medical staff bylaws 2019 - smh.com staff... · 4847-0883-8253, v. 5 sarasota memorial hospital...

4847-0883-8253, v. 5

SARASOTA MEMORIAL HOSPITAL MEDICAL STAFF BYLAWS,

POLICIES AND RULES AND REGULATIONS

MEDICAL STAFF BYLAWS

Revised: Medical Executive Committee – December 13, 2018 Medical Staff – January 22, 2019 Board – February 19, 2019

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MEDICAL STAFF BYLAWS TABLE OF CONTENTS

PAGE

1. GENERAL ..........................................................................................................................1

1.A. DEFINITIONS .........................................................................................................1 1.B. TIME LIMITS .........................................................................................................1 1.C. DELEGATION OF FUNCTIONS ..........................................................................1 1.D. MEDICAL STAFF DUES .......................................................................................1

2. CATEGORIES OF THE MEDICAL STAFF .................................................................2 2.A. ACTIVE STAFF ......................................................................................................2

2.A.1. Qualifications ...............................................................................................2 2.A.2. Prerogatives..................................................................................................2 2.A.3. Responsibilities ............................................................................................3

2.B. LIMITED ACTIVE STAFF ....................................................................................4 2.B.1. Qualifications ...............................................................................................4 2.B.2. Prerogatives and Responsibilities ................................................................4

2.C. CONSULTING STAFF ...........................................................................................5 2.C.1. Qualifications ...............................................................................................5 2.C.2. Prerogatives and Responsibilities ................................................................5

2.D. AFFILIATE STAFF ................................................................................................6 2.D.1. Qualifications ...............................................................................................6 2.D.2. Prerogatives and Responsibilities ................................................................6

2.E. COVERAGE STAFF ...............................................................................................7 2.E.1. Qualifications ...............................................................................................7 2.E.2. Prerogatives and Responsibilities ................................................................7

2.F. EMERITUS STAFF.................................................................................................8

2.F.1. Qualifications ...............................................................................................8 2.F.2. Prerogatives and Responsibilities ................................................................8

2.G. ADVANCED PRACTICE PROFESSIONAL STAFF ...........................................8 2.G.1. Qualifications ...............................................................................................8 2.G.2. Prerogatives and Responsibilities ................................................................8

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3. OFFICERS .........................................................................................................................9

3.A. DESIGNATION ......................................................................................................9 3.B. ELIGIBILITY CRITERIA .......................................................................................9 3.C. DUTIES .................................................................................................................10

3.C.1. Chief of Staff ..............................................................................................10 3.C.2. Chief of Staff-Elect ....................................................................................10 3.C.3. Immediate Past Chief of Staff ....................................................................11 3.C.4. Secretary-Treasurer ....................................................................................11

3.D. NOMINATIONS ...................................................................................................11 3.E. ELECTION ............................................................................................................11 3.F. TERM OF OFFICE................................................................................................12 3.G. REMOVAL ............................................................................................................12 3.H. VACANCIES .........................................................................................................12

4. STAFF DEPARTMENTS ...............................................................................................13 4.A. ORGANIZATION .................................................................................................13 4.B. ASSIGNMENT TO DEPARTMENT....................................................................13 4.C. FUNCTIONS OF DEPARTMENTS .....................................................................13 4.D. QUALIFICATIONS OF DEPARTMENT CHAIRPERSONS .............................13 4.E. APPOINTMENT AND REMOVAL OF DEPARTMENT CHAIRPERSONS ......................................................................14 4.F. DUTIES OF DEPARTMENT CHAIRPERSONS ................................................15 4.G. SECTIONS ............................................................................................................16

4.G.1. Functions of Sections .................................................................................16 4.G.2. Qualifications and Selection of Section Chiefs .........................................16 4.G.3. Duties of Section Chiefs ............................................................................16

5. MEDICAL STAFF COMMITTEES AND PERFORMANCE IMPROVEMENT FUNCTIONS ...................................................17

5.A. MEDICAL STAFF COMMITTEES AND FUNCTIONS ....................................17 5.B. APPOINTMENT OF COMMITTEE CHAIRPERSONS AND MEMBERS ..................................................................................................17 5.C. MEETINGS, REPORTS AND RECOMMENDATIONS ....................................17 5.D. MEDICAL EXECUTIVE COMMITTEE .............................................................17

5.D.1. Composition ...............................................................................................17 5.D.2. Duties .........................................................................................................18 5.D.3. Meetings .....................................................................................................19

5.E. PERFORMANCE IMPROVEMENT FUNCTIONS ............................................19 5.F. CREATION OF STANDING COMMITTEES .....................................................20 5.G. SPECIAL COMMITTEES ....................................................................................20

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6. MEETINGS ......................................................................................................................21

6.A. MEDICAL STAFF YEAR ....................................................................................21 6.B. MEDICAL STAFF MEETINGS ...........................................................................21

6.B.1. Regular Meetings .......................................................................................21 6.B.2. Special Meetings ........................................................................................21

6.C. DEPARTMENT AND COMMITTEE MEETINGS .............................................21 6.C.1. Regular Meetings .......................................................................................21 6.C.2. Special Meetings ........................................................................................21

6.D. PROVISIONS COMMON TO ALL MEETINGS ................................................21 6.D.1. Notice of Meetings .....................................................................................21 6.D.2. Quorum and Voting ...................................................................................22 6.D.3. Agenda .......................................................................................................22 6.D.4. Rules of Order ............................................................................................22 6.D.5. Minutes, Reports, and Recommendations .................................................23 6.D.6. Confidentiality ...........................................................................................23 6.D.7. Attendance Requirements ..........................................................................23

7. INDEMNIFICATION .....................................................................................................24 8. BASIC STEPS AND DETAILS ......................................................................................25

8.A. QUALIFICATIONS FOR APPOINTMENT ........................................................25 8.B. PROCESS FOR PRIVILEGING ...........................................................................25 8.C. PROCESS FOR CREDENTIALING (APPOINTMENT AND REAPPOINTMENT) .....................................................25 8.D. DISASTER PRIVILEGING ..................................................................................26 8.E. INDICATIONS AND PROCESS FOR AUTOMATIC RELINQUISHMENT OF APPOINTMENT AND/OR PRIVILEGES .................26 8.F. INDICATIONS AND PROCESS FOR PRECAUTIONARY SUSPENSION ....................................................................26 8.G. INDICATIONS AND PROCESS FOR RECOMMENDING TERMINATION OR SUSPENSION OF APPOINTMENT AND PRIVILEGES OR REDUCTION OF PRIVILEGES ..................................27 8.H. HEARING AND APPEAL PROCESS, INCLUDING PROCESS FOR SCHEDULING AND CONDUCTING HEARINGS AND THE COMPOSITION OF THE HEARING PANEL ............................................27

9. HISTORY AND PHYSICAL EXAMINATIONS .........................................................28 10. AMENDMENTS ..............................................................................................................30

10.A. MEDICAL STAFF BYLAWS ..............................................................................30 10.B. OTHER MEDICAL STAFF DOCUMENTS ........................................................31 10.C. CONFLICT MANAGEMENT PROCESS ............................................................32

11. ADOPTION ......................................................................................................................33 ............................................ APPENDIX A – MEDICAL STAFF CATEGORIES SUMMARY

SarasotaMemorialHospitalMedicalStaffBylawsFebruary19,2019 Page1

ARTICLE1–GENERAL

1.A.DEFINITIONS

ThedefinitionsthatapplytotermsusedinalltheMedicalStaffdocumentsaresetforthintheMedicalStaffCredentialsPolicy.

1.B.TIMELIMITSTimelimitsreferredtointheseBylawsareadvisoryonlyandarenotmandatory,unlessitis expressly stated that a particular right is waived by failing to take action within aspecifiedperiod.

1.C.DELEGATIONOFFUNCTIONS(1) Whena functionundertheseBylaws is tobecarriedoutbyamemberofHospital

management, by a Medical Staff member, or by a Medical Staff committee, theindividual,orthecommitteethroughitschairperson,maydelegateperformanceofthefunctiontoaqualifieddesigneewhoisapractitionerorHospitalemployee(oracommittee of such individuals). Any such designee must treat and maintain allcredentialing, privileging, and peer review information in a strictly confidentialmanner and is bound by all other terms, conditions, and requirements of theMedicalStaffBylawsandrelatedpolicies. Inaddition, thedelegating individualorcommitteeisresponsibleforensuringthatthedesigneeappropriatelyperformsthefunctioninquestion.Anydocumentationcreatedbythedesigneearerecordsofthecommitteethatisultimatelyresponsibleforthereviewinaparticularmatter.

(2) When a Medical Staff member is unavailable or unable to perform a necessary

function, one or more of the Medical Staff Leaders may perform the functionpersonallyordelegateittoanotherappropriateindividual.

1.D.MEDICALSTAFFDUES

(1) Annual Medical Staff dues shall be as recommended by the Medical ExecutiveCommitteeandmayvarybycategory.

(2) Dues shall be payable annually upon request. Failure to pay dues shall result inineligibilitytoapplyforMedicalStaffreappointment.

(3) SignatorytotheHospital’sMedicalStaffaccountshallbe theChiefofStaffandtheSecretary‐Treasurer.


ARTICLE2–CATEGORIESOFTHEMEDICALSTAFF

OnlythoseindividualswhosatisfythequalificationsandconditionsforappointmenttotheMedical Staff contained in theCredentialsPolicyareeligible toapply forappointment tooneofthecategorieslistedbelow.Allcategories,withtherespectiverightsandobligationsofeach,aresummarizedinthechartattachedasAppendixAtotheseBylaws.

2.A.ACTIVESTAFF2.A.1.Qualifications:

The Active Staff shall consist of physicians, dentists, oral surgeons, podiatrists andpsychologistswho:(a) areinvolvedinatleast24patientcontactspertwo‐yearappointmentterm;and(b) are expected to demonstrate a commitment to the Medical Staff and Hospital

throughserviceonHospitalorMedicalStaffcommitteesandactiveparticipationinperformance/qualityimprovementfunctions.

