OLYMPIA MEDICAL CENTER. Medical Staff Bylaws EFFECTIVE DATE:

Transcription

1 OLYMPIA MEDICAL CENTER Medical Staff Bylaws EFFECTIVE DATE: February 5, 2013

2 OLYMPIA MEDICAL CENTER Medical Staff Bylaws TABLE OF CONTENTS ARTICLE ONE NAME, PURPOSE AND DEFINITIONS 1.1 NAME PURPOSES DEFINITIONS... 8 ARTICLE TWO MEMBERSHIP 2.1 NATURE OF MEMBERSHIP QUALIFICATIONS FOR MEMBERSHIP GENERAL QUALIFICATIONS PARTICULAR QUALIFICATIONS EFFECT OF OTHER AFFILIATIONS ADMINISTRATIVE AND CONTRACT PRACTITIONERS CONTRACTORS WITH NO CLINICAL DUTIES CONTRACTORS WITH CLINICAL DUTIES NONDISCRIMINATION BASIC RESPONSIBILITIES OF MEDICAL STAFF MEMBERSHIP HARASSMENT PROHIBITED ARTICLE THREE CATEGORIES OF MEMBERSHIP 3.1 CATEGORIES ACTIVE STAFF QUALIFICATIONS PREROGATIVES RECLASSIFICATION OF ACTIVE STAFF MEMBERS COURTESY STAFF QUALIFICATIONS PREROGATIVES NON-CLINICAL STAFF Qualifications Prerogatives PROVISIONAL STAFF QUALIFICATIONS PREROGATIVES OBSERVATION OF PROVISIONAL STAFF MEMBERS TERM OF PROVISIONAL STAFF STATUS RESIDENT AND FELLOW STAFF QUALIFICATIONS PREROGATIVES HONORARY STAFF QUALIFICATIONS PREROGATIVES EXCEPTIONS AND LIMITATIONS TO PREROGATIVES LIMITED LICENSED PRACTITIONERS LIMITATION OF PREROGATIVES IN INDIVIDUAL CASES MODIFICATION OF MEMBERSHIP PRIORITY ACCESS TO THE HOSPITAL FACILITIES ARTICLE FOUR APPOINTMENT AND REAPPOINTMENT 4.1 GENERAL BURDEN OF PRODUCING INFORMATION DURATION OF APPOINTMENT AND REAPPOINTMENT APPLICATION FOR INITIAL APPOINTMENT APPLICATION FORM EFFECT OF APPLICATION VERIFICATION OF INFORMATION ACTION BY DEPARTMENT CHAIRPERSON MEC ACTION EFFECT OF MEC ACTION ACTION OF THE APPLICATION NOTICE OF FINAL DECISION

3 4.4.9 WAITING PERIOD AFTER ADVERSE ACTION TIMELY PROCESSING OF APPLICATIONS REAPPOINTMENTS AND REQUESTS FOR MODIFICATIONS OF STAFF STATUS OR PRIVILEGES APPLICATION FOR REAPPOINTMENT EFFECT OF APPLICATION STANDARDS AND PROCEDURES FOR REVIEW FAILURE TO FILE REAPPOINTMENT APPLICATIONS LEAVE OF ABSENCE LEAVE STATUS TERMINATION OF LEAVE FAILURE TO REQUEST REINSTATEMENT MILITARY LEAVE OF ABSENCE REINSTATMENT REINSTATEMENT FEE EXCLUSIVE CONTRACTS EXPEDITED PROCESS ARTICLE FIVE ALLIED HEALTH STAFF 5.1 GENERAL QUALIFICATIONS CATEGORIES OF AHP's ELIGIBLE FOR PRACTICE PREROGATIVES PROCEDURE FOR GRANTING PRACTICE PREROGATIVES RESPONSOBILITIES TERMINATION OF PRACTICE PREROGATIVES AUTOMATIC SUSPENSION GRIEVANCE PROCESS HOSPITAL EMPLOYEES ARTICLE SIX CLINICAL PRIVILEGES 6.1 EXERCISE OF PRIVILEGES DELINEATION OF PRIVILEGES IN GENERAL APPLICATIONS AND REQUESTS BASIS FOR PRIVILEGES DETERMINATION PROCTORING GENERAL PROVISIONS PROCTORING REPORTS FROM OTHER FACILITIES FAILURE TO OBTAIN PROCTORING REPORTS MEDICAL STAFF ADVANCEMENT CONDITIONS FOR PRIVILEGES OF LIMITED LICENSE PRACTITIONERS ADMISSIONS SURGERY MEDICAL APPRAISAL TEMPORARY CLINICAL PRIVILEGES CIRCUMSTANCES REQUEST AND PROCESS GENERAL CONDITIONS EMERGENCY PRIVILEGES EMERGENCY PRIVILEGES DISASTER PRIVILEGES MODIFICATION OF CLINICAL PRIVILEGES OR DEPARTMENT ASSIGNMENT LAPSE OF REQUEST ARTICLE SEVEN CORRECTIVE ACTION 7.1 CORRECTIVE ACTION ROUTINE MONITORING AND EDUCATION CRITERIA FOR INITIATION INITIATION INVESTIGATION MEC ACTION SUBSEQUENT ACTION INITIATION BY BOARD OF GOVERNORS SUMMARY RESTRICTION OR SUSPENSION CRITERIA FOR INITIATION MEC ACTION

