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GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS TABLE OF CONTENTS DEFINITIONS 6 ARTICLE I – NAME 8 ARTICLE 11 PURPOSE AND RESPONSIBILITIES 9 2.1 PURPOSES 2.2 RESPONSIBILITIES OF THE MEDICAL STAFF ARTICLE 111 – MEDICAL STAFF APPOINTMENT 3.1 NATURE OF MEDICAL STAFF APPOINTMENT 3.2 BASIC QUALIFICATIONS FOR APOINTMENT 3.2-1 LICENSURE 3.2-2 PROFESSIONAL EDUCATION & TRAINING 3.2-3 BOARD CERTIFICATION 3.2-4 CLINICAL PERFORMANCE 3.2-5 COOPERATIVENESS 3.2-6 SATISFACTION OF APPOINTMENT OF OBLIGATIONS 3.2-7 PROFESSIONAL ETHICS AND CONDUCT 3.2-8 HEALTH STATUS AND DISABILITY 3.2-9 VERBAL AND WRITTEN COMMUNICATION SKILLS 3.2-10 PROFESSIONAL LIABILITY INSURANCE 3.2-11 HOSPITAL &COMMUNITY NEED, & ABILITY TO ACCOMMODATE 3.2-12 EFFECTS OF OTHER AFFILIATIONS 3.2-13 NONDISCRIMINATION 3.2-14 OFFICE/RESIDENCE LOCATION 3.2-15 ADMINISRATIVE & MEDICO-ADMINISTRATIVE OFFICERS 3.2-16 ORGAN PROCUREMENT 3.3 BASIC RESPONSIBILITIES OF INDIVIDUAL STAFF APPOINTMENT 3.4 TERM OF APPOINTMENT 3.5 OBSERVATION REQUIREMENT 3.5-1 FOR INITIAL APPOINTMENT 3.5-2 FOR MODIFICATION OF APPOINTMENT STATUS OR PRIVILGES 3.5-3 TERM OF OBSERVATION PERIOD 3.5-4 EXTENSION OF PERIOD OF OBSERVATION 9 9 11 11 12 12 12 12 13 13 13 14 14 14 15 15 15 15 16 16 16 19 20 20 20 20 21 22 22 22 22 23 24 25 25 26 27 28 ARTICLE IV – CATEGORIES OF THE MEDICAL STAFF 4.1 CATEGORIES 4.2 ACTIVE STAFF 4.2-1 FULL ATTENDING 4.2-2 ASSOCIATE ATTENTING 4.2-3 SPECIAL STAFF 4.3 INACTIVE STAFF 4.3-1 COURTESY STAFF 4.3-2 HONORARY 4.3-3 CONSULTING STAFF 4.3-4 HOUSE PHYSICIANS 1 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS TABLE OF CONTENTS 4.4 ALLIED HEALTH PROFESSIONALS 4.4-1 DEFINED 4.4-2 CATEGORIES OF ALLIED HEALTH PROFESSIONS AUTHORIZED TO FUNCTION ON THE HOSPITAL 4.4-3 QUALIFICATIONS 4.4-4 PREROGATIVES 4.4-5 RESPONSIBILITIES OF ALLIED HEALTH PROFESSIONALS 4.4-6 TERMS AND CONDITIONS OF AFFILIATION 4.4-7 SCOPE OF PRIVILEGES AND DESCRIPTION OF SERVICES 4.4-8 PROCEDURE FOR CREDENTIALING 28 28 29 29 29 30 31 31 31 4.5 LIMITATION ON PREROGATIVES 4.6 WAIVER OF QUALIFICATIONS 4.7 ADVANCEMENT IN RANK FOR ACTIVE STAFF MEMBERS 32 32 32 ARTICLE V – DELINEATION OF PRACTICE PRIVILEGES 5.1 EXERCISE OF PRIVILEGES 5.1-1 IN GENERAL 5.1-2 EXPERIMENTAL, NEW UNTRIED OR UNPROVEN PROCEDURE TREATMENT MODALITIES OR INSTRUMENTATION 5.2 BASIS FOR DETERMINATION OF PRIVILEGES 5.3 PROCEDURE FOR DELINEATING PRIVILEGES 5.4 SPECIAL CONDITIONS FOR ORAL SURGEONS AND DENTISTS 5.5 SPECIAL CONDITION FOR PODIATRISTS 5.6 SPECIAL CONDITIONS FOR OTHER ALLIED HEALTH PROFESSIONAL SER 5.7 PRIVILEGES IN EMERGENCY SITUATIONS 5.8 TEMPORARY, LOCUM TENAN, EMERGENCY & DISASTER PRIVILEGES 5.8-1 TEMPORARY PRIVILGES 5.8-2 CIRCUMSTANCES 5.8-3 GENERAL 33 33 33 ARTICLE VI – CORRECTIVE ACTION 6.1 CRITERIA FOR INITIATING AN INVESTIGATION FOR POSSIBLE CORRECTIVE ACTION OTHER THAN SUMMARY OR AUTOMATIC SUSPENSION 6.2 DISCRETIONARY INTERVIEW PRIOR TO CORRECTIVE ACTION 6.3 SUMMARY SUSPENSION 6.4 AUTOMATIC SUSPENSION 6.4-1 LICENSE 6.4-2 CONTROLLED SUSTANCES (DEA) NUMBER 6.4-3 FURTHER ACTION 6.4-4 MEDICAL RECORDS 6.4-5 PROFESSIONAL LIABILITY INSURANCE 6.4-6 PROVISION OF REQUIRED DOCUMENTATION 6.4-7 SPECIAL APPEARANCE OR CONFERENCES 6.5 CONSULTATION AND SUPERVISION 33 33 34 34 34 35 35 35 35 36 38 39 39 39 40 40 41 41 42 42 42 43 43 43 ARTICLE VII - PROCEDURAL RIGHTS 7.1 NECESSITY FOR ADVERSE ACTION .....................................44 7.1-1 By Medical Executive Committee ............................44 7.1-2 By the Board of Trustees ..................................44 7.2 ADVERSE ACTION ...................................................44 7.2-1 Adverse Recommendations and Actions Defined ...............44 7.2-2 When Deemed Adverse .......................................45 7.2-3 Exceptions to Hearing Rights ..............................45 7.3 PROCESS FOR HEARINGS AND APPELLATE REVIEWS .......................46 ARTICLE VIII - CLINICAL DEPARTMENTS AND SECTION ...........................47 8.1 ORGANIZATION OF DEPARTMENTS AND SECTION ..........................47 8.2 DESIGNATION ......................................................47 8.2-1 Department and Sections ...................................47 2 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK 8.3 8.4 8.5 8.6 MEDICAL STAFF BYLAWS TABLE OF CONTENTS 8.2-2 Periodic Reorganization of Clinical Departments and Sections ........................................48 8.2-3 Criteria to Qualify as a Clinical Department ..............49 8.2-4 Criteria to Qualify as a Clinical Specialty Section .......49 PRACTITIONER'S REQUIREMENTS FOR AFFILIATION WITH DEPARTMENTS AND SECTIONS .........................................49 FUNCTIONS OF CLINICAL DEPARTMENTS ................................50 8.4-1 Generally .................................................50 8.4-2 Clinical Functions ........................................50 8.4-3 Administrative Functions ..................................50 8.4-4 Quality Management Functions ..............................51 8.4-5 Collegial and Education Functions .........................51 FUNCTIONS OF SECTIONS ............................................51 OFFICERS OF CLINICAL DEPARTMENTS AND SECTIONS ....................51 8.6-1 Department Directors ......................................51 8.6-2 Section Chief .............................................55 ARTICLE IX - OFFICERS .....................................................58 9.1 GENERAL OFFICERS OF THE MEDICAL STAFF ............................58 9.1-1 Identification ............................................58 9.1-2 Other Officials of the Medical Staff ......................58 9.1-3 Qualification .............................................58 9.1-4 Nominations ...............................................59 9.1-5 Election of Officers ......................................59 9.1-6 Exception: Office of Immediate Past President .............60 9.1-7 Term of Elected Office ....................................60 9.1-8 Removal of Elected Officers ...............................60 9.1-9 Vacancies in Elected Office ...............................61 9.2 DUTIES OF GENERAL OFFICERS .......................................61 9.2-1 President .................................................61 9.2-2 Vice President ............................................62 9.2-3 Immediate Past President ..................................62 9.2-4 Secretary .................................................62 9.2-5 Treasurer .................................................62 9.2-6 At-Large Member to the Medical Executive Committee ........66 ARTICLE X - COMMITTEES AND THEIR FUNCTIONS ................................64 10.1 DESIGNATION ....................................................64 10.2 MEDICAL EXECUTIVE COMMITTEE ....................................64 10.2-1 Membership ...............................................64 10.2-2 Duties and Authority .....................................65 10.2-3 Meetings .................................................66 10.3 STAFF FUNCTIONS .................................................66 10.4 STANDING COMMITTEES OF THE MEDICAL STAFF AS REQUIRED BY STATE, FEDERAL OR ACCREDITING AGENCIES ..........................67 10.4-1 Blood Utilization Committee .............................67 10.4-2 Bylaws Committee ........................................68 10.4-3 Cancer Committee ........................................68 10.4-4 Continuing Medical Education Committee ..................69 10.4-5 Credentials Committee ...................................70 10.4-6 Infection Control Committee .............................70 10.4-7 Joint Conference Committee ..............................71 3 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS TABLE OF CONTENTS 10.4.8 Leadership Morbidity & Mortality (M&M) Committee ........75 10.4-9 Medical Records Committee ...............................73 10.4-10 Nominating Committee ....................................74 10.4-11 Pharmacy and Therapeutics Committee .....................75 10.4-12 Quality Management Council ..............................76 10.4.13 Surgical Case Review Committee (Tissue Committee) ......... 10.4.14 Medical Staff Health and Behavior Committee .............79 10.5 SUBCOMMITTEES ..............................................78 10.6 SPECIAL COMMITTEES ..............................................78 10.7 APPOINTMENT OF MEMBERS AND CHAIRMAN .............................78 ARTICLE XI - MEETINGS .....................................................79 11.1 GENERAL MEDICAL STAFF MEETINGS .................................79 11.1-1 Regular Meetings .........................................79 11.1-2 Order of Business and Agenda .............................79 11.1-3 Special Meetings .........................................79 11.2 COMMITTEE, DEPARTMENT, AND SECTION MEETINGS .....................80 11.2-1 Regular Meetings .........................................80 11.2-2 Special Meetings .........................................80 11.3 NOTICE OF MEETING ...............................................80 11.4 QUORUM ..........................................................80 11.4-1 General Staff Meetings ...................................80 11.4-2 Department, Section and Committee Meetings ...............80 11.5 MANNER OF ACTION ................................................81 11.6 MINUTES .........................................................81 11.7 ATTENDANCE REQUIREMENTS .........................................81 11.7-1 Regular Attendance .......................................81 11.7-2 Absence from Meetings ....................................81 11.7-3 Special Appearance or Conferences ........................82 11.8 PROCEDURAL RULES ................................................82 ARTICLE XII - CONFIDENTIALITY, IMMUNITY AND RELEASES ......................83 12.1 SPECIAL DEFINITIONS .............................................83 12.2 AUTHORIZATIONS AND CONDITIONS ...................................83 12.3 CONFIDENTIALITY OF INFORMATION ..................................84 12.4 IMMUNITY FROM LIABILITY .........................................84 12.5 ACTIVITIES AND INFORMATION COVERED ..............................84 12.5-1 Activities ...............................................84 12.5-2 Information ..............................................85 12.6 RELEASES ........................................................85 12.7 CUMULATIVE EFFECT ...............................................85 ARTICLE XIII - GENERAL PROVISIONS .........................................87 13.1 STAFF RULES AND REGULATIONS .....................................87 13.2 DEPARTMENT RULES AND REGULATIONS ................................87 13.3 PROFESSIONAL LIABILITY (MALPRACTICE) INSURANCE ..................87 13.4 STAFF DUES ......................................................87 13.5 CONSTRUCTION OF TERMS AND HEADINGS ..............................88 13.6 TRANSMITTAL OF REPORTS ..........................................88 13.7 BOARD ACTION ....................................................88 4 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS TABLE OF CONTENTS 13.8 NOTIFICATION OF MAJOR CHANGES ...................................88 ARTICLE XIV - ADOPTION AND AMENDMENT ......................................89 14.1 MEDICAL STAFF AUTHORITY AND RESPONSIBILITY ......................89 14.2 MEDICAL STAFF ACTION ............................................89 14.3 BOARD OF TRUSTEES ACTION ........................................89 14.3-1 When Favorable to Medical Staff Recommendation ...........89 14.3-2 When Contrary to or Without Benefit of Medical Staff Recommendation ............................................89 14.4 TECHNICAL AND EDITORIAL AMENDMENTS ..............................90 ARTICLE XV - RULES AND REGULATIONS ........................................92 ARTICLE XVI - CREDENTIALING MANUAL ........................................93 ARTICLE XVII - FAIR HEARING PLAN ..........................................94 ARTICLE XVIII - DISSOLUTION OF THE MEDICAL STAFF ..........................95 CERTIFICATION OF ADOPTION AND APPROVAL ....................................96 5 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK NOTE: MEDICAL STAFF BYLAWS TABLE OF CONTENTS PREAMBLE DELETED DEFINITIONS 1. HOSPITAL means Good Samaritan Hospital of Suffern, New York. 2. BOARD OF TRUSTEES means the governing body of the corporation, or as appropriate to the context, any committee or individual authorized by the Board to act on its behalf on certain matters. 3. CEO means the individual appointed by the Members of the Corporation to act on their behalf in the overall administrative management of the Hospital. 4. MEDICAL STAFF means that component of the Hospital that stands for all practitioners, as defined below, who hold appointments and are privileged to attend patients or to provide other diagnostic, therapeutic, teaching or research services at the Hospital. 5. CLINICAL PRIVILEGES or PRIVILEGES means the permission granted by the Board to a practitioner, as defined below, to render diagnostic, therapeutic, medical, dental, podiatric, or surgical services specifically delineated to him. 6. PREROGATIVE means a participatory right granted, by virtue of Staff category or otherwise, to a (Staff appointee as defined below) and exercisable subject to the conditions imposed in these Bylaws, any related manuals, and in other Hospital and Medical Staff policies. 7. PHYSICIAN means an individual with an M.D. or D.O. degree who is fully licensed to practice medicine. 8. PRACTITIONER means, unless otherwise expressly provided, any physician, dentist or allied health professional who either: (a) is applying for appointment to the Medical Staff and for clinical privileges; or (b) currently holds appointment to the Medical Staff and exercises specific delineated clinical privileges; or (c) is applying for or is exercising temporary privileges pursuant to Section 5.8 of the Bylaws. 9. MEDICO-ADMINISTRATIVE OFFICER means a practitioner, employed by or otherwise serving the Hospital on a full or part-time basis, whose duties include certain responsibilities which are both administrative and clinical in nature. Clinical responsibilities are defined as those involving professional capability as a practitioner, such as to require the exercise of clinical judgment with respect to patient care and include the supervision of professional activities of practitioners under his direction. 10. ALLIED HEALTH PROFESSIONAL or AHP means an individual other than a licensed physician or dentist who has been credential and accorded specific practice privileges at the Hospital limited to his areas of competence, and where licensure may be required as a condition 6 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS TABLE OF CONTENTS precedent to the practice of his profession, and if so duly licensed by the State of New York, and who is qualified to render direct or indirect medical care under the supervision of a practitioner who has been accorded privileges to provide such care in the Hospital. 11. MEDICAL STAFF AND BOARD AUTHORITIES or AUTHORITIES OF THE MEDICAL STAFF AND BOARD means: committees, officers, and clinical units of the Staff and the Board and any committee or officer thereof having defined responsibilities in effecting the particular function or activity that is the subject of the particular provision in which the above defined phrase is used. 12. MEDICAL STAFF MEMBER IN GOOD STANDING or MEMBER IN GOOD STANDING means: a practitioner who has been appointed to the Medical Staff or to a particular category of the Staff, as the context requires, and who is not under full or partial suspension with respect to voting, officeholding or other prerogative imposed by operation of any section of the Bylaws or related manuals or any other policy of the Medical Staff or the Hospital. 13. MEDICAL STAFF BYLAWS means any one or more of the following documents as appropriate to the context: ----- Bylaws of the Medical Staff Medical Staff Credentialing Procedures Manual Medical Staff Fair Hearing Plan Rules and Regulations of the Medical Staff 14. MEDICAL STAFF EVALUATION PERIOD means the period utilized in computing attendance records and other parameters of reappointment evaluation. 15. MEDICAL STAFF YEAR means the period from January 1st through December 31st. 16. EX OFFICIO means service as a member of a body by virtue of an office or position held and, unless otherwise expressly provided, means with voting rights. 17. SPECIAL NOTICE means written notification sent by certified or registered mail, return receipt requested, or by personal delivery service with signed acknowledgment of receipt. 18. MEDICAL EXECUTIVE COMMITTEE or MEC means the executive committee of the Medical Staff. 19. Whenever a personal pronoun is used, it shall be interpreted to refer to persons of either gender. 7 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE I ARTICLE I - NAME The organizational component of the Hospital to which these Bylaws and the related manuals including the Rules and Regulations, Credentialing Procedures Manual and Fair Hearing Plan and such other manuals as may be adopted by the Medical Staff and Board of Trustees are addressed, is called the "Medical Staff of Good Samaritan Hospital." 8 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE II ARTICLE II - PURPOSE AND RESPONSIBILITIES 2.1 PURPOSES The purposes of the Medical Staff are as stated below. A. To serve as the structure through which (1) the benefits of appointment to the Staff may be obtained by individual practitioners and (2) the obligations of Staff appointment may be fulfilled. B. To serve as the primary means for accountability to the Board of Trustees for the appropriateness of the professional performance and ethical conduct of its appointees and the quality and efficiency of patient care delivered in the Hospital consistent with the state of the healing arts and the resources locally available. C. To promote a high level of professional performance of the professional staff through the appropriate delineation of privileges that each practitioner and allied health professional may exercise in the Hospital and regularly to review and evaluate the activities and performance of all individuals granted privileges in the Hospital. D. To initiate and maintain rules and regulations applicable to all members of the Medical Staff. E. To provide a means whereby issues concerning the Medical Staff of the Hospital may be discussed by authorized representatives of the Medical Staff with the Board of Trustees and Chief Executive Officer. F. To provide an appropriate educational setting and to maintain scientific and educational standards for continuing medical education programs for the Medical Staff. G. To promote that all patients shall receive care which is consistent with generally recognized standards of care given the Hospital's available resources, irrespective of race, religion, color, national origin, sex, disability or source of payment, with due respect for the rights of patients. H. To conduct all of the above activities with an overriding concern for the patient and the recognition of his dignity as a human being. 9 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK I. 2.2 MEDICAL STAFF BYLAWS ARTICLE II The staff is organized exclusively for one or more of the following purposes: religious, charitable, scientific, literary or educational purposes as specified in Section 501(c)(3) of the Internal Revenue Code of 1986, as amended. The staff shall not carry on any activities not permitted, to be carried on by an organization exempt from federal income tax under Section 501(c)(3) of the Internal Revenue Code of 1986, as amended. However, nothing in this subparagraph (i) shall limit the obligation of the Medical Staff to comply with (a) all applicable federal, state and local statutes, rules and regulation; (b) accreditation guidelines of the Joint Commission on Accreditation of Healthcare Organizations; and (c) Hospital Bylaws. RESPONSIBILITIES OF THE MEDICAL STAFF The responsibilities of the Medical Staff are as stated below. A. To supervise the overall quality and efficiency of patient care in the Hospital, subject to the ultimate authority of the Board of Trustees, and to participate in the Hospital's quality management programs by conducting all required and necessary activities for assessing, maintaining and improving the quality and efficiency of medical care provided in the Hospital, including but not limited to: (1) Evaluating practitioner and institutional performance through valid and reliable measurement systems based on objective, clinically-sound criteria. (2) Engaging in the ongoing monitoring of critical patient care practices. (3) Evaluating practitioners' credentials for appointment and reappointment to the Medical Staff and for the delineation of clinical privileges that may be exercised by each individual practitioner in the Hospital. (4) Promoting the appropriate use of the medical and health care resources at the Hospital for meeting the medical, social and emotional needs of patients consistent with sound practice of health care resources utilization. B. To recommend to the Board of Trustees action with respect to appointments, reappointments, staff category and department/section assignments, clinical privileges, specified services for allied health professionals and corrective action. C. To recommend to the Board of Trustees programs for the establishment, maintenance, continuing improvement and enforcement of professional standards in the delivery of health care within the Hospital. To account to the Board of Trustees for the quality and efficiency of patient care through regular reports and recommendations D. 10 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE II concerning the implementation, operation and results quality review, evaluation and monitoring activities. action with of respect the E. To initiate and pursue corrective practitioners, when warranted. to F. To develop and maintain Bylaws and related manuals and policies, rules and regulations, that are consistent with sound professional practices, organizational principles and external requirements, and to enforce compliance with them. G. To assist in identifying community health needs and in setting appropriate institutional goals and implementing programs to meet those needs. H. To oversee and coordinate the continuing medical education program, formulated at least in part on the needs demonstrated through the quality management programs. I. To exercise through its officers, committees and other defined components the authority granted by these Bylaws and related manuals, to fulfill these responsibilities in a timely and proper manner, and to forward reports and/or recommendations for the consideration of the Board of Trustees. J. The Medical Staff, in view of its close association with each other and with the Hospital itself, has an obligation to consider disclosure of activities which directly or indirectly impact on the members or the Hospital. K. In order to insure that quality of care standards the hospital are maintained, the medical staff shall by consulted prior to employing or terminating any practitioner or granting or terminating any excursive contract. Nevertheless the medical staff understands and accepts that the ultimate decision to employ or terminate any practitioner or grant any group exclusive contract at all times remains the legal responsibility of the Board of Trustees. ARTICLE III - MEDICAL STAFF APPOINTMENT 3.1 NATURE OF MEDICAL STAFF APPOINTMENT Appointment to the Medical Staff or the exercise of temporary privileges is a privilege which shall be extended only to professionally competent practitioners who continually meet the qualifications, standards and requirements set forth in these Bylaws and related manuals. Appointment to the Medical Staff shall confer on the practitioner only such clinical privileges and prerogatives as have been granted by the Board of Trustees in accordance with these Bylaws and related manuals. No practitioner shall admit or provide services to patients in the Hospital unless he holds a Medical Staff appointment 11 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE V or has been granted temporary privileges in accordance with the procedures set forth in Section 5.8 and the credentialing procedures manual. 3.2 BASIC QUALIFICATIONS FOR APPOINTMENT 3.2-1 Licensure Maintain a current valid license or other authority to act issued by the State of New York as well as any other licensure, registration certification or other authorization required by any regulatory authority to permit the practitioner to provide the appropriate health care service at GSH and any other related facilities. 