Staff Resources

CMMC Medical Staff By-Laws

(REVISED 9.28.09)
BYLAWS OF THE MEDICAL STAFF
CENTRAL MAINE MEDICAL CENTER
LEWISTON, MAINE

With updates adopted by the Medical Staff on September 28, 2009
Laird Covey
President

Approved by the Governing Body
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 members of the Medical Staff and Associate Professional Staff members.
9. The "Associate Professional Staff" consists of those individuals who have been granted clinical privileges to provide services at CMMC as a dentist, podiatrist, physician assistant, nurse practitioner, certified registered nurse anesthetist, or certified nurse midwife, pursuant to Article IV, Section VI. These individuals are not considered members of the Medical Staff.


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 (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 Medical Staff members, except for Honorary 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 consistent with the requirements of Appendix C of the Rules and Regulations, unless otherwise determined by the Executive Committee, upon request of an individual, section or department.
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 and other practitioners with admitting privileges 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.
f) Recognizing the role of the Medical Center as a regional referral center, all members of the Active Medical Staff will also respond, when on call, to calls from staff members at other area hospitals. However, nothing in this section shall be construed as requiring the on-call member to examine a patient unless said patient presents to CMMC.

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 to the Medical Staff and Associate Professional 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.
D) Provisional Staff members shall be appointed to a specific department. They shall have all the above stated privileges, rights and responsibilities of the category of membership to which they were provisionally appointed, Members provisionally appointed to the Active staff may not hold office until their supervisory restrictions are lifted.
1. Chief’s Review. 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 appointee 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 (in the appropriate category) 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. Notification of adverse recommendation. 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.
E) Privileges. Appointments to the Medical Staff or to the Associate Professional 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.
F) 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 coverage services consistent with the requirements of Appendix C of the Rules & Regulations.
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.

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 the timeframe for the applicable Department stated in Appendix C of The Rules and Regulations.
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 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 clinical privileges 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 the same amount and conditions as required for members of the Medical Staff by the Governing Body’s Bylaws and shall abide by the ethical principles established by their respective professional associations. Applications for appointment to the APS and delineation of clinical privileges shall be reviewed and voted upon in the manner designated for Medical Staff applications. Associate Professional Staff appointment is limited to persons with acceptable credentials in the categories outlined in the table below:

B) Limitations on Clinical Privileges: Certain Associate Professional Staff members are considered dependent upon the supervision of an Active Medical Staff physician. These shall include certified registered nurse anesthetists and physician assistants. Certified nurse midwives and nurse practitioners during the first two years of post training practice are required to be under the supervision of a member of the Active Medical Staff. The supervising physician must accept full responsibility and accountability for the conduct of the supervised practitioner within the Hospital. In the event that a supervising physician withdraws from the supervisory relationship, or the supervising physician’s clinical privileges are surrendered, suspended, or terminated, the supervised practitioner’s privileges are automatically suspended until the supervising physician’s clinical privileges are fully restored, or another qualified physician has agreed to assume supervisory responsibility. 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. It is the responsibility of the supervised practitioner to advise the Medical Affairs in writing of any change in supervising physician.

C) Associate Professional Staff Not Subject to Supervisory Requirement. Associate Professional Staff practitioners who are not subject to the supervisory requirement under paragraph B above shall be responsible to 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.
D) 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.
E) General Provisions Regarding Associate Professional Staff. The members of the Associate Professional Staff:
1. Shall not be considered members of the Medical Staff, but may attend Medical Staff meetings;
2. Shall serve as members of Medical Staff committees when requested;
3. Shall not be admitting providers of record, except that certified nurse midwives may be granted privileges to admit patients for obstetric care not covered by Medicare.
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;
6. Shall be subject to the same corrective action process as members of the Medical Staff, but shall not be entitled to a hearing with respect to denial of appointment, reappointment or denial, restriction, reduction, suspension, or revocation of clinical privileges, and any procedure shall be at the discretion of the Governing Body.
F) 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. In addition to the criteria as stated herein, the Governing Body may also apply the same factors in making a determination of appointment, reappointment, or scope of privileges for a member of the APS, as for a member of the Medical Staff.
G) 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.
H) General Considerations. Appointment to the APS will not be determined solely by professional criteria such as certification, 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.
I) General Staff. All individuals who are not physicians and not one of the categories in the Associate Professional Staff, and who provide or assist in providing clinical services at the hospital, shall not be governed by these Bylaws, shall not be considered to hold clinical privileges, and shall be subject to the administrative policies of the hospital.
Section VII: 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, Section 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 III, Section 4 C. 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. Outside peer review will be used when, in the judgment of the President of the Medical Staff, Chief Medical Officer, or President of the hospital, there is not adequate expertise within the organization or where there may be a conflict of interest or in any other situation where the President of the Medical Staff, Chief Medical Officer, or President of the Hospital deem that use of outside review would be in the best interests of the safe and effective operations of the hospital.
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) Neurology
j) Physical Medicine & Rehabilitation
k) Respiratory Diseases
l) Rheumatology
2. Department of Pediatrics, with the following sections:
a) General Pediatrics
b) Neonatology
3. Department of Obstetrics-Gynecology
4. Department of Surgery, with the following sections:
a) General Surgery
b) Neurosurgery
c) Ophthalmology Surgery
d) Oral and Maxillofacial Surgery
e) Orthopedic Surgery
f) Otolaryngology/Maxillofacial Surgery
g) Plastic/Reconstructive Surgery
h) Thoracic and Cardiovascular Surgery
i) Trauma Surgery
j) Urology Surgery
5. Department of Family Practice
6. Department of Emergency Medicine
7. Department of Pathology
8. Department of Radiology and Medical Imaging/Nuclear Medicine
9. Department of Radiation Oncology
10. Department of Anesthesiology

D) Division of Surgery. In addition to the Departments and Sections listed in subsection b., there shall be a Division of Surgery, consisting of the Departments of Surgery, OB/GYN and Anesthesia. The Division shall meet as needed to discuss issues of mutual concern.
1. At the same time as other Staff elections are held, a Chief of the Division of Surgery will be selected for a 2-year term from among the Chiefs of the three departments involved. The responsibilities of the Chief are as follows:
a) Call and chair meetings of the Division of Surgery.
b) Call and chair meetings of the Surgical Services Committee.
c) Serve as the primary liaison with the Medical Director of Perioperative Services regarding day-to-day operational issues of the Operating Room.
2. In a month that the Division meets, the meeting may constitute the monthly meeting of the Department of Surgery.

Section II: Qualifications, Selection, and Tenure of Department and Section Chiefs
A) Qualifications. Chiefs of Sections/Departments shall be Board certified in their specialties, shall be members of the Active Staff and shall have completed their provisional appointments. Upon two-thirds (2/3) vote of the particular section/department, a physician who is not Board certified can be selected as Department or Section Chief, so long as he or she has recognized clinical competency, training and experience within his/her specialty areas, with commensurate clinical privileges delineated in the department, so as to qualify for this leadership position.
B) Nominations. Each department and section Chief shall be nominated by the Executive Committee on recommendation of members of the appropriate department and section for a two (2) year term subject to the approval of the Medical Staff and Governing Body. Nominations for a department and section Chief shall occur two months prior to the annual meeting of the Staff. A department or section Chief may serve successive terms.
C) Removal. Removal of a Chief during his/her term of office may be initiated by a two-thirds vote of all active members of the department, but no such removal shall be effective unless ratified by a two-thirds vote of the Executive Committee and the Governing Body.

