Download good samaritan hospital medical staff bylaws

GOOD SAMARITAN HOSPITAL
SUFFERN, NEW YORK
MEDICAL STAFF BYLAWS
TABLE OF CONTENTS
DEFINITIONS
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ARTICLE I – NAME
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ARTICLE 11 PURPOSE AND RESPONSIBILITIES
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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
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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
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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
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4.5 LIMITATION ON PREROGATIVES
4.6 WAIVER OF QUALIFICATIONS
4.7 ADVANCEMENT IN RANK FOR ACTIVE STAFF MEMBERS
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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
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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
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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
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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
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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
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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
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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
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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.
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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."
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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.
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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.
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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
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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.
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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.
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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.
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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.
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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
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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
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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
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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
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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.
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GOOD SAMARITAN HOSPITAL
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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.
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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
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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
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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
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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
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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
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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.
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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
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GOOD SAMARITAN HOSPITAL
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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.
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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
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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.
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GOOD SAMARITAN HOSPITAL
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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
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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.
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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.
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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.
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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
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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
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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.
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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.
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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
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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
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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
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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
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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
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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
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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.
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GOOD SAMARITAN HOSPITAL
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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
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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
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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;
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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.
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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
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GOOD SAMARITAN HOSPITAL
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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
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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
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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.
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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
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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:
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GOOD SAMARITAN HOSPITAL
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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
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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.
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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
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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.
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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;
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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
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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.
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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.
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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.
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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.
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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.
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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