3.2-2 Professional Education and Training The graduate of a medical school or dental school or school of osteopathy approved by the Board of Regents of New York State. All AHP must also be graduates and hold appropriate certificates from their disciplines approved by NYS. If a graduate of a foreign medical school not approved by the Board of Regents of New York State, a certificate from the Educational Commission for Foreign Medical Graduates must be provided 3.2-3 Board Certification Except for members of the general dentistry staff, all individuals who apply for initial appointment after June 22, 2006 shall: 1) be board certified by an appropriate national specialty/subspecialty board recognized by the American Board of Medical Specialties (ABMS), or an equivalent specialty/subspecialty board approved by the hospital Board of Trustees after considering the recommendations of the MEC, or 2) shall have successfully completed a residency/fellowship approved by a specialty/subspecialty board recognized by the ABMS, the American Board of Oral and Maxillofacial Surgery, the American Osteopathic Association, the American Board of Podiatry, or an equivalent specialty/subspecialty board approved by the Board of Trustees and be eligible to become board certified. All individuals granted initial staff membership pursuant to this provision must maintain current eligibility and become board certified within five years after completion of residency or within 2 years of completing fellowship training which establishes eligibility for board certification; and 3) Shall be re-certified within the time frame specified by those boards which require re-certification to maintain board certification status, or within one year after board certification expires. 4) The Board of Trustees may for good cause shown by the practitioner waive the board certification requirement, or extend the time within which the applicant or practitioner is required to become board certified or re-certified, after considering the recommendations of the appropriate Department Director(s), the Credentials Committee and the Medical Executive Committee. The board certification and recertification requirement shall generally be waived only in rare circumstances based on the demonstrated competence of the practitioner and the needs of the Hospital and the communities it serves. 12 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE V 5) A request for a waiver of the board certification requirement by a new applicant shall be considered and acted on by the Board of Trustees before the applicant is provided an application for appointment to the Medical Staff. If the Board of Trustees denies the request for a waiver, the applicant shall be deemed not to meet the criteria for appointment to the Medical Staff and shall not be entitled to apply for Medical Staff membership or clinical privileges. The proposed applicant shall not be entitled to a hearing or any other procedural rights or review with regard to any denial of a request for a waiver or extension by the Board of Trustees. 6) If at any time it appears that a practitioner who became a member of the Medical Staff after [month] [day], [year] will not meet the requirements of section #1 above, the individual shall be notified and may, within 30 days after receipt of such notification, submit information which establishes the individual's board certification or eligibility, or may request a waiver or extension of time and submit any information in support of such request. 7) If no information or request is submitted within Thirty (30) days after notification, the Medical Staff membership and/or clinical privileges of any practitioner shall automatically terminate at that time 8) Any request for waiver or extension of time, or any information submitted concerning board certification, re-certification or eligibility shall be considered in accordance with section #4 & #5 above. If the Board of Trustees denies the request for a waiver or extension of time, the practitioner shall be deemed to no longer meet the criteria for appointment to the Medical Staff, and the practitioner’s Medical Staff membership and clinical privileges shall immediately terminate. The practitioner shall not be entitled to a hearing or any other procedural rights or review with regard to any denial of a request for a waiver or extension by the Board of Trustees. 3.2-4 Clinical Performance Clinical experience, clinical results and utilization patterns of practice; which verify continuing ability to provide patient care services at an acceptable level of quality and efficiency in accordance with the current state of the healing arts and consistent with available resources 3.2-5 Cooperativeness Demonstrate ability to work with and relate to other staff appointees, members of other health disciplines, hospital management and employees, the Board of Trustees, visitors and the community in general, in the cooperative, professional manner essential to maintain an environment appropriate to quality and efficient patient care. 3.2-6 Satisfaction of Appointment of Obligations Demonstrate satisfactory compliance with the basic obligations accompanying appointment to the Medical Staff as set forth in Section 3.3 of these Bylaws and in the discharge of Medical Staff obligations specific to Staff category as determined by the Medical Staff and Board of Trustees. 13 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK 3.2-7 MEDICAL STAFF BYLAWS ARTICLE V Professional Ethics and Conduct Demonstrated to be of high moral character and to adhere to generally recognized standards of medical, professional and personal ethics; specifically, but without limitation, this includes refraining from: 3.2-8 A. Paying or accepting commissions or referral fees for professional services as explained in section 3.3-5; delegating the responsibility for diagnosis or care of patients to a practitioner not qualified to undertake that responsibility; B. Failing to reveal to the patient the identity practitioners involved in providing services to him; C. Failing to indicated; D. Failing to provide or arrange for appropriate and timely medical coverage to care for patients for whom he is responsible; E. Failing to treatment. seek obtain appropriate informed consultation consent of when the of the medically patient for Health Status and Disability To be free of or to have under adequate control any significant impairment of physical or mental health and to be free from abuse of any type of substance or chemical that affects cognitive, motor or communicative ability or that interferes with, or presents a reasonable probability of interfering with the qualifications required by Sections 3.2-3 through 3.2-6. To comply with Title 10, Part 405.3 of the New York State Health Code, which defines the health requirements for medical staff members? At the time of and at any time during appointment, a medical staff member shall promptly inform his respective department director of any change in health status that materially affects his ability to provide quality patient care. In the event any member of the Medical Staff or other individual with clinical privileges is or may be suffering from any impairment, whether due to mental or physical illness, injury, substance abuse or aging, which affects or may affect the practitioners ability to provide patient care, the practitioner shall be evaluated and appropriate action shall be taken, in accordance with the Hospital’s “Licensed Practitioner Health and Well Being Policy.” 3.2-9 Verbal and Written Communication Skills Demonstrate the ability to read and understand the English language, to communicate verbally and in writing in the English language in an intelligible manner, and to prepare medical record entries and other 14 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE V required documentation in a legible manner. 3.2-10 Professional Liability Insurance Maintain professional liability insurance of a kind and in an amount consistent with his risk classification and satisfactory to the Board of Trustees. a) by means of professional liability insurance, actuarial funded self-insurance or another manner satisfactory to the Board; b) in an amount not less than the amount set forth on Exhibit A ($1,000,000/$3,000,000) opposite the specialty of such Member, except that in the appropriate circumstances and with the approval of the Board such amount may be reduced with regard to an individual Member to an amount not less than $1,000,000 per person and $1,000,000 per occurrence. 3.2-11 Hospital and Community Need, and Ability to Accommodate When acting on new applications for Medical Staff appointment and clinical privileges, and on applications for changes in clinical privileges, in Medical Staff appointment status, or in principal department/section affiliation, the Board of Trustees may also consider any policies, plans and objectives formulated by it concerning: A. The Hospital's current and projected need for patient care and teaching as outlined in the Medical Staff Development Plan and, B. The Hospital's ability to provide the physical, personnel and financial resources required if said application is acted upon favorably. Recommendations from any of the applicable Medical Staff authorities in the above processes may also be based in whole or in part on any of said policies, plans or objectives. 3.2-12 Effects of Other Affiliations No practitioner shall be automatically entitled to appointment, to reappointment or to the exercise of particular clinical privileges merely because: A. He is licensed to practice in New York or any other state; or, B. he is certified by any clinical board; or, C. he is a member of a medical school faculty; or, D. he had, or presently has, Medical Staff appointment or privileges at another health care facility or in another practice setting; or E. he had, or presently has, Medical Staff appointment or those particular privileges at this Hospital. 3.2-13 Nondiscrimination No aspect of Medical Staff appointment or granting particular clinical privileges shall be denied on the basis of age, sex, race, religion, color, national origin or disability unrelated to standards of patient 15 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE V care. 3.2-14 Office/Residence Location Appointees to the medical staff shall maintain their principal office and residence within the Hospital service area as defined from time to time by the Staff Development Plan. This provision need not be considered mandatory for physicians employed by or under contract to the Hospital and or for physicians whose individual presence may not be necessary under emergency conditions. 3.2-15 Administrative and Medico-Administrative Officers A. A practitioner employed by the Hospital in a purely administrative capacity and with no clinical duties or privileges is subject to ordinary personnel policies of the Hospital and to the terms of his contract or other conditions of employment, and need not hold appointment to the Medical Staff. In the event of termination of such practitioner's employment, he shall not be entitled to the procedural rights set forth in Article VII and Fair Hearing Plan. B. A practitioner employed by the Hospital as a medico-administrative officer shall hold appointment on the Medical Staff and achieve this status by the procedure indicated in the Credentialing Procedures Manual. His clinical privileges shall be delineated in accordance with Article V of the Credentialing Procedures Manual. The Medical Staff Appointment and clinical privileges of any medico-administrative officer shall not be contingent on his continued occupation of that position, unless otherwise provided for in an employment agreement, contract or other arrangement. In the event that a medico-administrative officer's employment by the Hospital is terminated but his Medical Staff and clinical privileges remain unaffected, he shall not be entitled to the due process procedures set forth in Article VII and the Fair Hearing Plan in regards to the termination of his employment. 3.2-16 Organ Procurement Practitioners from organ procurement organizations designated by the Secretary of the U.S. Department of Health and Human Services, engaged at the Hospital solely in the harvesting of tissues and/or other body parts for transplantation, therapy, research or educational purposes, shall be exempt from the requirement to obtain Medical Staff privileges. 3.3 BASIC RESPONSIBILITIES OF INDIVIDUAL STAFF APPOINTMENT Each appointee to the Medical Staff shall meet the basic responsibilities of appointment specified in the remainder of this Section. Failure to satisfy any of these basic responsibilities may be grounds for non-reappointment or for such other corrective action pursuant to Article VI of these Bylaws as warranted by the circumstances. 16 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE V Each member of the Medical Staff shall: 1. Provide all patients with professional care at the level quality and efficiency which is generally recognized appropriate. 2. Abide by the Medical Staff Bylaws and the provisions of all appropriate manuals, other bylaws, standards, policies, rules and regulations of the Medical Staff and the Hospital. 3. Discharge such Staff, department, section, committee and Hospital functions for which he is responsible by Medical Staff category assignment, appointment, election or otherwise. 4. Prepare and complete the medical and other required records in a timely fashion for all patients admitted by him or for whom he provides care in the hospital. Any Medical Record not completed within 30 days after discharge shall be considered delinquent. 5. Abide by the ethical principles set forth below: 6. of as a. The professional conduct of practitioners to the Medical Staff shall comply with generally accepted principles and ethical standards attributable to their profession, as well as the Ethical and Religious Directives for Catholic Health Facilities as promulgated by the Ordinary of the Arch-Diocese of New York. b. Appointees to the Medical Staff shall pledge themselves not to receive from, or pay to, another physician or dentist, or any other person, either directly or indirectly, any part of a fee received for professional services except as otherwise authorized by federal, state or local statutory or administrative law. At the time of appointment, all practitioners to the Medical Staff shall pledge themselves at all times to maintain such standards and to meet such requirements as shall warrant: a. Full accreditation of the Hospital by the Joint Commission on Accreditation of Healthcare Organizations; b. Continuance of the Hospital operating certificate issued to the Hospital pursuant to the provisions of the Public Health Law of the State of New York and all applicable parts of the Official Compilation of Codes, Rules and Regulations of the State of New York, including Title 10 (Health) and Title 14 (Mental Health); and c. approval, accreditation and certification by applicable review or certifying boards and/or agencies in connection with such intern and residency training programs and such other post-graduate professional training programs, as are or 17 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE V may be adopted by the Board of Trustees. 7. Each appointee shall be responsible for the diagnosis and care of his patients and shall refrain from delegating the responsibility for diagnosis or care of hospitalized patients to professionals who are not qualified to undertake this responsibility and who are not adequately supervised. 8. Be required to pay Staff dues and assessments in timely fashion. 9. Be required to participate in continuing medical education. The requirement can be fulfilled through one of the methods listed below. a. A current American Medical Association-Physician's Recognition Award, which is valid for a period of three years. b. Current satisfaction of the Continuous Medical Education requirement of a recognized specialty society, which is also valid for a period of three years. c. Passing a certification or recertification specialty board within the past three years; d. Obtaining a certificate of special competence specialty board within the past three years; e. Completing a residency program within the past three years; f. The number of CME credits required annually shall be consistent with the requirements of the AMA's Physician Recognition Award. The AMA requirements are 50 hours of CME credit for a one year certificate (20 hours category 1, 20 hours category 2 and 10 hours of either category 1 or 2). g. For Dentists and Allied Health Professionals such continuing medical education as shall be required by the Board of Trustees. For CRNA the requirements are 40 hours of CME credit every two years. exam of a from a 10. Maintain professional liability (malpractice) insurance in amount and type set forth in the Medical Staff Bylaws or as required by the Board of Trustees and comply with any changes in the amount and/or type of professional liability (malpractice) insurance which may be required. 11. Inform the Hospital at time of appointment and reappointment of any malpractice actions. Malpractice settlements shall be reported annually. Any investigation and/or sanction brought against a member of the Medical Staff shall be reported in writing in the Medical Staff Service Department as soon as it occurs. 18 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK 12. MEDICAL STAFF BYLAWS ARTICLE V Pursuant to 10 NYCRR 405.4, any physician who informs a patient that he or she refuses to give advice with respect to or participate in an induced termination of pregnancy shall be exempt from liability by the Hospital. 13. Agrees to notify the President of the Medical Staff and Executive Vice President immediately in writing upon learning that the applicant or practitioner: a. Is the subject of a complaint or investigation by any licensing or disciplinary authority of any state or federal agency; b. Has been charged with a misdemeanor or a felony; c. Has been notified that their professional liability insurance carrier intends to cancel, not renew, restrict or impose any conditions or deductibles on their professional liability insurance; d. Has been notified of the loss of their DEA number or exclusion from the Medicaid or Medicare program, is under investigation by Medicaid or Medicare, or has been subjected to any fine, penalty or sanction by Medicare or Medicaid; e. Is or has been the subject of any actual or proposed disciplinary action, including any modification of clinical privileges, restriction of clinical privileges, or placing of conditions on clinical privileges (including any form of monitoring), by any other hospital or health care facility or organization; f. Has voluntarily relinquished, agreed not to exercise, or involuntarily lost any licensure, registration, medical staff membership or clinical privileges, or has had any medical staff membership limited, reduced or modified in any way; g. Has entered into a contract or agreement with any impaired physicians committee or similar entity as a result of any substance abuse or other disease or disorder by any applicant or practitioner; or h. Has developed any mental or physical illness or sustained any injury which could have an effect on the exercise of the individual’s clinical privileges. 3.4 TERM OF APPOINTMENT All appointments or reappointments to the Medical Staff granting clinical privileges are for a period of no more than two (2) years, except that: A. New practitioners are subject to an initial provisional period as provided in Section 3.5 below and upon satisfactory conclusion of that period are placed in the appropriate reappointment cycle as determined by the Hospital's system of staggered reappointment which may result in the appointment period that immediately follows satisfactory conclusion or waiver of the provisional period being less than two full years; and B. The Board of Trustees, after considering the recommendations of the applicable department director, and the Medical Executive Committee, may set a shorter reappraisal period for the exercise 19 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE V of particular privileges in general, for a Medical Staff appointee who has an identified health disability, for Medical Staff appointees who have reached a defined age, for a Medical Staff appointee who has been the subject of disciplinary action, or for a Medical Staff practitioner who is deficient in meeting appointment responsibilities or obligations; and 3.5 C. Corrective action involving appointment and/or clinical privileges may be initiated during the term of appointment under the appropriate provisions of these Bylaws and the related manuals; and D. Contract/employment expiration or other termination alone will not affect the practitioner’s appointment, clinical privileges or procedural rights as contained in the Fair Hearing Plan, unless so provided by the contract/employment arrangement. OBSERVATION REQUIREMENT 3.5-1 For Initial Appointments Except as otherwise determined by the Board of Trustees, all initial appointments to any category of the Medical Staff shall be provisional and subject to a period of observation in accordance with Medical Staff Policy. Each initial practitioner shall be assigned to a department and/or section as appropriate where his performance shall be observed by the director of the department or the director's designee, to determine his eligibility for continued Medical Staff appointment in the category to which he was initially appointed and for exercising the clinical privileges initially granted in that department. Exercise of clinical privileges in any other department shall also be subject to observation by that department's director or his designee. An initial appointee shall remain subject to observation until he has furnished the following information and received approval from the department director, Medical Executive Committee and Board of Trustees: A. A statement signed by the director of the department to which he is assigned that the practitioner meets all of the qualifications, has discharged all of the responsibilities, and has not exceeded or abused the prerogatives of the Staff category to which he was appointed; and B. A statement signed by the director of the department to which he is assigned that the appointee has satisfactorily demonstrated his ability to exercise the clinical privileges initially granted to him. 3.5-2 For Modification of Appointment Status or Privileges The Medical Executive Committee may recommend to the Board of Trustees that a change be made in Medical Staff category or department assignment of a current Medical Staff member or that additional privileges be granted to a current Medical Staff appointee requesting such change pursuant to the Credentialing Procedures Manual and subject 20 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE V to observation in accordance with procedures outlined in section 3.5-1 for initial appointments. 3.5-3 Term of Observation Period An observation period for an initial provisional appointment or for a modification of appointment status or privileges shall extend for twelve (12) months. If an initial appointee fails to furnish the certification required in Section 3.5-1 within the observation period, his Medical Staff appointment or particular clinical privileges shall be terminated in accordance with Part 4 of the Credentialing Procedures Manual as applicable. If a Medical Staff practitioner requesting modification in clinical privileges fails to furnish the required certification within that period, the change in Medical Staff category or department assignment or the additional privileges, as applicable, shall be deemed denied, but he shall retain his original privileges. The initial or current Staff appointee so affected shall be given special notice of such termination or denial and shall be entitled to the procedural rights afforded in Article VII and in the Fair Hearing Plan. 3.5-4 Extension of Period of Observation If, at the conclusion of the twelve (12) month period of observation, it is determined by the department director that there has not been sufficient opportunity to observe the performance of or clinical competence of the appointee, the Department Director may recommend that the period of observation be extended for up to an additional twelve (12) month or may recommend that the Medical Staff appointment or particular clinical privileges of the appointee be terminated in accordance with Part 4 of the Credentialing Procedures Manual as applicable. If, at the end of the second 12 month period of observation, it is determined by the department director that there has not been sufficient opportunity to observe the performance of or clinical competence of the appointee, the Department Director may recommend that the Medical Staff appointment or particular clinical privileges of the appointee be terminated in accordance with Part 4 of the Credentialing Procedures Manual as applicable. 