Section III: Functions/Responsibilities of Department Chiefs
Within each department, the Chief or designee shall be responsible for the following:
A) Clinical Activity. All clinically related activities of the department;
B) Administrative Activity. All administratively related activities of the department, unless otherwise provided for by the hospital, including assisting in the preparation of such annual reports and budget planning as may be required by the Executive Committee, the Chief Executive Officer, or the Governing Body.
C) Professional Performance. Continuing surveillance of the professional performance of all individuals in department who have delineated clinical privileges. This shall include an annual review of provider-specific clinical performance improvement information and a mechanism for feedback to each member of the department. The Chief shall be available to members of the department or section to provide advisory guidance on the overall clinical policies of the hospital and to make specific recommendations regarding his/her own department to ensure quality patient care.

Outside peer review will be used when, in the judgment of the Chief, there is not adequate expertise within the organization or where there may be a conflict of interest or in any situation where the Chief deems that the use of an outside review would be in the best interests of the safe and effective operations of the hospital. If the evaluation of performance has been delegated to a Section Chief under the provision of Section V, B) 1. the responsibility above shall rest with the Section Chief.
D) Recommending Privileges. Recommending to the Medical Staff the criteria for clinical privileges that are relevant to the care provided in the department;
E) Recommending Appointment and Reappointment. Recommending to the Executive Committee the initial appointment, reappointment, Staff category and clinical privileges for each member of the department, based upon qualifications and documented clinical competence.
F) Orientation and Education. The orientation and continuing education of all persons with clinical privileges in the department or service;
G) Quality Improvement.
1. The continuous assessment and improvement of the quality of care and services provided, including determining continuing medical education requirements based on performance improvement activities;
2. The maintenance of quality control programs, as appropriate;
H) Assessing and Recommending Sources of Patient Care Services. Assessing and recommending to the relevant hospital authority off-site sources for needed patient care services not provided by the department or the organization;
I) Coordination and Integration.
1. The integration of the department or service into the primary functions of the organization;
2. The coordination and integration of interdepartmental and intradepartmental services;
J) Policies and Procedures. The development, implementation and enforcement of policies and procedures that guide and support the provision of services, including those developed within the department or section as well as actions taken by the Executive Committee;
K) Recommending Staffing.
1. The recommendations for a sufficient number of qualified and competent persons to provide care or service;
2. The determination of the qualifications and competence of department or service personnel who are not licensed independent practitioners and who provide patient care services;
L) Recommending Resources. Recommendations for supplies, space and other resources needed by the department or service;
M) Enforcing Bylaws. Enforcement of the hospital Bylaws and the Medical Staff Bylaws, Rules and Regulations.

Section IV: Functions of Section Chiefs
A) Each section with more than one member shall have a Chief nominated in accordance with Article X, Section 2, paragraph (b).
B) Each section Chief shall:
1. Be an appropriately qualified practitioner under the provisions of Section 2. A.
2. Be responsible to the respective department Chief; and
3. Assist the department Chief in the administration of the department in matters pertaining to his/her section, consistent with the responsibilities outlined in Section III above.

Section V: Functions and Responsibilities of Departments/Sections
A) Establish Criteria For Clinical Privileges. Each department or section shall establish its own criteria, consistent with the policies of the Medical Staff and of the Governing Body, for the recommending of clinical privileges and for the holding of office in the department.
B) Performance Improvement. Each major department or section shall participate in performance improvement activities using objective criteria to evaluate various aspects of care rendered to patients. This includes, but is not limited to, case specific review and mortality and morbidity. Dimensions of performance such as appropriateness, availability, timeliness, effectiveness and continuity, among others, will be assessed.
1. Each department is responsible for carrying out quality improvement functions, but may delegate that responsibility to sections. A section with such responsibility shall meet at least four (4) times per year.
C) Meetings. Each department shall meet at least four (4) times per year. At each meeting, performance improvement activities will be reviewed, with conclusions, recommendations and actions as appropriate. This review shall become part of the department minutes.
D) Recommend CME. Each department and/or section shall recommend continuing medical education programs based on changes within the field of practice and/or findings from any peer review activities or performance improvement initiatives.
E) Maintain Records. Each department and section if appropriate shall maintain a permanent record of its findings, proceedings and actions. A report and/or minutes shall be submitted after each meeting to the Executive Committee.

Section VI: Assignment to Departments and Delineation of Clinical Privileges
Members of the Medical and Associate Professional Staffs may, by virtue of their education, training, experience, and demonstrated competency, request privileges in more than one department. Assignment to Departments and Delineation of Clinical Privileges for Medical Staff and APS members will occur in the following manner:
A) Consideration of the Staff application, including privilege application form, by the appropriate department(s) and Chief(s), who will make a recommendation to the Credentials Committee.
B) Review by the Credentials Committee and recommendation to the Executive Committee.
C) Review by the Executive Committee and recommendation to Governing Body.
D) Review and approval by the Governing Body.

ARTICLE XI. COMMITTEES & MEETINGS
Section I: Purpose
The purpose of Medical Staff Committees is:
A) To perform such functions and carry out such business of the medical staff as is authorized in these Bylaws, Rules and Regulations.
B) To document meaningful compliance with the functions and goals defined in the Medical Staff and Quality Improvement Plan;
C) To provide a forum for ongoing review of clinical care rendered by staff members;
D) Professional education of members.
E) Improvement in clinical care of patients of CMMC.
Section II: General Committee and Meeting Requirements
All Medical Staff Committees will:
A) Keep attendance records of their meetings, which document members present and absent;
B) Maintain and permanently document meeting minutes, including agenda, discussions, votes, remedial actions, and follow-up to all issues.
C) Require a quorum, as set forth in these Bylaws.
D) Report activities and findings to the appropriate oversight body as defined in these Bylaws.
E) Meet with the frequency required by these Bylaws.
Section III: Membership
A) Members of all committees except the Executive Committee shall be appointed for two year terms by the President of the Medical Staff, who shall be an ex officio member of all committees.
1. Members of all committees shall be members from the Active or Courtesy Staff unless otherwise provided through appointment of the Medical Staff President, as approved by the Executive Committee. The President of the Medical Staff shall also select the Chair of each committee.
2. Hospital administrative staff are assigned to committee and department/sections for support as appropriate.
3. For educational purposes, and to gain exposure to the peer review and performance improvement processes, residents of CMMC’s Family Practice Residency Program may attend standing committee meetings.
B) Meeting Frequency and Attendance Obligations. Medical Staff Committees shall meet at least nine (9) times per year, unless otherwise specified in the committee description. Members of the Active Staff are expected to attend at least 50% of the meetings per year of committees of which they are a member.

