1 GLACIAL RIDGE HEALTH SYSTEM MEDICAL STAFF BYLAWS February 2016
2 Page 2 of 31 GLACIAL RIDGE HOSPITAL DISTRICT dba GLACIAL RIDGE HEALTH SYSTEM MEDICAL STAFF BYLAWS Index Preamble 3 Definitions 4 Article I: Name 5 Article II: Purpose and Authority 5 Article III: Medical Staff Membership 6 Article IV: Procedure for Appointment, Reappointment & 8 Clinical Privileges Article V: Categories of Medical Staff 12 Article VI: Allied Health Professionals & Practitioners 13 Article VII: Clinical Privileges 14 Article VIII: Telemedicine Services 16 Article IX: Disciplinary Action 17 Article X: Practitioner Impairment 19 Article XI: Organization of Services 20 Article XII: Officers of the Medical Staff 20 Article XIII: Committees 21 Article XIV: Listing of Committees and Staff Functions 21 Article XV: Medical Staff Meetings 24 Article XVI: Medical Staff Rules & Regulations 25 Article XVII: Adoption of the Bylaws 25 Article XVIII: Amendments to the Bylaws 25 Article XIX: Confidentiality and Immunity 25 Article XX: Hearing and Appellate Review Procedures 26
3 Page 3 of 31 BYLAWS OF THE MEDICAL STAFF OF THE GLACIAL RIDGE HEALTH SYSTEM PREAMBLE WHEREAS, the Glacial Ridge Health System is owned by the hospital district, a non-profit corporation organized under the laws of the State of Minnesota; and WHEREAS, its purpose is to serve as a general hospital providing patient care; and WHEREAS, the Medical Staff is responsible for the quality of medical care in the facility, and must accept and discharge this responsibility subject to the ultimate authority of the Governing Board. And that the cooperative efforts of the Medical Staff, the Chief Executive Officer and the Governing Board are necessary to fulfill the hospital s responsibility to its patients; NOW, THEREFORE, the physicians and other licensed individuals authorized by the Governing Board to practice in this hospital, hereby organize themselves into a Medical Staff in conformity with these Bylaws.
4 DEFINITIONS Medical Staff Bylaws Page 4 of Medical Staff means the organized group of practitioners who are privileged to attend to patients in the hospital. Disciplines included are Physicians (M.D. or D.O.), Dentists and Podiatrists. 2. Governing Board means the hospital s Board of Directors. 3. Executive Committee means the executive committee of the Medical Staff. The executive committee can be the active medical staff as a whole. 4. Chief Executive Officer or Administrator is the individual appointed by the Governing Board to act on their behalf in the overall administration of the organization. 5. Practitioner means a fully licensed person permitted by law and by the hospital to provide patient care services independently within the scope of his/her license and who is granted clinical privileges at the hospital. 6. Member means a practitioner appointed to the organized Medical Staff by the Governing Board. 7. Medical Staff Year means the calendar year from January through December. 8. Quality Assurance Program means the hospital wide program designed to objectively and systematically monitor and evaluate the quality and appropriateness of patient care and individual clinical competence in order to resolve identified problems and to pursue opportunities to improve patient care. 9. Allied Health Professionals or AHPs means those individuals who are neither physicians, dentists or podiatrists, but who wish privileges to provide, or assist in providing, direct patient care to Hospital patients. AHPs will exercise judgement within their areas of competence and participate in the management of patients under the direction or supervision of a member of the Medical Staff when appropriate, and will have their privileges, responsibilities and prerogatives designated by the Board upon recommendation of the Medical Executive Committee. Nurse Practitioners, Certified Nurse Midwives, and Certified Registered Nurse Anesthetists may hold an Advanced Practice Registered Nurse (APRN) license which allows them to practice independently of physician supervision as designated by the Board upon recommendation of the Medical Executive Committee. 10. Completed Application shall mean that the form is completely filled out by an applicant for medical staff or clinical privileges, and for which all information has been verified by reliable sources. 11. Quorum shall mean at least 50% of the Active Medical Staff members.
5 Page 5 of 31 ARTICLE I: NAME 1.1 The name of this organization shall be: The Medical Staff of Glacial Ridge Health System hereinafter referred to as the Medical Staff. ARTICLE II: PURPOSE AND AUTHORITY 2.1 The purpose of this organization is: To maintain a qualified Medical Staff whereby all patients treated in any of the facilities, departments, or services of the hospital shall receive quality medical care To provide a high level of professional performance of all members of the Medical Staff through the appropriate delineation of clinical privileges for each practitioner and through ongoing peer review and evaluation of each staff member's or allied health professional's clinical and ethical performance in the Hospital To initiate and maintain rules and regulations for self-government To provide a means of continuing accountability to the Governing Body for delivery of quality health care services and appropriate care in the Hospital To provide a means whereby issues concerning the medical staff and the hospital may be discussed and resolved by representatives of the Medical Staff, Chief Executive Officer and Governing Board To provide an appropriate educational setting that will maintain scientific standards and promote continuous advancement in professional knowledge and skill. 2.2 The authority of the Medical Staff: Subject to the authority and approval of the Governing Body, the Medical Staff shall have and exercise such power as is reasonably necessary to discharge its responsibilities under these Bylaws and under the corporate Bylaws of the Hospital. This includes, without limitation, the authority to establish Medical Staff policies, professional education requirements, clinical coverage requirements, medical malpractice insurance requirements, criteria for the granting of Medical Staff appointment and clinical privileges, attendance requirements, office location, residence and response time requirements and the authority to levy dues and assessments, impose fines and use outside consultants when performing peer review activities.