21 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE V ARTICLE IV - CATEGORIES OF THE MEDICAL STAFF 4.1 CATEGORIES The Medical Staff shall include active Staff categories consisting of Full, Associate Attending and Special Staff, and inactive Staff categories consisting of Courtesy Staff, Consulting, Honorary, House Physicians and Allied Health Professional. 4.2 ACTIVE STAFF 4.2-1 FULL ATTENDING A. Qualifications The Full Attending Medical Staff shall consist of practitioners who possess the qualifications listed below. (1) (2) (3) (4) B. Meet the Basic Qualifications for Appointment set forth in Section 3.2. Reside and maintain a primary office within Good Samaritan Hospital's service area as defined in the Credentialing Procedures Manual. Regularly admit patients to, or otherwise be regularly involved in care of patients in the Hospital. Have served as an Associate Attending Staff for not less than three (3) years. Prerogatives The prerogatives of Full Attending are listed below. (1) (2) (3) (4) Admit patients without limitation, unless otherwise provided in the Medical Staff rules and regulations. Exercise such clinical privileges as are granted pursuant to Article V. Vote on all matters presented at general and special meetings of the Medical Staff and of the department, section and committees to which appointed, unless otherwise provided by resolution of the Medical Staff, such department, section or committee. Hold office in the Medical Staff organization and in the department, section and committees to which appointed. C. Responsibilities Members of the Full Attending Medical Staff shall effectively and fully discharge the responsibilities listed below. 22 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK (1) (2) (3) (4) (5) (6) MEDICAL STAFF BYLAWS ARTICLE V Meet the Basic Responsibilities of Individual Medical Staff Appointment set forth in Section 3.3. Retain responsibility within his area of professional competence for the continuous care and supervision of each patient in the Hospital for whom he is providing services, or arrange a suitable alternative for such care and supervision. Actively participate in the quality management activities required of the Medical Staff, in supervising initial appointees of his same professional area, in the emergency services program where applicable, and in discharging such other Medical Staff functions as may be required from time to time. Satisfy the requirements set forth in Article XI for attendance at meetings of the Medical Staff and of the department, section and committees to which he is appointed. Accept and fulfill consultation, supervision and teaching assignments when requested by the department director. Full attending who have served on the active Medical Staff for a minimum of fifteen (15) years may be exempted from service in the emergency room and on committees at the discretion of the department director and with the approval of the Medical Executive Committee. Failure to maintain qualifications or fulfill the responsibilities of appointment may be grounds for modification or termination of Medical Staff appointment. 4.2-2 ASSOCIATE ATTENDING A. Qualifications The Associate Attending Medical Staff shall consist of practitioners who possess the qualifications listed below: (1) (2) (3) (4) (5) B. Meet the Basic Qualifications for Appointment set forth in Section 3.2. Reside and maintain a primary office within Good Samaritan Hospital's service area as defined in the Credentialing Procedures Manual. Regularly admit patients to, or otherwise be regularly involved in care of patients in the Hospital. Promotion is not to be considered automatic, and shall be requested in writing by the practitioner. Members of the Associate Attending Medical Staff are eligible for advancement to Full Attending Medical Staff Status after serving 3 years on the Associate Attending Staff. Prerogatives The prerogatives of Associate Attending are listed below. (1) Admit patients without limitation, unless otherwise provided 23 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK (2) (3) (4) C. MEDICAL STAFF BYLAWS ARTICLE V in the Medical Staff rules and regulations. Exercise such clinical privileges as are granted pursuant to Article V. Vote on all matters presented at general and special meetings of the Medical Staff and of the department, section and committees to which appointed, unless otherwise provided by resolution of the Medical Staff, such department, section or committee. Associate Attending Staff are not eligible to hold office in the Staff organization, or in departments, sections and committees. Responsibilities Members of the Associate Attending Medical Staff shall effectively and fully discharge the responsibilities listed below. (1) (2) (3) (4) (5) Meet the Basic responsibilities of Individual Medical Staff Appointment set forth in Section 3.3. Retain responsibility within his area of professional competence for the continuous care and supervision of each patient in the Hospital for whom he is providing services, or arrange a suitable alternative for such care and supervision. Actively participate in the quality management activities required of the Medical Staff, in the supervision of initial appointees of his same professional area, in the emergency services program where applicable, and in the discharge of such other Medical Staff functions as may be required from time to time. Satisfy the requirement set forth in Article XI for attendance at meetings of the Medical Staff and of the department, section and committees to which he is appointed. Accept and fulfill consultation, supervision and teaching assignments when requested. Failure to maintain qualifications or fulfill the responsibilities of appointment shall be grounds for denial of advancement to Full Attending Medical Staff and may be grounds for modification or termination of Medical Staff appointment. 4.2-3 SPECIAL STAFF Special Staff practitioners: members of the medical staff shall consist of (1) Who offer to the hospital, its medical staff, its patients, and/or its service area community an expertise, a specialty, or a function of benefit (2) And who fulfill the basic qualifications, prerogatives, and responsibilities of medical staff membership, except that qualifications, unrelated to clinical or professional competence, prerogatives, and/or responsibilities have been modified. 24 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE V Notwithstanding said modifications, these practitioners are for good cause considered qualified in the opinion of the appropriate department director, the Medical Executive Committee and the Board of Trustees. At all times, appointment of such practitioners shall be guided by and be consistent with the goals and objectives of the Staff Development Plan as formulated by the Staff Development subcommittee of the Board of Trustees. All modifications of qualifications, prerogatives, and responsibilities and the reasons thereof, shall be specified in the initial appointment and/or reappointment recommendation of a practitioner and shall be approved through the established credentialing process as defined in the Credentialing Procedures Manual. In particular, the appointment and/or reappointment recommendation shall describe, at a minimum, the requirements of location of residency and primary office, the ability to admit and/or attend patients in the hospital, and any exemption from meeting attendance or emergency room on-call obligations. It is the stated practice of the Medical Staff to grant a status, which encourages full, active membership. The granting of Special Staff status is a privilege. Therefore, at any time, should the needs of the Medical Staff or the Hospital warrant, and with the approval of the appropriate department director, the Medical Executive Committee, and the Board of Trustees, members granted this status may be required to fulfill the obligations of full, active membership. Any change from Special Staff Categories over to Active Staff or any other Category shall entitle the practitioner to an opportunity for a discussion as outlined under Section 2.5 of the Credentialing Procedures Manual of the Medical Staff Bylaws but shall not give rise to due process under the Fair Hearing Plan of the Medical Staff Bylaws. 4.3 INACTIVE STAFF 4.3-1 COURTESY Staff A. Qualifications The Courtesy Medical Staff shall consist of practitioners who meet the requirements and criteria of the applicable clinical department and, in addition, possess the qualifications listed below. (1) (2) (3) B. Meet the Basic Qualifications for Appointment set forth in Section 3.2. Reside and maintain a primary office within Good Samaritan Hospital's service area as defined in the Credentialing Procedures Manual. Admit and/or treat not more than twelve (12) patients per year. Prerogatives The prerogatives of Courtesy Medical Staff are listed below. 25 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK (1) (2) (3) C. MEDICAL STAFF BYLAWS ARTICLE V Admit patients to the Hospital within the limitations provided in Section 4.3-1A(3). At times of shortage of Hospital beds or other facilities, as determined by the Chief Executive Officer, the elective patient admissions of Members of the Courtesy I Medical Staff shall be subordinate to those of active staff. Exercise such clinical privileges as are granted pursuant to Article V. Members of the Courtesy Medical Staff are not eligible to hold office or to vote on any matters presented to meetings of the Staff, department, section or committees. Responsibilities Members of the Courtesy Medical Staff shall discharge the responsibilities listed below. (1) (2) (3) (4) 5) effectively and fully Meet the Basic responsibilities of Individual Medical Staff Appointment set forth in Section 3.3. Retain responsibility within his area of professional Competence for the continuous care and supervision of each patient in the Hospital for whom he is providing services, or arrange a suitable alternative for such care and supervision. Actively participate in the quality management activities required of the Medical Staff and in the discharge of such other Staff functions as may be required from time to time. Satisfy the requirements set forth in Article XI, Section 11.7-1 for attendance at departmental and staff meetings. The department director may grant a reduction of these requirements for good cause in accordance with Article XI, Section 11.7-2. Satisfy Continuous Medical Education requirements through attendance at departmental education and clinical case review meetings. Practitioners holding this status may apply for reduction of these requirements for good cause. Such application shall be made in writing to the department director and shall cite the reasons for the request. The above may be granted by the department director in accordance with Article XI, Section 11.7-2. Failure to maintain qualifications or to fulfill the responsibilities of Medical Staff appointment may be grounds for modification or termination of Staff appointment. 4.3-2 HONORARY A. Qualifications The Honorary Medical Staff shall consist of practitioners recognized for their outstanding reputations, their noteworthy contributions to the health and medical sciences, and/or their prior long-standing service to the Hospital. B. Prerogatives 26 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE V The prerogatives of Honorary Medical Staff are listed below. (1) (2) (3) C. May not admit patients as to exercise clinical privileges in the hospital. May attend Medical Staff and department meetings and Medical Staff and Hospital education meetings. Are not eligible to vote or to hold office in the Medical Staff organization or Departments. Responsibilities Members of the Honorary Medical Staff shall effectively and fully discharge the basic responsibilities set forth in Sections 3.3-2, 3.3-5 and 3.3-6. Once granted members of the Honorary Staff shall not be required to reapply for this status. 4.3-3 CONSULTING STAFF A. Qualifications The Consulting Medical Staff shall consist of practitioners who possess the qualifications listed below. (1) (2) (3) B. Meet the Basic Qualifications for Individual Medical Staff Appointment set forth in Section 3.2, with the exception of that contained in Section 3.2-13. Is a recognized specialist who serves solely as a consultant upon the request of a department director or of an active staff appointee Is on the active staff of another Hospital where he actively participates in a quality assurance, risk and utilization management program and other review activities similar to those required of the active Staff of Good Samaritan Hospital. Prerogatives The prerogatives of Consulting Medical Staff are listed below. (1) (2) (3) (4) May not admit patients or assume responsibility for their care. Perform consultations and report recommendations for patient care to the attending physician. May attend meetings of the Medical Staff and of the department and/or section where privileges are held, and any Medical Staff or Hospital-sponsored education programs. Are not eligible to vote or to hold office in the Medical Staff organization or Departments. 27 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK C. MEDICAL STAFF BYLAWS ARTICLE V Responsibilities Members of the Consulting Medical Staff shall effectively and fully discharge the basic responsibilities set forth in Section 3.3 with the exception of those set forth Section 3.3-8. 4.3-4 HOUSE PHYSICIANS A. Qualifications The House Physician Staff shall consist of practitioners who Meet Qualifications for Appointment set forth in Sections 3.2-1, 3.2-2, 3.23, 3.2-4, 3.2-5, 3.2-6, 3.2-7, 3.2-8, 3.2-9, 3.2-10, 3.2-11 and 3.2-12. B. Prerogatives The prerogatives of House Physician Staff are listed below. (1) Exercise clinical privileges assigned to this category in order to treat patients at the Hospital. (2) Attend Medical Staff and department meetings and any Medical Staff or Hospital education meetings. (3) Are not eligible to admit patients to the Hospital, to vote or to hold office in the Medical Staff organization or departments. C. Responsibilities Each House Physician shall be required to discharge the basic responsibilities of Individual Medical Staff Appointment specified in Sections 3.3-1, 3.3-2, 3.3-4, 3.3-5, 3.3-6, 3.3-8 and 3.3-9. D. Administrative Control The House Physicians will be supervised by and report to the VP of Medical Affairs 4.4 ALLIED HEALTH PROFESSIONALS 4.4-1 DEFINED The Allied Health Professional staff shall consist of practitioners who possess the qualifications listed below. A. Qualified by training, experience and current competence in a discipline which the Board of Trustees has determined by policy to allow to practice in the Hospital. B. Have a recognized but limited Scope of practice within the field of medicine. C. D. Where appropriate, duly licensed by the State of New York. Ability to provided services in the Hospital independently i.e. without the direction of immediate supervision of a 28 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE V physician ("Independent Allied Health Professional"); or E. 4.4-2 Ability to provide services of medical support to a physician ("Physician-directed Allied Health Professional"). CATEGORIES OF ALLIED HEALTH PROFESSIONALS AUTHORIZED TO FUNCTION IN THE HOSPITAL Pursuant to policy determined by the Board of Trustees, the following categories of Allied Health Professionals and such others as may be approved from time to time are authorized to provide services in the Hospital: A. Independent Allied Health Professionals 1. Clinical Psychologist B. Physician-Directed Allied Health Professionals 1. Certified Registered Nurse Anesthetist (CRNA) (Orders must be cosigned) 2. Registered Physician Assistant (Orders must be cosigned) 3. Certified Nurse Mid-wife 4. Specialist Assistant 5. Other Assistants 6. Licensed Nurse Practitioner (Orders do not need to be counter signed) 4.4-3 QUALIFICATIONS A statement of qualifications for each category of Allied Health Professionals shall be developed by the Medical Executive Committee for approval by the Board of Trustees. Each such statement shall: A. B. C. Be developed with input from the physician director of the clinical unit or service involved, from the physician supervisor of the Allied Health Professional, from other representatives of the Medical Staff, other professional staff and Hospital Management Staff where applicable, and in the case of Allied Health Professionals who are Hospital employees, with input from Hospital's Chief Executive Officer. Require that the individual Allied Health Professionals hold a current license, certificate or such other credential, if any, as may be required by State law. List as requirements the same types of basic qualifications as are set forth for Medical Staff appointment or for hospital employment, as applicable. 4.4-4 PREROGATIVES The prerogatives of Allied Health Professionals are listed below. A. If an independent Allied 29 Health Professionals, exercise GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE V clinical privileges as are specifically granted to him and consistent with limitations stated in the Medical Staff Bylaws and related manuals, the policies governing the Allied Health Professionals practice in the Hospital, and any other applicable Medical Staff or Hospital policies. B. If a physician directed Allied Health Professionals, provide specifically designated patient care services under the degree of supervision or direction of a Medical Staff appointee as specified in their delineation of privilege and consistent with any limitations stated in the Medical Staff Bylaws and related manuals, the policies governing the Allied Health Professionals practice in the Hospital, and any other applicable Medical Staff or Hospital policies. C. Serve on committees when so appointed and with vote if so specified by the appointing authority. D. Attend, when invited, clinical, scientific and education meetings of the Medical Staff or a department or section when appropriate to his discipline. E. Exercise such other prerogatives as the Medical Executive Committee may grant with the approval of the Board of Trustees. 4.4-5 RESPONSIBILITIES OF ALLIED HEALTH PROFESSIONALS Members of the Allied Health Professionals staff shall effectively and fully discharge the responsibilities listed below. A. Meet the basic qualifications required by Section 3.3 for Medical Staff appointees. B. An independent Allied Health Professional shall retain appropriate responsibility within his area of professional competence for the care and supervision of each patient in the Hospital for whom he is providing services. When necessary and as appropriate to the circumstances of the case, he shall either arrange for a suitable alternative for such care and supervision or alert the principal attending physician. C. Participate when requested in the quality management activities required of the Medical Staff, and in the discharge of such other Medical Staff functions as may be required from time to time. D. Satisfy the requirements set forth in Article attendance at departmental and staff meetings. E. Refrain from any conduct or acts that are or could reasonably be interpreted as being beyond the scope of authorized 30 XI for GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE V practice within the Hospital. 4.4-6 TERMS AND CONDITIONS OF AFFILIATION An allied health professional shall be assigned to the clinical unit appropriate to his professional training and is subject to an initial probationary period and formal periodic and disciplinary review. Procedures as appropriate, an Allied Health Professional is not entitled to the due process rights as provided in the Fair Hearing Plan for Medical Staff appointees and applicants, unless the Board of Trustees determines otherwise. Professional activities of Allied Health Professionals are subject to the rules and regulations of the applicable clinical unit and to the authority of the physician director of the unit. The quality and efficiency of the professional activity shall be monitored and reviewed as part of the regular Medical Staff and/or Hospital Quality Management mechanisms. 4.4-7 SCOPE OF PRIVILEGES AND DESCRIPTION OF SERVICES The scope of clinical privileges that may be exercised by any group of independent Allied Health Professionals shall be developed by the department chairman and/or section chief, and representatives of management, if applicable, and are subject to the approval of the Medical Executive Committee and Board of Trustees. The description of permissible service for each category of physician-directed Allied Health Professionals who are Hospital employees shall be developed by the Chief Executive Officer with similar input and subject to the same approval as provided above for non-hospital employed physician-directed Allied Health Professionals. A member of the medical or dental Staff or his designee shall supervise each physician-directed Allied Health Professional. The supervising physician or dentist of record shall have the ultimate responsibility for patient care. All orders written by a Physician Assistant for inpatients must be countersigned within twenty-four (24) hours. A physician or dentist may not supervise more than six (6) Allied Health Professionals. 4.4-8 PROCEDURE FOR CREDENTIALING Procedures for processing individual applications from Allied Health Professionals, for reviewing performance during the probationary period, for periodic reappraisal, and for disciplinary action shall be established for Allied Health Professionals who are non-Hospital employees by the credentials committee and for Allied Health Professionals who are Hospital employees by Chief Executive Officer. Said procedures shall be developed with input from appropriate representatives of the Board of Trustees, Medical Staff, management and other professional staffs, shall be periodically reviewed, and are subject to the approval of the Medical Executive Committee and Board of Trustees. 31 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK 4.5 4.6 MEDICAL STAFF BYLAWS ARTICLE V LIMITATION ON PREROGATIVES The prerogatives of Allied Health Professionals applicable Staff category are general in nature and To limitation by special conditions attached to a appointment, by other sections of these Bylaws and the Hospital. as set forth under may be subject practitioner's Staff by other policies of WAIVER OF QUALIFICATIONS A qualification may be waived at the discretion of the Board of Trustees, consistent with applicable law, upon determination that such waiver will serve the best interest of patient care in the Hospital. 4.7 ADVANCEMENT IN RANK FOR ACTIVE STAFF MEMBERS A. A practitioner may be eligible for advancement in rank when, in the opinion of his department director, he has successfully completed the qualifications therefore set forth in Section 4.2. B. The department director shall make an appropriate recommendation to the Medical Executive Committee; thereafter the procedures contained in the Credentialing Procedures Manual pertaining to new applications will be followed. C. A practitioner who has not been nominated for advancement in rank after having met the qualifications set forth in Section 4.2 may petition the Medical Executive Committee for promotion. Said petition shall clearly demonstrate that the practitioner has met the criteria for advancement in order for the petition to qualify for consideration. D. Upon receipt of the qualified petition, the Medical Executive Committee shall solicit from the department director the reasons for not nominating the practitioner. The Medical Executive Committee shall review the petition, examine the practitioner's qualifications, and then the pertinent procedures in the Credentialing Procedures Manual shall apply. 32 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE V ARTICLE V - DELINEATION OF PRACTICE PRIVILEGES 5.1 EXERCISE OF PRIVILEGES 5.1-1 In General A practitioner providing clinical services at this Hospital by virtue of Medical Staff appointment or when granted temporary privileges may, in connection with such practice and except as otherwise provided in Section 5.7 in an emergency, exercise only those clinical privileges specifically granted to him by the Board or as provided in Section 5.8 for temporary privileges. Regardless of the level of privileges granted, each practitioner shall provide or arrange for appropriate and timely medical care for his patients in the Hospital and to obtain consultation when appropriate to insure the safety of his patient or when required by the rules or other policies of the Medical Staff, clinical units, or the Hospital. Said privileges and services shall be within the scope of the license, certificate or other legal credential authorizing him to practice in the State of New York and consistent with any restrictions thereon. 