The Active Staff shall also include those administrative physicians as designated by theHospital.Guidelines:Unless an Active Staff member can definitively demonstrate to the satisfaction of theCredentials Committee at the time of reappointment that his/her practice patterns havechangedandthathe/shewillsatisfytheactivityrequirementsofthiscategory:* Any member who has fewer than 24 patient contacts during his/her two‐year

appointment termshallnotbeeligible torequestActiveStaffstatusat the timeofhis/herreappointment;and

** Thememberwill be automatically transferred to another staff category that bestreflectshis/herrelationshiptotheMedicalStaffandtheHospital(options–LimitedActiveorAffiliate).

For purposes of this Article, “patient contacts” means any admission, consultation,procedure,responsetoemergencycall,evaluation,treatment,orserviceperformedinanyfacilityoperatedbytheHospitaloraffiliate,includingoutpatientfacilities.Patientcontactsdo not include requests for diagnostic services from pathology, radiology, or otherdepartmentsoftheHospital.

2.A.2.Prerogatives:ActiveStaffmembersmay:(a) admit patients, consistent with granted privileges or as stated on an individual’s

delineation of privileges, except as otherwise provided in the Bylaws orBylaws‐relateddocuments,oraslimitedbytheBoard;

(b) exercisesuchclinicalprivilegesasaregrantedtothem;(c) hold office, serve as department chairpersons or section chiefs, serve onMedical

Staffcommittees,andserveascommitteechairpersons;and(d) vote in all general and special meetings of the Medical Staff and applicable

department,section,andcommitteemeetings.


2.A.3.Responsibilities:(a) Active Staff membersmust assume all the responsibilities of membership on the

ActiveStaff,including:(1) servingoncommittees,asrequested;(2) providing specialty coverage for the EmergencyDepartment and accepting

referrals from the Emergency Department for follow‐up care of patientstreatedintheEmergencyDepartment;

(3) providingcareforunassignedpatients;(4) participatingintheevaluationofnewmembersoftheMedicalStaff;(5) participating in the professional practice evaluation and performance

improvement processes (including constructive participation in thedevelopmentof clinicalpracticeprotocols andguidelinespertinent to theirmedicalspecialties);

(6) acceptinginpatientconsultations,whenrequested;(7) payinganyrequiredapplicationfees,dues,andassessments;and(8) performingassignedduties.

(b) MembersoftheActiveStaffwhoareatleast60yearsofageorwhohaveservedonthe Active Staff for at least 15 continuous years may request removal fromresponsibility for providing specialty coverage in the EmergencyDepartment andotherrotationalobligations.The department chairperson and section chief shall recommend to the MedicalExecutiveCommitteewhethertogranttheserequestsbasedonneedandtheeffectonothers who serve on the call roster for that specialty. The Medical ExecutiveCommittee’s recommendation shall be subject to final action by the Board. TheMedicalExecutiveCommitteemay require individualswhohavebeen removed fromtheresponsibility forproviding specialtycoverage inaccordancewith thissection toreturn to the call roster if the Medical Executive Committee finds that there areinsufficient Active Staff members in a particular specialty area to perform theseresponsibilities.


2.B.LIMITEDACTIVESTAFF2.B.1.Qualifications:

The Limited Active Staff shall consist of those physicians, dentists, oral surgeons,podiatristsandpsychologistswho:(a) areinvolvedinfewerthan24patientcontactspertwo‐yearappointmentterm;and(b) at the timeof initialappointmentandateachreappointment time thereafter,provide

suchqualitydataandotherinformationasmayberequestedtoassistinanappropriateassessment of current clinical competence and overall qualifications for appointmentandclinicalprivileges(including,butnotlimitedto,informationfromanotherhospital,information from the individual’s office practice, information from managed careorganizations in which the individual participates, and/or receipt of confidentialevaluationformscompletedbyreferring/referredtophysicians).

Guidelines:Unless a Limited Active Staff member can definitively demonstrate to the satisfaction of theCredentialsCommitteeat the timeof reappointment thathis/herpracticepatternshavechangedandthathe/shewillsatisfytheactivityrequirementsofthiscategory:* Anymemberwhohasnopatientcontactsduringhis/hertwo‐yearappointmenttermmust

requestanotherstaffcategorythatbestreflectshis/herrelationshiptotheMedicalStaffandthe Hospital, otherwise he/she shall be automatically transferred to the Affiliate Staffcategory.

** Anymemberwhohasmorethan24patientcontactsduringhis/hertwo‐yearappointmenttermshallbeautomaticallytransferredtotheActiveStaff.

2.B.2.PrerogativesandResponsibilities:

LimitedActiveStaffmembers:(a) mayadmitpatientsandexercisesuchclinicalprivilegesasaregranted;(b) may not hold office or serve as department chairpersons, section chiefs, or

committeechairpersons;(c) maybeinvitedtoserveoncommittees(withvote);(d) mayattendMedicalStaff,department,andsectionmeetings(withoutvote);(e) are generally excused from providing specialty coverage for the Emergency

Departmentforunassignedpatients,but:(1) mustassumethecareofanyoftheirpatientswhopresenttotheEmergency

Department when requested to do so by an Emergency Departmentphysician,

(2) mustacceptreferralsfromtheEmergencyDepartmentforfollow‐upcareoftheirpatientstreatedintheEmergencyDepartment,and

(3) willberequiredtoprovidespecialtycoverageiftheMECfindsthatthereareinsufficient Active Staff members in a particular specialty area to performtheseresponsibilities;

(f) shall cooperate in the professional practice evaluation and performanceimprovementprocesses;and

(g) shallpayanyrequiredapplicationfees,dues,andassessments.


2.C.CONSULTINGSTAFF2.C.1.Qualifications:

TheConsulting Staff shall consist of thosephysicians, dentists, oral surgeons, podiatristsandpsychologistswho:(a) areofrecognizedprofessionalabilityandexpertisewhoprovideaservicethatisnot

available on the Active Staff (should the service become readily available on theActive Staff, the Consulting Staff members would not be eligible to requestcontinued Consulting Staff status at the time of their next reappointments andwould have to transfer to a different staff category if they desire continuedappointment);

(b) provideservicesattheHospitalonlyattherequestofmembersoftheMedicalStaff;and

(c) at the time of initial appointment and at each reappointment time thereafter,providesuchqualitydataandotherinformationasmayberequestedtoassistinanappropriateassessmentofcurrentclinicalcompetenceandoverallqualificationsforappointmentandclinicalprivileges(including,butnotlimitedto,informationfromanotherhospital,informationfromtheindividual’sofficepractice,informationfrommanagedcareorganizations inwhichthe individualparticipates,and/orreceiptofconfidentialevaluationformscompletedbyreferring/referredtophysicians).

Guidelines:Unless a Consulting Staffmember can definitively demonstrate to the satisfaction of theCredentialsCommittee at the timeof reappointment that his/herpractice fitswithin thepurposeofthiscategoryorthathis/herpracticepatternshavechanged,anymemberwhohas more than 24 patient contacts during his/her two‐year appointment term shall beautomaticallytransferredtotheActiveStaffcategory.

2.C.2.PrerogativesandResponsibilities:ConsultingStaffmembers:(a) mayevaluateandtreatpatientsinconjunctionwithothermembersoftheMedical

Staff;(b) maynotadmitpatientstotheHospital;(c) mayexercisesuchclinicalprivilegesasaregranted;(d) may not hold office or serve as department chairpersons, section chiefs, or

committeechairpersons;(e) maybeinvitedtoserveoncommittees(withvote);(f) mayattendMedicalStaff,department,andsectionmeetings(withoutvote);(g) areexcusedfromprovidingspecialtycoveragefortheEmergencyDepartmentand

providingcareforunassignedpatients;(h) shall cooperate in the professional practice evaluation and performance

improvementprocesses;and(i) shallpayanyrequiredapplicationfees,dues,andassessments.


2.D.AFFILIATESTAFF2.D.1.Qualifications:The Affiliate Staff consists of those physicians, dentists, oral surgeons, podiatrists andpsychologistswho:

(a) desiretobeassociatedwith,butwhodonotintendtoestablishaclinicalpracticeat,thisHospitalandmeettheeligibilitycriteriasetforthintheMedicalStaffCredentialsPolicywith the exception of those pertaining to response times, emergency call coverage,coveragearrangements,andeligibilitycriteriaforclinicalprivileges;and(b) have indicatedordemonstratedawillingness to assumeall the responsibilitiesofmembership on the Affiliate Staff as outlined in Section 2.D.2, including providingconsultations to, and providing follow‐up care for, patientswho come to the EmergencyDepartment.

TheprimarypurposeoftheAffiliateStaffistopromoteprofessionalandeducationalopportunities,includingcontinuingmedicaleducation,andtopermittheseindividualstoaccessHospitalservicesfortheirpatientsbyreferralofpatientstoActiveStaffmembersforadmissionandcare.ThegrantofAffiliateStaffappointmentisacourtesyonly,whichmaybeterminatedbytheBoarduponrecommendationoftheMEC,withnorighttoahearingorappeal.