Section IV: Committees
The following standing committees shall be appointed from the Staff. Only members of the Active Staff may vote except as provided in Section III A) 1 above. The majority of voting members on a Committee shall be physician members on the Active or Courtesy Staff, except the following committees shall be exempt from this requirement: Infection Control Committee, Medical Informatics and Records Committee, Clinical Practice Committee, Clinical Ethics Committee, Pharmacy & Transfusion Committee, Institutional Review Board.
A) Executive Committee of the Medical Staff:
1. Composition. The Executive Committee shall consist of the following members:
a) President of the Medical Staff, who shall act as Chair;
b) Vice President of the Medical Staff, who shall act as Chair in the President's absence;
c) Secretary of the Medical Staff
d) Immediate Past President of the Medical Staff at his/her option. His/her absence shall not be counted against the formation of a quorum.
e) Chiefs of the Departments of Medicine, Obstetrics and Gynecology, Pediatrics, Family Practice, Emergency Medicine, Anesthesiology, Radiology and Pathology, and the Chief of the Division of Surgery.
f) Two (2) members of the Active Medical Staff to be elected bi-annually, with additional members to be elected if full complement drops below thirteen (13) (any inequities in representation of the Staff shall be considered by the nominating committee when choosing the members-at-large); and,
g) The Director of the Family Practice Residency Program.
h) The Chairman of the Governing Body and the President of CMMC, or their designees, shall be ex officio members of the Executive Committee. These two (2) members shall attend the meetings and participate in discussions, but shall have no voting rights and therefore shall not be considered as contributing to a quorum.
i) No member of the Medical Staff shall be ineligible for membership on the Executive Committee solely based on medical specialty. A majority of the voting members shall be fully licensed and actively practicing.
j) Any member of the Executive Committee may be removed from Committee membership upon a two-thirds vote of the Active Medical Staff, following a recommendation by a majority of the Executive Committee to remove the member.
2. Duties. The Duties of the Executive Committee shall be:
a) To act for the Medical Staff in the intervals between Medical Staff meetings subject to such limitations as may be imposed by these Bylaws.
b) To coordinate the activities and general policies of the various departments and to approve said policies if they impact upon members of more than one department.
c) To receive, review, and act upon reports and recommendations from Departments, Committees, and Officers of the Medical Staff concerning peer review and performance improvement activities, and other quality initiatives.
d) To implement policies of the Medical Staff not otherwise the responsibility of the departments;
e) To provide liaison among the Medical Staff, the President of CMMC and the Governing Body;
f) To recommend action to the President of CMMC on matters of a medico-administrative nature;
g) To make recommendations on hospital management to the Governing Body through the President of CMMC;
h) To fulfill the Medical Staff's accountability to the Governing Body for the quality of clinical care rendered to all CMMC patients;
i) To ensure the Medical Staff is apprised of the requirements of regulatory agencies and the status of compliance to these requirements.
j) To provide for the preparation of all programs, either directly or through delegation to a program committee or other suitable agent;
k) To review periodically all information available regarding the performance and competence of Staff members, and, as a result of such reviews, to make recommendations for termination and reappointment, including renewal or change in clinical privileges (which may include reduction, revocation, or suspension).
l) To take all reasonable steps to ensure the existence of professional and ethical conduct and competent clinical performance on the part of all members of the Medical Staff, including the initiation of and/or participation in the Medical Staff corrective or review measures when warranted. All actions will be reported to the Governing Body.
m) To report at general Medical Staff meetings; and
n) To maintain a permanent record and or minutes of its proceedings and actions and transmit same to the Medical Staff and Governing Body.
o) To make recommendations directly to the governing body for its approval. Such recommendations may include:
i) The Medical Staff’s structure;
ii) The mechanism used to review credentials and to delineate individual clinical privileges;
iii) Recommendations of individuals for Medical Staff membership;
iv) Recommendations for delineated clinical privileges for each eligible individual;
v) The participation of the Medical Staff in organization performance-improvement activities;
vi) The mechanism by which Medical Staff membership may be terminated; and
vii) The mechanism for fair-hearing procedures.
3. Frequency of Meetings. Meetings shall be held monthly. The Executive Committee shall meet in consultation with the Governing Body as requested.
4. Physician Health Subcommittee. The President of the Medical Staff with the consent of the Executive Committee will appoint a Subcommittee on Physician Health, consisting of three physicians. The President will designate one of the members as the Chair. The members may but need not be appointed from the Executive Committee. The three members will be appointed to serve staggered terms. Members may be reappointed.
a) Objectives. The Subcommittee on Physician Health will serve three objectives:
i) Educating Staff members and other employees on issues related to physician health and impairment.
ii) Encouraging, initiating or assisting any endeavor to improve the health and well being of all members of the Medical Staff.
iii) Identifying and assisting any physician or physician assistant whose ability to practice medicine safely is compromised because of medical or psychological illness, including alcohol and drug abuse/dependency, or any other potentially impairing condition. The President will be informed of any instance in which a physician is providing unsafe treatment because of impairment. In such an instance, appropriate corrective action may be employed.
b) Investigation. The Subcommittee will receive referrals from any source, including self-referral. Upon receipt of the information, two members, who do not have any conflict of interest, will be delegated to perform an investigation. At this time, consultation may be sought from the MMA Physician Health Committee. This investigation will include contact with the complainant with inquiry about:
i) Specific details of the precipitating event or events.
ii) Names of witnesses of the event who will also be contacted.
iii) Discussion of the referral with the identified physician.
c) Report and Referral. A detailed written report will be prepared and submitted to the Chairman. If information is discovered that indicates impairment, a referral can be made to the Physician Health Committee of the Maine Medical Association and further remedial action decided. If a referral is made, the President of the Medical Staff shall be notified.
d) Records. The office of Medical Affairs will keep records of the review. They will be retained in a secure storage place for five (5) years, separate from the physician's credential’s file. After five years, if no further problems are reported, the record shall be destroyed.
e) Role of Members. If intervention, treatment and monitoring are indicated, the hospital Committee may consult with and assist the MMA Committee on Physician Health. In carrying out its mission, Subcommittee members will be familiar with and abide by State and Federal law (as it pertains to physician health) and State Licensing Board Rules and Regulations. Committee members should also be familiar with the State Physician Health program, its functions and method of contacting them.
f) Professional Competence Committee. The Subcommittee will be considered a professional competence committee pursuant to the Health Security Act.
g) Confidentiality. Every effort will be made to maintain the confidentiality of any person providing information and of the physician seeking referral or referred for assistance, except as limited by law, ethical obligation or when the safety of a patient is threatened.
h) Purpose. The purpose of this process is assistance and rehabilitation, rather than discipline, in order to aid a physician in retaining or regaining optimal professional functions, consistent with protection of patients. Nothing in this section is intended to preclude or limit the use of the regular corrective action process, under Article VII, when this is deemed necessary.
B) Bylaws Committee:
1. Composition. Shall consist of five (5) members of the Active Medical Staff.
2. Duties. The Committee shall be responsible for making recommendations regarding the revision and updating of these Bylaws, rules and regulations of the Medical Staff. These documents will be reviewed at regular intervals, but in no case less than annually. The documents will be updated based upon currency, applicability and appropriateness.
3. Meetings. Meetings shall be held at least quarterly. The Committee shall forward all recommendations via its minutes, to the Executive Committee for review. The Executive Committee shall make its recommendations to the Medical Staff. The Executive Committee shall keep the full Medical Staff apprised of such recommendations as a part of its regular report to the Staff.
C) Cancer Committee (and Tumor Board):
1. Composition. Shall consist of representatives from the Departments of Surgery, Medical Oncology, Radiation Oncology, Diagnostic Radiology, Pathology, Cancer Liaison Program, Administration, Nursing, Social Services, Cancer Registry and Quality Improvement and other representatives as appropriate. At least one member shall be a primary care physician.
2. Duties. The duties of the Cancer Committee shall be to:
a) Maintain the cancer program as outlined in the current edition of the American College of Surgeons Standards of the Commission on Cancer, Vol. 1. Cancer Program Standards. These duties include but are not limited to supervising a regularly scheduled tumor board; supervising a quality management and improvement program; maintaining a cancer registry; overseeing a program of public education, prevention and detection; professional education and Staff support; and providing leadership for the cancer program.
b) Manage the cancer registry database by selecting members to act as physician advisors to identify and choose site to be studied, to verify quality of data and provide recommendations for changes as necessary.
c) Maintain a Tumor Board, the composition of which shall be multidisciplinary, including but not limited to members of the departments of Surgery, Oncology (Radiation and Medical), Radiology, and Pathology and Family Practice; also Nursing, Social Work, Cancer Registry and other allied health professionals as appropriate. The duties of the Tumor Board shall be:
i) To provide for multidisciplinary concurrent case review and educational presentations for the Staff.
ii) To address at least all major anatomical cancer sites occurring at CMMC annually; and
iii) To document all conferences according to the guidelines set forth by Commission on Cancer.
d) Meetings.
i) The total number of Tumor Board meetings will equal 52 per year.
ii) Meetings of the Cancer Committee shall be held at least quarterly, as specified in the Standards of the Commission on Cancer document. Written reports or minutes will be submitted to the Executive Committee.
iii) The Committee shall have the authority to hold site-specific conferences, in its discretion.