5.1-2 Experimental, New Untried or Unproven Procedures Treatment Modalities or Instrumentation Experimental drugs, procedures, or other therapies or tests may be administered or performed only after approval of the protocols involved by the Institutional Review Board. Any experimental or other new, untried, or unproved procedure, treatment modality or instrumentation may be performed or used only after the regular credentialing process has been completed, and the privilege to perform or use said procedure, treatment modality, instrumentation has been granted to the individual practitioner. For the purposes of this paragraph, a new, untried, or unproved procedure, treatment modality or instrumentation is one that is not generally recognizable from an established procedure, treatment modality or instrumentation with respect to the same or similar skills, the same or similar instrumentation and technique, the same or similar indications, or the same or similar expected physical outcome for the patient as the established procedure, treatment modality, or instrumentation. 5.2 BASIS FOR DETERMINATION OF PRIVILEGES Clinical practice privileges shall be granted in accordance with prior and continuing education and training, prior and current experience of practice patterns, utilization patterns, current health status, and demonstrated current competence and judgment in order to provide quality and appropriate patient care in an efficient manner. Pertinent data will be documented and verified in each practitioner's credentials file. Additional factors that may be used in determining privileges are those specified in Section 3.2 of these Bylaws, patient care needs for the type of privileges being requested by the applicant, the geographic location of the practitioner, availability of qualified medical coverage in his absence, and an adequate level of 33 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE V professional liability insurance. Where appropriate, review of the records of patients treated in other hospitals or practice settings may also serve as the basis for determination of privileges. The simultaneous exercise of clinical privileges in a department other than the primary one shall demand the fulfillment of all requirements made of other appointees of that department. The basis for determination of privileges for current Medical Staff practitioners in connection with reappraisal, including termination of the provisional period, or of a request for change in privileges, also include observed clinical performance, documented results of the staff's quality management activities, and in the case of a request for additional privileges, evidence of appropriate training and experience necessary and sufficient to support the request. 5.3 PROCEDURE FOR DELINEATING PRIVILEGES The procedures by which requests for clinical privileges are processed are provided in Part Three of the Credentialing Procedures Manual. 5.4 SPECIAL CONDITIONS FOR ORAL SURGEONS AND DENTISTS Requests for clinical privileges from oral surgeons and dentists are processed in the manner specified in this Article. Surgical procedures performed by oral surgeons and dentists are under the overall supervision of the Director of the Department of Surgery and the Chief of the Dental Section. Prior to surgery a physician appointee to the Medical Staff shall perform a complete medical appraisal including history and physical examination on each oral surgery or dental patient, shall determine the risk and effect of any proposed surgical or special procedure on the total health status of the patient, and shall be responsible for the care of any medical problem that may be present at admission or that may arise during hospitalization. When significant medical abnormality is present, the decision on whether to proceed with the surgery shall be made by the oral surgeon or dentist and the physician consultant in agreement. The Director of the Department of Surgery will decide the issue in case of dispute. A dentist may be granted privileges to perform the admission history and physical examination for dental patients without medical problems if the dentist: (i) has successfully completed a post-graduate program of study incorporating training and physical diagnosis equivalent to that of a post-graduate program of study in oral and maxillofacial surgery accredited by a nationally recognized body approved by the United States Education Department; and (ii) as determined by the Credentials Committee, is currently competent to conduct a complete history and physical examination to determine a patient's ability to undergo a proposed dental procedure. 5.5 SPECIAL CONDITION FOR PODIATRISTS Requests for clinical privileges from podiatrists are processed in the manner specified in this Article. Surgical procedures performed by podiatrists are under the overall supervision of the Director of the 34 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE V Department of Surgery. A podiatrist may initiate the process for admitting a patient, but a physician appointee to the Medical Staff shall co-admit the patient, perform a complete medical appraisal (including history and physical examination) for each patient preoperatively, be responsible for the care of any medical problem that may be present at admission or that may arise during hospitalization, and determine the risk and effect of any proposed surgical or special procedure on the total health status of the patient. 5.6 SPECIAL CONDITIONS FOR OTHER ALLIED HEALTH PROFESSIONAL SERVICES The policies and procedures governing the granting and performance of certain specified patient care services by allied health professionals are set forth in Section 4.4 of these Bylaws. 5.7 PRIVILEGES IN EMERGENCY SITUATIONS In case of an emergency in which the life or well-being of a patient is in immediate danger in which a delay in administering treatment would increase that danger, and when superior alternative sources of care are not available within the necessary time frame, any practitioner is authorized to do everything possible to save the life of a patient or to save a patient from serious harm, to the degree permitted by the practitioner's license but regardless of department/section affiliation, staff category or privileges. A practitioner providing services in an emergency situation that is outside the usual scope of his privileges is obligated to summon all necessary consultative assistance and to arrange for appropriate follow-up care. Postgraduate trainees, nurses or other practitioners involved in the emergency care of a patient shall not be precluded from requesting consultation with a specialist physician. 5.8 TEMPORARY, LOCUM TENEN, EMERGENCY & DIASTER PRIVILIGES Upon the recommendation of the director of any department or the President of the Medical Staff, the hospital chief executive officer or designee may grant temporary or emergency privileges as follows: 5.8-1 Temporary Privileges Temporary privileges may be granted under the following circumstances. (a) At any time after an application for initial appointment and clinical privileges has been received and approved by the appropriate department director and the Credentials Committee or Credentials Committee Chair has recommended approval of any application for initial clinical privileges and/or appointment to the Medical Staff, temporary privileges may be granted by the hospital chief executive officer for a period not to exceed ninety (90) days while the application is pending approval by the Medical Executive Committee and Board of Trustees upon the following terms and conditions (1) The granting of temporary privileges has been recommended by the department director or the President of Medical Staff 35 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE V (2) All information and documentation required for appointment to the Medical Staff and/or clinical privileges (including current licensure, relevant training or experience, current competence and ability to perform privileges requested) has been received reviewed and verified by the Medical Staff Office (3) The results of the National Practitioner Data Bank query have been received and evaluated (4) There is no current or previously successful challenge to the applicant’s licensure, registration or certification and the applicant has not been subject to involuntary termination of medial staff membership or limitation, reduction, denial or loss of clinical privileges at any other health care facility. 5.8-2 Circumstances Upon the written recommendation of either the President of the Medical Staff or the director of the department in which privileges will be exercised, the Chief Executive Officer may grant temporary privileges in the following circumstances. A. Pendency of Application The Chief Executive Officer may grant temporary admitting and clinical privileges to a practitioner who has submitted a completed application for Medical Staff appointment if the following conditions are met: (1) (2) (3) (4) (5) the practitioner is appropriately licensed, there is proof of Drug Enforcement Agency registration, there is proof that appropriate level of professional liability insurance is maintained, the Credentials and Medical Executive Committees have recommended appointment of the individual, and there is information available which reasonably may be relied upon attesting to the practitioner's competence and ethical standing. In exercising such privileges, the applicant shall function under the supervision of the director of the department to which he is assigned. B. 1) Care of Specific Patient In order to meet an important patient care need, temporary privileges may be granted to a practitioner who is not a member of the Medical Staff; but who has unique skills or knowledge and who wishes to participate in a specific procedure or render care to a specific patient. Temporary privileges granted pursuant to this division shall be limited to the identified procedure(s), patient(s) and time period and shall automatically expire at such time as the patient(s) concerned are discharged. Before temporary privileges may be granted pursuant to this division, the practitioner shall submit to the Medical Staff Services Office such information and documentation as Good Samaritan Hospital may require, including but not limited to the following a copy of the practitioner's current New York license. 36 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE V 2) a certificate from the practitioner's malpractice insurance carrier showing that the physician currently has in force malpractice insurance in the amount, and with an insurance carrier, currently approved by Good Samaritan Hospital. 3) a copy of the practitioner's curriculum vitae. 4) documented verification of the practitioner’s current clinical Competence from another hospital where the practitioner is a member in good standing of the hospital's medical staff with the same clinical privileges as those sought on a temporary basis. 5) a letter from the President of the Medical Staff, Chief Executive Officer, or the appropriate Medical Staff department director, recommending the practitioner for temporary privileges 6) a written request from a current staff member requesting that an individual be given temporary privileges and specifying the scope of the requested privileges including the patient(s) and any surgical or invasive procedures involved. C. LOCUM TENEN PRIVILEGES Locum Tenens privileges may be granted by the hospital chief executive officer, to a practitioner who is substituting for a member of the Medical Staff, or who is temporarily providing services in one of Good Samaritan Hospital’s contract departments such as anesthesiology, pathology, radiology or emergency medicine, upon the following terms and conditions: (a) Applicants for Locum Tenens privileges shall submit an application in such form as Good Samaritan Hospital directs and shall provide such information and documentation as the Hospital requires, including, but not limited to, all of the information required by 5.8.1. (b) Above, with the exception of verification of active staff privileges at another hospital. In addition, references shall be obtained from the last threehospitals where the applicant had locum tenens privileges unless the Hospital Chief Executive Officer or designee determines such information is not reasonably available or is not required. (b) No Locum Tenens privileges shall be granted by the hospital chief executive officer until such time as all required information has been received and verified and the application has been reviewed and approved by the appropriate department director, the Chair of the Credentials Committee and the Medical Staff Chief Executive Officer. (c) Locum Tenens privileges shall be for a period not to exceed ninety (90) days. D. EMERGENCY & DIASTER PRIVILEGES (a) In the event a patient in the Hospital is suffering from a condition requiring immediate treatment and no qualified member of the Medical Staff is reasonably available to provide such treatment the hospital chief executive officer, or designee, upon recommendation by the department director or the Medical Staff President, may grant emergency privileges to any health care practitioner who is otherwise licensed and qualified to provide the required health care service. Such emergency privileges shall be restricted to the particular patients or conditions involved in the emergency and shall terminate as soon as a qualified member of the Medical 37 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE V Staff is available to assume the care of the patient or the emergency no longer exists (b) Whenever the Hospital’s disaster preparedness plan has been activated as a result of disaster, disaster privileges may be granted by the hospital chief executive officer, the President or Vice President of the Medical Staff, the Chair of the Credentials Committee or any department director in accordance with the procedures set forth in the Credentialing Procedures Manual E. Term of Temporary Privileges Temporary Privileges shall be granted for a maximum period of 90 days and may be renewed upon the written recommendation under the same terms and conditions of Section 5.8. 5.8-3 GENERAL (a) The granting or termination of temporary, locum tenens or emergency privileges shall be in the sole and absolute discretion of the hospital chief executive officer or other individual authorized to grant privileges. Such privileges may be terminated or withdrawn at any time by the hospital chief executive or his/her designee or other authorized individual, with or without cause, after consultation with the Medical Staff President (b) The refusal to grant or termination of temporary or emergency privileges shall not entitle the practitioner involved to a hearing or any other procedural rights or review (c) The granting of temporary, locum tenens or emergency privileges shall not confer Medical Staff membership on any practitioner, nor shall practitioners holding such privileges have any of the rights provided to Medical Staff members by these Bylaws or otherwise except as expressly Statedherein. 38 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE VI ARTICLE VI - CORRECTIVE ACTION 6.1 CRITERIA FOR INITIATING AN INVESTIGATION FOR POSSIBLE CORRECTIVE ACTION OTHER THAN SUMMARY OR AUTOMATIC SUSPENSION Whenever a practitioner who has a Medical Staff appointment or otherwise has clinical privileges engages in, exhibits acts, statements, demeanor or professional conduct, either within or outside the Hospital, and said actions are reasonably likely to be: A. contrary to the Bylaws and related manuals, rules, policies or standards of the Hospital or Medical Staff; or B. detrimental to patient safety or to the delivery of quality or efficient patient care in the Hospital; or C. disruptive to Hospital operations, such that the quality or efficiency of patient care is, or is likely to be, adversely affected; or D. inimicable or damaging to the reputation of the Medical Staff or Hospital such that the objectives of the Hospital may be impeded; corrective action against the practitioner may then be initiated by any of the following persons: A. any officer of the Medical Staff B. the director of any clinical department in which practitioner holds appointment or exercises privileges C. the Medical Executive Committee or the Chairman thereof D. the President/Chief Executive Officer E. the Executive Committee of the Board of Trustees F. the Board of Trustees or G. the Vice President of Medical Affairs the Specific procedures for initiating and processing routine corrective action, other than summary or automatic suspension, are contained in section 5.1 of the Credentialing Procedures Manual. 6.2 DISCRETIONARY INTERVIEW PRIOR TO CORRECTIVE ACTION Prior to initiating or proceeding with corrective action against a practitioner, the initiating or acting party may, but is not obligated to, afford the practitioner an interview at which the circumstances prompting the corrective action may be discussed and the practitioner permitted to present relevant information in his own behalf. Such an 39 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE VI interview shall be initiated by special notice to the practitioner, with copies transmitted to the Chief Executive Officer and the President of the Medical Staff. A written record (not a verbatim transcript) reflecting the substance and conclusion of the interview shall be made and transmitted to the practitioner, the President of the Staff, the Chief Executive Officer, and the practitioner's credentials file. The President of the Staff and the Chief Executive Officer or their respective designees may, at their option, be present as observers at an interview. If the practitioner fails to respond to the special notice or declines to participate in the interview, corrective action shall immediately proceed in accordance with Section 5.1 of the Credentialing Procedures Manual. The interview afforded in this Section 6.2 is not a procedural right of the practitioner and need not be conducted according to the procedural rules outlined in Article VII of these Bylaws and in the Fair Hearing Plan. 6.3 SUMMARY SUSPENSION Whenever a practitioner's conduct reasonably appears to require that immediate action be taken to protect the life of any patient or to reduce substantial likelihood of injury or harm to any patient, employee or other person present in the Hospital, any one of the following or their designated representative, has the authority to summarily suspend the Medical Staff appointment, or to reduce all or any portion of the clinical privileges of such practitioner. A. B. C. D. E. F. G. H. President of the Medical Staff Applicable clinical department director Chairman of the Medical Executive Committee Chief Executive Officer Medical Executive Committee Executive Committee of the Board of Trustees Board of Trustees or Vice President of Medical Affairs. A summary suspension is effective immediately upon imposition and the person or group imposing the suspension shall follow it promptly by giving special notice to the practitioner. The procedure for further action on summary suspension is set forth in Section 5.2 of the Credentialing Procedures Manual. The patients of a suspended practitioner who are then in Hospital shall be assigned to another practitioner by the applicable department director or his designee. The wishes of the patient will be considered when feasible in choosing a substitute practitioner. 6.4 AUTOMATIC SUSPENSION Whenever any of the actions occur which are specified in Sections 6.41, 6.4-2, or 6.4-5, the practitioner or Allied Health Professional shall immediately report same to the President of the Medical Staff and 40 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE VI the Chief Executive Officer. Failure to so report, without good cause, shall be grounds for automatic and permanent revocation of Staff appointment and clinical privileges of the practitioner. 6.4-1 License A. Revocation: Whenever a practitioner's license, certificate or other legal credential authorizing him to practice in this State is revoked, his Medical Staff appointment, clinical privileges and other specified services are immediately and automatically revoked. Further action on such matter shall proceed pursuant to Section 6.4-3. B. Restriction: Whenever a practitioner's license, certificate or other legal credential authorizing him to practice in this State is limited or restricted by the applicable licensing or certifying authority, clinical privileges and other specified services that are within the scope of said limitation or restriction are immediately and automatically revoked. Further action on the matter shall proceed pursuant to Section 6.4-3. C. Whenever Suspension: other legal credential is suspended, his Staff specified services are Further action on the 6.4-3. D. Probation: Whenever a practitioner is placed on probation by the applicable licensing or certifying authority, authorizing him to practice in this State, his voting, office-holding and teaching prerogatives and responsibilities, if any, are automatically suspended for the term of the probation. Further action on this matter such as, but not limited to, shall proceed pursuant to Section 6.4-3. a practitioner's license, certificate or authorizing him to practice in this State appointment, clinical privileges and other immediately and automatically suspended. matter shall proceed pursuant to Section 6.4-2 Controlled Substances (Drug Enforcement Agency) Number A. Revocation: Whenever a practitioner's Drug Enforcement Administration (DEA) certificate or other controlled substances number is revoked, his right to prescribe medications pursuant to said certificate or number is immediately and automatically revoked. Further action on this matter shall proceed pursuant to Section 6.4-3. B. Suspension: Whenever a practitioner's Drug Enforcement Administration (DEA) certificate or other controlled substances number is suspended, his right to prescribe medications pursuant to said certificate or number is immediately and automatically suspended. Further action on this matter shall proceed pursuant to Section 6.4-3. C. Restriction: Whenever a 41 practitioner's Drug Enforcement GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE VI Administration (DEA) certificate or other controlled substance number is restricted or limited in any way, his right to prescribe medications pursuant to said certificate or number is immediately and automatically restricted. Further action on the matter proceeds under Section 6.4-3. D. Probation: Whenever a practitioner is placed on probation with respect to the use of his Drug Enforcement Administration certificate or other controlled substances number, further action on the matter shall proceed under Section 6.4-3. 6.4-3 Further Action The procedures for further action on the matters set forth in Sections 6.4-1 B. through D. and 6.4-2 A. through D. are contained in Section 5.3 of the Credentialing Procedures Manual. 6.4-4 Medical Records A. Timely Completion: A practitioner shall complete the Medical Record of a patient for which he is responsible within thirty days following discharge of said patient. A completed chart shall be defined as one in which all progress notes are entered, all dictation is completed and all required signatures provided. Failure to comply with this requirement in timely fashion shall result in immediate and automatic suspension of clinical privileges and other specified prerogatives as outlined in the Medical Record Suspension Policy adopted by the Medical Executive Committee. Procedures for enforcing this provision are set forth in Section 5.3-3 of the Credentialing Procedures Manual. A practitioner under suspension pursuant to this section shall not be entitled to the procedural rights provided in these Bylaws or the Fair Hearing Plan. B. Appointment Status Review: A record of each suspension imposed under this section 6.4-4 shall be made a permanent part of the individual's credential file and shall be reviewed as part of the normal re credentialing process. Specific action taken with regards to a practitioner's appointment status shall be done in accordance with the Medical Record Suspension Policy adopted by the Medical Executive Committee. 6.4-5 Professional Liability Insurance A practitioner's Medical Staff appointment and clinical privileges shall be immediately suspended for failure to maintain the minimum amount of professional liability insurance required under Sections 3.29 and 13.3 of these Bylaws. Privileges may be reinstated in accordance with Section 5.3-5 of the Credentialing Procedures Manual. 