2.D.2.PrerogativesandResponsibilities:

AffiliateStaffmembers:(a) mayattendeducationalactivitiessponsoredbytheMedicalStaffandtheHospital;(b) mayreferpatientstomembersoftheActiveStaffforadmissionand/orcareandreviewthemedicalrecordsandtestresults(viapaperorelectronicaccess)foranysuchpatient;(c) maynotadmitpatients,attendpatients,write inpatientorders,performconsultationsin an inpatient setting, assist in surgery, or otherwise participate in the provision ormanagementofclinicalcaretopatientsattheHospital;(d) maynotexerciseclinicalprivilegesintheHospital;(e) maynotholdofficeorserveasdepartmentchairpersons,sectionchiefs,orcommitteechairpersons;(f) mayattendMedicalStaff,department,andsectionmeetings(withoutvote);(g) maybeinvitedtoserveoncommittees(withvote);(h) may perform history and physical examinations in the office and have those reportsenteredintotheHospital’smedicalrecords;(i) mustprovideconsultationto,andacceptreferralsfrom,theEmergencyDepartmentforfollow‐upcareoftheirpatientstreatedandreleasedfromtheEmergencyDepartment;(j) mayreferpatientstotheHospital’sdiagnosticfacilitiesandordersuchtests;(k) at the timeof initialappointmentandateachreappointment time thereafter,providesuch quality data and other information as may be requested to assist in an appropriateassessment of current clinical competence and overall qualifications for membership(including, but not limited to, information from another hospital, information from theindividual’s office practice, information from managed care organizations in which theindividual participates, and/or receipt of confidential evaluation forms completed byreferring/referredtophysicians);and(l) mustpayanyrequiredapplicationfees,dues,andassessments.


2.E.COVERAGESTAFF2.E.1.Qualifications:

The Coverage Staff shall consist of physicians, dentists, oral surgeons, podiatrists andpsychologistswho:(a) desire appointment to the Medical Staff solely for the purpose of being able to

provide coverage assistance to Active Staff members who are unable to obtaincoveragefromothermembersoftheActiveStaff;

(b) ateachreappointmenttime,providesuchqualitydataandotherinformationasmay

berequestedtoassistinanappropriateassessmentofcurrentclinicalcompetenceandoverallqualificationsforappointmentandclinicalprivileges(including,butnotlimited to, information from another hospital, information from the individual’soffice practice, information from managed care organizations in which theindividual participates, and/or receipt of confidential evaluation forms completedbyreferring/referredtophysicians);

(c) arenotrequiredtosatisfyanydefinedresponsetimerequirements inplaceatthe

Hospital,exceptforthosetimeswhentheyareprovidingcoverage;and(d) agree that their Medical Staff appointment and clinical privileges will be

automatically relinquished,with no right to a hearing or appeal, if their coveragearrangementwiththeActiveStaffmember(s)terminatesforanyreason.

2.E.2.PrerogativesandResponsibilities:

CoverageStaffmembers:(a) whenprovidingcoverageassistanceforanActiveStaffmember,shallbeentitledto

admitand/or treatpatientswhoare the responsibilityof theActiveStaffmemberwho is being covered (i.e., the Active Staffmember’s own patients or unassignedpatients who present through the Emergency Department when the Active Staffmemberisoncall);

(b) mayexercisesuchclinicalprivilegesasaregranted;(c) may not hold office or serve as department chairpersons, section chiefs, or

committeechairpersons;(d) maybeinvitedtoserveoncommittees(withvote);(e) mayattendMedicalStaff,department,andsectionmeetings(withoutvote);(f) shall assume all Medical Staff functions and responsibilities as may be assigned,

including,whereappropriate,careforunassignedpatients,emergencyservicecare,consultation,andteachingassignmentswhencoveringformembersoftheirgrouppracticeorcoveragegroup;and

(g) shallpayanyrequiredapplicantfees,dues,andassessments.


2.F.EMERITUSSTAFF2.F.1.Qualifications:

The Emeritus Staff shall consist of practitioners who are recognized for outstanding ornoteworthy contributions to the medical sciences, or have a record of previouslong‐standingservicetotheHospital,andhaveretiredfromtheactivepracticeofmedicine.

2.F.2.PrerogativesandResponsibilities:EmeritusStaffmembers:(a) maynotconsult,admit,orattendtopatients;(b) maynotexerciseclinicalprivilegesintheHospital;(c) may not hold office or serve as department chairpersons, section chiefs, or

committeechairpersons;(d) maybeappointedtocommittees(withvote);(e) mayattendMedicalStaff,department,andsectionmeetings(withoutvote);(f) are entitled to attend educational programsof theMedical Staff and theHospital;

and(g) arenotrequiredtopayapplicationfees,dues,orassessments,withtheexceptionof

ContinuingMedicalEducationassessments.

2.G.ADVANCEDPRACTICEPROFESSIONALSTAFF2.G.1.Qualifications:

The Advanced Practice Professional Staff consists of licensed independent practitionersandadvanceddependentpractitionerswhoarenotphysiciansbutwhoareauthorizedbylawandbytheHospitaltoprovidepatientcareserviceswithintheHospital.TheAdvancedPractice Professional Staff is not a category of the Medical Staff, but is included in thisArticleoftheBylawsforconvenientreference.

2.G.2.PrerogativesandResponsibilities:AdvancedPracticeProfessionalStaffmembers:(a) mayfunctionintheHospitalaspermittedbytheirlicenseandclinicalprivilegesand

undertheoversightofaSupervisingPhysician,whereapplicable;(b) mayattendapplicabledepartmentmeetings(withoutvote);(c) maybeappointedasmembersofMedicalStaffcommittees(withorwithoutvote,as

determined by the committee chair or as otherwise provided by these Bylaws orBylawsdocuments);

(d) must actively participate in the professional practice evaluation and performance

improvementprocesses;and(e) mustpayapplicablefees,dues,andassessments.


ARTICLE3–OFFICERS3.A.DESIGNATION

Theofficersof theMedicalStaffshallbe theChiefofStaff,ChiefofStaff‐Elect, ImmediatePastChiefofStaff,andSecretary‐Treasurer.

3.B.ELIGIBILITYCRITERIA

Only those members of the Active Staff who satisfy the following criteria initially andcontinuouslyshallbeeligibletoserveasanofficeroftheMedicalStaff.Theymust:(1) be appointed in good standing to the Active Staff, have no suspension, lapse, or

restriction on the exercise of their clinical privileges (other than an automaticrelinquishment for failure to completemedical records as long as themember isreinstated pursuant the Medical Staff Bylaws, Rules, and Regulations regardingmedical record completion), and have served on the Active Staff for at least fiveyears*;

*MembersoftheActiveStaffwhohaveservedforlessthanfiveyearsmaybeappointedwithamajorityvoteapprovalbytheMedicalExecutiveCommittee.ThisprovisiondoesnotapplytotheChiefofStafforChiefofStaff‐Elect.

(2) have no past or pending adverse recommendations concerning Medical Staffappointmentorclinicalprivileges;

(3) not presently be serving as medical staff or corporate officers, Board members,

department chairpersons, or credentials committee chairpersons at any otherhospitalandshallnotsoserveduringtheirtermsofoffice;

(4) bewillingtofaithfullydischargethedutiesandresponsibilitiesoftheposition;(5) have experience in a leadership position, or other involvement in performance

improvementfunctions,foratleasttwoyears;(6) participate in Medical Staff Leadership training as determined by the Medical

Executive Committee or Medical Staff Leaders, and attend continuing educationrelating to Medical Staff Leadership, credentialing, and/or professional practiceevaluationfunctionspriortoorduringthetermoftheoffice;and

(7) havedemonstratedanabilitytoworkwellwithothers.


3.C.DUTIES3.C.1.ChiefofStaff:

TheChiefofStaffshall:(a) actincoordinationandcooperationwithHospitalmanagementinmattersofmutual

concerninvolvingthecareofpatientsintheHospital;(b) receiveandinterpretthepoliciesoftheBoardtotheMedicalStaffandserveasthe

Medical Staff’s representative for clinicalperformanceandmaintenanceofqualitywithrespecttothedelegatedresponsibilitytoprovidemedicalcaretothepatientsoftheHospital;

(c) represent and communicate the views, policies and needs of, and report on the

activitiesof,theMedicalStafftothePresidentandtheBoard;(d) call,presideat,andberesponsiblefortheagendaofallmeetingsoftheMedicalStaff

andtheMedicalExecutiveCommittee;(e) chair the Medical Executive Committee (with vote, as necessary) and the Chiefs’

Council andbeamemberofallotherMedicalStaff committees,exofficio,withoutvote;

(f) promoteadherencetotheBylaws,policies,andRulesandRegulationsoftheMedical

StaffandtothePoliciesandProceduresoftheHospital;(g) recommendMedicalStaffrepresentativestoHospitalcommittees;(h) periodicallyreporttotheMedicalStaffontheproceedingsoftheQualityCommittee

oftheBoard;and(i) perform all functions authorized in all applicable policies, including collegial

interventionstepsoutlinedintheCredentialsPolicy.

3.C.2.ChiefofStaff‐Elect:TheChiefofStaff‐Electshall:(a) assumealldutiesoftheChiefofStaffandactwithfullauthorityasChiefofStaffin

hisorherabsence;(b) serveontheMedicalExecutiveCommitteeandtheChiefs’Council;(c) serveaschairpersonoftheQualityImprovementPatientSafetyCommittee;(d) assumeallsuchadditionaldutiesasareassignedtohimorherbytheChiefofStaff

ortheMedicalExecutiveCommittee;and(e) becomeChiefofStaffuponcompletionofhis/herterm.


3.C.3.ImmediatePastChiefofStaff:TheImmediatePastChiefofStaffshall:(a) serveontheMedicalExecutiveCommitteeandChiefs’Council;(b) serveasanadvisortootherMedicalStaffleadersandcommittees;and(c) assume all such additional duties assigned by the Chief of Staff or the Medical

ExecutiveCommittee.

3.C.4.Secretary‐Treasurer:TheSecretary‐Treasurershall:(a) beresponsibleforprovidingnoticesasspecifiedintheseBylaws;(b) serveontheMedicalExecutiveCommittee;(c) beresponsibleforthecollectionof,accountingfor,anddisbursementsofanyfunds

collected,donated,orotherwiseassessedandpresentintheMedicalStaffFundandreporttotheMedicalStaff;and

(d) assume all such additional duties assigned by the Chief of Staff or the MedicalExecutiveCommittee.

