the body that conducts the investigation before a recommendation is made by that body.
H) The Chairman of the Executive Committee shall promptly notify the President of CMMC in writing of all requests for corrective action received by the Executive Committee and shall continue to keep him/her fully informed of all action taken in connection therewith.
I) Any final order, or judgment of conviction, plea of guilty, no contest or nolo contendre, in any criminal, civil, or administrative proceeding shall constitute conclusive evidence of the matters alleged therein, for purposes of any proceeding under this Article.
Section II: Summary Suspension
A) The Chairman of the Executive Committee, the President of the Medical Staff, the President of CMMC, the Executive Committee of the Medical Staff, or the Executive Committee of the Governing Body shall have the authority to summarily suspend all, or any portion, of the clinical privileges of a practitioner, whenever such person or body concludes that there is a substantial risk that continuing said privileges would be likely to jeopardize the health or safety of patients, a patient, or Staff if such privileges were to be continued until a hearing could be held. Such summary suspension may be made effective immediately upon notice to the practitioner.
B) Unless the Medical Staff Executive Committee imposed the summary suspension, the party imposing the suspension shall notify the Medical Staff Executive Committee promptly of the action, and the Medical Staff Executive Committee shall convene promptly to review the basis for the summary suspension, and it may uphold, revoke, or revise the terms of such summary suspension. The Medical Executive Committee will report its recommendation and/or actions to the Governing Body.
1.A practitioner whose clinical privileges have been summarily suspended shall be offered an opportunity to appear personally and respond before the Executive Committee, or ad hoc committee, not later than ten (10) days after the imposition of the suspension, unless the practitioner requests additional time.
2.After providing the practitioner with an opportunity to appear and respond to the summary suspension, the Executive Committee may uphold, revoke, or revise the terms of such suspension.
3.At the request of the practitioner, or on its own motion, the Executive Committee may refer the matter to an ad hoc committee, which shall exercise the authority and assume the responsibilities of the Executive Committee with respect to reviewing the summary suspension, and it shall then report its findings, conclusions, and recommendations to the Executive Committee.
a) The President of the Medical Staff shall appoint the members of the ad hoc committee, and there shall be not less than three (3), nor more than five (5), voting members, who shall be members of the Medical Staff.
b) The President may also appoint one or more persons who are not members of the Medical Staff to the Committee to serve as non-voting advisors, consultants, or presiding officer.
C) Immediately upon the imposition of summary suspension, the Chair of the Executive Committee or the responsible department Chief shall have authority to provide for alternative medical coverage for the patients of the suspended practitioner still in the hospital at the time of such suspension. The wishes of the patient shall be considered in the selection of such alternative practitioner where practical.
Section III: Automatic Suspension
A) Suspension or Revocation of License. Action by the relevant State licensing body revoking or suspending the license of a practitioner shall automatically suspend all of his/her hospital privileges, and unless the license is restored within 90 days, the practitioner’s privileges and Staff membership shall be automatically terminated.
B) Delinquent Medical Records. A temporary suspension in the form of withdrawal of a practitioner's admitting privileges, effective until medical records are completed, shall be imposed automatically after warning of delinquency for failure to complete medical records within 15 days of a patient's discharge.
C) Loss of Active Membership at a Licensed Hospital. Loss of Active Membership at licensed hospital. The clinical privileges of a member of the Courtesy Staff who is no longer a member of the active staff of any other licensed hospital shall be suspended automatically, and unless written evidence of active staff membership at another licensed hospital is provided to the office of medical affairs within 90 days, the practitioner’s privileges and staff membership shall be automatically terminated.
D) Lapse In Liability Insurance. The clinical privileges of a practitioner shall be automatically suspended in the event of a lapse in professional liability insurance coverage as specified in Article III, Section 3, Paragraph f, and shall not be reinstated until the practitioner produces satisfactory evidence of coverage.
E) Automatic suspensions shall not confer on the affected practitioner any right to appellate review thereof in Article VIII of these Bylaws.
F) It shall be the duty of the President of the Medical Staff to cooperate with the President of CMMC in enforcing all automatic suspensions.
ARTICLE VIII. ACTION ON ADVERSE RECOMMENDATION
Section I: Written Response
A member of the Active, Senior Active, or Courtesy Medical Staff may, not more than ten days after the Executive Committee sends him/her notice of an adverse recommendation relating to restriction, reduction, suspension, denial or revocation of privileges, reappointment, or suspension or termination of Staff membership, deliver a written response to the Governing Body or the President of the hospital.
A) If no such response is received within the time specified, the Governing Body may take final action on the recommendation without further notice to the practitioner.
B) If the practitioner does file a timely response, the Governing Body shall proceed to consider action on the recommendation in accordance with its procedures and Bylaws. If there has been no opportunity for the practitioner to be heard before the recommendation of the Executive Committee was made, and the Governing Body is considering adverse action, the practitioner will be given an opportunity for a hearing before the Governing Body takes final adverse action.
Section II: Courtesy Staff
Notwithstanding any other provision of these bylaws, neither a recommendation of the Executive Committee, nor a decision of the Governing Body, with respect to non-reappointment to the Courtesy Staff or limitation of Courtesy privileges shall entitle a member of the Courtesy Staff to a hearing.
Section III: Summary Suspension
In the case of a summary suspension of privileges, the practitioner may, not more than ten (10) days after notice that the Executive Committee has declined to fully restore suspended privileges, deliver a written request for restoration of privileges to the Governing Body or President of the hospital.