4 7.2.3 PROCEDURAL RIGHTS INITIATION BY BOARD OF GOVERNORS AUTOMATIC SUSPENSION OR LIMITATION LICENSURE CONTROLLED SUBSTANCES FAILURE TO SATISFY SPECIAL ATTENDANCE REQUIREMENT MEDICAL RECORDS PROFESSIONAL LIABILITY INSURANCE FAILURE TO PAY DUES FAILURE TO COMPLY WITH GOVERNMENT AND OTHER THIRD PARTY PAYOR REQUIREMENTS AUTOMATIC TERMINATION NOTICE OF AUTOMATIC TERMINATION OR ACTION SUSPENSION, EXCLUSION, DEBARMENT OR SANCTION UNDER ANY FEDERAL OR STATE HEALTH CARE AGENCY EXPULSION FOR A CRIMINAL ACT AUTOMATIC RESIGNATION FOLLOWING LOSS OF EXCLUSIVE CONTRACT INTERVIEW CONFIDENTIALITY ARTICLE EIGHT HEARING AND APPELLATE REVIEW PROCEDURES 8.1 GENERAL PROVISIONS; DEFINITIONS; SETTLEMENT DUTY TO EXHAUST REMEDIES DEFINITIONS SETTLEMENTS CATEGORY ONE HEARING NOTICE OF ADVERSE ACTION OR RECOMMENDED ACTION: REQUEST FOR HEARING GROUNDS FOR CATEGORY ONE HEARING NOTICE OF HEARING STATEMENT OF CHARGES MEDICAL REVIEW HEARING COMMITTEE (MRC) OR ARBITRATOR; APPOINTMENT, REMOVAL AND QUALIFICATIONS HEARING OFFICER; CHAIRMAN OF THE MRC POSTPONEMENTS AND EXTENSIONS CATEGORY ONE HEARING PROCEDURE PRE-HEARING EXCHANGE OF INFORMATION AND DISCOVERY FAILURE TO APPEAR REPRESENTATION RECORD OF THE HEARING OATH OF A WITNESS ORGANIZATION AND CONDUCT OF THE HEARING PROCESS BURDEN OF PROOF ADMISSIBLE EVIDENCE AND GENERAL PROCEDURES CATEGORY TWO HEARING GROUNDS FOR CATEGORY TWO HEARING NOTICE OF ADVERSE ACTION OR RECOMMENDED ACTION CATEGORY TWO HEARING PROCEDURE HEARING OFFICER EXCHANGE OF PRE-HEARING DOCUMENTS AND WITNESS LISTS BURDEN OF PRODUCING EVIDENCE AND BURDEN OF PROOF APPEAL DECISION AND REPORT OF MRC; NOTICE BOARD OF GOVERNORS ACTION AFTER MRC DECISION APPEAL TO BOARD OF GOVERNORS AND/OR APPEAL BOARD TIME FOR REQUESTING APPEAL NATURE AND EFFECT OF APPEAL PROCESS GROUNDS FOR APPEAL NOTICE OF TIME, DATE, PLACE OF APPELLATE REVIEW MEETING APPELLATE REVIEW PROCEEDINGS FINAL DECISION; EFFECTIVE DATE RIGHT TO ONLY ONE MRC HEARING AND APPEAL PROCESS INFORMAL INTERVIEWS RESIGNATION OR WITHDRAWAL OF APPLICATION CONFIDENTIALITY EXCEPTIONS TO HEARING AND APPEAL RIGHTS CLOSED DEPARTMENTS/EXCLUSIVE CONTRACTS