3.D.NOMINATIONSTheChiefs’CouncilshallappointaNominatingCommitteethatwillconveneatameetingandshallsubmittotheMedicalExecutiveCommitteethenamesofoneormorequalifiednomineesfortheoffices of Chief of Staff‐Elect, *Secretary‐Treasurer, and two at‐large members of the *MedicalExecutiveCommittee.NoticeofthenomineesshallbeprovidedtotheMedicalStaffpromptlyandbepostedintheMedicalStafflounge.NominationsmayalsobesubmittedinwritingbypetitionsignedbyatleastfiveActiveStaffmembersatleast30dayspriortotheelection. Inorderforanominationtobeplacedontheballot,thecandidatemustmeetthequalificationsinSection3.B,inthejudgmentoftheChiefs’Council,andbewillingtoserve.Nominationsfromthefloorshallnotbeaccepted.

*Members of the Active Staffwho have served for less than five yearsmay be appointedwith amajority voteapprovalby theMedicalExecutiveCommittee.This provisiondoesnot apply to theChiefofStafforChiefofStaff‐Elect.

3.E.ELECTION

(1) Candidates receiving a majority of votes cast at a Medical Staff meeting shall beelected, subject toBoardconfirmation. Ifnocandidate receivesa simplemajorityvoteon the firstballot, a run‐off election shallbeheldpromptlybetween the twocandidatesreceivingthehighestnumberofvotes.

(2) Inthealternative,atthediscretionoftheMedicalExecutiveCommittee,theelectionshallbebywrittenballot.Ballotsmaybereturnedinperson,bymail,byfacsimile,orbye‐mailballot.AllballotsmustbereceivedinMedicalStaffServicesbythedayoftheelection.Thosewhoreceiveamajorityofthevotescastshallbeelected.


3.F.TERMOFOFFICEOfficersshallserveforatermofoneyearoruntilasuccessoriselected.TheofficershallassumeofficeonthefirstdayoftheMedicalStaffyearfollowingelection,exceptthatanofficerelectedorappointedtofillavacancyassumesofficeimmediately.Eachofficerservesuntiltheendofhisorhertermanduntilasuccessoriselected,unlessheorsheresignsorisremovedfromoffice.3.G.REMOVAL

(1) RemovalofanelectedofficeroramemberoftheMedicalExecutiveCommitteemaybeeffectuatedbyatwo‐thirdsvoteoftheActiveStaff,orbyatwo‐thirdsvoteoftheMedicalExecutiveCommittee,orbytheBoard.Groundsforremovalshallbe:

(a) failuretocomplywithapplicablepolicies,Bylaws,orRulesandRegulations;(b) failure toremain ingoodstandingon theMedicalStaff, includingbeing the

subjectofanadverserecommendationpursuanttotheCredentialsPolicy,orhavingautomaticallyrelinquishedprivilegespursuanttothatPolicy;

(c) failuretoperformthedutiesofthepositionheld;(d) conductdetrimentaltotheinterestsoftheHospitaland/oritsMedicalStaff;

or(e) an infirmity that renders the individual incapable of fulfilling the duties of

thatoffice.

(2) Atleast10dayspriortotheinitiationofanyremovalaction,theindividualshallbegivenwrittennoticeofthedateofthemeetingatwhichactionistobeconsidered.The individual shall be afforded an opportunity to speak to the Active Staff, theMedicalExecutiveCommittee,ortheBoardpriortoavoteonremoval.

3.H.VACANCIES

AvacancyintheofficeofChiefofStaffshallbefilledbytheChiefofStaff‐Elect,whoshallserveuntiltheendoftheChiefofStaff’sunexpiredterm.AvacancyintheofficeofChiefofStaff‐Elect shall be filled by the Secretary‐Treasurer. In the event there is a vacancy inanotheroffice,theMedicalExecutiveCommitteeshallappointanindividualtofilltheoffice.The acting officer/representative serves pending the outcome of a special election to beconducted as expeditiously as possible, provided that the Medical Executive Committeemaydecidenot tocallaspecialelection if theregularelection for theoffice is tobeheldwithin180days.Inthislatterinstance,theactingofficer/representativeservesonlyuntilsucceededbythenewlyelectedofficer.


ARTICLE4–STAFFDEPARTMENTS4.A.ORGANIZATION

(1) TheMedicalStaffshallbeorganizedintothedepartmentsandsectionsas listedintheOrganizationManual.

(2) Subjecttotheapprovalof theBoard, theMedicalExecutiveCommitteemaycreate

new departments, eliminate departments, create sections within departments, orotherwisereorganizethedepartmentstructure.

4.B.ASSIGNMENTTODEPARTMENT

(1) Upon initialappointment to theMedicalStaff,eachmembershallbeassignedtoaclinicaldepartment. Assignment to aparticulardepartmentdoesnotprecludeanindividual from seeking and being granted clinical privileges typically associatedwithanotherdepartment.

(2) Anindividualmayrequestachangeindepartmentassignmenttoreflectachangein

theindividual’sclinicalpractice.

4.C.FUNCTIONSOFDEPARTMENTS

The departments shall be organized for the purpose of implementing processes (i)tomonitorandevaluatethequalityandappropriatenessofthecareofpatientsservedbythedepartments; (ii) to monitor the practice of all those with clinical privileges in a givendepartmentassetby thespecialty;and(iii) toprovideappropriatespecialtycoverage inthe Emergency Department, consistent with the provisions in these Bylaws and relateddocuments.

4.D.QUALIFICATIONSOFDEPARTMENTCHAIRPERSONS

Eachdepartmentchairpersonshall:(1) beanActiveStaffmember;(2) becertifiedbyanappropriatespecialtyboardorpossesscomparablecompetence,

asdeterminedthroughthecredentialingandprivilegingprocess;and(3) satisfytheeligibilitycriteriainSection3.B*.*MembersoftheActiveStaffwhohaveservedforlessthanfiveyearsmaybeappointedwithamajorityvoteapprovalbytheMedicalExecutiveCommittee.ThisprovisiondoesnotapplytotheChiefofStafforChiefofStaff‐Elect.


4.E.APPOINTMENTANDREMOVALOFDEPARTMENTCHAIRPERSONS

(1) Departmentchairpersons(orchairpersons‐electifappropriate)shallbeselectedbythedepartment,subjecttoBoardconfirmation.Anominatingcommittee,appointedby the current department chairperson and the Chief of Staff, shall nominatequalified candidates. The election shall be by written ballot. Ballots may bereturned in person, bymail, by facsimile, or by e‐mail ballot. All ballotsmust bereceived inMedicalStaffServicesby thedayof theelection. Thosewhoreceiveamajorityofthevotescastshallbeelected.

(2) Thedepartmentchairperson‐electassumesthepositionofdepartmentchairperson

at the conclusion of the current department chairperson’s term. A departmentchairpersonshall servea termof twoyearsoruntil a successor is elected. Thereshallbenolimitationonthenumberoftermsdepartmentchairpersonsmayserve.

(3) Anydepartmentchairpersonmayberemovedbyatwo‐thirdsmajorityvoteofthe

department members, or by a two‐thirds majority vote of the Medical ExecutiveCommittee,orbytheBoard.Groundsforremovalshallbe:

(a) failuretocomplywithapplicablepolicies,Bylaws,orRulesandRegulations;(b) failure toremain ingoodstandingon theMedicalStaff, includingbeing the

subjectofanadverserecommendationpursuanttotheCredentialsPolicy,orhavingautomaticallyrelinquishedprivilegespursuanttothatPolicy;

(c) failuretoperformthedutiesofthepositionheld;(d) conductdetrimentaltotheinterestsoftheHospitaland/oritsMedicalStaff;

or(e) an infirmity that renders the individual incapable of fulfilling the duties of

thatoffice.

(4) Prior to the initiation of any removal action, the individual shall be givenwrittennoticeofthedateofthemeetingatwhichsuchactionshallbetaken,atleast10dayspriortothedateofthemeeting.Theindividualshallbeaffordedanopportunitytospeak to the department or Medical Executive Committee or the Board, asapplicable,priortoavoteonsuchremoval.


4.F.DUTIESOFDEPARTMENTCHAIRPERSONSEachdepartmentchairpersonisaccountableforthefollowing:(1) allclinically‐relatedactivitiesofthedepartment;

(2) alladministratively‐relatedactivitiesofthedepartment,unlessotherwiseprovidedforbytheHospital;

(3) continuing surveillance of the professional performance of all individuals in thedepartmentwhohavedelineatedclinicalprivileges;

(4) recommendingcriteriaforclinicalprivilegesthatarerelevanttothecareprovidedinthedepartment;

(5) evaluatingrequestsforclinicalprivilegesforeachmemberofthedepartment;

(6) enforcementoftheMedicalStaffBylawsandallapplicableRulesandRegulationsinthedepartment;

(7) assessingand recommendingoff‐site sources forneededpatient care servicesnotprovidedbythedepartmentortheHospital;

(8) theintegrationofthedepartmentintotheprimaryfunctionsoftheHospital;

(9) the coordination and integration of interdepartmental and intradepartmentalservices;

(10) the development and implementation of policies and procedures that guide andsupporttheprovisionofservices;

(11) recommendations for a sufficient number of qualified and competent persons toprovidecareorservice;

(12) determinationof thequalificationsandcompetenceofdepartmentpersonnelwhoprovidepatientcareservices;

(13) continuous assessment and improvement of the quality of care and servicesprovided;

(14) maintenanceofqualitymonitoringprograms,asappropriate;

(15) theorientationandcontinuingeducationofallpersonsinthedepartment;

(16) implementationwithin the department of actions taken by theMedical ExecutiveCommittee;

(17) recommendationsforspaceandotherresourcesneededbythedepartment;

(18) performing all functions authorized in the Credentials Policy, including collegialintervention;and

(19) appointingoneormorevicechairpersonsasdeemednecessary,subjecttoapprovaloftheMedicalExecutiveCommittee.