42 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE VI 6.4-6 Provision of Required Documentation After timely receipt of a written warning of delinquency for failure to provide required documentation (i.e. licensure, Drug Enforcement Agency, professional liability insurance) the clinical privileges of a practitioner (except with respect to his patients already in the Hospital), including his right to admit patients, and to consult with respect to new patients, and his prerogative to vote and hold office, are immediately suspended effective on the date specified. Suspension will continue until the delinquent documentation is provided. Enforcement of this provision shall be in accordance with Section 5.3-6 of the Credentialing Procedures Manual. A practitioner under suspension by operation of this section is not entitled to the procedural rights provided in these Bylaws by the Fair Hearing Plan. 6.4-7 Special Appearance or Conferences Failure to comply with Automatic Suspension. 6.5 Article 11, Section 7.3 shall result in Consultation and Supervision Whenever the Medical Executive Committee recommends that a practitioner be placed on probation and/or be required to have consultation and supervision and at such time as said action becomes final as provided for in these Bylaws, it shall be the obligation of all other practitioners to provide the necessary consultation and supervision in accordance with the guidelines, policies and procedures established by the department in which the affected practitioner holds privileges. 43 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE VII ARTICLE VII - PROCEDURAL RIGHTS 7.1 NECESSITY FOR ADVERSE ACTION 7.1-1 By Medical Executive Committee When a practitioner receives special notice of an adverse recommendation of the Medical Executive Committee pursuant to Section 7.2, he is then entitled, upon timely and proper request, to a hearing in accordance with the procedures set forth in the Fair Hearing Plan. 7.1-2 By the Board of Trustees When a practitioner receives special notice of an adverse decision of the Board of Trustees, pursuant to Section 7.2, he is then entitled, upon timely and proper request, to a hearing in accordance with the procedures set forth in the Fair Hearing Plan. 7.2 ADVERSE ACTION 7.2-1 Adverse Recommendations and Actions Defined Subject to the exceptions set forth in Section 7.2-3 below, the following recommendations and actions are deemed adverse when made under the circumstances described in Section 7.2-2: A. B. C. D. E. F. G. H. I. J. K. L. Denial of initial Medical Staff appointment. Denial of Medical Staff reappointment. Suspension of Medical Staff appointment, provided that summary suspension entitles the practitioner to request a hearing only as specified in subsection (N) of this Section 7.2-1. Revocation of Medical Staff appointment. Denial of requested appointment to or advancement in Medical Staff category. Reduction in Medical Staff category. Suspension or limitation of the right to admit patients provided that such suspension or limitation is not related to the adoption or implementation of a general administrative action or Medical Staff policy, whether throughout the Hospital as a whole or within one or more specific departments. Denial of requested department/section or other clinical unit affiliation. Denial or restriction of requested clinical privileges. Reduction in clinical privileges. Suspension of clinical privileges, provided that summary suspension entitles the practitioner to request a hearing only as specified in subsection (n) of this Section 7.2-1. Revocation of clinical privileges. 44 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK M. N. O. P. MEDICAL STAFF BYLAWS ARTICLE VII Application of, change in, or the modification of the requirement for mandatory consultation or concurrent supervision, provided that such application, change, or modification is not related to the adoption or implementation of a general administrative action or medical staff policy, whether throughout the Hospital as a whole or within one or more specific departments. Summary suspension of Medical Staff appointment or clinical privileges, provided that the recommendation of the Medical Executive Committee or action by the Board of Trustees under Section 5.2 of the Credentialing Procedures Manual continues the suspension or takes such other action which would entitle the practitioner to request a hearing under this Section 7.2-1. Formal letter of reprimand and/or issuance of verbal warning, as evidenced in the minutes, by the Medical Executive Committee or The Board of Trustees. Issuance of a verbal warning. 7.2-2 When Deemed Adverse Recommendation or decision under Section 7.2 is deemed adverse only when it has been: A. B. adopted by the Medical Executive Committee; or adopted by the Board of Trustees under circumstances where no prior right to request a hearing existed. 7.2-3 Exceptions to Hearing Rights A. Certain Actions or Recommendations: Notwithstanding any provision to the contrary of these Medical Staff Bylaws, Credentialing Procedures Manual, or Fair Hearing Plan, the following actions or recommendations do not entitle the practitioner to a hearing: (1) (2) (3) (4) B. Issuance of a verbal warning by other than the Medical Executive Committee or the Board of Trustees. The imposition of a monitoring or consultation requirement as a condition to the exercise of clinical privileges during a provisional period; The imposition of a probationary period involving review of cases but with no requirement of direct or of concurrent supervision or of mandatory consultation; The removal of a practitioner from a medico administrative office within the Hospital provided that this action does not affect clinical or medical staff appointment. Other Situations: An action or recommendation listed in Section 7.2-1 above does not entitle the practitioner to a hearing when it is: 1) 2) Voluntarily imposed or accepted by the practitioner; Automatic, pursuant to a provision of the Medical 45 Staff GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK 3) 7.3 MEDICAL STAFF BYLAWS ARTICLE VII Bylaws or related manuals or general staff Rules and Regulations; Taken or recommended with respect to temporary privileges. PROCESS FOR HEARINGS AND APPELLATE REVIEWS All hearings and appellate reviews will be conducted in accordance with the procedures and safeguards set forth in the Fair Hearing Plan. 46 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE VIII ARTICLE VIII - CLINICAL DEPARTMENTS AND SECTION 8.1 ORGANIZATION OF DEPARTMENTS AND SECTION Each department shall be organized as a separate part of the Medical Staff and shall have a director who is selected and has the authority, duties, and responsibilities as specified in Article IX. Each section shall be organized as a specialty subdivision within a department, shall be directly responsible to the department within which it functions, and shall have a section chief who is selected and has the authority, duties and responsibilities as specified in Article IX. 8.2 DESIGNATION 8.2-1 Department and Sections A. Department of Anesthesiology B. Department of Emergency Services C. Department of Family Practice The Department of Family Practice shall not be a separate medical service, but shall be a separate department for administrative and educational purposes only. Patients shall not be admitted through this department. Practitioners holding appointments within the Department of Family Practice shall have privileges in clinical services of other departments in accordance with their experience and training. The extension of such privileges shall be based on the recommendations of the Credentials Committee and the Medical Executive Committee of the Medical Staff. A practitioner shall be subject to the rules and the jurisdiction of the director of the clinical service in which he holds privileges and shall attend at least 2/3 of the regular departmental meetings held per year by said clinical service. This attendance requirement is in addition to the basic requirement of attendance at 75% of the quarterly Medical Staff meetings. D. Department of Internal Medicine 1) 2) 3) 4) 5) 6) Allergy & Immunology Cardiology Dermatology Endocrinology Gastroenterology Hematology 47 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK 7) 8) 9) 10) 11) 12) MEDICAL STAFF BYLAWS ARTICLE VIII Oncology General Medicine Neurology Nephrology Pulmonary Medicine Rheumatology E. Department of Obstetrics/Gynecology F. Department of Pathology G. Department of Pediatrics H. Department of Psychiatry I. Department of Radiology J. Department of Radiation Oncology K. Department of Surgery 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 11) General Surgery Neurosurgery Ophthalmology Orthopedics Otolaryngology Plastic and Reconstructive Urology Vascular Surgery Thoracic Surgery Dentistry Podiatry 8.2-2 Periodic Reorganization of Clinical Departments and Sections The Medical Executive Committee shall periodically restudy the structure and organization of medical services and recommend to the Board of Trustees desirable action in creating new, or eliminating or combining clinical departments or sections for the purpose of increased organizational efficiency and improved patient care. All changes shall be effective as determined by the Board of Trustees. These Bylaws shall be amended to reflect such changes at the next regular Medical Staff meeting. The criteria set forth in Sections 8.2-3 and 8.2-4 and such others as may be deemed appropriate shall be used by the Medical Executive Committee and Board of Trustees in making recommendations and taking action under this Section 8.2-2 with respect to department and section designations. The Board of Trustees, with the recommendation of the Medical Executive Committee, may make exceptions to those criteria as deemed appropriate in the best interests of fulfilling major purposes, objectives or commitments of the Hospital. Any department or section created or existing as such an exception shall satisfy the functions of the departments or sections as applicable, as required under Section 8.4 of these Bylaws either on its own, in combination with another department or section, or through the activities and input 48 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE VIII of the department director or section chief or his designee. 8.2-3 Criteria to Qualify as a Clinical Department The following criteria shall apply in making the designation of a clinical department. A. The area of practice medical practice; and represents a sizable, distinct field of B. The level of clinical activity at this Hospital is sufficient to warrant the functions and responsibilities of a department; and C. The practitioners assigned to the department are ready, willing and able to accomplish said functions and responsibilities. 8.2-4 Criteria to Qualify as a Clinical Specialty Section The following criteria shall apply in making the designating section a clinical specialty: 8.3 A. The area of practice represents an established, professionally recognized specialty or subspecialty within the general field of the department; B. The level of clinical activity at this Hospital is sufficient to warrant the functions and responsibilities of a department; and C. The practitioners assigned to the department are ready, willing and able to accomplish said functions and responsibilities. PRACTITIONER'S SECTIONS REQUIREMENTS FOR AFFILIATION WITH DEPARTMENTS AND Every Medical Staff appointee shall have a primary affiliation with the department and section, where applicable, which most closely reflects his professional training, experience, and current clinical practice. A practitioner may be granted clinical privileges in one or more of the other departments or sections if warranted by his professional training, experience and current clinical practice, except that simultaneous affiliation in medical/surgical or family practice/surgery shall not be granted. Practitioners who currently hold simultaneous affiliations in medicine/surgery shall be permitted to continue these affiliations. In order to be eligible for assignment to a specialty department or section, all new practitioners to the medical staff shall be pursuing Board certification, or, shall have successfully completed an approved residency program in that specialty. For the exercise of clinical privileges in any department other than the primary affiliation, a practitioner shall fulfill the requirements of every clinical 49 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE VIII department or section with which he is affiliated. 8.4 FUNCTIONS OF CLINICAL DEPARTMENTS 8.4-1 Generally Each clinical department fulfills certain administrative, quality management and educational functions as set forth in Sections 8.4-2 through 8.4-5. Each department and its sections shall formulate its own Rules and Regulations for the conduct of its affairs and discharge of its responsibilities. Such rules and regulations shall be consistent with these Bylaws and related manuals and other policies of the Hospital. Each department and section shall hold meetings as required under Section 11.2 of these Bylaws for the purpose of fulfilling the required functions as set forth in Sections 8.4-2 through 8.4-5. All departmental functions shall be subject to review by the Bylaws Committee and recommendation of the Medical Executive Committee and approval by the Board of Trustees. 8.4-2 Clinical Functions Each department shall: A. Establish and implement clinical standards, policies, procedures and practices relevant to the clinical disciplines under its jurisdiction, and shall monitor the adherence to these of all affiliated practitioners; B. Provide an inter-specialty and inter-departmental forum for matters of clinical concern and to resolve clinical issues which arise from the interface between activities of its appointees and the activities of other patient care and administrative services; C. Develop consistency of standards, policies, procedures, practices, and the accumulation of patient care data within the department and its constituent sections. 8.4-3 Administrative Functions Each department shall: A. Provide a forum for its practitioners to contribute professional views and insights in the formulation of departmental, Medical Staff and Hospital policies and plans B. Communicate, through its director, formulated departmental, Medical Staff and Hospital policies and plans to its appointees for implementation C. Coordinate, through its director, the professional services of its appointees with those of other departments and with Hospital and Medical Staff support services 50 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK D. MEDICAL STAFF BYLAWS ARTICLE VIII Make recommendations as appropriate, through its director, to the Medical Executive Committee, the Chief Executive Officer, and other individuals and hospital organizations with respect to acquisitions and allocations of Hospital resources and services. 8.4-4 Quality Management Functions Each department shall: A. Review Quality Management data pertinent to the department, and make recommendations or take actions as appropriate B. Conduct mortality and morbidity reviews, perform special studies and monitoring activities, and otherwise participate as required by applicable law, Joint Commission on Accreditation of Health Organization standards and regulations in the quality management programs. C. Report all findings of studies and other activities performed under paragraphs A and B to the Quality Management Committee and all other appropriate Staff committees. 8.4-5 Collegial and Education Functions Each department and/or section, encourage among its members: 8.5 as appropriate, A. Mutual clinical support, B. Sharing new knowledge and exchange of ideas, C. Consultative advice and, D. Continuing medical education. shall foster and FUNCTIONS OF SECTIONS A section is defined as a subunit of a department. Each section, if assigned, shall fulfill the same requirements of clinical, administrative and quality management functions as described above for department. Where sections exist within a department, each section shall be the principal organizational component for carrying out the collegial and educational functions described in Section 8.4-5. 8.6 OFFICERS OF CLINICAL DEPARTMENTS AND SECTIONS 8.6-1 Department Directors A. Qualifications 51 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE VIII Each department director shall: 1. Be a Full Attending in good standing in his department and so throughout his term. 2. Be recognized for his clinical ability, holding specialty board certification within his discipline. In the absence of board certification, the Department Director shall have established, through the privilege delineation process, that he possesses comparable competence. 3. Have demonstrated leadership qualities through experience participation in Medical Staff and Hospital activities. 4. Have demonstrated a high degree of interest in and support for the Medical Staff and Hospital by the length of his Staff tenure and the level of his clinical activity at this Hospital. 5. Willingly and faithfully in the exercise of his authority, discharge the functions of his office, and work in harmony with officers of other clinical departments, Medical Staff, Chief Executive Officer of the Hospital, Board of Trustees and its committees. 6. These qualifications may be modified for good cause upon the recommendation of both Medical Executive Committee and Chief Executive Officer and with the subsequent approval of the Board of Trustees. B. Voluntary and Paid/Contractual Directors Distinguished and For purposes of these Bylaws, a department director serving on a voluntary basis is referred to as a "voluntary" director, and one serving on a paid basis, full or part time, is referred to as "paid". C. Selection and Appointment 1. Voluntary: Each department shall hold an election in the last quarter of each odd numbered year to nominate candidates for the position of Voluntary Director. Full and Associate Attending of the respective clinical department may participate in the nominating and elections in accordance with Article IV. Voting shall be by secret written ballot, and proxy shall not be permitted. With respect to the positions of Director of Surgery, members of the Dental Section may not participate in the nominating process. No more than three names may be placed in nomination by a department. Should a vacancy occur the full and associate attending of the respective clinical department shall meet and repeat the procedure outlined above. The President of the staff may call this meeting in the absence of a department director. The names of all nominees, together with the record of the votes 52 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE VIII received by each, shall be submitted to the Chief Executive Officer for presentation to the Board of Trustees for approval. 2. Paid/Contractual: If a paid department director is to be employed by the Hospital, a Joint Search Committee composed of four members of the Board of Trustees and four elected members of the Medical Executive Committee, one of whom is an appointee of the department involved, shall act as a nominating committee. Final decision for employment shall rest with the Board of Trustees. A paid director shall immediately be appointed to Full Attending status. D. Term of Office 1. Voluntary: A voluntary department director shall serve for a term of two years commencing on the first day of the Medical Staff year following his appointment. A voluntary department director may serve no more than three consecutive full terms in office. In the event that the director resigns or is removed from office, a successor shall be chosen to complete the un-expired term. The completion of an un-expired term shall be considered an addition to the limitations of three consecutive full terms in office. Removal of a voluntary department director from office may be accomplished as follows: a) Upon the recommendation of a 3/4 majority vote of the Medical Executive Committee b) Upon a 3/4 majority vote of the department appointees eligible to vote on departmental matters, in which case the final decision shall rest with the Board of Trustees c) By the Board of Trustees acting upon its own initiative 2. Paid/Contractual: A paid department director shall serve until his term of office expires, or until he resigns or is removed from office in accordance with the provisions of his employment agreement/contract. E. Responsibility, Authority and Reporting Obligations 1. Responsibility and Authority A department director has the responsibility and authority to take all appropriate and lawful action in order to carry out the functions delegated to him and to the department by the Board of 53 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE VIII Trustees, by the Medical Executive Committee, by these Bylaws and related manuals, and, where applicable, by contract or job description. A department director shall designate a qualified person temporarily to assume all the responsibility and authority of the director in the event of his temporary absence. 2. Reporting Obligations Each department director shall report: a) On the activities of the department and its constituent sections as requested by the Board of Trustees, Medical Executive Committee, members of the medical staff and members of the clinical department, at regularly scheduled or special meetings. b) Whenever appropriate or whenever requested to the Chief Executive Officer, the Medical Executive Committee or the Vice President of Medical Affairs on matters pertaining to clinical services in order to maintain quality or to assure patient safety. c) To the Medical Executive Committee, the Quality Management Committee and the Vice President of Medical Affairs on action taken in response to a suggestion, recommendation or finding by any of the Hospital's quality management programs. d) To the Chief Executive Officer or designee on matters pertaining to the director's administrative functions in supervision of Hospital personnel, in proper functioning of equipment and in efficient scheduling. e) To the Medical Executive Committee and Chief Executive Officer on matters pertaining to acquisition and allocation of resources for the various departments and sections, budgetary and general fiscal matters. 3. Specific Duties A department director shall: a) Be accountable for all professional and administrative activities within his department and its constituent sections. b) Be a member of the Medical Executive Committee, make specific recommendations and suggestions regarding his department and its constituent sections recommend offsite sources for needed patient care and services not provided by his department or any other department and offer guidance on the general medical policies of the Hospital. c) Be responsible for the conduct of continuing review of the professional performance of all practitioners with clinical 54 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE VIII privileges to practice or to perform specified services in his department and recommend to the Medical Staff the criteria for clinical privileges that are specific to his department. d) Transmit to the appropriate authorities his recommendation with respect to practitioners and Allied Health Professionals in his department or constituent sections as required by the Credentialing Procedures Manual, concerning appointment and classification, reappointment, delineation of clinical privileges or privileges to perform specified services, and corrective action. e) Appoint such committees as are necessary and appropriate to the proper functioning of the department, constituent sections as clinical service for which he is accountable. f) Enforce the Hospital and Medical Staff Bylaws, rules, policies and regulations within his department and constituent sections, including evaluations, clinical performance, requiring that consultations and supervision be sought and provided as necessary and appropriate, and initiating corrective action as necessary. g) Perform such other functions and duties appropriate to his office as may reasonably be requested by him from time to time. By the Vice President of Medical Affairs, President of the Medical Staff, by the Medical Executive Committee or by the Board of Trustees. 8.6-2 Section Chief A. Qualifications Each section chief shall: 1) Be a Full Attending in good standing of the applicable department and section, and remain so throughout his term; and 2) Be recognized for his current clinical ability in the clinical area covered by the section, and preferably be certified by the applicable specialty board; and 3) Have demonstrated executive and administrative abilities through experience and participation in Medical Staff and Hospital activities; and 4) Have demonstrated a high degree of interest in and support of the Medical Staff and Hospital by his Medical Staff tenure and his level of clinical activity at the Hospital. 