D) Clinical Practice Committee:
1. Composition. This committee shall consist of a minimum of three representatives from the Medical Staff with demonstrated interest in quality improvement and outcomes measurement. At least one physician member shall also be a member of the Executive Committee. Membership shall include the Vice President of Medical Affairs, Vice President of Nursing (or designee), Executive Director of Integrated Healthcare, Director of Case Management, Director of Health Information Management, Manager of Social Work, a representative from the laboratory, a pharmacist and representatives from clinical departments as appropriate.
2. Duties. The Clinical Practice Committee shall be responsible to:
a) Ensure existence of a Medical Staff and Hospital Wide performance improvement plan that is approved annually by the Medical Staff, and Governing Body, and which clearly states accountabilities for reporting of Plan elements.
b) Direct and coordinate review activities.
c) Assess the effectiveness of actions taken.
d) Review information from multiple sources.
e) Identify opportunities for improvement.
f) Suggest areas for focused review.
g) Act as the coordinating body for interdisciplinary quality concerns.
h) Ensure that quality issues are addressed and brought to closure in a timely way, and that documents are coherent/consistent, including individual cases reviewed at department or committee level.
i) Ensure the results of review activities are reported on a regular basis to the Executive Committee and the Governing Body. Results of the review activities will be reported to others as appropriate.
j) Function as the Risk Management Committee as necessary.
k) Function as the Utilization Review Committee
l) Provide effective mechanisms for reviewing and evaluating patient care to identify patterns in resource utilization. Mechanisms may include: screening of appropriateness and medical necessity of: continued stay, patient admission, length of stay, and discharge practices against established criteria.
m) Observe, assess, and report on utilization patterns;
n) Promote optimum documentation and certification for hospital services;
o) Identify problems that have the potential of elevating the disagreement rate between CMMC and the fiscal intermediary.
p) Identify utilization issues where more in-depth study is required.
q) Where problems or potential problems relating to quality of patient care are identified, refer to the appropriate department/section, the Executive Committee, or other peer review committees
r) Coordinate and oversee the elements, processes and functions related to quality improvement.
3. Meetings. There shall be at least nine (9) meetings a year. The Committee shall maintain written reports or minutes of its activities and submit same to the Executive Committee and, as appropriate, to other peer review committees. The Committee shall maintain a flow sheet of the CMMC Performance Improvement Plan, which shall be provided as an attachment to the Bylaws.
E) Continuing Medical Education Committee:
1. Composition: At least (5) members of the Medical and/or Associate Professional Staff from different major disciplines, with a special interest in medical education. One of these members will be a member of the Residency Education Committee, to serve as a liaison between these two committees. A representative of the CMMC library may also be invited to meetings as a non-voting member. The CME Director, if a physician, will be a non-voting member. CME representatives of CMMC – affiliated hospitals may attend as guests, by invitation or if they have a CME application to present.
2. Duties: The duties of the Medical Education Committee shall be:
a) To be familiar with ACCME/MMA (Maine Medical Association) guidelines for CME, including those for disclosure and commercial support, and accreditation.
b) To help educate other Medical Staff about these.
c) To help monitor and uphold these guidelines at CMMC-accredited CME conferences in which they participate, and in their CME Committee work.
d) To review assessments and vote on applications for single event CME Activities and CME series.
e) To address CME concerns and to advise CME Director on problem resolution.
f) To develop, plan, or participate in programs that are designed to help keep the Medical Staff informed of significant new developments in health care and which respond to findings from quality and performance improvement activities, including risk management components.
g) To evaluate, through feedback from quality improvement activities and initiatives, and thorough review of annual surveys of the CME program, the effectiveness of the continuing medical educational programs.
h) To act upon continuing education recommendations from the Executive Committee, the Departments/Sections, or other Committees responsible for quality and performance improvement activities.
i) To recommend as appropriate the purchase of textbooks, periodicals and other materials for the operation of the medical library, and to recommend allocation of Medical Staff funds for library purchases.
j) To encourage financial support for CME at administrative and Medical Staff levels.