4.G.SECTIONS4.G.1.FunctionsofSections:

(a) Sectionsmayperformanyofthefollowingactivities:(1) continuingeducation;(2) discussionofpolicy;(3) discussionofequipmentneeds;(4) development of recommendations to the department chairperson and/or the

MedicalExecutiveCommittee;(5) participation in the development of criteria for clinical privileges (when

requestedbythedepartmentchairperson);(6) discussionofaspecificissueatthespecialrequestofadepartmentchairperson

and/ortheMedicalExecutiveCommittee;and(7) monitoring of members (and others at the request of the Medical Executive

Committee)intheperformanceofclinicalresponsibilities.(b) Nominutesorreportswillberequiredreflectingtheactivitiesofsections,exceptwhen

asectionismakingaformalrecommendationtoadepartment,departmentchairperson,CredentialsCommittee,orMedicalExecutiveCommittee.

(c) Sectionsshallnotberequiredtoholdanynumberofregularlyscheduledmeetings.

4.G.2.QualificationsandSelectionofSectionChiefs:(a) Section chiefs shall meet the same qualifications as department chairpersons. They

shallbeselectedbythedepartmentchairperson,afterreceivinginputfromthesection.*Membersof theActiveStaffwhohaveserved for less than fiveyearsmaybeappointedwithamajorityvoteapprovalbytheMedicalExecutiveCommittee.ThisprovisiondoesnotapplytotheChiefofStafforChiefofStaff‐Elect.

(b) Theyshallberemovedinthesamemannerasfordepartmentchairpersons,exceptthatthesectionsshallbeinvolvedinsteadofthefulldepartment.

(c) Section chiefs shall serve a term of two years. There shall be no limitation on thenumberoftermstheymayserve.

4.G.3.DutiesofSectionChiefs:Thesectionchiefshallcarryout thedutiesrequestedby thedepartmentchairpersonand/ortheMedicalExecutiveCommittee.Thesedutiesmayinclude:(a) reviewingandreportingonapplicationsforinitialappointmentandclinicalprivileges,

includinginterviewingapplicants;(b) reviewing and reporting on applications for reappointment and renewal of clinical

privileges;(c) participationinthedevelopmentofcriteriaforclinicalprivileges;(d) reviewing and reporting on the professional performance of individuals practicing

withinthesection;(e) implementation and supervision of, in cooperation with the department chairperson

and other officials of the staff and Hospital, systems to carry out the qualityimprovementfunctionsassignedtothesection;

(f) participation, as applicable, in planning with respect to the section’s personnel,equipment,facilities,services,andbudget;and

(g) assistanceindeveloping,implementing,supervisingandevaluating,inconjunctionwithotherappropriateofficialsandcommitteesofthestaff,education,research,andtrainingprogramsforsectionmembersandotherinterestedparties.


ARTICLE5–MEDICALSTAFFCOMMITTEESANDPERFORMANCEIMPROVEMENTFUNCTIONS

5.A.MEDICALSTAFFCOMMITTEESANDFUNCTIONS

ThisArticleandtheMedicalStaffOrganizationManualoutlinetheMedicalStaffcommitteesthat carry out peer review and other performance improvement functions that aredelegatedtotheMedicalStaffbytheBoard.

5.B.APPOINTMENTOFCOMMITTEECHAIRPERSONSANDMEMBERS(1) AllcommitteechairpersonsandmembersshallbeappointedbytheChiefs’Council.

CommitteechairpersonsshallbeselectedbasedonthecriteriasetforthinSection3.BoftheseBylaws.

(2) Committee chairpersons andmembers shall be appointed for initial terms of twoyears,butmaybereappointedforadditionalterms.Allappointedchairpersonsandmembers may be removed and vacancies filled by the Chief of Staff at his/herdiscretion.

(3) Where necessary to accomplish a function or task assigned to a committee, thecommittee chairperson may call on outside consultants or special advisors fromclinical specialties or administrative or patient care sourceswith expertise in thesubjectmatterinvolved,afterconsultationwiththePresidentorhisdesignee.

(4) Unless otherwiseprovided, allHospital andadministrative representatives on thecommitteesshallbeappointedbythePresident.Allsuchrepresentativesshallserveonthecommittees,withoutvote.

(5) The Chief of Staff and the President (or their respective designees) shall bemembers,exofficio,withoutvote,onallcommittees.

5.C.MEETINGS,REPORTSANDRECOMMENDATIONS

Unless otherwise indicated, each committeedescribed in theseBylawsor in theMedicalStaff OrganizationManual shall meet as necessary to accomplish its functions and shallmaintain a permanent record of its findings, proceedings, and actions. Each committeeshallmakeatimelywrittenreportaftereachmeetingtotheMedicalExecutiveCommitteeandtoothercommitteesandindividualsasmaybeindicated.

5.D.MEDICALEXECUTIVECOMMITTEE5.D.1.Composition:

(a) TheMedicalExecutiveCommitteeshallincludetheofficersoftheMedicalStaff,thechairperson of each clinical department, the chairperson‐elect of Medicine, thechairperson‐elect of Surgery, three representatives‐at‐large elected from theDepartment of Medicine, three representatives‐at‐large elected from theDepartment of Surgery, and two representatives‐at‐large nominated by theNominatingCommitteeandelectedbytheMedicalStaff.

(b) The President shall be an exofficiomember of theMedical Executive Committee,

withoutvote.


5.D.2.Duties:(a) TheMedicalExecutiveCommitteeisdelegatedtheprimaryauthorityoveractivities

related to the functions of theMedical Staff and for performance improvement ofthe professional services provided by individuals with clinical privileges. ThisauthoritymayberemovedbyamendingtheseBylawsandrelatedpolicies.

(b) TheMedicalExecutiveCommitteeisresponsibleforthefollowing:(1) acting onbehalf of theMedical Staff in the intervals betweenMedical Staff

meetings (the officers are empowered to act in urgent situations betweenMedicalExecutiveCommitteemeetings);

(2) recommendingdirectlytotheBoardonatleastthefollowing:(i) theMedicalStaff’sstructure;(ii) themechanismusedtoreviewcredentialsandtodelineateindividual

clinicalprivileges;(iii) applicantsforMedicalStaffappointment;(iv) delineationsofclinicalprivilegesforeacheligibleapplicant;(v) participation of the Medical Staff in Hospital performance

improvementactivitiesandthequalityofprofessionalservicesbeingprovidedbytheMedicalStaff;

(vi) the mechanism by which Medical Staff appointment may beterminated;

(vii) hearingprocedures;(viii) reports and recommendations from Medical Staff committees,

departments,andothergroups,asappropriate;

(3) consulting with the President on quality‐related aspects of contracts forpatientcareservices;

(4) receiving and acting on reports and recommendations from Medical Staffcommittees, departments, and other groups as appropriate, and makingappropriate recommendations for improvementwhen there are significantdeparturesfromestablishedorexpectedclinicalpracticepatterns;

(5) reviewing (or delegating the review of) quality indicators to ensureuniformityregardingpatientcareservices;

(6) providingleadershipinactivitiesrelatedtopatientsafety;(7) providing oversight in the process of analyzing and improving patient

satisfaction;(8) prioritizingcontinuingmedicaleducationactivities;(9) reviewing, or delegating to the Bylaws Committee the responsibility to

review,atleasteverythreeyears,theBylaws,Policies,RulesandRegulations,and associated documents of the Medical Staff and recommending suchchangesasmaybenecessaryordesirable;

(10) providing and promoting effective liaison among the Medical Staff,Administration,andtheBoard;and

(11) performing such other functions as are assigned to it by theseBylaws, theCredentialsPolicy,theBoardorotherapplicablepolicies.


5.D.3.Meetings:The Medical Executive Committee shall meet as often as necessary to fulfill itsresponsibilities,ondatesandattimesestablishedbytheChiefofStaff,andshallmaintainapermanentrecordofitsproceedingsandactions.

5.E.PERFORMANCEIMPROVEMENTFUNCTIONS(1) The Medical Staff is actively involved in performance improvement functions,

including reviewing data and recommending and implementing processes toaddressthefollowing:(a) patient safety, includingprocesses to respond topatient safetyalerts,meet

patientsafetygoalsandreducepatientsafetyrisks;(b) theHospital’sandindividualpractitioners’performanceonJointCommission

andCMScoremeasures;(c) medicalassessmentandtreatmentofpatients;(d) utilizeperformancedataincredentialingandprivilegingactivities;(e) medication usage, including review of significant adverse drug reactions,

medicationerrorsandtheuseofexperimentaldrugsandprocedures;(f) theutilizationofbloodandbloodcomponents,includingreviewofsignificant

transfusionreactions;(g) operative and other procedures, including tissue review and review of

discrepanciesbetweenpre‐operativeandpost‐operativediagnoses;(h) appropriatenessofclinicalpracticepatterns;(i) significantdeparturesfromestablishedpatternsofclinicalpractice;(j) educationofpatientsandfamilies;(k) coordination of care, treatment and services with other practitioners and

Hospitalpersonnel;(l) accurate,timelyandlegiblecompletionofmedicalrecords;(m) theuseofdevelopedcriteriaforautopsies;(n) sentinelevents,includingrootcauseanalysesandresponsestounanticipated

adverseevents;(o) nosocomialinfectionsandthepotentialforinfection;(p) unnecessaryproceduresortreatment;(q) appropriateresourceutilization;(r) the required content and quality of history and physical examinations, as

well as time frames required for completion, all of which are set forth inArticle9oftheseBylaws;

(s) review of findings from the ongoing and focused professional practiceevaluationsactivitiesthatarerelevanttoanindividual’sperformance;and

(t) communication of findings, conclusions, recommendations, and actions toimproveperformancetoappropriateMedicalStaffmembersandtheBoard.

(2) A description of the committees that carry out systematic monitoring and

performance improvement functions, including their composition, duties, andreportingrequirements,iscontainedintheMedicalStaffOrganizationManual.