5 MEDICO-ADMINISTRATIVE PRACTITIONER AUTOMATIC SUSPENSION OR TERMINATION OF PRIVILEGES DESIGNATED PROFESSIONAL PERSONNEL REMOVAL FROM EMERGENCY ROOM CALL PANEL HOSPITAL POLICY DECISION ARTICLE NINE OFFICERS AND MEDICAL DIRECTORS 9.1 OFFICERS IDENTIFICATION QUALIFICATIONS NOMINATIONS ELECTIONS TERM OF ELECTED OFFICE REMOVAL OF ELECTED OFFICERS FROM OFFICE VACANCIES IN ELECTED OFFICE DUTIES OF OFFICERS CHIEF OF STAFF VICE CHIEF OF STAFF SECRETARY-TREASURER ARTICLE TEN CLINICAL DEPARTMENTS 10.1 ORGANIZATION OF CLINICAL DEPARTMENTS CURRENT DEPARTMENTS ASSIGNMENT TO DEPARTMENTS DEPARTMENT FUNCTIONS FREQUENCY DEPARTMENT CHAIRPERSONS QUALIFICATIONS SELECTION TERM OF OFFICE REMOVAL DUTIES ARTICLE ELEVEN COMMITTEES AND FUNCTIONS 11.1 DESIGNATION and SUBSTITUTION GENERAL PROVISIONS TERMS OF COMMITTEE MEMBERS REMOVAL VACANCIES CONFIDENTIALITY PERFORMANCE OF FUNCTIONS MEDICAL EXECUTIVE COMMITTEE (MEC) COMPOSITION DUTIES MEETINGS Attendance Subcommittees of the Medical Executive Committee SPECIAL COMMITTEES OF THE MEDICAL STAFF BYLAWS COMMITTEE...55 A. COMPOSITION...55 B. DUTIES...55 C. MEETINGS WELL-BEING COMMITTEE...55 A. COMPOSITION...55 B. DUTIES...56 C. MEETINGS BIOETHICS COMMITTEE...56 A. COMPOSITION...56 B. DUTIES...56 C. MEETINGS INTERDISCIPLINARY PRACTICE COMMITTEE...56 A. COMPOSITION...56 B. DUTIES...57 C. MEETINGS RESEARCH ADVISORY COMMITTEE

6 A. COMPOSITION...57 B. DUTIES...57 C. MEETINGS QUALITY COUNCIL...58 A. COMPOSITION...58 B. DUTIES...58 C. MEETINGS AD HOC DISPUTE RESOLUTION COMMITTEE...58 A. COMPOSITION...59 B. DUTIES STAFF FUNCTIONS DESCRIPTION OF FUNCTIONS PATIENT CARE EVALUATION AND MONITORING UTILIZATION MANAGEMENT CONTINUING MEDICAL EDUCATION MEDICAL RECORDS REVIEW MEDICATION REVIEW DISASTER PLANNING SURGICAL AND OTHER PROCEDURE REVIEW BLOOD AND BLOOD PRODUCTS UTILIZATION REVIEW PHARMACY AND THERAPEUTICS INFECTION CONTROL...63 ARTICLE TWELVE MEETINGS 12.1 MEDICAL STAFF MEETINGS SPECIAL MEETINGS COMMITTEE AND DEPARTMENT MEETINGS REGULAR MEETINGS SPECIAL MEETINGS QUORUM REQUIREMENTS MEDICAL STAFF MEETINGS MEDICAL EXECUTIVE COMMITTEE DEPARTMENT AND COMMITTEE MEETINGS (EXCLUDING MEC MEETINGS) MANNER OF ACTION MINUTES ATTENDANCE REQUIREMENTS REGULAR ATTENDANCE SPECIAL ATTENDANCE CONDUCT OF MEETINGS NOTICE...65 ARTICLE THIRTEEN CONFIDENTIALITY, IMMUNITY AND RELEASE 13.1 AUTHORIZATION AND CONDITIONS CONFIDENTIALITY OF INFORMATION GENERAL AGREEMENT TO MAINTAIN CONFIDENTIALITY BREACH OF CONFIDENTIALITY IMMUNITY FROM LIABILITY FOR ACTION TAKEN FOR PROVIDING INFORMATION ACTIVITIES AND INFORMATION COVERED ACTIVITIES RELEASES SCOPE OF INDEMNIFICATION...67 ARTICLE FOURTEEN GENERAL PROVISIONS 14.1 RULES AND REGULATIONS GENERAL MEDICAL STAFF RULES AND REGULATIONS DEPARTMENT RULES AND REGULATIONS Medical Staff Self Governance DUES OR ASSESSMENTS CONSTRUCTION OF TERMS AND HEADINGS AUTHORITY TO ACT DIVISION OF FEES NOTICES

7 14.7 MEDICAL STAFF CREDENTIALS FILES INSERTION OF ADVERSE INFORMATION REVIEW OF ADVERSE INFORMATION AT THE TIME OF REAPPOINTMENT CONFIDENTIALITY MEMBER S OPPORTUNITY TO REQUEST CORRECTION/DELETION OF, AND TO MAKE ADDITION TO, INFORMATION IN FILE...69 ARTICLE FIFTEEN ADOPTION AND AMENDMENT OF BYLAWS 15.1 INITIATION METHODOLOGY ACTION OF MEDICAL STAFF APPROVAL EXCLUSIVITY BYLAWS REVIEW SUCCESSOR IN INTEREST