F) The Credentials Committee
1. Composition. Shall consist of at least five (5) members representing the five (5) major clinical departments (OB-GYN, Pediatrics, Family Practice, Surgery, and Internal Medicine) with its Chairman selected from the Executive Committee by the President of the Staff.
2. Duties. The duties of the Credentials Committee shall be:
a) To review the credentials of all applicants and to make recommendations for appointment and reappointment to membership and delineation of clinical privileges in compliance with Articles V and VI of these Bylaws. The Credentials Committee ensures that privileges granted are supported by evidence of appropriate current clinical experience and competence.
b) To submit to the Executive Committee recommendations on each applicant for Medical Staff membership and his/her clinical privileges, including specific consideration of the recommendations from the Department in which the applicant requests privileges;
c) To meet when called, at least within thirty (30) days after receiving a application for appointment or change in status, and to maintain a permanent record and/or minutes of its proceedings and actions and transmit same to the Executive Committee.
d) The Credentials Committee shall also be responsible for a review of individual reappointments as recommended by the Chief of the Department/Section. This review shall include peer review information, practitioner-specific quality assurance and quality improvement activities, complaints, remedial actions, recommendations from departments and any other pertinent information. The Credentials Committee's recommendations shall be forwarded to the Executive Committee and shall include delineation of any changes in a member's privileges or status.
e) The Credentials Committee shall also evaluate the provisional status of each new Active and Courtesy Staff member approximately 12 months after provisional appointment is made.
i) The first criterion will include a thorough review of patient charts for the purpose of determining: effective documentation of History & Physical, proper use of consultants, discharge summaries, and other applicable data. Quality of patient care delivered.
ii) The second criterion will include an evaluation of the interpersonal relationships affected by the Staff member during the provisional period. These relationships include his/her working rapport with other Staff members and members of the health care delivery team. Specific attention shall be given to any aspect of the Staff member's behavior, which appears to compromise the goals and objectives of quality clinical care.
3. Meetings. Meetings shall be held regularly, as defined in Article XIII, Section 1, with a summary report or minutes forwarded to the Executive Committee for review and action.
G) Critical Care Committee
1. Composition. Shall consist of representatives from the departments of Neurosurgery, General Surgery, Cardiology, Anesthesiology, Emergency Medicine, Neonatology, Critical Care Medicine and Pulmonary Medicine, and the department managers of Coronary/Intensive Care, Neonatal Care, and the Emergency Department. The Chair will be a member of the Critical Care Section.
2. Duties. The Committee shall be responsible to:
a) Establish policies regarding the care of patients in the Coronary, Intensive, and Neonatal Intensive Care Units.
b) Make recommendations, when indicated, to the Executive Committee and/or Administration in matters affecting operation of these units.
c) To review hospital wide cardiac or pulmonary arrests (code 99s) and the utilization of the critical care units, including admission to and discharge from those units.
3. Meetings. Meetings shall be held as often as is necessary to perform the functions of the Committee, but not less than nine (9) times per year. Reports and/or minutes shall be submitted to the Executive Committee and other peer review committees as appropriate.
H) Emergency Steering Committee. A Steering Committee composed of the President, the Vice President, the Secretary, and one at-large Staff member will act on behalf of the Executive Committee when immediate action is necessary because of the conduct of a Staff member and it is not feasible to convene a quorum of the Executive Committee.
I) Clinical Ethics Committee
1. Composition. Shall consist of the Vice President for Medical Affairs, at least one member of the clergy, one or more members of the Board of Trustees or of the Corporation, one psychologist, at least one attorney, and a physician or physicians representing the Medical Staff and other allied professionals as appropriate.
2. Duties.
a) The Committee shall review--upon request of an affected CMMC party--any case that poses ethical problems to Staff with respect to quality of life or other ethical issues. The Committee is not a decision-making body and shall act in an advisory capacity only. The Committee may also organize educational programs on ethics issues for the benefit of Staff members.
b) The Committee may review and may make recommendations on policies, procedures, etc., addressing patient’s rights’ and organization ethics. Such policies may include determination of death, orders not to resuscitate, foregoing life-sustaining treatment, supportive care (limited therapy) and treatment of handicapped newborns.
c) Procedures. The Committee may formulate procedures, consistent with these Bylaws, which delineate the types of cases it may consider, how cases may be brought before the Committee and the confidentiality of Committee deliberations and decisions.
3. Meetings. Meetings shall be held as needed. Reports or minutes shall be submitted to the Executive Committee for review.
J) Infection Control Committee
1. Composition. The Chairman of the Committee shall be a physician, preferably one experienced and trained in infectious diseases and/or hospital infection control. Membership shall consist of members of the departments of Pathology, Critical Care, Anesthesia, Emergency Medicine, and the Department of Surgery; a primary care physician, representatives from Administration, Nursing, Microbiology, Environmental Services, Central Supply, Employee/Occupational Health, Surgical Services, Respiratory Therapy, Pharmacy, Health Information Management (Manager or designee), and the Infection Control Practitioner. Representatives from Plant Operations, Food Service, Biomedical Engineering and State or Local Health Department officials will serve as consultants as needed.
2. Duties. The Committee's responsibilities include the following:
a) To review and assess the effectiveness of the hospital Infection Control Program in establishing and operating a practical system for identifying, reporting and evaluating infections in all patients and personnel.
b) To distinguish between nosocomial and community acquired infections.
c) To attempt to identify the reservoir, source and method of transmission of each outbreak of nosocomial infection and initiate appropriate measures to limit further spread from the identified source of contagion.
d) To make definitive provision for adequate isolation policies and procedures.
e) To make certain that all personnel are educated regarding all components of the Infection Control Program, including such issues as the proper practice of medical and surgical asepsis and how, in their respective roles and responsibilities, prevention, transmission and control of nosocomial infections are managed.
f) To analyze data on infections regularly, evaluate current trends and experiences, and undertake such control measures as may be indicated.
g) To ensure the Infection Control Program demonstrates compliance with regulatory agencies’ requirements. To review departmental Infection Control Procedures and to ensure their adequacy and compatibility with institutional policies.
h) To review practices and procedures which tend to compromise patients’ resistance to infection, such as antibiotic and invasive procedures.
i) To provide infection control input to appropriate hospital committees (e.g. Pharmacy & Transfusion for antibiotic use, Value Analysis for product use, Safety Management Committee, etc.)
j) To report notifiable infections to health authorities.
k) To prepare an annual review and update of the Infection Control Program Policies and Plan.
l) To assist in reducing the cost of care by being cognizant of and employing effective interventions at a reasonable cost.
3. Meetings. Meetings shall be held at least six (6) times a year. The Committee shall record its deliberations and forward a copy of its reports or minutes to the Executive Committee, and other peer review committees as appropriate.