5.F.CREATIONOFSTANDINGCOMMITTEESIn accordance with the amendment provisions in the Organization Manual, the MedicalExecutive Committee may, by resolution and upon approval of the Board and withoutamendmentoftheseBylaws,establishadditionalcommitteestoperformoneormorestafffunctions. In the same manner, the Medical Executive Committee may dissolve orrearrange committee structure, duties, or composition as needed to better accomplishMedicalStaff functions. AnyfunctionrequiredtobeperformedbytheseBylawswhichisnot assigned to an individual, a standing committee, or a special task force shall beperformedbytheMedicalExecutiveCommittee.

5.G.SPECIALCOMMITTEESSpecial committees shall be created and their members and chairpersons shall beappointed by the Chief of Staff. Such committees shall confine their activities to thepurpose for which they were appointed and shall report to the Medical ExecutiveCommittee.


ARTICLE6–MEETINGS6.A.MEDICALSTAFFYEAR

TheMedicalStaffyearisNovember1toOctober31.

6.B.MEDICALSTAFFMEETINGS6.B.1.RegularMeetings:

TheMedicalStaffshallmeetatleastonceayear.

6.B.2.SpecialMeetings:Specialmeetings of theMedical Staffmay be called by the Chief of Staff or theMedicalExecutiveCommittee,orbyapetitionsignedbynotlessthan25%oftheActiveStaff.

6.C.DEPARTMENTANDCOMMITTEEMEETINGS6.C.1.RegularMeetings:

ExceptasotherwiseprovidedintheseBylawsorintheMedicalStaffOrganizationManual,eachdepartmentandstandingcommitteeshallmeetatleastquarterly,attimessetbythepresidingofficer.

6.C.2.SpecialMeetings:A special meeting of any department, section, or committeemay be called by or at therequestofthepresidingofficerortheChiefofStaff,orbyapetitionsignedbynotlessthanone‐fourthoftheActiveStaffmembersofthedepartment,section,orcommittee,butnotbyfewerthantwomembers.

6.D.PROVISIONSCOMMONTOALLMEETINGS6.D.1.NoticeofMeetings:

(a) Medical Staff members shall be provided notice of all regular meetings of theMedicalStaffandregularmeetingsofdepartments,sections,andcommitteesatleasttwoweeksinadvanceofthemeetings.Noticemayalsobeprovidedbypostinginadesignatedlocationatleasttwoweekspriortothemeetings.Allnoticesshallstatethedate,time,andplaceofthemeetings.

(b) When a special meeting of the Medical Staff, a department, a section, and/or a

committeeiscalled,alloftheprovisionsinparagraph(a)shallapplyexceptthatthenoticeperiodshallbereducedto48hours(i.e.,mustbegivenatleast48hourspriortothespecialmeeting).Postingmaynotbethesolemechanismusedforprovidingnotice for specialmeetings. All persons entitled to notice shall be sent notice bymail,facsimile,ore‐mail.

(c) The attendance of any individual at anymeeting shall constitute awaiver of that

individual’sobjectiontothenoticegivenforthemeeting.


6.D.2.QuorumandVoting:(a) Foranyregularorspecialmeetingof theMedicalStaff,department,orcommittee,

thosevotingmemberspresent(butnotfewerthantwo)shallconstituteaquorum.Exceptionstothisgeneralruleareasfollows:

(1) formeetingsof theMedicalExecutiveCommittee, theCPE, and theChiefs’

Council,thepresenceofatleast40%ofthevotingmembersofthecommitteeshallconstituteaquorum;and

(2) for amendments to these Medical Staff Bylaws, at least 10% of the voting

staffshallconstituteaquorum.

(b) Once a quorum is established, the business of the meeting may continue and allactionstakenshallbebinding.

(c) Recommendations and actions of theMedical Staff, departments, and committees

shallbebyconsensus.Intheeventitisnecessarytovoteonanissue,thatissuewillbedeterminedbyamajority voteof those individualspresent. Votingmaybebywrittenballotatthediscretionofthepresidingofficer.

(d) ThevotingmembersoftheMedicalStaff,adepartment,oracommitteemayalsobe

presentedwithaquestionbymail,facsimile,e‐mail,handdelivery,websiteposting,or telephone and their votes returned to the presiding officer by the methoddesignatedinthenotice.ExceptforamendmentstotheseBylaws(whichrequirea10%quorum) and actions by theMedical Executive Committee, the CPE, and theChiefs’ Council (which require a 40% quorum), a quorum for purposes of thesevotesshallbethenumberofresponsesreturnedtothepresidingofficerbythedateindicated.Thequestionraisedshallbedeterminedintheaffirmativeifamajorityoftheresponsesreturnedhassoindicated.

(e) At thediscretionof thepresidingofficer,oneormoreMedicalStaffmembersmay

participateinameetingbyelectronicmeans.

6.D.3.Agenda:

ThepresidingofficerforthemeetingshallsettheagendaforanyregularorspecialmeetingoftheMedicalStaff,department,section,orcommittee.

6.D.4.RulesofOrder:

ThelatesteditionofRobert’sRulesofOrdermaybeusedforreferenceatallmeetingsandelections,butshallnotbebinding. SpecificprovisionsoftheseBylaws,andMedicalStaff,department, section, or committee custom, shall prevail at all meetings. The presidingofficershallhavetheauthoritytoruledefinitivelyonallmattersofprocedure.


6.D.5.Minutes,Reports,andRecommendations:

(a) Minutes of all meetings of the Medical Staff, departments, and committees (andapplicable section meetings) shall be prepared and shall include a record of theattendance of members and the recommendations made and the votes taken oneach matter. The minutes shall be authenticated by the secretary or presidingofficer.

(b) Asummaryofall recommendationsandactionsof theMedicalStaff,departments,

sections,andcommitteesshallbetransmittedtotheMedicalExecutiveCommitteeand President. The Board shall be kept apprised of the recommendations of theMedicalStaffanditsdepartments,sections,andcommittees.

(c) ApermanentfileoftheminutesofallmeetingsshallbemaintainedbytheHospital.

6.D.6.Confidentiality:

MembersoftheMedicalStaffwhohaveaccesstoorarethesubjectsofcredentialingand/orpeer review information agree to maintain the confidentiality of this information.Credentialingandpeerreviewdocuments,andinformationcontainedtherein,mustnotbedisclosed to any individual not involved in the credentialing or peer review processes.MedicalStaff leadersmaybeasked tosignastatementconfirming theircompliancewiththisconfidentialityrequirement.Abreachofconfidentialitymayresultintheimpositionofdisciplinaryaction.

6.D.7.AttendanceRequirements:

(a) Attendance at meetings of the Medical Executive Committee and the CredentialsCommitteeisrequired.Allmembersarerequiredtoattend75%ofallregularandspecial meetings of these committees. Failure to attend the required number ofmeetings may result in replacement of the member. Excused absences will beallowed.

(b) Forallothermeetings(MedicalStaff,departments,sections,andcommittees),each

ActiveStaffmemberisexpectedtoattendandparticipate.


ARTICLE7–INDEMNIFICATION

TheresolutionoractionoftheBoard,andnottheseMedicalStaffBylaws,shallgoverntheindemnityofMedicalStaffmembersandothersinvolvedinMedicalStaffaffairs.The Medical Staff and the Medical Staff Bylaws serve to enable the Board to providemedical service to the greater Sarasota community. In light of the functions which theMedicalStaffanditscommitteesperformonbehalfoftheBoard,theyandtheirmemberswillbeindemnifiedbytheBoardforallpeerreviewandrelatedactionsasprovidedintheBoardresolutionpassedonDecember13,1982andreaffirmedonDecember20,2004. Itshallbe thedutyof theChiefofStaff tonotify theMedicalStaff timely, inwriting,ofanychanges,amendmentsormodificationstotheBoardresolution.


ARTICLE8–BASICSTEPSANDDETAILS

ThedetailsassociatedwiththefollowingBasicStepsarecontainedintheCredentialsPolicyinamoreexpansiveform.

8.A.QUALIFICATIONSFORAPPOINTMENT

To be eligible to apply for initial appointment or reappointment to theMedical Staff orAdvancedPracticeProfessionalStaff forthegrantofclinicalprivileges,anapplicantmustdemonstrate appropriate education, training, experience, current clinical competence,professionalconduct, licensure,andabilitytosafelyandcompetentlyperformtheclinicalprivilegesrequestedassetforthintheCredentialsPolicy.

8.B.PROCESSFORPRIVILEGING

Requests for privileges are provided to the applicable department chairperson whoreviews the individual’s education, training, and experience and prepares a reportprovidedbyMedicalStaffServicesstatingwhetherthe individualmeetsallqualifications.TheCredentialsCommitteethenreviewsthechairperson’sassessment,theapplication,andallsupportingmaterialsandmakesarecommendationtotheMedicalExecutiveCommittee.The Medical Executive Committee may accept the recommendation of the CredentialsCommittee,refertheapplicationbacktotheCredentialsCommitteeforfurtherreview,orstate specific reasons for disagreement with the recommendation of the CredentialsCommittee.IftherecommendationoftheMedicalExecutiveCommitteetograntprivilegesis favorable, it is forwarded to the Board for final action. If the recommendation of theMedicalExecutiveCommitteeisunfavorable,theindividualisnotifiedbythePresidentoftherighttorequestahearing.

8.C.PROCESSFORCREDENTIALING(APPOINTMENTANDREAPPOINTMENT)

Completeapplicationsareprovidedtotheapplicabledepartmentchairpersonwhoreviewsthe individual’s education, training, and experience and prepares a report provided byMedical Staff Services stating whether the individual meets all qualifications. TheCredentialsCommitteethenreviewsthechairperson’sassessment,theapplication,andallsupportingmaterials andmakesa recommendation to theMedicalExecutiveCommittee.The Medical Executive Committee may accept the recommendation of the CredentialsCommittee,refertheapplicationbacktotheCredentialsCommitteeforfurtherreview,orstate specific reasons for disagreement with the recommendation of the CredentialsCommittee. If the recommendation of the Medical Executive Committee to grantappointmentorreappointmentisfavorable,itisforwardedtotheBoardforfinalaction.IftherecommendationoftheMedicalExecutiveCommitteeisunfavorable, theindividual isnotifiedbythePresidentoftherighttorequestahearing.