8 ARTICLE ONE NAME, PURPOSE AND DEFINITIONS 1.1 NAME The name of the organization is the Medical Staff of Olympia Medical Center. 1.2 PURPOSES The purposes of the Medical Staff shall be: (a) To assure that all patients admitted to or treated by any of the facilities, departments, or services of the Hospital receive a uniform standard of quality patient care, treatment and service and efficiency consistent with generally accepted standards in the community and attainable within the Hospital s means and circumstances; (e) To assure a level of professional performance of all Practitioners authorized to practice in the Hospital consistent with generally accepted standards in the community and within the hospital s means and circumstances through an ongoing review and evaluation of each Practitioner s performance in the Hospital; To provide appropriate educational opportunities for staff members; To initiate and maintain Rules and Regulations, policies, and procedures for self-government of the Medical Staff; to carry out its responsibilities for the professional work performed in the Hospital, pursuant to the authority delegated by the Board of Governors; and, provide a means for the Medical Staff and Board of Governors, and Administration to discuss issues of mutual concern and accountability; To support the Medical Staff Mission statement of Olympia Medical Center, the Medical Staff will: 1.3 DEFINITIONS 1 Ensure the training, competency and ethics of it s staff members meets or exceeds the community standards. 2. Work with Senior Management and hospital staff to promote optimum processes and satisfactory outcomes for our patients within the hospital s means and circumstances. 3. Be accountable to the Board of Governors for the quality of the medical care, treatment and services provided to patients. (a) (e) (f) ALLIED HEALTH PROFESSIONAL or AHP means a duly licensed or approved individuals, other than a licensed physician, dentist, podiatrist, or clinical psychologist whose patient are activities require that his or her authority to perform specified patient care services be processed through the procedures adopted by the Medical Staff pursuant to these Bylaws, CHIEF EXECUTIVE OFFICER, CEO or HOSPITAL ADMINISTRATOR means the individual appointed by the Board of Governors to act on their behalf in the overall administrative management of the Hospital. CLINICAL PRIVILEGES or PRIVILEGES means the permission granted to an individual to render specific diagnostic, therapeutic, medical, dental, podiatric or surgical services. EX OFFICIO means service as a member of a body by virtue of an office or position held and, unless otherwise expressly provided, means with voting rights. GOOD STANDING means (1) a member who is not currently on suspension (other than a medical records automatic suspension), has no pending corrective action investigation, has no pending recommendation or action for which the member was entitled to request a medical staff hearing, and has no disciplinary action in effect for which the member was entitled to request a medical staff hearing, and (2) a former member who was not subject to any of the foregoing at the time the individual ceased being a member and who did not have outstanding delinquent medical records which resulted in the records being closed without being completed. BOARD OF GOVERNORS means the body that is approved by the owners of the Hospital to have delegated authority and responsibility for establishing policy, maintaining quality of care and providing for organization management and planning and for fulfilling the functions of a governing body as set forth in State and Federal statutes, regulations and accreditation standards. 8

9 (g) (h) (i) (j) (k) (l) HOSPITAL means the Olympia Medical Center, and each of the locations where the Hospital is licensed by the California Department of Public Health to provide services pursuant to its general acute care hospital license. INVESTGATION means a process specifically initiated by the Medical Executive Committee to determine the validity, if any, of a concern or complaint raised against a member or individual with clinical privileges, and does not include the reviews or usual activities of other committees or departments of the Medical Staff. MAIL or NOTICE (which does not include Special Notice or notices sent as part of the hearing and appellate review process; notices as part of the hearing and appellate review process being defined in Section 8.1.2) means any of the following methods of delivery: U.S. Mail Service, private courier service, hand delivery, facsimile or . If mail is required to be sent by certified mail or registered mail, return receipt requested, it includes U.S. Certified Mail return receipt requested, U.S. Registered mail, return receipt requested, hand delivery with delivery receipt or private courier service with delivery receipt, and includes documented receipt by the addressee s office staff. Documented refusal to accept mail by the addressee or addressee s office staff is considered delivery and receipt. MEDICAL DISCIPLINARY CAUSE OR REASON OR MDCR means that aspect of a practitioner s competence or professional conduct which is reasonably likely to be detrimental to patient safety or to the delivery of patient care. MEDICAL EXECUTIVE COMMITTEE or MEC means the Executive Committee of the Medical Staff. MEDICAL STAFF or STAFF means the formal organization of all licensed physicians, dentists, podiatrists, and clinical psychologists who are privileged to attend patients in the Hospital. (m) MEDICAL STAFF YEAR means the period from January 1 through December 31. (n) (o) (p) (q) (r) (s) PHYSICIAN means a duly licensed medical physician and surgeon or osteopathic physician and surgeon applying for, or exercising clinical privileges in, the Hospital. PRACTITIONER means a physician, dentist, podiatrist, or clinical psychologist applying for, or exercising clinical privileges in, the Hospital. PROFESSIONAL ASSOCIATION The Medical Staff operates as a Professional Association within the meaning of Section 23701e of the California Revenue and Taxation Code and is recognized by the United States Internal Revenue Service as a non-profit organization. The Medical Staff organization does not contemplate pecuniary gain or profit to the members thereof and is organized for non-profit purposes. Notwithstanding any of the above statements of purposes and powers, this Medical Staff shall not, except to an insubstantial degree, engage in any activities or exercise any powers that are not in furtherance of the specific purposes of the Medical Staff. SPECIAL NOTICE means written notification sent by certified or registered mail, return receipt requested. TELEMEDICINE means the use of medical information exchanged from one site to another via electronic communications for the health and education of the patient or health care provider for the purpose of improving patient care, treatment and services. TELEMEDICINE PRACTITIONER means any licensed and appropriately credentialed practitioner who prescribes, renders a diagnosis or otherwise provides clinical treatment to a patient who has expressly applied for and been granted telemedicine privileges. 9