6 Page 6 of 31 ARTICLE III: MEDICAL STAFF MEMBERSHIP 3.1 Nature of Medical Staff Membership: Membership on the Medical Staff of Glacial Ridge Health System is a privilege, which shall be extended only to licensed, clinically competent practitioners who continuously meet the qualifications, standards, and requirements set forth in these Bylaws Appointment to and membership on the Staff shall confer on the appointee or member only such clinical privileges as have been granted by the Board in accordance with these Bylaws Only members of the Medical Staff shall be allowed to admit patients to the Hospital, unless such admitting privileges are granted on a temporary basis in accordance with the procedures set forth in Article VII, Section Qualifications for Membership: No practitioner shall be entitled to membership in this organization solely because of membership on another hospital staff, because of membership in any professional organization, or because of certification by a specialty board Membership will neither be granted nor denied on the basis of sex, race, creed, color, religion, or national origin, or any other criterion unrelated to the delivery of quality health care in the Hospital, to professional capabilities, to the Hospital's purposes, needs and capabilities, or to community need Applicants for membership shall: a. Provide evidence of their education, training, current competence, physical health status and mental health status (in relation to the clinical privileges requested), and verbal and written English language proficiency with sufficient adequacy to demonstrate to the Medical Staff and the Board that any patient treated by them will receive care of the generally recognized professional level of quality; and b. document current required licensures, to include State licensure and Drug Enforcement Administration licensure numbers; current CALS or ATLS certification if ER privileges are desired; document any previously successful or currently pending challenges to licensure or registration or the voluntary or involuntary relinquishment of such licensure or registration; document voluntary or involuntary termination of Medical Staff membership or voluntary or involuntary limitation, reduction, or loss of privileges at any Hospital; and c. document, with the exception of applicants to the Honorary category of the Medical Staff, evidence of a minimum of $1,000,000 per occurrence /$3,000,000 aggregate (as jointly prescribed by the Medical Staff and Board) of continuous professional liability insurance coverage written by a company authorized to do business in the State of Minnesota; and d. document information concerning any claims alleging malpractice asserted against the applicant prior to applying for appointment as well as information concerning the disposition of such claims and indication of such claims presently pending; and e. be determined, on the basis of documented references, to adhere strictly to the ethics of their respective professions, to work cooperatively with others, and to be willing to participate in the discharge of Staff responsibilities; and f. Sign a statement that they have read, and agree to be bound by the Medical Staff Bylaws and by current hospital policies that apply to their activities as staff members and that are consistent with the organized Medical Staff Bylaws; and g. Agree to abide by the ethical standards of their respective professions.
7 Page 7 of Conditions and Duration of Appointment All initial appointments and all reappointments to the Medical Staff shall be made by the Governing Board, which shall act upon them only after there has been a recommendation from the Medical Staff All initial appointments and all practitioners granted new or additional privileges will be subject to a provisional period of one year. Provisional status may be extended by the Medical Executive Committee for one additional year upon determination of good cause, which determination shall not be subject to the procedural rights under Article XIX. Provisional members shall not be eligible to hold office but may serve on Medical Staff committees and may attend general Medical Staff meeting Reappointment shall be for a two-year period, or until resignation Appointment to the Medical Staff shall confer on the appointee such clinical privileges as have been granted by the Governing Board in accordance with these Bylaws Every application for staff appointment shall be signed by the applicant and shall contain the applicant s specific acknowledgment of his/her obligation to abide by the Medical Staff Bylaws, and the Rules and Regulations. 3.4 Basic Responsibilities of Individuals with Staff Membership or Clinical Privileges Each individual with Staff membership or clinical privileges shall: a. provide patient care at the generally recognized professional level of quality and efficiency. b. retain responsibility within his/her area of professional competence for the continuous care and supervision of each patient in the Hospital for whom he/she is providing services, or arrange a suitable alternative for such care and supervision. c. abide by the Medical Staff Bylaws, Rules and Regulations, and by all other lawful standards, policies and rules of the Hospital. d. discharge such Staff, service, committee and Hospital functions for which he/she is responsible by appointment, election, or otherwise. e. prepare and complete in a timely fashion the medical record and other required records for all patients he/she admits, or in any way provides care to, in the Hospital within time periods required by the Hospital unless otherwise specified in these Bylaws, Rules and Regulations. f. abide by the ethical principles of his/her profession. g. maintain personal medical malpractice insurance coverage as determined by the Hospital. h. inform the Medical Staff and the Board, through the Administrator, in a timely manner, of any changes made or formal action initiated that could result in a change of license, DEA registration, participation in any program or plan for the reimbursement of services, professional liability insurance coverage, membership or employment status or clinical privileges at other health care institutions or affiliations and the status or initiation of malpractice claims. i. satisfy requirements set forth in Article XIX for special appearances. j. comply with continuing education requirements in accordance with State regulations applicable to his/her profession. k. participate as appropriate in the Quality Improvement and other review activities required of the Staff, and in the discharge of other Staff functions as may be required from time to time.