K) Institutional Review Board
1. Composition. Shall consist of a Hospital Administrator, at least one (1) member of the clergy, one or more lay members of the Governing Body or of the Corporation, one (1) psychologist, at least one (1) attorney, and representation from the Medical Staff.
2. Duties. The Committee shall review proposed research and teaching projects which involve human subjects to ensure the rights and welfare of the subjects are adequately protected, that the risks to subjects are outweighed by potential benefits, and that appropriate informed consent of subjects is obtained. The Committee’s review shall be conducted with objectivity and in such a manner as to ensure the exercise of independent judgment by its members. Members shall be excluded from review of projects or activities in which they have active roles or conflicts of interest. The Committee shall function according to the Federal guidelines as currently set forth in 21 CFR Part 56.
3. Meetings. Meetings shall be held as needed. Reports or minutes shall be submitted to the Executive Committee.
L) Joint Conference Committee. The Medical Staff shall participate in a Joint Conference Committee, as established in the Corporation’s Bylaws (see Appendix III). The Committee shall serve as an additional means of liaison among Medical Staff, Administration and the Governing Body.
M) Medical Informatics and Records Committee.
1. Purpose: To ensure that all clinical information systems at CMMF are designed, operated, and supported to maximize the quality and outcome reporting of medical care.
2. Composition: Shall consist of following members:
a) Chief medical information officer
b) At least three members of the medical staff or varied clinical specialties
c) A representative of the Pharmacy/Transfusion Committee
d) A representative of the Clinical Practice Committee
e) A representative of the Regional PHO
f) A representative of the Emergency Department
g) A representative of the Health Information Management
h) A representative of the Quality Services Department
i) A representative of nursing
j) Director of Clinical Research
k) Representatives of the information systems
l) A representative of each of the regional hospitals, (Bridgton and Rumford)
Members on the Committee may serve in more than one capacity.
3. Duties: The Medical Informatics and Records Committee shall be responsible to:
a) Promote the design, usability, and integration of health records throughout CMMF and its associated clinical facilities.
b) Review and approve evidence-based standards of care, point-of-care protocols, guidelines, clinical maps, decision support tools and alerts for use with such electronic clinical data systems.
c) Advise and develop policies to guide the Manager of Information Systems, the Medical Staff, and the Administration:
i) to ensure the accuracy, timeliness, usability, security, storage and support of electronic information systems and related processes
ii) as to matters concerning the format of the completed medical record forms to be used within the record and the use of microfilming.
d) Document Medical and APS compliance with policies, procedures, Bylaws, Rules and Regulations pertaining to any aspect of medical records, and implement such remedial actions as consistent with these Bylaws, Rules and Regulations.
e) Promote the usage and design of electronic clinical systems for outcome reporting and research.
i) Advise prioritization and resources for installation and integration of such electronic health systems to Administration.
ii) Review the medical records for timely completion, clinical pertinence, and overall adequacy for use in quality improvement activities and as medico-legal documents. Such review shall ensure medical records properly describe: the condition and progress of the patient, the response to treatment and therapy provided, the result thereof, and the identification of responsibility of all actions taken.
f) Meetings: Meetings shall occur at least 9 times per year. The committee shall maintain written reports or minutes of its activities and submit same to the Executive Committee of each representative hospitals and respective Chief of Operations Officer.

N) Residency Education Committee:
1. Composition. The Committee shall include at least three non-faculty members of the Medical Staff representing a variety of specialties, the Director of the Family Practice Residency Program, residents, other faculty, and the Medical Librarian and the administrator assigned to the Residency Program. The chair shall be a member of the Medical Staff who is not a member of the employed Residency faculty.
2. Duties: The Residency Education Committee is responsible for overseeing graduate medical education at CMMC. The Committee shall:
a) Review and recommend policies for graduate medical education which address quality assessment and improvement activities, resident financial support and benefits, supervision, working environment, ancillary support, conditions of resident employment, counseling and support services;
b) Establish and maintain appropriate liaison with residency directors and administrator of all participating/sponsoring programs;
c) Conduct regular ongoing review of the residency training program to assure compliance with ACGME “Essentials” and AOA requirements; this will be accomplished by the process outlined in the formal Internal Review Plan and Program;
d) Review periodically (at least every three years), all Residency Program policies and procedures including but not limited to selection, evaluation, promotion and dismissal of residents; institutional policies and procedures addressing discipline, and adjudication of complaints and grievances consistent with requirements of the ACGME;
e) Review and make recommendations as appropriate for equitable resident position funding, including benefits and support services;
f) Assure appropriate working conditions and resident duty hours;
g) Annually formally review issues that affect graduate medical education topics including ethics, socio-economics, medical/legal, cost containment and other relevant components;
h) Maintain mechanisms for ongoing review and amendment of all activities related to the curricula;
i) Regularly review the curriculum and,
j) Coordinate the work of any subcommittees appointed by the Director or chair and act as liaison with these subcommittees.
k) Define the mechanisms for supervising residents.
3. Meetings. Shall be conducted at least eight (8) times annually, with minutes to be forwarded to the Executive Committee for review and action.
O) Perinatal Health Committee
1. Composition. The Committee shall consist of representation of at least 8 members from the following groups: Family Practice, OB/GYN, Pediatrics, Anesthesiology, NICU, Nurse Midwives and Nursing services. The Chair shall be appointed by the President of the Medical Staff. The Chair position shall be rotated biannually among members of the Departments of Family Practice, Pediatrics, and Obstetrics/Gynecology, unless mutually agreed by the Chiefs of those Departments to do otherwise.

2. Duties. The Committee shall:

a) Develop evidence based protocols for perinatal care.
b) Undertake quality assurance initiatives in the perinatal/maternal area.
c) Conduct peer review.
d) Provide a forum to discuss issues of mutual interest across relevant sections and Departments.
e) Serve as a forum for suggestions and comments from Section and Department staff.
f) Act as a resource for privileging criteria upon request of an involved Department or the Medical Executive Committee.

3. Meetings. Meetings shall be held at least six times per year. A written report or minutes will be submitted to the Executive Committee and to the Department/Section Chiefs, as appropriate.

P) Pharmacy/Transfusion Committee
1. Composition. Shall consist of 8 members of the Active Medical Staff including an infectious disease specialist and representatives from at least 4 other Medical Staff departments. Additionally, representation from: nursing, blood bank supervisor, microbiology supervisor, manager of pharmacy, infection control, and school of nursing.
2. Duties. The duties of the Pharmacy/Transfusion Committee shall be:
a) To recommend a recognized standard formulary for hospital use, with additions and revisions as required to promote high standards of pharmaceutical availability and avoid unnecessary duplication;
b) To evaluate new drugs requested for inclusion in the hospital formulary;
c) To survey patterns of drug prescribing, ordering and use within the hospital, making inquiries when necessary into apparent inappropriate use;
d) To ensure proper medication preparation, storage and dispensing practices;
e) To ensure (through a subcommittee task force) that review of the clinical use and monitoring of medications (antibiotics and other drugs, including Adverse Drug Reactions) are conducted routinely for inpatients, ambulatory care patients, and emergency care patients. Such reviews shall include the development of written criteria for the prophylactic, empiric and therapeutic drug/antibiotic use in known or suspected areas. Departures from these criteria shall be reviewed. A final report of all medication usage reviews will be submitted to the Pharmacy/Transfusion Committee and other peer review committees as appropriate.
f) To review all blood and blood product components including the following: ordering practices, distribution, handling, dispensing, administration and indications for clinical use. This review includes assessments of confirmed Transfusion Reactions. Written criteria will be developed to conduct blood and blood product component monitoring; departures from these criteria shall be reviewed. A final report of all monitoring activities will be generated and submitted to appropriate peer review committees.
3. Meetings. Meetings shall be held at least quarterly. A written report or minutes will be submitted to the Executive Committee.