10 ARTICLE TWO MEMBERSHIP 2.1 NATURE OF MEMBERSHIP (a) Membership on the Medical Staff is a privilege that shall be extended only to, and maintained by, those professionally competent Practitioners who continuously meet the standards and requirements set forth in these Bylaws and Rules and Regulations. With the exception of the Honorary and Non- Clinical Staff category of membership, members of the Medical Staff shall be limited to Practitioners who are currently licensed in the State of California to practice medicine, podiatry, dentistry or psychology. No Practitioner, including those in a medical administrative position by virtue of a contract with the Hospital, may admit or provide medical or health-related services to patients in the Hospital unless he is a member of the Medical Staff, or has been granted temporary privileges in accordance with the procedures set forth in these Bylaws and Rules and Regulations. Appointment to the Medical Staff shall confer only such clinical privileges as have been granted in accordance with these Bylaws and Rules and Regulations. Activities of the Medical Staff shall be included in the ongoing review and evaluation of the quality of clinical care to promote the most effective and efficient use of available health resources and services consistent with patient needs. The Medical Staff shall participate in the identification, review, evaluation, reduction and correction of potential risks in the clinical aspects of patient care and safety. 2.2 QUALIFICATIONS FOR MEMBERSHIP GENERAL QUALIFICATIONS Members of the Medical Staff, except such members appointed to the Honorary or Non-Clinical staff category, must meet all of the following criteria at the time of appointment, reappointment and throughout the entirety of their Medical Staff membership period: (a) Hold a current license to practice medicine, podiatry, dentistry or psychology in the State of California; (e) (f) (g) (h) (i) Provide adequate evidence of professional experience, education, training, judgment, demonstrated current clinical competence and mental/health status; Adhere to the ethics of his respective profession; Refrain from disruptive behavior that does or might interfere with patient care or the orderly operation of the Hospital; Maintain in force professional liability insurance of $1,000,000 per occurrence/$3,000,000 aggregate; Maintain offices and residences which, in the opinion of the MEC, are located close enough to the Hospital to provide appropriate continuity of quality care; Provide the Medical Staff Services Office with a business and/or residence address and telephone number where the Member may receive mail and telephone calls. It shall be the Member s obligation to provide his most current address and telephone number to the Medical Staff Services Office; and Provide documentation of current DEA certification, or provide reasonable explanation for lack of DEA certification (e.g., scope of practice does not require DEA certification). Assure the timely completion of a medical history and physical examination on all patients within 24 hours after admission or immediately before the admission and that meets the requirements in the Medical Staff Rules; (j) Applicants for telemedicine privileges do not need to comply with paragraph f PARTICULAR QUALIFICATIONS (a) PHYSICIANS An applicant for membership on the Medical Staff, except for applicants to the Honorary or Non- Clinical Staff, must hold a valid license to practice medicine issued by the Medical Board of California or the Board of Osteopathic Examiners of the State of California. LIMITED LICENSE PRACTITIONERS 10