8 Page 8 of 31 ARTICLE IV: PROCEDURE FOR APPOINTMENT, REAPPOINTMENT AND CLINICAL PRIVILEGES 4.1. The Medical Staff through its designated committees and officers shall investigate and consider each application for appointment or reappointment to the Staff and each request for modification of Staff membership status or privileges and shall adopt and transmit recommendations thereon to the Board. The Medical Staff shall perform these same investigations, evaluation and recommendation functions in connection with any Allied Health Professional or other individual; who seeks to exercise privileges or provide specified services in the Hospital whether or not such individual is eligible for staff membership Each application for appointment to the Staff or request for clinical privileges shall be in writing, submitted on the prescribed forms with all provisions completed (or accompanied by acceptable explanations of why answers are unavailable), and signed by the applicant. Application forms shall be developed or adopted by the Medical Executive Committee and approved by the Board. The form shall require detailed information which shall include, but not be limited to, information concerning: a. Acknowledgement and Agreement: A statement that the applicant has had access to or been given the opportunity to read the Bylaws, Rules and Regulations of the Medical Staff and that he/she agrees to be bound by the terms thereof if he/she is granted membership and/or clinical privileges, and to be bound by the terms in all matters relating to consideration of his/her application without regard to whether or not he/she is granted membership and/or clinical privileges. b. Qualifications: Detailed information concerning the applicant's qualifications, including information in satisfaction of the basic qualifications specified in Sections 3.2, and of any additional qualifications specified in these Bylaws for the particular staff category to which the applicant requests appointment or the particular category of Allied Health Professional privileges which the applicant is requesting. c. Requests Identify the clinical privileges for which the applicant wishes to be considered. d. References: Names are required of at least three peer references who have recently (within the last five years) worked with the applicant and directly observed his/her professional performance over a reasonable period of time and who can and will provide reliable information regarding the applicant's current clinical ability, ethical character, and ability to work with others. If the applicant has not previously held staff privileges, one of such references shall be the director of the clinical training program from which he/she graduated. e. Professional Sanctions: Information as to whether any of the following have ever been or are in the process of being voluntarily or involuntarily denied, revoked, suspended, reduced, limited, not renewed, challenged or relinquished: (1) Staff membership status or clinical privileges at any other hospital or health care institution or membership on any health care facility staff (2) Membership/fellowship in local, state or national professional organizations (3) Specialty Board certification/eligibility (4) License to practice any profession in any jurisdiction (5) Drug Enforcement Administration (DEA) number If any such actions ever occurred or are pending, the particulars thereof shall be included.
9 Page 9 of 31 f. Final judgements or settlements, together with pending actions, against the applicant in professional liability actions and current professional liability insurance in such amounts and types as are required by the Hospital. g. Any criminal convictions, involving any felony and any misdemeanor, provided the misdemeanor involved professional activity or a crime of moral turpitude. h. Whatever additional reasonable information the Hospital or the Medical Staff deems relevant. i. Notification of Release and Immunity Provisions: Statements notifying the applicant of the scope and extent of the authorization, confidentiality, immunity, and release provisions of Section and Article XVIII shall be provided By applying for appointment, each applicant signifies his/her willingness to appear for interviews in regard to his/her application; authorizes Glacial Ridge Health System to consult with members of other hospital staffs with which the applicant has been associated and with persons who may have information bearing on his/her competence, character and ethical qualifications; consents to the inspection of all records and documents that may be material to an evaluation of his/her professional qualifications and competence to carry out the requested clinical privileges, as well as any moral and ethical qualifications for staff membership; releases from any liability all individuals who provide information to Glacial Ridge Health System in good faith and without malice concerning the applicant s competence, ethics, character and other qualifications related to appointment and privileges. It shall be the applicant s responsibility to present proof adequate to justify his/her staff status and clinical privileges requested especially concerning the information requested on the application The applicant shall deliver the application to the Chief Executive Officer or designee within 90 days of the date it was mailed. A failure to do so, without good cause, will terminate the application without any procedural rights under Article XIX, and the applicant may not reapply for one year. The Administrator, or designee, shall expeditiously seek to collect or verify the references, licensure, and other qualification evidence submitted in support of the application. The verification process must include, as set forth by the Health Care Quality Improvement Act of 1986, the requesting of information from the National Practitioner Data Bank. The applicant shall be promptly notified of any problem in obtaining the information required, and it shall then be the applicant's obligation to obtain the required information in a timely manner. Failure to do so shall be considered a voluntary withdrawal of the application, which is not subject to the procedural rights otherwise available under Article XIX. When collection and verification of all elements described in Article 3 are accomplished, the application is considered complete. Any deliberate falsification or omission of information on the part of the applicant will result in immediate termination of the review process with a recommendation to the executive committee for disapproval. When the application is complete and verified, the Chief Executive Officer shall forward the application and supporting materials to the Chief of Staff for evaluation Appointment Process After receipt of a completed application, the Chief of Staff shall review the application and supporting documentation. The Chief of Staff shall transmit to the Medical Executive Committee a written recommendation as to appointment and, if appointment is recommended, as to Medical Staff category, clinical privileges to be granted, and any special conditions to be attached.