8.D.DISASTERPRIVILEGINGWhen thedisasterplanhasbeen implemented, thePresident,CMO,orChiefofStaffmayuse amodified credentialing process to grant disaster privileges after verification of thevolunteer’sidentityandlicensure.

8.E.INDICATIONSANDPROCESSFORAUTOMATICRELINQUISHMENT OFAPPOINTMENTAND/ORPRIVILEGES

(1) Appointment and clinical privileges may be automatically relinquished if anindividual:(a) failstodoanyofthefollowing:

(i) timelycompletemedicalrecords;(ii) satisfythresholdeligibilitycriteria;(iii) providerequestedinformation;(iv) completeand/orcomplywitheducationalortrainingrequirements;(v) attendaspecialconferencetodiscussissuesorconcerns;or(vi) timelypaydues;

(b) ischarged,indicted,convicted,orpleadedguiltyornocontestpertainingtoadefinedcriminalactivityasdefinedmorefullyintheCredentialsPolicy;

(c) makesamisstatementoromissiononanapplicationform;(d) remains absent on leave for longer than one year, unless an extension is

grantedbythePresident;or(e) inthecaseofanAdvancedPracticeProfessionalStaff,fails,foranyreason,to

maintain an appropriate supervision relationship with a SupervisingPhysician.

(2) Automaticrelinquishmentshalltakeeffectimmediatelyandshallcontinueuntilthematterisresolved,ifapplicable.

8.F.INDICATIONSANDPROCESSFORPRECAUTIONARYSUSPENSION

(1) Wheneverfailuretotakeactionmayresultinimminentdangertothehealthand/orsafety of any individual, the Medical Executive Committee, the Chief of Staff, thechairperson of a clinical department, the CMO, or the President is authorized tosuspend or restrict all or any portion of an individual’s clinical privileges as aprecautionpendinganinvestigation.

(2) AprecautionarysuspensioniseffectiveimmediatelyandwillremainineffectunlessitismodifiedbythePresidentortheMedicalExecutiveCommittee.

(3) Theindividualshallbeprovidedabriefwrittendescriptionofthereason(s)fortheprecautionarysuspension.

(4) TheMedicalExecutiveCommitteewillreviewthereasonsforthesuspensionwithinareasonabletimeunderthecircumstances,nottoexceed29days.

(5) Prior to, or as part of, this review, the individualmaybe given an opportunity tomeetwiththeMedicalExecutiveCommittee.


8.G.INDICATIONSANDPROCESSFORRECOMMENDINGTERMINATION ORSUSPENSIONOFAPPOINTMENTANDPRIVILEGES ORREDUCTIONOFPRIVILEGES

Following an investigation or a determination that there is sufficient information uponwhich to base a recommendation, the Medical Executive Committee may recommendsuspension or revocation of appointment or clinical privileges based on concerns about(1)clinical competenceorpractice; (2) safetyorproper carebeingprovided topatients;(3)violationof ethical standardsor theBylaws,policies, orRules andRegulationsof theHospitalortheMedicalStaff;or(4)conductthatislowerthanthestandardsoftheHospitalor itsMedicalStafforisdisruptivetotheorderlyoperationoftheHospitalor itsMedicalStaff.

8.H.HEARINGANDAPPEALPROCESS,INCLUDINGPROCESSFOR SCHEDULINGANDCONDUCTINGHEARINGSANDTHE COMPOSITIONOFTHEHEARINGPANEL

(1) Thehearingwillbeginnosoonerthan30daysafterthenoticeofthehearing,unlessanearlierdateisagreeduponbytheparties.

(2) TheHearingPanelwillconsistofatleastthreemembersortherewillbeaHearingOfficer.

(3) The hearing process will be conducted in an informal manner; formal rules ofevidenceorprocedurewillnotapply.

(4) Astenographicreporterwillbepresenttomakearecordofthehearing.(5) Bothsideswillhavethefollowingrights,subjecttoreasonablelimitsdeterminedby

the Presiding Officer: (a) to call and examine witnesses, to the extent they areavailableandwilling to testify; (b) to introduceexhibits; (c) to cross‐examineanywitnessonanymatterrelevanttotheissues;(d)tohaverepresentationbycounselwho may call, examine, and cross‐examine witnesses and present the case; and(e)tosubmitproposedfindings,conclusions,andrecommendationstotheHearingPanelintheformofapost‐hearingstatementsubmittedatthecloseofthehearing.

(6) Thepersonalpresenceoftheaffectedindividualismandatory.Iftheindividualwhorequestedthehearingdoesnottestify,heorshemaybecalledandquestioned.

(7) The Hearing Panel may question witnesses, request the presence of additionalwitnesses,and/orrequestdocumentaryevidence.

(8) TheaffectedindividualandtheMedicalExecutiveCommitteemayrequestanappealoftherecommendationsoftheHearingPaneltotheBoard.


ARTICLE9–HISTORYANDPHYSICALEXAMINATIONS

(a) GeneralDocumentationRequirements(1) Acompletemedicalhistoryandphysicalexaminationmustbeperformedand

documentedinthepatient’smedicalrecordwithin24hoursafteradmissionor registration (but in all cases prior to surgery or an invasive procedurerequiring anesthesia services) by an individual who has been grantedprivilegesbytheHospitaltoperformhistoriesandphysicals.

(2) The scope of themedical history and physical examinationwill include, as

pertinent: patientidentification; chiefcomplaint; historyofpresentillness; reviewofsystems; personalmedicalhistory,includingmedicationsandallergies; familymedicalhistory; socialhistory,includinganyabuseandneglect; physical examination, to include pertinent findings in those organ

systems relevant to the presenting illness and to co‐existingdiagnoses;

datareviewed; assessment,includingproblemlist; planoftreatment;and if applicable, signs of abuse, neglect, addiction, or

emotional/behavioral disorder, which shall be specificallydocumentedinthephysicalexamination,andanyneedforrestraintorseclusionwhichwillbedocumentedintheplanoftreatment.

(3) Inthecaseofapediatricpatient,thehistoryandphysicalexaminationreport

mustalso include: (i)developmentalage;(ii) lengthorheight; (iii)weight;(iv)headcircumference(ifappropriate);and(v)immunizationstatus.

(b) IndividualsWhoMayPerformH&Ps

Thefollowingtypesofpractitionersmaygenerallyperformhistoriesandphysicalsat the Hospital pursuant to appropriately granted Medical Staff appointment orpermissiontopracticeandclinicalprivileges:(1) physicians;(2) podiatrists(inaccordancewiththeMedicalStaffCredentialsPolicy);(3) dentists(inaccordancewiththeMedicalStaffCredentialsPolicy);and(4) appropriatelyprivilegedAdvancedPracticeProfessionals.


(c) H&PsPerformedPriortoAdmission

(1) Anyhistoryandphysicalperformedmorethan30dayspriortoanadmissionorregistrationisinvalidandmaynotbeenteredintothemedicalrecord.

(2) Ifamedicalhistoryandphysicalexaminationhasbeencompletedwithinthe

30‐dayperiodprior to admissionor registration, a durable, legible copyofthisreportmaybeused in thepatient’smedicalrecord. However, in thesecircumstances,thepatientmustalsobeevaluatedwithin24hoursofthetimeofadmission/registrationorpriortosurgery/invasiveprocedure,whichevercomes first,andanupdaterecorded in themedical recordbyan individualwhohasbeengrantedclinicalprivilegestocompletehistoriesandphysicals.

(3) The update of the history and physical examination shall be based on an

examinationof thepatientandmust (i) reflectanychanges in thepatient’scondition since the date of the original history and physical thatmight besignificant for theplanned courseof treatmentor (ii) state that therehavebeennochangesinthepatient’scondition.

(4) In the case of readmission of a patient, all previous records will bemade

availablebytheHospitalforreviewandusebytheattendingphysician.

(d) Cancellations,Delays,andEmergencySituations

(1) When the history and physical examination is not recorded in themedicalrecord before a surgical or other invasive procedure (including, but notlimited to, procedures performed in the operating suites, endoscopy,colonoscopy,bronchoscopy,cardiaccatheterizations,radiologicalprocedureswith sedation, and procedures performed in the Emergency Room), theoperation or procedure will be canceled or delayed until an appropriatehistory and physical examination is recorded in themedical record, unlesstheattendingphysicianstatesinwritingthatanemergencysituationexists.

(2) Inanemergencysituation,whenthereisnotimetorecordeitheracomplete

or a Short Stay history and physical, immediately following the emergencyprocedure, the attending physician is then required to complete anddocumentacompletehistoryandphysicalexamination.

(e) ShortStayDocumentationRequirements

A Short Stay History and Physical Form, approved by the Medical ExecutiveCommittee,maybeutilizedfor(i)ambulatoryorsamedayprocedures,or(ii)shortstayobservationswhichdonotmeetinpatientcriteria.Theseformsshalldocumentthechiefcomplaintorreasonfortheprocedure,therelevanthistoryofthepresentillnessorinjury,andthepatient’scurrentclinicalcondition/physicalfindings.


ARTICLE10–AMENDMENTS10.A.MEDICALSTAFFBYLAWS

(1) Neither the Medical Executive Committee, the Medical Staff, nor the Board shallunilaterallyamendtheseBylaws.

(2) Amendments to these Bylaws may be proposed by the Medical Executive

Committee,bytheBylawsCommittee,orbyapetitionsignedbyatleast10%ofthevotingmembersoftheMedicalStaff.

(3) All proposed bylaws amendments must be reviewed by the Bylaws Committee.

Aftersuchreview,theBylawsCommitteewillforwardtheproposedamendmenttotheMedicalExecutiveCommittee for review.Allproposedamendmentsmustalsobe reviewed by the Medical Executive Committee prior to a vote by the MedicalStaff. TheMedical Executive Committee shall provide notice by reporting on theproposedamendmentseitherfavorablyorunfavorablyatthenextregularmeetingoftheMedicalStafforataspecialmeetingcalledforsuchpurpose. Theproposedamendmentsmaybevoteduponatanymeetingifnoticehasbeenprovidedatleast14 days prior to the meeting. To be adopted, the amendment must receive amajorityofthevotescastbythevotingstaffatthemeeting.