11 (1) Dentists. An applicant for dental membership on the Medical Staff, except for the applicants to the Honorary or Non-Clinical staff category, must hold a D.D.S. or equivalent degree issued by a dental school approved at the time of the issuance of such degree by the Board of Dental Examiners of California and must also hold a valid license to practice dentistry issued by the Board of Dental Examiners of California. (2) Podiatrists. An applicant for podiatric membership on the Medical Staff, except for the Honorary or Non-Clinical staff, must hold a D.P.M. degree conferred by a school approved at the time of issuance of such degree by the Medical Board of California and must hold a valid license to practice podiatry issued by the Medical Board of California. (3) Clinical Psychologists. An applicant for clinical psychology membership on the Medical Staff, except for the Honorary or Non-Clinical Staff, must hold a clinical psychology degree conferred by a school approved at the time of issuance of such degree by the California Board of Behavioral Sciences and must hold a valid license to practice clinical psychology issued by the California Board of Behavioral Sciences. 2.3 EFFECT OF OTHER AFFILIATIONS No person shall be automatically entitled to membership on the Medical Staff merely because he holds a certain degree, is licensed to practice in this or any other State, is a member of any professional organization, is certified by any clinical board, or because such person had, or presently has, staff membership or privileges at another health care facility. 2.4 ADMINISTRATIVE AND CONTRACT PRACTITIONERS CONTRACTORS WITH NO CLINICAL DUTIES A Practitioner employed by or contracting with the Hospital in a purely administrative capacity with no clinical duties or privileges is subject to the regular personnel policies of the Hospital and to the terms of his contract or other conditions of employment and need not be a Member of the Medical Staff CONTRACTORS WITH CLINICAL DUTIES (a) A Practitioner with whom the Hospital contracts to provide services which involve clinical duties or privileges must be a Member of the Medical Staff, achieving his status by the procedures described in these Bylaws. Unless otherwise required by law, those privileges made exclusive or semi-exclusive pursuant to a closed-staff or limited-staff specialty policy will automatically terminate, without the right of access to the review, hearing and appeal procedures set forth in these Bylaws, upon termination or expiration of such Practitioner s contract or agreement with the Hospital. The provisions of contracts between Practitioners and the Hospital that address termination, relinquishment or resignation of Medical Staff membership or privileges shall prevail over these Bylaws and the Rules and Regulations, except that the contracts may not reduce any hearing rights granted when an action will be taken that must be reported to the Medical Board of California or the National Practitioner Data Bank. 2.5 NON-DISCRIMINATION Neither Medical Staff membership nor clinical privileges shall be denied on the basis of sex, race, age, creed, color or national origin. 2.6 BASIC RESPONSIBILITIES OF MEDICAL STAFF MEMBERSHIP Except for members assigned to the Honorary or Non-Clinical Staff, each Medical Staff member and each Practitioner exercising Temporary Privileges shall continuously satisfy each of the following responsibilities: (a) Providing patients with the quality of care meeting the professional standards of the Medical Staff of this Hospital, notwithstanding the patient s ability to pay; Abiding by the Medical Staff Bylaws, the general Rules and Regulations and the Member s Department Rules and Regulations; Discharging in a responsible and cooperative manner such reasonable responsibilities and assignments imposed upon the member by virtue of his Medical Staff membership, including Committee assignments; Preparing and completing medical records for all the patients to whom the member provides care in the Hospital within the time period set forth in these Bylaws and Rules and Regulations. 11

12 (e) (f) (g) (h) (I) (j) (k) (l) (m) (n) (o) (p) (q) Working cooperatively with members, nurses, Hospital administration and others so as not to adversely affect patient care; Refraining from disruptive behavior that does or might interfere with patient care or the orderly operation of the Hospital; Making appropriate arrangements for coverage for his patients as determined by the Medical Staff; Refusing to engage in improper inducements for patient referral; Participating in continuing education programs as determined by the Medical Staff; Participating in such emergency service coverage or consultation panels as may be determined by the Medical Staff; Discharging such other staff obligations as may be lawfully established from time to time by the Medical Staff or MEC; Agreeing to participate as a proctor if requested to do so by a MEC representative or by the Chairperson of a Department of the Medical Staff; Participating in peer review functions and cooperating in the Medical Staff s performance improvement activities and the Hospital programs that have been approved by the Medical Staff; Informing the Chief of Staff within 24 hours of any material changes in any information the member would be required to disclose on his appointment or reappointment application; Continuously meeting the qualifications for membership set forth in these Bylaws. A Member may be required to demonstrate continuing satisfaction of any of the requirements of these Bylaws upon the reasonable request of the MEC; and The physician is in control of the diagnosis, treatment, and management of a patient regardless of financial considerations. Responding to letters from Department and Committee Chairs within the lesser of the specified time or thirty (30) days. Failure to respond will result in a referral to the MEC. Failure to respond to a Medical Executive Committee request within the lesser of the time specified or thirty (30) days shall be deemed a Voluntary Resignation of membership and privileges from the medical staff. 2.7 HARASSMENT PROHIBITED (a) Harassment by a Medical Staff member against any individual (e.g., against another Medical Staff member, resident, house staff, volunteer vendor, Hospital employee or patient) on the basis of race, religion, color, national origin, ancestry, physical disability, mental disability, medical disability, marital status, sex, gender or sexual orientation shall not be tolerated. "Sexual harassment" is unwelcome verbal or physical conduct of a sexual nature that may include verbal harassment (such as epithets, derogatory comments or slurs), physical harassment (such as unwelcome touching, assault, or interference with movement or work), and visual harassment (such as the display of derogatory cartoons, drawings, or posters). Sexual harassment includes unwelcome advances, requests for sexual favors, and any other verbal, visual, or physical conduct of a sexual nature when (1) submission to or rejection of this conduct by an individual is used as a factor in decisions affecting hiring, evaluation, retention, promotion, or other aspects of employment; or (2) this conduct substantially interferes with the individual's employment or creates an intimidating, hostile, or offensive work environment. Sexual harassment also includes conduct that indicates that employment and/or employment benefits are conditioned upon acquiescence in sexual activities. All allegations of sexual harassment shall be immediately investigated by the Medical Staff and, if confirmed, will result in appropriate corrective action, from reprimands up to and including termination of Medical Staff privileges or membership, if warranted by the facts. 12