10 Page 10 of At its next regular meeting, the executive committee shall consider the reports and all other relevant information. The executive committee shall make a written report to the Governing Board, together with recommendations regarding appointment, clinical privileges and staff category. a. When the decision of the Medical Staff is favorable, the Chief Executive Officer shall forward it promptly to the Governing Board. b. When the decision of the Medical Staff is unfavorable, the Chief Executive Officer shall promptly, within three (3) working days, notify the applicant by certified mail. The Chief Executive Officer shall not forward any application with adverse recommendation to the Governing Board until after the applicant has exercised or been considered to have waived his/her right to a hearing as provided in Article XIX of these Bylaws Each recommendation for reappointment and clinical privileges shall be based on the following information, gathered from Quality Improvement and other review activities conducted by the Hospital as required by these Bylaws, and pertinent information concerning clinical performance in care settings where a practitioner exercises the clinical privileges requested. Such information shall include: a. evidence of the applicant's professional ability, clinical judgement, and clinical technical skill in the treatment of patients; b. his or her current licensure as required by the Bylaws; c. his or her current physical and mental health status which reflects an ability, with or without reasonable accommodation, to perform the essential functions of a practitioner within the scope of his/her requested privileges without posing a significant health or safety risk to his/her patients. d. evidence of the required amount of professional liability insurance as required by these Bylaws; e. his or her professional ethics; f. recommendations made by his/her peers; g. his or her discharge of Staff obligations; h. his or her cooperation and ability to work with other practitioners and with patients; i. other matters bearing on his/her ability and willingness to contribute to quality patient care in this Hospital; j. results of National Practitioner Data Bank queries At the next regular meeting of the Governing Board, after all the applicant s rights under Article XIX have been exhausted, the Governing Board shall act on the matter. The Board may accept the recommendation of the Medical Executive Committee or may refer the matter back to the Executive Committee for further consideration, stating the purpose for such referral and setting a time limit within which a subsequent recommendation shall be made. The following procedures shall apply with respect to action on the application: a. If the Board concurs with the recommendation of the Medical Executive Committee, the decision of the Board shall be final.
11 Page 11 of 31 b. If the Board does not concur with the recommendation of the Medical Executive Committee, then the matter shall be referred to a joint conference committee of equal members of the Medical Staff and Board. The joint conference committee shall review the application and provide the Board with its written recommendation within thirty (30) days. Within thirty (30) days of its receipt of the recommendation of the joint conference committee, the Board shall make a decision in writing explaining its rationale. If this decision is adverse to the applicant, the applicant shall then be entitled to procedural rights under Article XIX, if they were not previously exercised in regards to this adverse action Notice of the Board's final decision shall be given, through the Administrator, to the applicant by means of special notice. This notice to appoint, reappoint, or grant privileges shall include: a. the Medical Staff category to which the applicant is appointed; b. the clinical privileges granted; and c. any special conditions attached to the appointment or clinical privileges Reappointment process: At least 90 days prior to the expiration date of the appointment of each Medical Staff member and/or individual with clinical privileges, the Chief Executive Officer or designee, shall mail an application for reappointment and submit an inquiry to the National Practitioner Data Bank. If a reappointment application is not received at least forty-five (45) days prior to the expiration date, written notice by certified mail shall be promptly sent to the Member advising that the application has not been received. The reappointment application form shall include all information necessary to update and evaluate the qualifications of the applicant including, but not limited to, the matters set forth in Section 4.1.1, as well as other relevant matters. The applicant shall submit evidence that the continuing medical education requirements required by the State of Minnesota for licensure have been met. In addition, the Member is required to submit any reasonable evidence of current health status that may be requested by the Medical Executive Committee. All provisions of the reappointment application form must be completed (or accompanied by acceptable explanations of why answers are unavailable) and signed by the applicant. Upon receipt of the application, the information shall be processed as set forth in Article 4, commencing at Section Request for Modification of Membership Status or Clinical Privileges A Medical Staff member who seeks a change in Medical Staff status or modification of clinical privileges may submit such a request at any time on the prescribed form; except that such application may not be filed within six (6) months of the time a similar request has been denied. Such application shall be processed in substantially the same manner as provided in Section 4.2 for reappointment.