5) Agree willingly and faithfully to discharge the functions and to exercise the authority of his office and to work with the 55 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE VIII other general and departmental officers of the Medical Staff and with the Chief Executive Officer, the Board of Trustees and its committees. B. Selection and Appointment The Director of the Department shall appoint section Chiefs. The Chief of the Dental Division shall be selected and appointed in the same manner as that specified for voluntary department directors (cf. 8.6-1 C. (1)). The above appointments shall be submitted to the Chief Executive Officer for presentation to and approval by the Board of Trustees. C. Term of Office Section chief shall serve a term of two years commencing on the first day of the Medical Staff year following his appointment. Section chief may serve no more than three consecutive full terms in office. In the event that the Section Chief resigns or is removed from office, a successor shall be chosen to complete the un-expired term. The completion of an un-expired term shall be considered an addition to the limitations of three consecutive full terms in office. Removal of a section chief from office may be accomplished as follows: a) Upon the recommendation of a 3/4 majority vote of the Medical Executive Committee b) Upon a 3/4 majority vote of the department appointees eligible to vote on departmental matters, in which case the final decision shall rest with the Board of Trustees c) The Board of Trustees acts upon its own initiative. D. Duties Each section chief shall: 1) Account to the department director for the effective operation of the section and for discharge of all tasks delegated to the section consistent with Section 8.5. 2) Develop and implement programs in cooperation with the department director, to carry out quality management functions assigned to the section. 3) Exercise general supervision over all clinical work performed within the section. 56 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE VIII 4) Submit reports and recommendations to the department director regarding the clinical privileges exercised by section appointees. 5) Act as presiding officer at all section meetings. 6) Submit a monthly report to the department director on the activities of the section. 7) Perform such other duties commensurate be reasonably requested of him from department director, by the President by the Medical Executive Committee Trustees. 57 with his office as may time to time by his of the Medical Staff, or by the Board of GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE IX ARTICLE IX - OFFICERS 9.1 GENERAL OFFICERS OF THE MEDICAL STAFF 9.1-1 Identification The general officers of the Medical Staff are: A. B. C. D. E. President Vice President Immediate past President Secretary Treasurer The At-large Members to the Medical Executive Committee, defined in Article 10.2-1, represent the Medical Staff on the Executive Committee. further Medical 9.1-2 Other Officials of the Medical Staff Other officials of the Medical Staff may include a medical director, a director of medical education, academic chiefs and such other officials as may be selected from time to time pursuant to these Bylaws. To the extent that any such official performs a clinical function, that person must have been granted appropriate clinical privileges in accordance with policies and procedures of the Medical Staff; and in respect of such clinical activity, that person is subject to all other policies of the hospital. In respect of his clinical functions, that person is subject to these Bylaws, the Medical Staff rules and regulations and all other lawful policies of the hospital. 9.1-3 Qualification A. Shall be full attending members of the Medical Staff in good standing at the time of both nomination and election and shall remain members in good standing throughout the term of office. Failure to maintain such status shall immediately create a vacancy in the office involved. B. Shall have demonstrated a high degree of interest in and commitment to the Medical staff and the Hospital as evidenced by staff tenure, clinical and medicoadministrative competence, and clinical activity at the Hospital. C. Shall agree to willingly and faithfully discharge the duties of the office; exercise the authority of the office held; and work with both the Medical Staff and the Hospital administration as well as with all associated officer, directors, and committee. No Attending Physician may serve as an elected officer of the Medical Staff while employed by the Hospital Administration. This restriction shall include Attending Physicians serving as Directors of Medical 58 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE IX Affairs and similar administrative positions. It shall not restrict Attending Physicians from holding positions such as PRO Reviewer or similar administrative duties. 9.1-4 Nominations A. By Nominating Committee: as defined in Article X.4-9. B. By Petition: Nominations may also be made by petition signed by at least 10% of the appointees to the active Medical Staff eligible to vote and filed with the Medical Staff secretary at least 14 days prior to the annual meeting. As soon thereafter as reasonably possible, the names of these additional nominees shall be reported to the Medical Staff. C. At the Annual Meeting: If, prior to the election, any of the individuals nominated for office pursuant to Sections 9.1-4 shall refuse, be disqualified from, or otherwise be unable to accept nomination, then the nominating committee shall submit one or more substitute nominees at the annual meeting of the staff. D. Nominations from the floor will be accepted for all elections. 9.1-5 Election of Officers Officers and At-large Members shall be elected, as term expirations dictate, at the annual meeting of the Medical Staff, provided a quorum is present. Only those Medical Staff members qualified to vote for officers and At-large Members in accordance with Article IV of these bylaws shall participate. Voting shall be by secret written ballot. Voting by proxy or by absentee ballot shall not be permitted. A nominee shall be elected if and only if named on a majority of the valid ballots, ignoring blanks and defective ballots. A. Runoff Election for General Staff Officer and/or only one At-large Member If no nominee for General Staff Office or At-large Member receives a majority of the votes on the first, or any subsequent ballot, a runoff election shall be held between the two nominees named on the most ballots. B. Election involving more than one At-large Member If more than one At-large position is to be determined, then all nominees shall be voted upon simultaneously, with each participating Medical staff member permitted to vote for as many nominees as there are open seats. Each member shall cast all votes on a single ballot. A duplicate name on any ballot shall render the ballot invalid. An At-large Member shall be elected if an only if a nominee is named on a majority of valid ballots, ignoring blanks and defective ballots. 59 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK C. MEDICAL STAFF BYLAWS ARTICLE IX Runoff Election for more than one At-large Member If any vote does not elect all contested seats, than a runoff election shall be held. The runoff election shall be among those nominees with the highest votes, selecting a number of nominees for the runoff equal to one (1) plus the number of seats still to be determined. 9.1-6 Exception: Office of Immediate Past President The president of the staff, upon the completion of his term of office, shall immediately succeed to the office of Immediate past President, and Sections 9.1-4 and 9.1-5 shall not be applicable to this position. 9.1-7 Term of Elected Office Each officer shall serve a two-year term commencing the first day of the Medical Staff year following his election. Each officer shall serve until the end of his term and until a successor is elected, unless he shall sooner resign or be removed from office. An officer may succeed himself in office, but in no event shall he be eligible to hold a particular office for more than four (4) consecutive years. He shall again be eligible to hold said office after a lapse of one-year following his last term in office. An officer may succeed to another office without restrictions. Each at-large member to the Medical Executive Committee shall serve a four - (4) year term commencing the first day of the New Year following election. An at-large member may serve two (2) consecutive full terms and no more than ten (10) consecutive years, in the event the member is also completing the term of another member. A member shall again be eligible to hold said office after a lapse of one-year following the last term in office. A member may succeed to another office without restrictions. 9.1-8 Removal of Elected Officers Except as otherwise provided a general staff officer or at-large member may be removed by the Medical Staff at a General Medical Staff meeting, provided a quorum is present, or by the Operating Board, pursuant to its Bylaws. A two-thirds (2/3)-majority vote in favor of removal by those Medical Staff members eligible to vote is required. A general staff officer or at-large member who is no longer qualified under Section 9.1-3 shall be deemed ineligible for office and shall be removed by the above mechanism. An officer or at-large member who is the subject of a removal action shall be removed by the above mechanism. An officer or at-large member who is the subject of a removal action shall receive written notice from the initiating body ten (10) days prior to the proposed vote. The officer or at-large member shall be afforded the opportunity to speak to the initiating body prior to any vote. Grounds which constitute permissible bases of removal of an officer or at-large member includes, but are not limited 60 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE IX to. Failure to satisfy the qualifications of the position as outlined in Section 9.1-2; failure to perform the duties of the position in a timely or responsible manner; display of conduct or expression in conflict with the best interests of the Hospital, its Medical Staff, its employee staff, or its patients; and/or exhibiting physical or mental impairment that renders the officer or at-large member incapable of fulfilling the duties. 9.1-9 Vacancies in Elected Office In the event of a vacancy in the office of president, the vicepresident shall serve out the remaining term. All other vacancies in elected office shall be filled by special election to be held as soon, as is reasonably possible in accordance with the principles of Sections 9.1-4 and 9.1-5. Filling an un-expired term shall not constitute a term for the individual filling the un-expired term. 9.2 DUTIES OF GENERAL OFFICERS 9.2-1 President The President shall serve as the chief elected officer of the Medical Staff and shall: A. Have direct responsibility for the organization and administration of the Medical Staff in accordance with these Bylaws. B. Aid in coordinating medical staff activities with the Hospital administration, nursing and other patient care services. C. Communicate the opinions, policies, concerns, needs and grievances of the Medical Staff to the Chief Executive Officer, the Board of Trustees and other related parties. D. Assist the Vice President of Medical Affairs, who has ultimate responsibility for the Medical Staff including the enforcement of Medical Staff Bylaws, Rules and Regulations, and in implementing sanctions in all instances where corrective action is indicated, and has been requested against a practitioner. E. Call, presides at, and is responsible for the agenda of all general meetings of the Medical Staff. Serve as a member of the Medical Executive Committee, as an ex officio member of the Joint Conference Committee, and all other Medical Staff committees. F. G. Attend meetings of the Board of Trustees and appropriate committees thereof to provide relevant information and advice concerning Medical Staff attitudes and positions. H. Consult with the Chief Executive Officer on matters of special concern to Medical Staff appointees. 61 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE IX I. Appoint chairmen and members of all standing and special committees of the Medical Staff, with the exception of the Medical Executive Committee and those committees whose responsibilities are a function of a specific clinical department or service. (The Chief Executive Officer will appoint all Hospital personnel who serve as official members of Medical Staff committees). J. Be responsible Staff. K. Be the spokesperson for the Medical Staff for professional and public relations. for the educational activities of the Medical 9.2-2 Vice President The Vice President shall be a member of the Medical Executive Committee. In the absence of the President (whether temporary or permanent), he shall assume all duties and authority of the President. He shall perform such additional duties as may be assigned to him by the President, the Medical Executive Committee or the Board. 9.2-3 Immediate Past President The immediate Past President shall be a member of the Medical Executive Committee and the Joint Conference Committee. He shall perform such other advisory duties as are assigned to him by the President, the Medical Executive Committee or the Board. 9.2-4 Secretary The Secretary shall be a member of the Medical Executive Committee and shall: A. Give proper notice of all Medical Staff meetings to all members of the Medical Staff. B. Prepare and publish complete and accurate minutes of all Medical Staff meetings. C. Perform such other duties as ordinarily pertaining to his office and such additional duties as may be appropriately assigned to him by the President 9.2-5 Treasurer The Treasurer shall be a member of the Medical Executive Committee and shall: A. Supervise the collection and accounting of all Medical Staff dues and assessments. B. Serve as Chairman of the Budget and Finance Committee of the Medical Staff. 62 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE IX C. Prepare and publish complete and accurate records of all financial transactions of the Medical Staff and the Medical Executive Committee. D. Perform such other duties as ordinarily pertain to his office and the President may appropriately assign such additional duties as to him. 9.2-6 At-large Member to the Medical Executive Committee Each at-large member shall represent the Medical Staff on the Medical Executive Committee. 63 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE X ARTICLE X - COMMITTEES AND THEIR FUNCTIONS 10.1 DESIGNATION There shall be a Medical Executive Committee and such other standing and special committees of the Medical Staff as may from time to time be necessary and desirable to perform the staff functions listed in Section 10.3 and elsewhere in these Bylaws. The Medical Executive Committee may, by resolution and upon approval of the Board, establish staff committees in addition to those committees delineated herein to perform one or more of the required staff functions. 10.2 MEDICAL EXECUTIVE COMMITTEE 10.2-1 Membership The Medical Executive Committee shall be composed of: A. The President, Vice President, Secretary, Treasurer and Immediate Past President of the Staff; each serving for a two (2) year term; B. Eleven (11) appointed directors of clinical departments, namely Anesthesiology and Surgery. If a clinical department is created or eliminated pursuant to Section 8 of these Bylaws, then membership to the MEC shall be similarly affected to reflect the change in the number and composition of the department directors. C. Chief of the Dental Division of the Department of Surgery; D. Six (6) Full Attending elected at-large by the Medical Staff, each to a four-year term, to maintain an even balance between independent practitioners and the hospital-based practitioners. A Medical Staff member is deemed to be hospital-based and, therefore, ineligible for an at-large position if the practitioner is employed by the hospital on a full time basis or if the practitioner (or a group of the department’s members) has an exclusive contractual arrangement with the hospital for the total or near total provision of department services. The atlarge members therefore shall not be affiliated with the current hospital-based departments of Anesthesiology, Emergency Services, Pathology, Psychiatry, Radiation Oncology, and Radiology. This balance shall be maintained without regard to the composition of the Medical Executive Committee as a whole. If a hospital-based clinical department is created, eliminated, or otherwise modified then the number of at-large positions shall so reflect this change. A non-hospital-based director, who received payment for administrative duties and who also is in active practice, shall not require the election of an additional member-at-large. A non-hospital based director, who receives payment for administrative duties, but who is not in active practice, shall 64 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE X require the election of an additional at-large member. E. Chief Executive Officer or designee, but with advisory and nonvoting status. F. The Vice President of Medical Affairs with Attending Physician may be elected to Committee while employed by the Hospital Director of Medical Affairs or other duties. non-voting status. No the Medical Executive Administration as the similar Administrative A majority of the members of the Medical Executive Committee shall at all times be fully licensed physicians actively practicing in this Hospital. A representative of the Allied Health Professional staff may be invited from time to time to attend, but with advisory and nonvoting status. At the first meeting held in each Medical Staff year, a Chairman and a Secretary shall be elected, each to serve a (1) one-year term. Eligibility to serve as Chairman shall be limited to the voting members. In the absence of the Chairman, the President of the Staff shall serve as Chairman. The Chairman of the Medical Executive Committee shall not be eligible to serve in that capacity for more than six consecutive years. After a lapse of one year, a previous Chairman of the Medical Executive Committee shall again be eligible for election to that position. 10.2-2 Duties and Authority The duties and authority of the Medical Executive Committee are to: A. Receive coordinates and act upon the written and oral reports and recommendations of departments and sections, and standing and special committees. B. Coordinate activities and approve policies of the Medical Staff, departments, sections, clinical units and committees. C. Implement approved policies of the Medical Staff, and monitors the implementation of such policies by departments, sections, clinical units and committees. D. Review proposal for changes in the Bylaws and make recommendations to the Medical Staff in their regard. E. Develop criteria with respect to credentials, with assistance from appropriate specialists and sub-specialists, to be used in making recommendations for initial appointment, reappointment, grant of clinical privileges, concluding the provisional period, and other matters of credentials as required by the Credentialing Procedures Manual. F. Make recommendations to the Board of Trustees, as required by these Bylaws, Credentialing Procedures Manual and Fair Hearing 65 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE X Plan, with respect to matters of the Medical Staff's structure; credentialing procedures; appointment, reappointment, assignment to category department and section, clinical privileges, specified services; the delineation of individual clinical privileges; the participation of the Medical Staff in all phases of the Hospital's Quality Management Program activities; termination of Medical Staff membership and other disciplinary action; and Fair Hearing procedures. G. Account to the Board of Trustees from time to time by written report with respect to the quality and efficiency of medical care provided to patients in the Hospital, and include a summary of specific findings, appropriate action taken and follow-up evaluations. H. Take reasonable measures to insure competent clinical performance and ethical professional conduct on the part of Medical Staff members, including when warranted, initiating investigations and pursuing corrective action. I. Make recommendations to the Chief Executive Officer and the Board of Trustees with respect to matters of medical administration, Hospital management and planning. J. Inform the Medical Staff with respect to matters of accreditation of the Hospital. K. Cooperate in attempts to identify community health needs and to set hospital goals and to implement programs to meet those needs. L. Represent and act on behalf of the Medical Staff in all matters of Medical Staff business and in the intervals between Medical Staff meetings subject to such limitations imposed by these Bylaws. 10.2-3 Meetings The Medical Executive Committee shall meet at least once a month and shall maintain a permanent record of its proceedings, actions and attendance. 10.3 STAFF FUNCTIONS The Medical Staff shall make provisions for the effective performance of all staff functions as reasonably required by these Bylaws, by resolution of the Medical Executive Committee, or by the Board of Trustees. The Medical Staff shall: A. Participate in the Hospital-wide Quality Management Program as specified in the Quality Management Plan. 66 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE X B. Coordinate the activities and policies of the Medical departments, sections, clinical units and committees. C. Conduct, coordinate and review credentials investigations, recommendations regarding Medical Staff appointments, and grants of clinical privileges and other specified services. D. Provide the opportunity for continuing medical education in response to the advancing state-of-the-art of quality medical care and other perceived educational needs of the Medical Staff; and to supervise the Hospital's professional library services. E. Review patient medical and related timeliness and clinical pertinence. F. Develop and maintain surveillance over policies and practices of drug utilization. G. Monitor the Hospital's infection control program control and prevent infections acquired in Hospital. H. Plan for response to fire and other disasters, for Hospital's growth and development, and for the provision of services required meeting the changing needs of the community. I. Direct Medical Staff organizational activities, including regular review and revisions of the Bylaws, nominations of staff officers, committee appointments, liaison with the Board of Trustees and Hospital administration, and maintenance of Hospital accreditation. J. Coordinate the medical care provided by practitioners with that of the nursing service, and other patient care and administrative services. records for Staff, completeness, in order to 10.4 STANDING COMMITTEES OF THE MEDICAL STAFF AS REQUIRED BY STATE, FEDERAL OR ACCREDITING AGENCIES 10.4-1 Blood Utilization/Tissue Committee A. Membership These combined meetings shall consist of members of the medical staff departments of Pathology/Clinical Laboratory, Surgery and Anesthesia. A member of the Hematology/Oncology section and the General Surgery department will chair the meetings respectively. Membership will also include Blood Bank Services, Quality Improvement, Staff Development/Nursing, and Peri-operative Services. B. Functions 1. Review blood usage, including appropriateness of units, all transfusion reactions, and wastage. 67 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE X 2. Develop and/or approve policies and procedures relating to the distribution, handling, use of, and administration of, blood and blood components. 3. Review the adequacy of transfusion services as they relate to the needs of the community. 4. Report on reviews of tissue and non-tissue indicators, including evaluation and comparison of preoperative and postoperative diagnoses, indications for surgical and other invasive procedures, and pathology reports. 5. Annual summary of autopsies. 10.4-2 C. Meetings and Reports 1. The Blood Utilization/Tissue Committee shall meet at least quarterly or as often as necessary as directed by the Chairpersons. 2. Minutes of each meeting shall be submitted to the Medical Executive Committee. Bylaws Committee A. Membership The Bylaws Committee shall consist of at least two Medical Staff members and the President of the Medical Staff or his designee. B. Functions 1. Conduct a Bi-annual review of the Bylaws, Fair Hearing Plan, Credentialing Procedures Manual, and the Rules and Regulations of the Medical Staff. 2. Submit periodic reports to the Medical Executive Committee, which shall include recommended changes in the bylaws, rules and regulations to reflect the hospital's current practices, applicable law and regulations, and requirements of the Joint Commission on Accreditation of Health Care Organization. C. Meetings The Bylaws Committee shall meet as often as necessary as directed by the Chairperson. 