(4) TheMedicalExecutiveCommitteemaypresentproposedamendmentstothevoting

staffbymailballot,e‐mail,orwebsite, tobereturnedtoMedicalStaffServices(orrecordedonthewebsite)bythedateindicatedbytheMedicalExecutiveCommittee.Alongwiththeproposedamendments,theMedicalExecutiveCommitteemay,initsdiscretion,provideawrittenreportonthemeitherfavorablyorunfavorably.Tobeadopted, an amendmentmust receive amajority of the votes cast, so long as theamendmentisvotedonbyatleast10%ofthestaffeligibletovote.Iflessthan10%of the staff eligible to vote cast ballots, the Medical Executive Committee mayrequestare‐ballotinguntilsuchtimeasasufficientnumberofvotesarecast.

(5) TheMedicalExecutiveCommitteeshallhavethepowertoadoptsuchamendments

to these Bylaws which are needed because of reorganization, renumbering, orpunctuation,spellingorothererrorsofgrammarorexpression.

(6) AllamendmentsshallbeeffectiveonlyafterapprovalbytheBoard.(7) IftheBoardhasdeterminednottoacceptarecommendationsubmittedtoitbythe

MedicalExecutiveCommitteeortheMedicalStaff,theMedicalExecutiveCommitteemayrequestaconferencebetweentheofficersoftheBoardandtheofficersoftheMedical Staff. Suchconference shallbe for thepurposeof furthercommunicatingtheBoard’srationale for itscontemplatedactionandpermittingtheofficersoftheMedical Staff todiscuss the rationale for the recommendation. Sucha conferencewillbescheduledbythePresidentwithintwoweeksafterreceiptofarequest forsamesubmittedbytheChiefofStaff.


10.B.OTHERMEDICALSTAFFDOCUMENTS(1) InadditiontotheMedicalStaffBylaws,thereshallbepolicies,proceduresandrulesandregulationsthatshallbeapplicabletoallmembersoftheMedicalStaffandotherindividualswhohavebeengrantedclinicalprivilegesorascopeofpractice.AllMedicalStaffpolicies,proceduresandrulesandregulationsshallbeconsideredanintegralpartoftheMedicalStaffBylaws.

(2) The Credentials Policy addresses the following matters: qualifications for appointment, the process forgranting initial appointment, clinical privileges, reappointment, collegial intervention, the investigation process,automaticrelinquishments,precautionarysuspensions,andtheprocessforhearingsandappeals.

(3) TheMedicalStaffOrganizationManualliststhedepartmentsandsectionsoftheMedicalStaff. TheMedicalStaffOrganizationManualalsocontainsadescriptionofthecommitteesoftheMedicalStaff.

(4) An amendment to the Credentials Policymay bemade by amajority vote of themembers of theMedicalExecutiveCommitteepresentandvotingatanymeetingofthatcommitteewhereaquorumexists,providedthatthewrittenrecommendationsoftheCredentialsCommitteeconcerningtheproposedamendmentsshallhavefirstbeenreceived and reviewed by the Medical Executive Committee. Notice of all proposed amendments to these twodocuments shall be provided to each voting member of the Medical Staff at least 14 days prior to the MedicalExecutiveCommitteemeetingwhenthevoteistotakeplace.AnyvotingmembermaysubmitwrittencommentsontheamendmentstotheMedicalExecutiveCommittee.

(5) AnamendmenttotheMedicalStaffOrganizationManualortheMedicalStaffRulesandRegulationsmaybemadebyamajorityvoteof themembersof theMedicalExecutiveCommitteepresentandvotingatanymeetingofthatcommitteewhereaquorumexists.NoticeofallproposedamendmentstothesetwodocumentsshallbeprovidedtoeachvotingmemberoftheMedicalStaffatleast14dayspriortotheMedicalExecutiveCommitteemeetingwhenthevoteistotakeplace,andanyvotingmembermaysubmitwrittencommentsontheamendmentstotheMedicalExecutiveCommittee.

(6) The Medical Executive Committee and the Board shall have the power to provisionally adopt urgentamendments to the Rules and Regulations that are needed in order to comply with a law or regulation, withoutproviding prior notice of the proposed amendments to the Medical Staff. Notice of all provisionally adoptedamendmentsshallbeprovidedtoeachmemberoftheMedicalStaffassoonaspossible.TheMedicalStaffshallhave14days to reviewandprovide commentson theprovisional amendments to theMedical ExecutiveCommittee. IfthereisnoconflictbetweentheMedicalStaffandtheMedicalExecutiveCommittee,theprovisionalamendmentsshallstand. If there isconflictovertheprovisionalamendments,thentheprocess forresolvingconflictsset forthbelowshallbeimplemented.

(7) All other policies of the Medical Staff may be adopted and amended by a majority vote of the MedicalExecutiveCommittee.Nopriornoticeisrequired.

(8) Amendments toMedical Staff policies andMedical StaffRules andRegulationsmayalso beproposedby apetitionsignedbyatleast10%ofthevotingmembersoftheMedicalStaff.AnysuchproposedamendmentswillbereviewedbytheMedicalExecutiveCommittee,whichmaycommentontheamendmentsbeforetheyareforwardedtotheBoardforitsfinalaction.

(9) AdoptionofandchangestotheCredentialsPolicy,MedicalStaffOrganizationManual,MedicalStaffRulesandRegulations,andotherMedicalStaffpolicieswillbecomeeffectiveonlywhenapprovedbytheBoard.

(10) ThepresentMedicalStaffandDepartmentalRulesandRegulationsoftheHospitalareherebyreadoptedandplacedintoeffectinsofarastheyareconsistentwiththeseBylaws,untilsuchtimeastheyareamendedinaccordancewiththetermsoftheseBylaws.TotheextentanypresentRuleorRegulationisinconsistentwiththeseBylaws,itisofnoforceoreffect.

(11) DepartmentalRulesandRegulationsdevelopedbydepartmentsmustbeapprovedbytheMedicalExecutiveCommitteeandtheBoardbeforetheybecomeeffective.


10.C.CONFLICTMANAGEMENTPROCESS(1) When there is a conflict between the Medical Staff and the Medical Executive

Committeewithregardto:(a) proposedamendmentstotheMedicalStaffRulesandRegulations;(b) anewpolicyproposedoradoptedbytheMedicalExecutiveCommittee;or(c) proposedamendmentstoanexistingpolicythatisundertheauthorityofthe

MedicalExecutiveCommittee,a special meeting of the Medical Staff to discuss the conflict may be called by apetitionsignedbynotlessthan10%ofthevotingmembersoftheMedicalStaff.Theagendaforthatmeetingwillbelimitedtoattemptingtoresolvethedifferencesthatexistwithrespecttotheamendment(s)orpolicyatissue.

(2) If the differences cannot be resolved, the Medical Executive Committee shallforward its recommendations, along with the proposed recommendationspertainingtotheamendmentorpolicyatissueofferedbythevotingmembersoftheMedicalStaff,totheBoardforfinalaction.

(3) Thisconflictmanagementsectionislimitedtothemattersnotedabove.Itisnotto

beusedtoaddressanyotherissue,including,butnotlimitedto,professionalreviewactionsconcerningindividualmembersoftheMedicalStaff.

(4) Nothing in this section is intended to prevent individual Medical Staff members

from communicating positions or concerns related to the adoption of, oramendments to, the Medical Staff Rules and Regulations or other Medical Staffpoliciesdirectly to theBoard. Communication fromMedicalStaffmembers to theBoard will be directed through the President, who will forward the request forcommunication to the Chairperson of the Board. The Presidentwill also providenotificationtotheMedicalExecutiveCommitteebyinformingtheChiefofStaffofallsuch exchanges. The Chairperson of the Board will determine the manner andmethodoftheBoard’sresponsetotheMedicalStaffmember(s).


ARTICLE11–ADOPTION

TheseBylawsareadoptedandmadeeffectiveuponapprovaloftheBoard,supersedingandreplacing any and all previous Medical Staff Bylaws, Rules and Regulations, policies,manualsorHospitalpoliciespertainingtothesubjectmatterthereof.Originallyadoptedby theMedicalStaffonApril16,2009andapprovedby theBoardonApril20,2009.Revised: MedicalExecutiveCommittee–September15,2016

MedicalStaff–October25,2016Board–November22,2016.

Revised: MedicalExecutiveCommittee–December13,2018MedicalStaff–January22,2019Board–February19,2019

4847-0883-8253, v. 5

APPENDIX A

MEDICAL STAFF CATEGORIES SUMMARY

Active Limited Active

Consulting Affiliate Coverage Emeritus

Number of Patient Contacts per two-year period

≥ 24 < 24 NA NA NA NA

Eligible for admitting privileges

Y Y N N Y N

Eligible for clinical privileges

Y Y Y N Y N

FPPE/OPPE required Y Y Y N Y N

Serve as a Medical Staff Officer

Y N N N N N

Serve as a department chairperson or section chief

Y N N N N N

Serve as a committee chairperson

Y N N N N N

Serve on Medical Staff committees (with vote)

Y Y Y Y Y Y

May attend Medical Staff and applicable department and section meetings

Y Y Y Y Y Y

Vote at Medical Staff and applicable department and section meetings

Y N N N N N

Accept Consults/Referrals

Y Y Y Y, from ED

only Y, when covering

N

Emergency Call Responsibilities

Y* Follow-Up

Care N

Follow-Up Care

Y, when covering

N

Y = Yes N = No NA = Not Applicable * Unless an exception is granted based on age/years of service.

medical staff bylaws 2019 - smh.com staff... · 4847-0883-8253, v. 5 sarasota memorial hospital...

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