12 Page 12 of Extension of Appointment If an application for reappointment has not been fully processed by the expiration date of the Member's appointment and is otherwise in order, the Medical Staff Member shall maintain membership status and clinical privileges until such time as the processing is completed unless the delay is due to the Member's failure to timely complete and return the reappointment application form or provide other documentation, in which case Section applies. Any extension of an appointment pursuant to this Section does not create a vested right in the Member for continued appointment through the entire next term, but only until such time as processing of the application is concluded Failure to File Reappointment Application If a completed application for reappointment and/or renewal of clinical privileges is not received by the end of the current appointment period, a warning notice shall be sent via certified mail to the practitioner stating that if the Member or other individual with clinical privileges fails to submit an application for reappointment and/or renewal of privileges within thirty (30) days past the Reapplication Due Date, the Member shall be deemed to have voluntarily resigned membership in the Medical Staff and/or relinquished clinical privileges effective at the end of the current appointment period; unless membership or privileges are otherwise extended by the Medical Executive Committee with the approval of the Board. In the event membership terminates for the reasons set forth herein, the procedures set forth in Article XIX shall not apply. ARTICLE V: CATEGORIES OF MEDICAL STAFF 5.1. The Staff shall be divided into the following categories: Active, Courtesy, Consulting, Dental and Podiatry, Honorary, and Telemedicine. Allied Health Professionals shall not be considered as a category of the Medical Staff. 5.2 Active Staff The Active Staff shall be considered members who regularly admit patients to the hospital, or who participate in their care. Active Medical Staff must live close enough to the hospital to provide continuous care to their patients. All members of the Active Staff have admitting privileges. Active staff members may vote and hold office and serve as Medical Directors of clinical services. To retain active staff membership, they must attend at least 60% of staff and committee meetings; provide emergency coverage as required in these Bylaws; consult as requested; and cooperate fully with the quality assurance process as needed. 5.3 Courtesy Staff Courtesy staff members are those who admit patients to the hospital on an occasional or infrequent basis; are members of the active staff at another hospital and who otherwise meet the qualifications described in these Bylaws. Courtesy staff members may attend medical staff meetings but may not vote, hold office or serve on committees. Courtesy staff are not required to provide emergency service coverage. Members of the Courtesy staff may have admitting privileges. Courtesy staff who admit more than ten (10) patients per year to the hospital must apply for active staff membership Members of the Courtesy Staff who admit patients or perform on any "on call" basis must live or make suitable temporary living arrangements within a reasonable distance from the Hospital in order to provide continuous care to and supervision of their patients.
13 Page 13 of Consulting Staff Consulting staff are those who come to the hospital on call or on regular scheduled basis, have recognized professional ability (specialties), and who otherwise meet the qualifications described in these Bylaws. Consulting staff must serve on the active staff of another hospital. Members of the Consulting Staff may be granted admitting privileges. Consulting staff who admit more than ten (10) patients per year to the hospital must apply for active staff membership. Consulting staff may attend medical staff meetings without voting privileges, may serve on committees but may not hold office and do not provide emergency service coverage. 5.5 Dental and Podiatry Staff The Dental and Podiatry Staff shall consist of dentists and podiatrists who meet the qualifications described in these Bylaws. Members of the Dental and Podiatry Staff may not admit patients to the hospital; however, they may exercise such clinical privileges as are granted to them pursuant to these Bylaws. They may attend staff meetings or education programs, but are not eligible to vote or hold office. 5.6 Honorary Staff Honorary staff are retired medical staff from our hospital who are recognized for their outstanding contributions to health care in our community. Honorary staff may attend medical staff meetings and serve on committees but do not have voting privileges. They cannot admit patients or hold office. Honorary staff are exempt from the malpractice insurance requirements and all licensing requirements are waived. 5.7 Telemedicine Staff Telemedicine staff are licensed independent practitioners who prescribe, render a diagnosis, or otherwise provide clinical treatment to a patient at the Glacial Ridge Health System (GRHS) through the use of electronic communication or other communication technologies from a distant site. Members of the Telemedicine Staff may not admit patients to the hospital; however, they may exercise such clinical privileges as are granted to them pursuant to these Bylaws. They may attend staff meetings or education programs, but are not eligible to vote or hold office. ARTICLE VI: ALLIED HEALTH PROFESSIONALS 6.1 BASIC QUALIFICATIONS FOR ALLIED HEALTH PROFESSIONALS Only Allied Health Professionals (AHPs) holding a current license, certificate, or other legal credential as required by State law, who: document their experience, background, training, demonstrated ability, current competence, physical health status and mental health status (in relation to the clinical privileges requested), and verbal and written English language proficiency with sufficient adequacy to demonstrate to the Medical Staff and the Board that any patient treated by them will receive care of the generally recognized professional level of quality and efficiency and that they are qualified to provide a needed service within the Hospital; and document evidence of a minimum of $1,000,000 per occurrence/$3,000,000 aggregate (as jointly prescribed by the Medical Staff and Board) of continuous professional liability insurance coverage written by a company authorized to do business in the State of Minnesota; and