10.4-3 Cancer Committee The Cancer Committee shall be a standing committee of the Good Samaritan Hospital Medical Staff. A. Membership The Cancer Committee shall be composed of multidisciplinary representation from all medical specialties involved in the care of patients with cancer. It shall include representatives from 68 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE X Surgery, Medical Oncology, diagnostic Radiology, Radiation Oncology, Pathology, and other disciplines that manage patients with cancer, as appropriate. It shall also be composed of ancillary services involved in cancer patient care and quality monitoring, including representatives from administration, nursing, social services, cancer registry and quality assurance, and other specialties, such as pharmacy, clergy, nutrition and rehabilitation, as appropriate. The committee shall include a physician liaison to the commission on Cancer of the American College of Surgeons. B. Functions The Cancer Committee shall provide the leadership for the hospital's cancer program. It shall plan, initiate, stimulate and evaluate the activities of this program, insure the availability of multidisciplinary consultative services to provide optimal cancer patient care, and conduct educational programs and quality care evaluations and re-evaluations, as appropriate. It shall establish and monitor program standards, organize, publicize, conduct and evaluate institution-wide, multidisciplinary, patient oriented Cancer Conferences, and oversee the Cancer Registry and the cancer patient lifelong follow-up program. C. Meetings The Cancer Committee shall meet quarterly. Documentation shall be maintained of its policy and advisory functions. 10.4-4 Continuing Medical Education Committee A. Membership The Continuing Medical Education Committee shall consist Medical Staff members representing each major department section. of or B. Functions 1. Participate in developing, planning, implementing and evaluating programs of and requirements for continuing education that are relevant to the type and scope of patient care services delivered at the Hospital. These programs shall be designed to keep the Medical Staff informed of significant new developments and skills in the practice of medicine, and shall be responsive to the findings of the Quality Management program. 2. Coordinate, as necessary, the education activities of the departments and other clinical units. 3. Maintain a written record of education activities participation in them by members of the Medical Staff. 69 and GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK 10.4-5 MEDICAL STAFF BYLAWS ARTICLE X C. Meetings and Records 1. The Continuing Medical Education Committee shall often as necessary as directed by the Chairperson. 2. The committee shall report its findings and recommendations to the Medical Executive Committee. meet as Credentials Committee A. Membership The Credentials Committee shall consist of Associate and/or Full Attending members of each clinical department and the Hospital President/Chief Executive Officer or designee. 10.4-6 B. Functions 1. Review applications and interview candidates for appointment to the Medical Staff. Make recommendations to the Medical Executive Committee that concern initial appointment and to the Medical Staff the delineation of clinical privileges including any conditions placed upon the appointment of the applicant. 2. Report on the status of pending applications, reasons therefore and pertinent details. 3. Review and evaluate qualifications of each Allied Health Professional who makes application to perform specified services. 4. Act in an advisory and investigative capacity and make recommendations. The committee has no disciplinary or punitive powers. 5. Perform such other functions as provided in these Bylaws and the Credentialing Procedures Manual, or as otherwise required by applicable law or standards. C. Meetings and Records 1. The Credentials Committee shall meet as often as necessary as directed by the Chairperson. 2. The Committee shall report its findings and recommendations to the Medical Executive Committee. 3. A permanent record shall be maintained of all recommendations and actions taken. Infection Control Committee A. Membership 70 including GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE X The Infection Control Committee is multidisciplinary and is co-chaired by Infectious Disease physicians. Membership includes representation from medical staff, administration, infection control, nursing, occupational health, quality improvement, pharmacy, laboratory, surgical, mother/child and renal services, facilities, and risk management. Representation from other departments/services is available on a consultative basis. Statement of Authority The committee acting through its chairmen has the authority to institute appropriate surveillance, prevention and control measures or studies to prevent or control the spread of infection among patients or healthcare personnel. C. Function 1. oversees the hospital-wide program for surveillance, prevention and control of infection 2. participates in on-going review and analysis of infection data, risk factors, ancillary department reports and as needed, special studies that relate to these activities 3. approves type and scope of surveillance activities 4. reviews and approves all policies and procedures related to the infection control program and to those activities in all departments/services 5. recommend actions associated with committee findings D. Meetings and Reports 1. The committee shall meet at least six times per year. When an emergent issue arises a meeting shall be called at any time between scheduled meetings with appropriate committee members. 2. Minutes of each meeting shall be submitted to the Medical Executive Committee 10.4-7 Joint Conference Committee A. Membership The Joint Conference Committee shall include six (6) or more members of the Board of Trustees and an equal number of full attending members of the Medical Staff, including the President, Immediate Past President and four (4) members or more as necessary elected by the Medical Executive Committee. At least two of the elected medical staff members shall be clinical department directors. The Hospital President/Chief Executive Officer shall also be a member of this committee. The representatives of the Board of Trustees and Medical Staff shall include members of the executive committee of each group. The Chairperson of the committee shall be the Chairperson of the Board of Trustees, or 71 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE X some other member of the Board of Trustees designated. 10.4-8 B. Functions 1. The Joint Conference Committee shall provide a means of medical-administrative liaison between the Medical Staff and the Board of Trustees and Hospital Administration. 2. The Committee shall serve as a forum for discussion to which significant issues are brought for consideration which arise in connection with the affairs and operation of the Hospital and which affect the interests of the patient, the physician, the Hospital and the community at large. 3. The Committee shall serve as a forum for discussion of matters of administrative and medical policies and procedures and which require agreement among the Board of Trustees, Medical Staff and Administration. 4. The Committee shall receive reports of the findings of the Joint Commission on Accreditation of Healthcare Organizations and other accrediting and licensing agencies, and also of any trial surveys conducted during the interim years between regular surveys for the purpose of constructive selfcriticism. In addition, the Committee shall receive reports on the status and efficiency of resolutions developed in response to such surveys. C. Meetings and Reports 1. The Joint Conference Committee shall meet necessary as directed by the Chairperson. 2. Minutes of each meeting of the Joint Conference Committee shall be recorded and shall be sent to the Medical Executive Committee & BOD as often as Leadership Morbidity & Mortality (M&M) Committee A. Membership The Leadership M&M Committee shall consist of Directors from the Departments of Surgery, Anesthesia, Internal Medicine, Obstetrics/Gynecology, Pathology, Emergency Services and Radiology. The VP of Medical Affairs or his designee will chair the meeting. Membership will also include the VP of Patient Care Services, the Senior Risk Manager and the Director of Quality Improvement. B. Functions 1. Functions as a sub-committee of the Medical Executive Committee to provide a standard mechanism across the organization for Peer 72 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE X Review. 2. Conduct multidisciplinary case reviews based on score of three or greater on the Greeley Scale. The score is to be determined by the appropriate department director after his/her review. 3. Recommend actions associated with committee findings. C. Meetings and Reporting 1. The Leadership M&M Committee shall meet at least eight (8) times per calendar year. If an emergent problem arises a meeting shall be called at any time between scheduled meetings; all members shall make every effort to attend. Support staff department director or his/her designee shall be invited on an “as needed” or consultative basis. 2. 2.1 3. The committee members recognize the importance of efficient two-way information flow among this committee, the Quality Committee of the Board the Medical Executive Committee and the BOD. Therefore: 3.1 10.4-9 This shall include, but not limited to, Case Management, Infection Control and Perioperative Services. The Leadership Morbidity & Mortality (M&M) Committee has been established as a sub-committee of the Medical Executive Committee (MEC) and reports to the Quality Committee of the Board and to the MEC. Medical Records Committee A. Membership The Medical Records Committee shall consist of at least six (6) members of the active Medical Staff. There shall be at least one representative of each of the following clinical departments: Family Practice, Internal Medicine, Obstetrics-Gynecology, Pediatrics, Psychiatry and Surgery. Additional members may be appointed as appropriate by the Chief Executive Officer to represent nursing, medical records, quality review and other patient service departments. B. Functions 1. Review and evaluate medical records quarterly to determine that they (a) (b) Properly describe the condition and progress of the patient, therapy and tests provided, results thereof, diagnosis, patient's condition at discharge, and identification of responsibility for all actions taken; and Are sufficiently complete at all times so as to foster continuity of care for the parties and to facilitate 73 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE X communications between all those providing patient care services in the Hospital. 10.4-10 2. Develop, review and maintain surveillance over enforcement of Staff and Hospital policies and rules relating to medical records, including the completion of medical records, preparation of records and forms, proper formats, filing, indexing, storage, destruction and availability and to recommend methods of enforcement thereof and changes therein. 3. Provide liaison with Hospital administration, nursing service and the department of medical records in matters relating to medical record practices. 4. Serve as a clearinghouse for requests for changes in medical record forms and formats and to make recommendations thereof. 5. Formulate rules and procedures for appropriate access to patients' charts, x-rays, and other clinical records for use in communications both inside and outside of the Hospital. C. Meetings and Reports 1. The Medical Records Committee shall meet quarterly and as often as necessary as directed by the Chairperson. 2. Periodic reports shall be submitted to the Medical Executive Committee and Quality Management Committee. Policy proposals, rules, procedures, and recommendations shall be submitted to the Medical Executive Committee for approval. Nominating Committee A. Membership The Nominating Committee shall consist of at least three (3) Full Attending appointed by the President of the Medical Staff at the beginning of the President’s term of office. The President shall designate one member as chairman. B. Functions 1. Identify nominees for election to general staff offices and to at-large membership on the Medical Executive Committee. 2. In accomplishing 10.4-8, B-1 (above), consult as appropriate with other practitioners, the Chief Executive Officer and the Medical Executive Committee, and with each nominee to determine his willingness to serve. C. Meetings and Reports 1. The Nominating Committee shall meet as often as necessary as directed by the Chairperson. 74 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK 2. 10.4-11 MEDICAL STAFF BYLAWS ARTICLE X Recommendations shall be reported to the President of the Medical Staff no later than November 15 and circulated to the Medical Staff. Pharmacy and Therapeutics Committee A. Membership The Pharmacy and Therapeutics Committee shall consist of six (6) or more active members of the Medical Staff, plus representatives from Pharmacy, Nursing and Dietary services, and other appropriate patient service departments. B. Functions 1. Assist in the formulation of policies regarding the: 1) 2) 3) 4) 5) 6) 7) 8) Selection Procurement Use Evaluation Appraisal Storage Distribution, and Safety procedures relating to drugs medical material in the Hospital. and all other 2. Advise the Medical Staff and the Hospital's pharmacy matters pertaining to the choice of available drugs. 3. Make recommendations concerning drugs to be stocked on the nursing unit floors and by other services. 4. Develop and periodically review a drug formulary for use in the Hospital, propose the necessary operating rules for its use, and assure that said rules are available to and observed by all Medical Staff members. 5. Develop a mechanism to identify, review and receive reports on all unexpected drug reactions. 6. Evaluate clinical data concerning new drugs or preparations being considered for use in the Hospital. 7. Review and evaluate drug therapy practices and drug utilization including appropriateness of empiric and therapeutic use. Results shall be reported at least quarterly. 8. Review and evaluate the appropriateness, safety, efficiency and effectiveness of the prophylactic, empiric, and therapeutic use of antibiotics in the Hospital. 9. Propose Medical Staff 75 education programs consistent on with GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE X findings and results of evaluation of drug/antibiotic usage. 10.4-12 C. Meetings and Reports 1. The Pharmacy and Therapeutics Committee shall meet quarterly or as often as necessary as directed by the Chairperson. 2. Policy and formulary recommendations shall be made to the Medical Executive Committee. 3. Quality assessment activity reports shall be made to the Medical Executive Committee. 4. Recommendations for improved cost effectiveness shall be made to the Medical Executive Committee. Quality Committee of the Board A. Membership The membership shall be comprised of at least one member of the local community that serves on the Good Samaritan Hospital Board of Directors. The Vice President of Sponsorship for the Bon Secours System, the Executive Vice President and other hospital leadership, the Vice President of Medical Affairs, the President of the Medical Staff, Medical Staff Directors, the Risk Manager and the Director of Quality Improvement. A board member chairs the committee. B. Functions 1. Provide an organized structure for oversight of the Performance Improvement (PI) activities. 2. Review and evaluate PI activities and recommend improvement strategies when appropriate. 3. Assure that PI activities follow all regulatory standards and are aligned with the mission, vision and SQPs. C. Meetings and Reports 1. The Quality Committee of the Board shall meet at least eight times per year, and shall be chaired by a board member. The reporting schedule is disseminated annually. 2. The committee chair at a subsequent Board of Directors meeting will perform reporting. 2.1 Reporting at the Quality Committee of the Board meeting shall include but not be limited to Key Quality Measures, Risk Management, and Patient Satisfaction, Care of the Dying, Human Resources, Patient Safety and Medication Safety. 10.4.13 Care Management Council A. Membership The Care Management Council is multidisciplinary and is led by the Vice President of Medical Affairs. Membership includes 76 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE X at a minimum the President of the Medical Staff, Medical Staff Department Directors, Vice President of Patient Care Services, Vice President of Mission, Ancillary Service Leadership, the Risk Manager, and the Directors of Infection Control, Case Management and Quality Improvement. B. C. Functions 1. Provides an organized structure for carrying out the activities of care management: planning, care coordination, utilization review, service delivery, outcome monitoring, performance improvement, evaluation and reporting. 2. Aligned with the mission, vision and SQPs (Strategic Quality Plans) it establishes a collaborative focus on care delivery and outcomes management. 3. Establishes clinical and operational leadership for care management while obtaining medical staff support and involvement. 4. Aids in providing appropriate allocation of resources. 5. Provides credible data to assist in identifying opportunities and evaluating outcomes. Meetings and Reports 1. The Care Management Committee shall meet at least eight times per year. 2. Clinical and support staff department managers/directors shall be invited when they are scheduled to report. The reporting schedule is disseminated annually. 3. Minutes of each meeting shall be submitted to the Medical Executive Committee, and the Board of Directors. 10.4-14 Medical Staff Health & Behavior Committee A. B. COMPOSITION In order to improve the quality of care and promote the competence of the medical staff, the Medical Executive Committee shall establish a Medical Staff Behavioral Committee comprised of no less than (5) active members of the medical staff. Members of this committee shall not serve as active participants on Medical Executive Committee or other peer review or quality assurance committees while serving on this committee. DUTIES The Medical Staff Health & Behavior Committee may receive reports related to the health, well being, impairment, or behavior of the medical staff members and, as it deems appropriate, may investigate such reports. With respect to matters involving individual medical staff members, the committee may, on a voluntary basis, provide such advice, counseling, or referrals as may seem appropriate. Such activities shall be confidential. However, in the event information received by the committee shall be confidential; 77 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE X however, in the event information received by the committee clearly demonstrates that the health or known impairment of a medical staff member poses an unreasonable risk of harm to hospitalized patients, that information may be referred for corrective action. Federal and State Laws, as well as guidelines will guide the committee from the Medical Society of the State of New York and the American Medical Association. C. MEETINGS The committee will meet as often as necessary but at least quarterly. It shall report on its activities on a routine basis to the Medical Executive Committee. 10.5 SUBCOMMITTEES Any standing committee may elect to perform any of its specifically designated functions by constituting a subcommittee for this purpose. Such subcommittee shall report in writing to its parent committee, and when appropriate, directly to the Medical Executive Committee. Such subcommittee may include individuals other than members of the standing committee. Such additional members shall be appointed by the committee chairman after consultation with the President of the Medical Staff in the case of Medical Staff members, and with the approval of the Chief Executive Officer in the case of administrative staff appointments. 10.6 SPECIAL COMMITTEES The Medical Executive Committee as required may constitute special committees. A Special Committee shall confine its activity to its specified purpose and shall report its activities to the Medical Executive Committee. 10.7 APPOINTMENT OF MEMBERS AND CHAIRMAN Except as otherwise expressly provided, the President of the Medical Staff shall appoint the practitioner members and Chairmen of all standing and special staff committees. The Chief Executive Officer shall appoint committee members of the Hospital Administrative Staff. 78 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE XI ARTICLE XI - MEETINGS 11.1 GENERAL MEDICAL STAFF MEETINGS 11.1-1 Regular Meetings Regular quarterly meetings of the general Medical Staff shall be held during the months of March, June, September and December. The December meeting shall be the annual meeting. The Medical Executive Committee may authorize additional special general Medical Staff meetings by resolution. Written notice may be given personally, or by placement in the practitioner's Hospital mailbox, or by regular mail. The resolution authorizing any such additional meeting shall require notice specifying the date, time and place for the meeting, and that the meeting can transact any business as may come before it. Attendance at all meetings shall be duly recorded. 11.1-2 Order of Business and Agenda The President of the Medical Staff shall determine the order of business at a regular Medical Staff meeting. The agenda shall include: A. Accept minutes from the last regular meeting and all intervening special meetings. B. Administrative reports from the President and the Chief Executive Officer. C. Election of officers and representatives to the Medical Executive Committee where appropriate. D. Reports of standing and special committees. E. New Business 11.1-3 Special Meetings A Special Meeting of the Medical Staff may be called at any time by the Board of Trustees, the President of the Medical Staff, the Vice President of Medical Affairs, and the Medical Executive Committee or by at least 10% of the members of the active Medical Staff. A Special Meeting shall be held at the time and place designated in the meeting notice. No business shall be transacted at any special meeting except for that stated in the notice of meeting. The agenda at Special Meetings shall be as follows: A. Call to order 79 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK B. C. MEDICAL STAFF BYLAWS ARTICLE XI Reading of the notice calls the special meeting. Transaction of the business that the Special Meeting was called. D. Adjournment Attendance shall be duly recorded. 11.2 COMMITTEE, DEPARTMENT, AND SECTION MEETINGS 11.2-1 Regular Meetings Any Committees, Departments or Sections may, by resolution, designate the date, time and place for regular meetings and no notice other than such resolution shall then be required. The frequency of such meetings shall be as required by these Bylaws or as determined by department, section or committee policies and procedures. 11.2-2 Special Meetings A special meeting of any committee, department or section may be called by the chairman or director thereof, the Board of Trustees, the President of the Medical Staff, the Vice President of Medical Affairs, or by at least one-third of the current members group. No business shall be transacted at any special meeting except that stated in the meeting notice. 11.3 NOTICE OF MEETING Notice of Meeting may be given by written or oral means stating the date, time and place and shall be given not less than five days nor more than twenty days before the appointed date of such meeting. Written notice may be given personally, or by placement in the practitioner's Hospital mailbox, or by regular mail. If mailed, Notice of Meeting shall be deemed delivered 72 hours after deposit, postage prepaid in United States mail, addressed to each person entitled to such notice at his address as it appears in the records of the Hospital. Personal attendance at a meeting shall constitute a waiver of notice of such meeting. 11.4 QUORUM 11.4-1 General Staff Meetings The presence of more than fifty percent of the voting members of the active Medical Staff shall constitute a quorum for the transaction of all business. 11.4-2 Fifty Department, Section and Committee Meetings percent of the voting members 80 of a department, section or GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE XI committee, but not less than two members, shall constitute a quorum at any meeting of such department, section or committee. 