13 ARTICLE THREE CATEGORIES OF MEMBERSHIP 3.1 CATEGORIES The categories of the Medical Staff shall include the following: active, courtesy, provisional, honorary and non-clinical. At each time of appointment and/or reappointment, the Member's staff category shall be determined. 3.2 ACTIVE STAFF QUALIFICATIONS The Active Staff category shall consist of Members of the Medical Staff who: (a) Meet the general qualifications set forth in Section 2.2; (e) In the opinion of the MEC, are capable of providing appropriate continuity of quality care to hospitalized patients; Admit or, as determined by the appropriate department(s) and/or committee(s) of the Medical Staff, have significant patient contact (including outpatient procedures and surgeries) with an average of at least twenty-four (24) separate patient visits per reappointment cycle in the Hospital; Have satisfactorily completed their designated term in the provisional staff category; and Agree to act as a proctor when so requested by the member s department chairman or the Chief of Staff PREROGATIVES Except as otherwise provided, the prerogatives of an Active Medical Staff Member shall be to: (a) Admit patients and exercise such clinical privileges as are granted pursuant to Article VI of these Bylaws; Attend and vote on matters presented at general and special meetings of the Medical Staff and of the department and committees of which he is a member; and Hold staff or department office and serve as a voting member of committees to which he is duly appointed or elected by the Medical Staff or duly authorized representative thereof RECLASSIFICATION OF ACTIVE STAFF MEMBER If, at the time of reappointment, a member of the Active Staff fails to meet the qualifications of as determined by the Medical Staff, that Member shall be automatically reclassified to the appropriate staff category, if any, for which the Member is qualified. 3.3 COURTESY STAFF QUALIFICATIONS The Courtesy staff category shall consist of Members of the Medical Staff who: (a) Meet the general qualifications set forth in subsections (a),, and (e) of Section 3.2.1; Admit or, as determined by the appropriate department(s) and/or committee(s) of the Medical Staff, have significant patient contacts (including consultations, outpatient procedures, and/or surgeries) with an average of no less than eight (8) separate patient visits, but not more than twenty-three (23) separate patient visits per reappointment cycle. Staff members who do not meet the activity requirement as noted above shall be deemed to have immediately voluntarily relinquished privileges. Are members in good standing on the active Medical Staff of another California licensed hospital PREROGATIVES Except as otherwise provided, the prerogatives of a Courtesy Medical Staff Member shall be to: (a) Admit patients and exercise such clinical privileges as are granted pursuant at Article VI; and Attend in a non-voting capacity meetings of the general Medical Staff and the department of which he is a member, including educational programs, but shall have no right to vote at such meetings. A member of the Courtesy Staff shall not be eligible to hold office in the Medical Staff organization, but may serve upon its committee. 13