14 Page 14 of document information concerning any claims alleging malpractice asserted against the applicant prior to applying for privileges as well as information concerning the disposition of such claims and indication of such claims presently pending; and are determined, on the basis of documented references, to adhere strictly to the ethics of their respective professions as applicable and to work cooperatively with others shall be eligible to provide specified services in the Hospital. Where appropriate, the Medical Executive Committee may establish particular qualifications required of members of a specific category of AHPs, provided that such qualifications are not founded on an arbitrary or discriminatory basis and are in conformance with applicable law. 6.2 Privileges Allowed for Allied Health Professionals Requests from Allied Health Professionals to perform specified patient care services shall be processed in the manner specified in Article IV. An Allied Health Professional may, subject to any licensure requirements or other legal limitations, exercise independent judgment within the areas of his/her professional competence, and may participate directly in the medical management of patients under the supervision of a physician who has been accorded privileges to provide such care and who has ultimate responsibility for the patient's care. a. Admitting: As delegated by the supervising physician who is a member of the Active Medical Staff, a nurse practitioner (CNP), physician assistant (PA) or certified nurse midwife (CNM) may be authorized to admit and treat patients in the hospital within the individual practitioner s scope of practice as defined by the State of Minnesota licensure rules; as approved by the medical staff protocol; within their practice agreement and under the required physician supervision. b. Supervision: A supervising physician shall review and evaluate patient services provided by a PA, CNP, or CNM on a regular basis as follows: PA, CNP, or CNM: 25% of all outpatient records and 100% of inpatient records APRN CNP or APRN CNM: 25% of outpatient observation records and 100% of inpatient records. An M.D./D.O. must be available by telemedicine or in person for consultations within 15 minutes when the PA or CNP is treating patients at the hospital. c. Emergency room coverage: As delegated by the supervising physician, the PA or CNP may provide emergency room coverage within their scope of practice and in conjunction with applicable rules and regulations, Article VI of these Bylaws. ARTICLE VII: CLINICAL PRIVILEGES 7.1 Exercise of Privileges Except as otherwise provided in these Bylaws, a Member of the Medical Staff with clinical privileges at this Hospital shall have access to the Hospital to exercise only those clinical privileges specifically granted. Said clinical privileges must be Hospital specific, within the scope of any license, certificate or other legal credential authorizing practice in this State and consistent with any restrictions thereon, and shall be subject to the rules and regulations of the Medical Staff The initial application shall contain a request for specific clinical privileges desired. The applicant has the burden of establishing her/her qualifications and competency to perform requested clinical privileges.
15 Page 15 of Applicants for reappointment shall have their clinical privileges reviewed and adjusted based on direct observation of care provided, review of patient records, quality assurance reports and medical staff records which document the evaluation of the applicants delivery of care Privileges granted to dentists or podiatrists shall be based on their training, experience, and demonstrated competence and judgment. The scope and extent of surgical procedures shall be delineated and granted in the same manner as other surgical applicants. Surgical procedures provided by dentists shall be under the overall supervision of a member of the Active Medical Staff. A physician member of the Active Medical Staff shall be responsible for the care of any medical problems that may be present at the time of admission for a dental procedure or that may arise during hospitalization. 7.2 Temporary Privileges and Locum Tenens Privileges Temporary clinical privileges a. In cases of medical necessity, temporary clinical privileges may be granted to a practitioner for the care of specific patients provided that the procedure in Section has been followed. Physicians given temporary clinical privileges in this situation shall not have admitting privileges; however, they shall be permitted to admit patients to observation status at the Hospital. b. Temporary clinical privileges may be granted while awaiting completion of the approval process provided that the procedure in Section has been followed. Temporary privileges in this situation shall be for ninety (90) days Locum Tenens privileges may be granted by the Chief Executive Officer in conjunction with the Chief of Medical Staff to a licensed practitioner for a period of time not to exceed six (6) months; the period may exceed six months if the Chief of Staff, or designee, recommends a longer period for a good cause. The Locum Tenens must complete a medical staff application using the same process as provided in these Bylaws for all applicants. Physicians given locum tenens privileges shall have admitting privileges Application and Review Upon receipt of a completed and signed application from a practitioner authorized to practice in Minnesota, the Board, acting through the Administrator or his/her designee, may grant temporary privileges to a practitioner who appears to have qualifications, ability and judgement, consistent with these Bylaws, but only after: a. Primary source verification of current and valid licensure and education is completed. A current, valid DEA certificate is presented (when applicable). Evidence is provided of adequate professional liability insurance as defined in these Bylaws. b. the Chief of Staff has reviewed two peer references from persons who have: (1) worked with the applicant during the prior five (5) years (2) directly observed the applicant's professional performance over a reasonable period of time; and who (3) provide reliable information regarding the applicant's qualifications, technical skill, judgment, health status, current professional competence, character and ability to exercise the privileges requested. c. an inquiry is submitted to the National Practitioner Data Bank; d. after reviewing the applicant's file and attached materials, the Medical Executive Committee, through the Chief of Staff or his/her designee, recommends granting temporary privileges.