A) If no such request is received within the time specified, the Governing Body may take final action without further notice to the practitioner.
B) If the practitioner does file a timely request, the Governing Body shall proceed to consider action on the suspension in accordance with its procedures and Bylaws.
C) The request for restoration shall not operate to stay the action of the Executive Committee or ad hoc committee, and such suspension shall remain in effect unless and until the Governing Body takes contrary action.
ARTICLE IX. OFFICERS
Section I: Officers of the Medical Staff
The officers of the Medical Staff shall be:
A) President
B) Vice President
C) Secretary
D) Treasurer
Section II: Qualifications of Officers
Officers must be members of the Active Medical Staff at the time of nomination and election and must remain members in good standing during their term of office. Failure to maintain such status shall immediately create a vacancy in the office involved.
Section III: Election of Officers
A) Officers shall be elected at the annual meeting of the Medical Staff. Only members of the Active Medical Staff shall be eligible to vote.
B) The nominating committee shall consist of the following members:
1.Immediate past President of the Staff, who shall be named as the Chair.
2.At least four (4) other members representing the different major departments not represented by the past President.
3.The nominating committee shall be appointed in February and the slate of officers presented at the March Staff meeting.
C) Nominations may be made from the floor only at the meeting during which the report of the nominating committee is presented.
D) If there are three (3) or more nominees for an office, the candidate receiving the majority of votes shall be elected. If a majority is not obtained on the first ballot, the candidate receiving the lowest number of votes shall be eliminated successively until a majority is reached.
Section IV: Term of Office
All officers shall serve for two (2) successive years from their election date or until a successor is elected. Officers shall take office at the annual meeting of the Medical Staff. A member shall not serve in any office for more than two (2) successive terms of two years each, with the exception of the Treasurer who may be re-elected indefinitely.
Section V: Vacancies in Office
Vacancies in office during the Medical Staff year, except for the Presidency, shall be filled by the Executive Committee of the Medical Staff. If there is a vacancy in the office of the President, the Vice President shall serve out the remaining term as follows:
A) If there are six (6) months or less remaining of his/her two-year term, the Vice President shall cover the office of President of Staff as well as his/her own office;
B) If there are more than six (6) months remaining, the Staff shall elect by majority vote a replacement for the Vice President for the remainder of his/her original term.
C) Should the Vice President be unable to fill any vacated office for the President, the President of the Staff shall designate an appropriate replacement from the senior members of the Executive Committee.
Section VI: Duties of Officers
A) President: The President shall serve as the Chief administrative officer of the Medical Staff to:
1.Act in coordination and cooperation with President of CMMC in all matters of mutual concern within the hospital;
2.Call, preside at, and be responsible for the agenda of all general meetings of the Medical Staff;
3.Serve as Chair of the Medical Staff Executive Committee;
4.Serve as an ex officio member of all other Medical Staff committees;
5.Be responsible for the enforcement of Medical Staff Bylaws, Rules and Regulations, for implementation of sanctions where these are indicated, and for the Medical Staff's compliance with procedural safeguards in all instances where corrective action has been requested against a practitioner;
6.Appoint committee members to all standing, special, and multi disciplinary committees, except the Executive Committee, subject to the approval of the Executive Committee of the Medical Staff;
7.Represent the views, policies, needs, and grievances of the Medical Staff to the Governing Body and to the Chief Executive Officer;
8.Receive and interpret the policies of the Governing Body to the Medical Staff and report to the Governing Body on the performance and maintenance of quality with respect to the Medical Staff's delegated responsibility to provide quality clinical care;
9.Be the official spokesperson for the Medical Staff; and
10. At his/her option, serve on the Executive Committee as a voting member for his/her term as immediate past President.
11. Attend meetings of the Governing Body in order to provide effective communications among the Medical Staff, hospital administration, and governing body.
12. Meet at least monthly with representatives of administration to discuss matters of mutual concern and interest. These meetings may be informal and no agenda or minutes shall be required.
B) Vice President: In the absence of the President, he/she shall assume all the duties and have the authority of the President. He/she shall automatically succeed the President when the latter fails to serve for any reason.
C) Secretary: He/she shall keep accurate and complete minutes of all Staff meetings, call meetings on order of the President, attend to all correspondence, and perform such other duties as ordinarily pertain to his/her office.
D) Treasurer: He/she shall account for and be custodian of all funds, collect dues, and disburse such monies to settle legitimate bills incurred by the Staff and pay other sums as may be directed by authorized members of the Medical Staff. For the purpose of determining Executive Committee membership, the Treasurer shall not be considered an officer of the Staff.
Section VII: Removal
Any officer of the Medical Staff may be removed from office for cause upon a two-thirds vote of the Active Medical Staff.
ARTICLE X. ORGANIZATION OF THE STAFF
Section I: Organization of Departments
A) Each department shall be organized as a separate part of the Medical Staff and shall have a Chief who shall be responsible for the supervision of the work within his/her department. Each Chief shall in turn be responsible to the Executive Committee of the Staff.
B) Policy Making: Each Department or Section shall establish its own policy, consistent with the policies of the Medical Staff and of the Governing Body. Any such policy which impacts upon members of other departments shall be reviewed and approved by the Executive Committee.
C) The Medical Staff shall be divided into the following departments and sections:
1.Department of Medicine, with the following sections:
a) General Internal Medicine
b) Cardiology
c) Critical Care Medicine
d) Dermatology
e) Gastroenterology
f) Hematology and Oncology
g) Infectious Diseases
h) Nephrology
i) & | 