Q) Surgical Review Committee
1. Composition. Shall consist of at least the following members: One (1) pathologist, one (1) anesthesiologist, one (1) obstetrician/gynecologist, one (1) radiologist, one (1) internist or family practitioner, two (2) members of the surgical Staff (one of whom will be a general surgeon), and one nurse. At least one member shall be on the Executive Committee.
2. Duties. The Surgical Review Committee shall be deliberative in nature. Discussion of cases should include subspecialty review where appropriate. The Committee shall review surgical cases for appropriateness and quality of care including, but not limited to, pre-operative medical and surgical evaluation, appropriateness of procedure, occurrence of untoward events and/or complications, peri- and post-operative management, use of consultants, outcome, and consensus of pre-operative, post-operative, and pathologic diagnoses. The Surgical Review Committee shall review in detail and on an on-going basis selected cases from the following categories: Cases with disagreements, no tissue submitted, complications, unplanned return to the operating room, all deaths on surgical services, and such others as deemed appropriate by the Committee. All cases reviewed shall be recorded as being found acceptable, or trended for patterns, and referred to the attending physician, appropriate Department/Section Chief, the Executive Committee, the Clinical Practice Committee or, as appropriate, other peer review committees for review and comment. The Committee shall also maintain records of all cases reviewed and their disposition.
3. Meetings. Meetings shall be held monthly with a minimum of nine (9) meetings per year; the Committee shall submit reports or minutes to the Executive Committee, to the Department/Section Chiefs as appropriate, and other peer review committees as appropriate.
R) The Surgical Services Committee
1. The committee shall include the Chiefs of anesthesiology and Chiefs or their designees of each surgical department and section; the Director of Perioperative Services, the Manager of Perioperative Services, and the senior administrator who supervises Perioperative Services. The Chief of the Division of Surgery shall chair the committee.
2. The Committee shall
a) Recommend and enforce policy for Medical Staff as pertains to the use of Perioperative Services.
b) Serve as a forum for suggestions and comments from surgical and Perioperative Services Staff.
c) Review and make recommendations regarding the capital and operating budget for Perioperative Services and changes to the surgical facilities, or associated issues.
d) Receive reports from the New Products Subcommittee.
e) Participate in the development of long-term plans and policies for Surgical Service
3. Meetings. Meetings will be held at least nine times per year. The Committee shall report via its minutes to the Executive Committee.
S) Trauma Committee
1. Composition. The Committee shall be multi disciplinary and shall include the Trauma Medical Director, the Trauma Coordinator, at least five members of the Medical Staff from a variety of specialties involved in trauma care. Additional representatives may include representatives from nursing, the laboratory and blood bank, radiology, respiratory therapy, and other ancillary departments as well as social workers and representatives of other departments involved in the delivery of trauma care.
2. Duties.
a) The Trauma Committee shall assess and address global trauma program issues. It shall oversee all trauma related processes and trauma program related services and work to correct overall program deficiencies to continue to optimize patient care.
b) Additionally, the Trauma Committee shall manage a subcommittee on Trauma Quality Improvement, which shall be composed of at least three (3) physician members of the larger Trauma Committee, and shall include all physicians who participate in the Trauma Surgery call schedule.
c) The Trauma QI Subcommittee shall be responsible for conducting trauma peer review, which is separate from department based peer review. The Subcommittee may refer cases to other departments or committees as appropriate. This may include review of response times, appropriateness and timeliness of care, and evaluation of care priorities among specialists.
3. Meetings. The Trauma Committee and the Trauma QI Committee shall each meet at least nine (9) times per year. The Trauma QI Subcommittee shall maintain written reports or minutes of its activities and submit same to the Trauma Committee and other peer review committees as appropriate. The Trauma Committee shall maintain written reports or minutes of its activities and submit same to the Executive Committee and other peer review committees as appropriate.

ARTICLE XII. MEDICAL STAFF MEETINGS
I. Regular Meetings

The Medical Staff shall hold at least four (4) meetings per year, on the second Thursday of the month. Attempts shall be made to have the meetings spaced throughout the year. The Annual meeting shall occur on the date of the regular June meeting of the Medical Staff. The agenda of regular meetings shall include a report from the Executive Committee on general and performance improvement activities.

II. Special Meetings
A. The President of the Executive Committee may call a special meeting of the Medical Staff at any time, or upon written request of at least one-fourth of the Active Staff, stating the purpose of the meeting.
B. Written notice stating the place and time of any special meeting of the Medical Staff shall be delivered to each member of the Active Staff not less than five (5) days before the date of such meeting. Business transacted at any special meeting shall be limited to that stated in the notice calling the meeting.

III. Quorum
For purposes of amendment of these Bylaws, Rules and Regulations, and for all other actions, a quorum shall be presumed to exist, as long as adequate notice of the meeting has been provided. If a quorum count is requested, presence of 35% or more of the active Medical Staff shall constitute a quorum.

IV. Attendance Requirements
Each member of the Active Medical Staff shall be expected to attend at least fifty percent (50%) of all regular Medical Staff meetings.

V. Agenda
The agenda at any regular Medical Staff meeting shall be:
A. Call to order,
B. Acceptance of the minutes of the last regular and all special meetings of the Executive Committee and Medical Staff and reports as indicated of meetings of the Governing Body,
C. Administrative Report, designed in part to provide effective communication among Medical Staff, hospital administration and governing body.
D. Executive Committee Report: a summary of general activities and performance improvement activities.
E. Old Business
F. New Business
G. Communications
H. Adjournment

VI. Attendance Limited
Only Active, Senior Active, Courtesy, Consulting, Honorary Staff Members and Associate Professional Staff members shall be entitled to attend Staff meetings unless otherwise determined by the Executive Committee.

VII. Voting
Only members of the Active Medical Staff and Senior Active Medical Staff shall vote on any matter at a meeting of the Medical Staff.

ARTICLE XIII. COMMITTEE AND DEPARTMENT MEETINGS
Section I: Regular Meetings

Medical Staff Committees meet as listed in Article XI (Committees and Meetings). Medical Staff departments shall hold regular meetings at least four (4) times per year to review and evaluate the clinical work of practitioners with privileges in the department.

Section II: Special Meetings
The Chairman thereof may call a special meeting of any committee or department, by the President of the Medical Staff, or by at least two committee members.

Section III: Notice of Meetings
Written or oral notice stating the place and time of any special meeting and/or any regular meeting shall be given to each member of the committee or department not less than five (5) days before the time of such meeting, by the person or persons calling the meeting.

Section IV: Quorum
A quorum shall be presumed to exist. If a quorum count is requested, presence of 20% or more of the active Medical Staff members assigned to the committee or department shall constitute a quorum.

Section V: Manner of Action
The action of a majority of the members present at a meeting at which a quorum is present shall be the action of that committee or department. Action may be taken without a meeting by the unanimous verbal or written consent of each member entitled to vote.

Section VI: Minutes
Minutes of each regular and special meeting of a committee or department shall be prepared and shall include a record of the attendance of members and the vote taken on each matter. The presiding officer shall sign the minutes, with copies forwarded to the Executive Committee. Each committee and department shall maintain a permanent file of the minutes of each meeting, and there shall be a master file maintained by the Executive Committee in the Office of Medical Affairs.