16 Page 16 of General Conditions a. All practitioners requesting or receiving temporary privileges shall be bound by the Bylaws, Rules and Regulations and policies of the Medical Staff. b. A practitioner shall not be entitled to the procedural rights afforded by Article XIX because a request for temporary privileges is refused or because all or any portion of temporary privileges are terminated or suspended Termination of Temporary Privileges a. Temporary privileges shall automatically terminate at the end of the designated period, unless earlier terminated by the Medical Executive Committee upon recommendation of the Chief of Staff or unless affirmatively renewed following the procedure as set forth in Section b. Any or all of a practitioner's temporary privileges may be immediately terminated at any time by any person entitled to impose summary suspensions under Article IX. Such immediate terminations are subject to prompt review by the Medical Executive Committee and the Board. In the event of any such termination, the practitioner's patients then in the Hospital shall be assigned to another Member of the Medical Staff by the Chief of Staff. The wishes of the patient shall be considered, where feasible, in the choice of a replacement Medical Staff Member. 7.3 Emergency Privileges In case of an emergency, any practitioner, to the degree permitted by their license, shall be permitted to do everything possible to save the life of a patient using our hospital facilities and/or calling for consultation. When the emergency situation no longer exists, the practitioner must request privileges in order to continue to care for the patient. If those privileges are denied or not requested by the practitioner, the Chief of Medical Staff shall assign another member of the Active Medical Staff to the care of that patient with the patient s consent. Emergency is defined as a condition, which could result in serious permanent harm or death to a patient, and any delay in administering treatment would add to that danger. ARTICLE VIII: TELEMEDICINE SERVICES 8.1 Conditions: The term telemedicine shall mean licensed independent practitioners who prescribe, render a diagnosis, or otherwise provide clinical treatment to a patient at the Glacial Ridge Health System (GRHS) through the use of electronic communication or other communication technologies from a distant site Services shall be provided via telemedicine only after a determination has been made by the Medical Staff that the clinical service involved would be appropriately delivered through this medium according to commonly accepted quality standards Medical Staff Membership: Telemedicine Staff shall be required to comply with all provisions of the Medical Staff Bylaws and Rules and Regulations, and all GRHS policies applicable to the exercise of their clinical privileges Credentialing: Telemedicine practitioners are subject to the credentialing and privileging process of Glacial Ridge Health System as follows: GRHS may rely on the credentialing and privileging process conducted by the Privileging Organization of the Telemedicine practitioner.
17 Page 17 of Upon presentation of evidence of clinical privileges granted by the Privileging Organization and acceptance thereof by the Medical Staff and the Governing Board; the practitioner holding such privileges from the Privileging Organization shall be granted identical privileges at GRHS, except that no privileges shall be granted for services not performed by GRHS Quality: A method to evaluate the services provided by the telemedicine practitioner will be established within the department using the telemedicine services. The Medical Staff Executive Committee will evaluate all telemedicine services for quality of services, timeliness and appropriateness. This evaluation will be conducted annually. ARTICLE IX: DISCIPLINARY ACTION 9.1 Procedure Whenever the activities or professional conduct of any member of the Medical Staff are considered to be lower than the standards established at this facility and in this community, or the activities and conduct are considered disruptive to the operations of this hospital, corrective action shall be taken at the request of any officer of the Medical Staff, Chief Executive Officer or by the Governing Board. All requests for corrective action shall be in writing, shall be made to the Medical Staff and to the Chief Executive Officer and shall be supported by documentation of the specific activities or conduct which constitutes the grounds for the request Whenever corrective action could result in a reduction or suspension of Medical Staff membership or clinical privileges, the Medical Staff shall forward such a request to the Chief of Medical Staff. Upon receipt of such a request, the Chief of Medical Staff shall immediately appoint an ad hoc committee to investigate the matter. The Chief Executive Officer shall be a member of the committee in an advisory capacity with no voting privileges Within thirty (30) days after receipt of the request for corrective action, the Chief of Medical Staff shall make a report of the investigation to the Medical Staff. Prior to making such a report, the practitioner against whom corrective action has been requested shall have an opportunity for an interview with the ad hoc committee appointed to make the investigation. At the interview he/she will be informed of the nature of the charges and invited to discuss, explain or refute them. This interview shall not constitute a hearing but shall be preliminary in nature for the purpose of gathering information. A record of this interview shall be made and included with the committee report to the Medical Staff The Medical Staff shall take action using the information provided by the ad hoc committee. If the Medical Staff anticipates the action will involve a reduction or suspension of clinical privileges or expulsion from the Medical Staff, the practitioner shall be invited to make an appearance before the Medical Staff. This appearance shall not constitute a hearing, shall be preliminary in nature, and none of the procedural rules provided in these Bylaws with respect to hearings shall apply. There shall be a record of such appearance The action of the Medical Staff on a request for corrective action may include the following: a. to issue a oral or written warning. b. letter of admonition. c. letter of reprimand.