11.5 MANNER OF ACTION Except as otherwise specified the action of a majority of the members present and voting at a meeting at which a quorum is present shall be the action of the group. Action may be taken by a department, section or committee without a meeting by a writing which sets forth the action so taken and signed by each member entitled to vote in the matter. 11.6 MINUTES Minutes of all meetings shall be prepared in writing and shall include at least the following: attendance, date and duration of the meeting, synopsis of issues discussed and actions or recommendations made. A record of attendance and a permanent file of the minutes of each meeting shall be maintained. Copies of said minutes shall be signed by the presiding officer, forwarded to the Medical Executive Committee or, in the case of a subcommittee to its parent committee. Minutes shall be made available, upon request to and at the discretion of the President of the Medical Staff and Chief Executive Officer, to any Medical Staff appointee who has a legitimate interest in them. However, no access shall be granted to minutes or records pertaining to quality assurance and peer review activities unless such access complies with applicable law and/or regulations concerning confidentiality of such records and information. When access is provided, it shall be afforded in a manner consistent with the policies of confidentiality of the Hospital with respect to Medical Staff minutes and activities. 11.7 ATTENDANCE REQUIREMENTS 11.7-1 Regular Attendance Each member of the Staff who is required to attend meetings under Article IV shall attend no less than: A. B. C. 11.7-2 3/4 of the quarterly Medical Staff meetings. 2/3 of other general medical staff meetings duly convened pursuant to these Bylaws. 2/3 of meetings of each department, section and committee of which he is a member. Absence from Meetings An individual who is required to be absent from Medical Staff, department, or committee meeting shall promptly provide the reason for such absence, to the regular presiding officer thereof. Unless excused 81 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE XI for good cause, failure to meet the attendance requirements of this Article 11.7-1 may be grounds for any corrective action specified in Section 7.2-1, including removal from such department, section or committee. Reinstatement of a Staff member whose appointment has been revoked because of absence from meetings shall be made only upon written application, and such application shall be processed in the same manner as an application for initial appointment. 11.7-3 Special Appearance or Conferences A. A practitioner whose patient's clinical course of treatment is scheduled for case discussion at a staff, department, section or committee meeting as part of regular quality review activities shall be so notified and invited to present the case. B. Whenever a staff department or section education program or clinical conference is prompted by findings of Quality Review, Risk Management, Utilization Management or like monitoring activities, the practitioner(s) whose patterns of performance prompted the program will be notified of the date, time and place of the program, of the subject matter to be covered, and of its special applicability to the practitioner's practice. Attendance is optional. C. Whenever actual, apparent or suspected deviation from standard practice is identified with respect to a practitioner's performance, the Medical Staff President or the applicable department director may require the practitioner to confer with him or with a standing or ad hoc committee that is considering the matter. The practitioner shall be given special notice in writing at least seven days in advance, including the date, time, and place of the conference and a statement of the issue involved. The practitioner's appearance is mandatory. Failure of a practitioner to appear at any such conference, unless excused for good cause by the Medical Executive Committee, shall result in an automatic suspension of all or such portion of the practitioner's clinical privileges as the Medical Executive Committee may direct. Suspension under this Section will remain in effect until the matter is resolved by subsequent action of the Medical Executive Committee and the Board of Trustees. 11.8 PROCEDURAL RULES Meetings of the Medical Staff, departments, sections and committees shall be conducted according to the then current edition of Roberts' Rules of Order. In the event of a conflict between said Rules and any provision of the Medical Staff Bylaws or any of its related manuals, the latter shall control. 82 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE XII ARTICLE XII - CONFIDENTIALITY, IMMUNITY AND RELEASES 12.1 SPECIAL DEFINITIONS For the purposes of this Article only, the following definitions shall apply: A. Information: any record of proceedings, minutes, interviews, records, reports, forms, memoranda, statements, investigations, examinations, hearings, meetings, recommendations, findings, evaluations, opinions, conclusions, actions, data and all other disclosures or communications whether in written or oral form relating to any of the subject matter specified in Section 12.5. B. Malice: intent to harm, either by the dissemination of a known falsehood or by the distribution of information with a reckless disregard for whether or not it is true or false. C. Practitioner: a Medical Staff appointee or applicant, or Allied Health Professional. D. Representative: the Board of Trustees of the Hospital corporation or any trustee or committee thereof; the Chief Executive Officer or her designees; registered nurses and other employees of the Hospital; the Medical Staff organization and any member, officer, clinical unit or committee thereof; and any individual authorized by any of the foregoing to perform specific functions such as the gathering, analysis, and disseminating of information. E. Third Party: any individual or information to any representative. organization which provides 12.2 AUTHORIZATIONS AND CONDITIONS By submitting an application for Medical Staff appointment or reappointment or by applying for or exercising clinical privileges or by providing specified patient care services at the Hospital, a practitioner: A. Authorizes representatives to solicit, provide and act upon all information which bears on his professional ability, utilization practices and other qualifications; and B. Agrees to be bound by the provisions of this Article and to waive all legal claims against any representative who acts in good faith in accordance with the provisions of this Article; and C. Acknowledges that the provisions of this Article are express conditions to his application for, or acceptance of, Medical Staff appointment and to the continuation of such appointment and to his 83 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE XII exercise of clinical privileges or the provision of specified patient care services at the Hospital. 12.3 CONFIDENTIALITY OF INFORMATION Information submitted, collected or prepared by any representative of this or any other health care facility, organization or medical staff for the purpose of evaluating, monitoring or improving the quality and efficiency of patient care, reducing morbidity and mortality, contributing to teaching or clinical research, or determining that health care services were professionally indicated or were performed in compliance with the applicable standard of care, shall be confidential to the fullest extent permitted by law. Said information shall not be disseminated to anyone other than a representative or other health care facility or organization of health professionals engaged in an official, authorized activity for which the information is required, nor shall it be used in any way except as provided herein or except as otherwise specifically required by law. Such confidentiality shall also extend to information of like kind which may be provided by third parties. Said information shall not become part of any particular patient's record. It is expressly acknowledged by each practitioner that violation of the confidentiality provided for herein constitutes grounds for immediate and permanent revocation of Medical Staff appointment, clinical privileges or specified services. 12.4 IMMUNITY FROM LIABILITY No representative and no third party shall be liable to a practitioner for damages or other relief by reason of having provided information, including otherwise privileged or confidential information, to a representative or to any other health care facility or organization of health professionals concerning said practitioner who is or has been an applicant or appointee to the Medical Staff or who does exercise clinical privileges or provide specified services at this Hospital, provided that such representative or third party acts in good faith and without malice within the scope of his function and has made a reasonable effort to obtain the facts of the matter about which he is providing information and provided further that such information is related to the performance of the duties and functions of the recipient and is reported in a factual manner. 12.5 ACTIVITIES AND INFORMATION COVERED 12.5-1 Activities The confidentiality and immunity afforded by this Article applies to any information or disclosure obtained or provided in connection with the activities of this or any other health care facility or organization with respect to, but not limited to: 84 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK A. B. C. D. E. F. G. H. I. 12.5-2 MEDICAL STAFF BYLAWS ARTICLE XII applications for appointments, clinical privileges or specified services including temporary privileges, and periodic reappointments or reappraisals thereof; corrective or disciplinary actions; hearings and appellate reviews; quality review activities; utilization review and management activities; malpractice claims reviews; profiles and profile analyses; risk management activities; any other Hospital, committee, department, section or Medical Staff activities which relate to monitoring and maintaining quality and efficient patient care and appropriate professional conduct. Information The information referred to in this Article may relate to a practitioner's professional licensure or certification, education, training, clinical ability, judgement, utilization practices, character, physical or mental health, emotional stability, professional ethics, or any other matter that might directly or indirectly affect the quality, efficiency and appropriateness of patient care provided in the Hospital. 12.6 RELEASES Each practitioner shall, upon appropriate request by the Hospital, execute general and specific releases in accordance with the tenor and import of this Article, subject to such requirements, including those of good faith and the exercise of a reasonable effort to ascertain truthfulness, as may be applicable under relevant New York State and Federal law. Execution of such releases is not a prerequisite to the effectiveness of this Article. Failure to execute such releases shall result in an application for appointment, reappointment or clinical privileges being deemed incomplete and to have been voluntarily withdrawn, and such application shall not be further processed. Failure to execute such releases in connection with conclusion of the period of provisional appointment shall be deemed a voluntary resignation of Medical Staff appointment or particular clinical privileges as appropriate to the context. Failure to execute such releases in connection with a disciplinary or corrective action shall permit the acts or circumstances that are the subject matter of said releases to be construed in a negative manner with respect to the practitioner involved. 12.7 CUMULATIVE EFFECT Provisions in these Bylaws and in application forms relating to authorization, confidentiality of information and immunity from liability are in addition to all other protections provided by relevant 85 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE XII New York State and Federal law and not in limitation thereof. A finding by a court of law or administrative agency with proper jurisdiction that all or any portion of any such provision is not enforceable shall not affect the legality or enforceability of the remainder of such provision or any other provision. 86 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE XIII ARTICLE XIII - GENERAL PROVISIONS 13.1 STAFF RULES AND REGULATIONS Subject to approval by the Board of Trustees and following Review and Recommendations by the Bylaws Committee, the Medical Executive Committee shall adopt such rules and regulations as may be necessary to implement the general principles found in these Bylaws. The principles outlined in Article XIV of these Bylaws shall be followed in the adoption and amending of the rules and regulations, except that the Medical Executive Committee may act for the Medical Staff in adopting or amending the rules and regulations after Review by the Bylaws Committee. 13.2 DEPARTMENT RULES AND REGULATIONS Subject to the recommendation of the Medical Executive Committee and approval by the Board of Trustees, each department shall formulate its own rules and regulations for the conduct of its affairs and the discharge of its responsibilities. Such rules and regulations shall not be inconsistent with these Bylaws and related manuals, the general rules and regulations of the Medical Staff, and other policies of the Hospital. 13.3 PROFESSIONAL LIABILITY (MALPRACTICE) INSURANCE Each appointee to the Medical Staff holding clinical privileges shall maintain professional liability (malpractice) insurance coverage with limits in the amounts of $1,000,000/$3,000,000 written by a company licensed and approved by the State of New York or the State of New Jersey. If the malpractice insurance carrier is not so licensed, the practitioner shall provide a certificate of insurance to Good Samaritan from the carrier which states that said carrier will defend and pay claims for that physician in New York State. The practitioner shall comply with any increase in the minimum amount of malpractice insurance coverage which the Board of Trustees may, from time to time, require, and he shall notify the Hospital at least thirty (30) days in advance of any change in or non-renewal of his malpractice insurance coverage. Immediately upon appointment to the Medical Staff the practitioner shall provide a certificate from his insurance carrier(s) which gives evidence of the required coverage and which provides that the Hospital shall be given at least thirty (30) days advance written notice by the carrier(s) in the event of any change in, termination or non-renewal of such insurance coverage. 13.4 STAFF DUES The Medical Executive Committee shall establish the amount of annual dues, and shall determine the manner of expenditure of funds received. Notice of dues shall be given to the Medical Staff at a quarterly meeting and shall be duly posted. Dues are payable on or before 87 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE XIII December 31st. If dues have not been paid by January 1st for the calendar year, a special notice of delinquency shall be sent to the practitioner and shall be given an additional thirty (30) days to make payment unless excused by the Medical Executive Committee for good cause failure to render payment at that point shall result in automatic suspension of Medical Staff appointment and clinical privileges until the delinquency is remedied. All new Medical Staff practitioners shall be billed upon their appointment to the Medical Staff. Individuals appointed on or after July 1 shall pay one-half the regular amount. Special assessments may be voted by the Medical Executive Committee, and in such event similar rules of payment shall apply. The following groups of practitioners are exempt from payment of dues and assessments: Consulting Medical Staff, Honorary Medical Staff and individuals on an approved leave of absence. 13.5 CONSTRUCTION OF TERMS AND HEADINGS Words used in these Bylaws and related manuals shall be read as the masculine or feminine gender and as the singular or plural, as the context requires. The captions or headings in these Bylaws and related manuals are for convenience only and are not intended to limit or define the scope or effect of any provision of these Bylaws and related manuals. 13.6 TRANSMITTAL OF REPORTS Reports and other information required by these Bylaws to be transmitted to the Board of Trustees shall be deemed to have been transmitted when delivered to the President/Chief Executive Officer unless otherwise specified. 13.7 BOARD ACTION Whenever these Bylaws require or authorize action to be taken by the Board of Trustees, such action may be taken by a committee of the Board to which the Board has duly delegated appropriate responsibility and authority. Whenever the Board of Trustees takes action which affects medical care and the delivery of patient services, the Board of Trustees before taking such action, shall obtain input from the Medical Staff. 13.8 NOTIFICATION OF MAJOR CHANGES Notification of all changes in Bylaws, Rules and Regulations, Credentialing Procedure Manual and Fair Hearing Plan shall be provided upon adoption to all Medical Staff practitioners and copies of such changes shall be provided upon request. 88 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE XIV ARTICLE XIV - ADOPTION AND AMENDMENT 14.1 MEDICAL STAFF AUTHORITY AND RESPONSIBILITY The Board of Trustees holds the Medical Staff responsible for the development, adoption, and periodic review of Medical Staff Bylaws and related manuals, all of which shall be consistent with Hospital policies, applicable laws and other requirements. The Medical Staff Bylaws and related manuals shall be reviewed bi-annually by the Bylaws Committee, and may be reviewed whenever deemed necessary by the medical staff or its appropriate authorities. Suggestions for changes in the Bylaws shall be referred to the Bylaws Committee which shall present its recommendations in a timely fashion to the Medical Executive Committee for review and referral to the Medical Staff. Except as provided in Section 14.3-2, the adoption and amending of the Medical Staff Bylaws require the actions specified in Sections 14.2 and 14.3-1. The principles expressed here shall also apply to the adoption and amending of the related manuals. 14.2 MEDICAL STAFF ACTION Medical Staff action is taken by the affirmative vote of a majority of the Full and Associate Attending Medical Staff practitioners in good standing present at a regular or special Medical Staff meeting at which a quorum is present, provided that a copy of the appropriate documents or proposed amendments was given or made available to each Medical Staff member entitled to vote thereon. Affirmative action of the Medical Staff shall be forwarded to the Board of Trustees through its Bylaws Committee. Other Medical Staff action shall be transmitted to the Board of Trustees through the Chief Executive Officer for its information. 14.3 BOARD OF TRUSTEES ACTION 14.3-1 When Favorable to Medical Staff Recommendation Medical Staff recommendations are approved upon the affirmative vote of a majority of the Board of Trustees. The effective date of such approved shall be the date approved or such later date as the Board may specify. 14.3-2 A. When Contrary Recommendation to or Without Benefit of Medical Staff Notice to Staff Whenever the Board of Trustees shall contemplate either: 1. Taking an action with respect to Bylaws or amendments thereto which is contrary to the recommendation of the Medical Staff; 89 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE XIV or 2. Taking an action with respect to Bylaws or amendments thereto without having received a recommendation in the matter from the Medical Staff; The Board of Trustees shall, by written notice to Staff President, inform the Staff of its concerns and therefore and of the date by which the response of Staff is requested, which date shall be not less than than 120 days after the date of said notice. B. the Medical the reasons the Medical 90 nor more Action Following Staff Response If the response of the Medical Staff satisfies the concerns of the Board of Trustees, the Board of Trustees shall act upon the matter in accordance with Section 14.3-1. If the response of the Medical Staff fails to satisfy the concerns of the Board of Trustees or if no Medical Staff response is received within the specified time frame, the matter shall be referred to a special combined committee for review, discussion and report as provided in Section 14.3-2(c). This special combined committee shall be composed of 6 representatives each from the Medical Staff and Board of Trustees appointed respectively by the Medical Staff President and the Chairperson of the Board of Trustees. Included among the Medical Staff representatives shall be the President of the Staff, Chairman of the Medical Executive Committee and Chairman of the Bylaws Committee. The Chief Executive Officer shall sit with this committee as a member ex-officio without vote. C. Action Following Combined Committee Review Within twenty working days after receiving a matter referred to it under Section 14.3-2 B. above, the special combined committee described in B. above shall convene to review, discuss and prepare its written report on the matter. This shall be communicated to the Medical Staff for consideration and for response to the Board of Trustees within a specified time period. Action of the Board of Trustees after receiving the response of the Medical Staff or after expiration of the response period without receiving a response of the Staff shall be effective as the final decision. The actions or amendments the Board of Trustees approved are effective as of the date of the Board of Trustees action or at such later date as the Board of Trustees may specify. 14.4 TECHNICAL AND EDITORIAL AMENDMENTS The Medical Executive Committee shall have the power to adopt such amendments to the Bylaws as are, in its judgement, technical or legal modifications or clarifications, reorganization or renumbering of the Bylaws, or amendments made necessary because of punctuation, spelling or other errors of grammar or expression. Such amendments shall be 90 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE XIV effective immediately and shall be permanent unless disapproved by the Medical Staff or the Board of Trustees within 90 days of adoption by the Medical Executive Committee. Such action to amend may be taken by motion acted upon in the same manner as any other motion before the Medical Executive Committee. After approval, such technical and editorial amendments shall be promptly communicated in writing by some reasonable mechanism to the Medical Staff and to the Board of Trustees. 91 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE XV ARTICLE XV - RULES AND REGULATIONS The Rules and Regulations of the Medical Staff shall also be known as Article XV of the Medical Staff Bylaws and shall be incorporated into said document. 92 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE XVI ARTICLE XVI - CREDENTIALING MANUAL The Credentialing Manual shall also be known as Article XVI of the Medical Staff Bylaws and shall be incorporated into said document. 93 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE XVII ARTICLE XVII - FAIR HEARING PLAN The Fair Hearing Plan shall also be known as Article XVII of the Medical Staff Bylaws and shall be incorporated into said document. 94 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE XVIII ARTICLE XVIII - DISSOLUTION OF THE MEDICAL STAFF In the event of dissolution of the Medical Staff Organization, the assets and property of the organization remaining after payment of expenses and the satisfaction of all liabilities shall be distributed to the Hospital to be used for substantially similar purposes provided that no such distribution shall be made to the Hospital unless the distributes shall at the time qualify as an exempt organization under Section 501(c)(3) of the Internal Revenue Code of 1986, as amended, or corresponding provisions of any subsequent tax law (the code). Any of such assets not so distributed shall be disposed of as directed by a Justice of the Supreme Court of the State of New York or such other court having jurisdiction over the organization. This paragraph relating to the disposition of assets upon dissolution of the Medical Staff organization shall apply only to assets of the Medical Staff organization and shall not apply to assets of the Hospital. 95 GOOD SAMARITAN HOSPITAL SUFFERN, NEW YORK MEDICAL STAFF BYLAWS ARTICLE XVIII CERTIFICATION OF ADOPTION AND APPROVAL Adopted by the Medical Staff of Samaritan Hospital on June 26, 2008 Good President of the Medical Staff Good Samaritan Hospital of Suffern, N.Y. Approved by the Board of Directors Good Samaritan Hospital on July 18, 2008 Chairperson, Board of Directors _____________________________ Cliff L. Wood Chief Executive Officer _____________________________ Dominick Stanzione, CEO