Section VII: Attendance Requirements

Attendance and participation in departmental/section, committee and Staff meetings is expected.
A) Each member of the Active Medical Staff shall be required to attend annually not less than fifty percent (50%) of all meetings of each department/section in which peer review (including, but not limited to, case-specific review and morbidity and mortality) is conducted and to which the member belongs.
B) For Medical Staff members not appearing to meet this requirement, reminder telephone calls from the Chiefs of Department/Sections will be placed, with subsequent written reminders if there is no response to the verbal reminders. Active Medical Staff members who do not meet the attendance requirements will be placed on non-voting member status at the Departmental level for a six (6) month probationary period.
C) A practitioner whose patient's clinical course is scheduled for discussion at a regular departmental meeting shall be so notified and shall be expected to attend such meeting. If such practitioner is not otherwise required to attend the regular monthly departmental meeting, the Chief of the department shall give the practitioner advance written notice of the time and place of the meeting at which his/her attendance is expected. Whenever apparent or suspected deviation from standard clinical practice is involved, the notice to the practitioner shall so state, shall be given by certified mail, return receipt requested, and shall include a statement that his/her attendance at the meeting at which the alleged deviation is to be discussed is mandatory.
D) Failure by a practitioner to attend any meeting with respect to which he/she was given notice that attendance was mandatory, unless excused by the Executive Committee upon a showing of good cause, shall result in such action as the Executive Committee may direct. In all other cases, if the practitioner shall make a timely request for postponement by an adequate showing that his/her absence will be unavoidable, such presentation may be postponed by the Chief of his department/section until not later than the next regular departmental/section meeting; otherwise, the pertinent clinical information shall be presented and discussed as scheduled.

ARTICLE XIV. CONFIDENTIALITY, IMMUNITY, REMEDIES
Each practitioner who applies for, or is granted, clinical privileges, thereby expressly agrees to the following:
Section I: Confidentiality

All reports by any other practitioner, or by any other health care provider or facility, or by any employee, officer, agent or trustee of this Corporation, in connection with or relating to a practitioner’s application for privileges or any peer review process, whether formal or informal, shall be confidential and shall be privileged from disclosure to the maximum extent permitted by law, and shall not be disclosed to persons outside of the hospital administration and Medical Staff except as otherwise necessary to an application for privileges or peer review process, unless expressly required by law,

Section II: Immunity
A) Any act, communication, report recommendation, or disclosure, with respect to any such practitioner, performed or made at the request of an authorized representative of this or any other health care facility, for the purpose of achieving and maintaining quality patient care in this or any other health care facility, shall be privileged to the fullest extent permitted by law;
B) Such privileges shall extend to members of the hospital's Medical Staff and of its Governing Body, its other practitioners, the President of CMMC and his/her representatives, and to third parties who supply information to any of the foregoing authorized to receive, release, or act upon the same. For the purpose of this Article XIV, the term "third parties" means both individuals and organizations from whom information has been requested by an authorized representative of the Governing Body of the Medical Staff;
C) There shall, to the fullest extent permitted by law, be absolute immunity from civil liability arising from any such act, communication, report, recommendation, or disclosure, even where the information involved would otherwise be deemed privileged;
D) Such immunity shall apply to all acts, communications, reports, recommendations, or disclosures performed or made in connection with this or any other health care institution's activities related, but not limited to:
1. Application for appointment or clinical privileges,
2. Periodic reappraisals for reappointment or clinical privileges,
3. Corrective action, including summary suspension,
4. Credentials Committee and ad hoc committee proceedings,
5. Medical care evaluations,
6. Utilization reviews, and
7. Other hospital, departmental, service or committee activities related to quality patient care and inter-professional conduct;
8. The acts, communications, reports, recommendations, and disclosures referred to in this Article XIV may relate to a practitioner's professional qualifications, clinical competency, character, mental or emotional stability, physical condition, ethics, or any matter that might directly or indirectly have an effect on patient care or on the effective operation of the Hospital;
9. The consents, authorizations, releases, rights, privileges, and immunities provided by Sections I and II of Article V of these Bylaws for the protection of this hospital's practitioners, other appropriate hospital officials and personnel, and third parties, in connection with applications for initial appointment, shall also be fully applicable to the activities and procedures covered by this Article XIV.

Section III: Remedies
A) Any actual or threatened violation of the confidentiality and non-disclosure provisions of this Article shall entitle the hospital or practitioner to injunctive relief.
B) Any practitioner who initiates legal action against any person based on actions or omissions, which are subject to immunity under this Article, shall be liable for the reasonable attorney fees and costs incurred by such person in defending such claims.

ARTICLE XV. RULES AND REGULATIONS
The Medical Staff shall adopt such rules and regulations as may be necessary to implement more specifically the general principles found within these Bylaws, subject to the approval of the Governing Body. These shall relate to the proper conduct of Medical Staff organizational activities as well as to the level of practice that is to be required of each practitioner in the hospital. Such rules and regulations shall be a part of these Bylaws, except that they may be amended or repealed at any regular meeting at which a quorum is present and without previous notice or at any special meeting on notice, by a two-thirds vote of those present of the Active Medical Staff. Such changes shall become effective when approved by the Governing Body. The Credentials Committee may amend that portion of the Rules and Regulations consisting of the Policy and Procedure manual governing appointment and reappointment processes at any time.

ARTICLE XVI. AMENDMENTS AND DISTRIBUTION
Section I: These bylaws will be reviewed not less than triennially for consideration of changes that may be necessary or advisable. Proposed amendments to these Bylaws will be referred to the Medical Staff Bylaws Committee, which shall report to the Executive Committee, which shall make its recommendation to the Medical Staff. To be endorsed by the Staff, a proposed amendment shall require the affirmative vote of two-thirds of the Active Medical Staff present. Such proposed amendment shall be effective when approved by the Board of Trustees.
Section II: Anything in this Article to the contrary notwithstanding, the Board of Trustees may on its own motion, after consultation with the Medical Staff, amend these Bylaws in whole or in part, at any meeting, if such amendment is necessary to comply with applicable law or regulation or necessary to maintain accreditation, and the Medical Staff has not proposed or will be unable to propose, an appropriate amendment within the time required. Neither the Board nor the Medical Staff may unilaterally amend these bylaws or rules and regulations.
Section III: When significant changes to these bylaws, rules and regulations, or policies are enacted, all individuals with clinical privileges shall be provided with notification of such changes. To the extent practicable, the provisions of these Bylaws, rules and regulations, or policies shall be construed so as to be consistent with the Bylaws of the Corporation, but the latter shall govern in the case of any conflict or inconsistency.

ARTICLE XVII. APPLICABILITY
When these Bylaws contain what appear to be mandatory provisions with respect to action by the Governing Body and the President of CMMC, it is recognized that ultimate authority with respect to such matters is vested by law in the Governing Body. These Bylaws shall not, therefore, be deemed to limit the power of the Governing Body to change any provisions made herein with respect to its actions, the actions of the President of CMMC, or the actions of any other hospital officer or employees.

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