18 Page 18 of 31 d. impose terms of probation or requirement for consultation. e. recommend that an already imposed summary suspension or clinical privileges be terminated, modified, sustained or suspended or revoked. f. to recommend that the practitioners staff membership be suspended or revoked Any recommendation by the Medical Staff for reduction, suspension, or revocation of clinical privileges, or for suspension or expulsion from the Medical Staff, shall entitle the practitioner to the procedural rights provided in these Bylaws The Chief of Medical Staff shall promptly notify the Chief Executive Officer in writing of all requests for corrective actions and shall keep the Chief Executive Officer informed of all actions in connection therewith Every practitioner, by accepting membership and/or clinical privileges and by virtue of these Bylaws, agrees that he/she will not begin a lawsuit for invasion of privacy, or for libel or slander, or for any other cause arising out of disciplinary proceedings involving him/her, against the Board or against any person who in good faith brings charts or produces evidence or participates in any other manner, in disciplinary proceedings against him/her Copies of all reports, decisions, and recommendations called for by these Bylaws, relating to disciplinary proceedings and appeals, shall be filed with the Administrator when issued and he/she shall be kept fully informed of all action planned or taken in connection with disciplinary proceedings and appeals. Such reports and documents shall be kept by the Administrator as confidential and for use only by the Medical Staff and the Hospital Administration and Board unless otherwise stated in these Bylaws or by law made available for other purposes. Disciplinary action shall be reported to the Minnesota Board of Medical Examiners or other appropriate Board within fifteen (15) days from the date the disciplinary action was taken. Disciplinary action shall be reported to other agencies and governmental authorities as permitted or required by law. 9.2 Summary Suspension Any one of the following: Chief of Medical Staff, Chief Executive Officer, or the Medical Staff shall have the authority whenever action must be taken immediately in the best interest of patient care in the hospital to summarily suspend all or any portion of the clinical privileges of a practitioner, and such summary suspension shall become effective immediately upon disposition A practitioner whose clinical privileges have been summarily suspended shall be entitled to request that the medical staff hold a hearing on the matter within a reasonable time period thereafter The Medical Executive Committee may recommend modification, continuance, or termination of the terms of the summary suspension. If, as a result of such hearing, the summary suspension is upheld, the affected practitioner shall be entitled to request an appellate review by the Governing Board of the hospital. The terms of the summary suspension as sustained or as modified by the Medical Staff shall remain in effect pending a final decision thereon by the Governing Board Immediately upon the imposition of a summary suspension, the Chief of Medical Staff shall have authority to provide for alternative medical coverage for the patients of the
19 Page 19 of 31 suspended practitioner still in the hospital at the time of suspension. The wishes of the patients shall be considered in the selection of an alternate practitioner. 9.3 Automatic Suspension - Trigger Events Action by Licensing Agencies a. Action by a State agency revoking or suspending a practitioner s license to practice, or placing him/her on probation, shall require the Administrator, acting for the Board, upon learning of the action, to revoke or suspend such practitioner s staff membership and/or clinical privileges or place him/her on probation in accordance with the conditions imposed by his/her licensing agency. There shall be no right of appeal from such action. b. If the practitioner has their DEA registration revoked, suspended or restricted, they shall automatically lose prescription-writing privileges, pending investigation by the Medical Staff Incomplete Records Failure to complete a record after twenty-five (25) days of patient discharge will trigger a reminder letter from Administration. If the medical record remains incomplete after thirty (30) days, a letter of temporary suspension will be served to the practitioner and shall stand until the delinquent records are complete. A copy of the temporary suspension shall be given to the Chief of Medical Staff. Failure to complete an H&P in accordance with the Rules and Regulations can also be cause for automatic suspension. The Chief of Medical Staff will cooperate with the Chief Executive Officer as the need arises to assure compliance. In the event the Chief of Medical Staff is not compliant with this section, the Chief Executive Officer will work with other Medical Staff Officers who will cooperate to assure compliance. Upon completion of record, full privileges are reinstated. 9.4 Health Care Quality Improvement Act of 1986 The Health Care Quality Improvement Act of 1986, Public Law , promulgated by the ninety-ninth Congress of the United States, as may be amended from time to time, is incorporated into these Bylaws as though fully set forth herein. Where the provisions of this law would provide a practitioner with greater rights than provided in these Bylaws, such law shall take precedence over these Bylaws. Where the provisions of this law and any regulations promulgated pursuant to it require reporting, the Medical Staff shall comply with all such requirements. ARTICLE X: PRACTITIONER IMPAIRMENT 10.1 Upon determination by the Medical Staff Executive Committee, members of the Medical Staff or Allied Health Professional staff that have an ongoing impairment that could negatively affect patient care even with reasonable accommodation or have been identified as having such impairment will voluntarily enter the Health Professional Services Program in the State of Minnesota. Information on this program is available from the Minnesota Board of Medical Practice.