14 3.4 NON-CLINICAL STAFF QUALIFICATIONS The Non-Clinical Staff category shall consist of Members of the Medical Staff who: (a) To the extent applicable to the functions for which they are appointed to the Medical Staff, meet the general qualifications set forth in subsection (a) of Section 2.2.1; (shows the following): Serve the Medical Staff by performing a specific administrative function. Administrative functions may include but are not limited to assisting the Medical Staff in quality assessment and improvement, utilization review, assisting in Medical Staff hearings, and serving on Medical Staff Committees when appointed PREROGATIVES Except as otherwise provided, the prerogatives of a Non-Clinical Staff Member shall be to: (a) Refer an unlimited number of patients to Olympia Medical Center; Attend meetings of the Medical Staff, including open committee meetings and educational programs, but shall have no right to vote at such meetings except, within committees to which he or she has been duly appointed, when the right to vote is specified at the time of appointment. The limitations are, as follows: (a) May not admit patients, (e) Are not eligible to hold any clinical privileges May not vote or hold medical staff office May not examine patients or make entries in the medical records Staff members who do not meet the requirements, as noted above, shall be deemed to have immediately voluntarily relinquished Non-Clinical Staff status. In the event the member is not eligible for any other category, his or her medical staff membership shall automatically be terminated. The Chief of Staff or MEC may elect to excuse an applicant for Non-Clinical Staff from completing the application process or paying dues. 3.5 PROVISIONAL STAFF QUALIFICATIONS The Provisional staff category shall consist of Members of the Medical Staff who: (a) Meet the General Medical Staff membership qualifications set forth in Section 2.2; Are initial appointees to the Medical Staff and plan to qualify for, and seek transfer to, the Active, Courtesy or in six (6) to twelve (12) months. Staff members who successfully complete the proctoring requirements, must meet activity requirements for Courtesy or Active category criteria before their next reappointment or they shall be deemed to have immediately voluntarily relinquished their medical staff membership privileges PREROGATIVES Except as otherwise provided, the prerogatives of a Provisional Medical Staff Member shall be to: (a) Exercise such clinical privileges as are granted pursuant to Article VI; and Attend meetings of the Medical Staff and the department of which that person is a member, including educational programs, but shall have no right to vote at such meetings. A member of the Provisional Staff shall not be eligible to hold office in the Medical Staff organization, but may serve upon its committees OBSERVATION OF PROVISIONAL STAFF MEMBER Each Provisional Staff member shall undergo a period of observation as described in Section 6.3 of these Bylaws. The observation shall be to evaluate the member's (1) proficiency in the exercise of clinical privileges initially granted and (2) overall eligibility for continued staff membership and advancement within staff categories. Observation of Provisional Staff members shall follow whatever frequency and format each department deems appropriate in order to adequately evaluate the provisional staff member including, 14

15 but not limited to, concurrent or retrospective chart review, mandatory consultation, and/or direct observation. Appropriate records shall be maintained. The Department Chairman shall communicate the results of the observation to the MEC TERM OF PROVISIONAL STAFF STATUS A member shall remain on the Provisional staff for a period of not less than six (6) months nor more than twelve months. Failure to complete proctoring within the twelve-month period shall result in removal from staff. Members who are removed from the Medical Staff for failure to complete proctoring shall not be entitled to the hearing rights set forth in Article VIII of these Bylaws. A Provisional Staff member who is removed from staff for failure to complete proctoring shall not be allowed to reapply for staff for a period of one (1) year after the appointment date expires (must reapply as a new applicant). They will be assessed the customary application processing fee. 3.6 RESIDENT AND FELLOW STAFF The Resident Medical Director shall report to the Department of Surgery at least annually about the performance of it residents, patient safety issues, and quality of patient care. The Resident Medical Director shall provide a mechanism for resident staff participation in the development, review and evaluation of resident staff patient care responsibilities and functions to include quality assessment and improvement, measures taken to assure supervision, and progressive involvement in specific patient care activities RESIDENT AND FELLOW QUALIFICATIONS Residents and Fellows refer to practitioners who are currently enrolled in a graduate medical education program approved by the MEC and the Board of Governors and who, as part of their educational program, will provide supervised health care services at the Hospital. Residents and Fellows shall not be considered independent practitioners, and shall not be deemed members of the Medical Staff. Residents and Fellows may render patient care services at this Hospital only pursuant to and limited by the following: (a) Applicable provisions of the hospital licensing laws of this state; The written affiliation agreement between this Hospital and the sponsoring medical school or training program; such agreement shall identify the individual or entity responsible for providing professional liability insurance coverage for residents in amounts of $1,000,000 per occurrence/$3,000,000 aggregate; and The protocols established by the MEC, in conjunction with the sponsoring school or training program, regarding the scope of the Resident and/or Fellow s authority, direction and supervision of the Resident or Fellow and other conditions imposed upon the Resident or Fellow by this Hospital or its Medical Staff RESIDENT AND FELLOW PREROGATIVES (a) While functioning at this Hospital, Residents and Fellows shall abide by all provisions of the Medical Staff Bylaws and Rules and Regulations, as well as the Hospital and Medical Staff s Policies and Procedures, and shall be subject to limitation or termination of their ability to function at the Hospital at any time in the discretion of the Hospital Administrator or Chief of Staff. Residents and Fellows may perform only those services set forth in the training protocols developed by the applicable training program to the extent that such services do not exceed or conflict with the Medical Staff s Bylaws and/or Rules and Regulations or the Hospital or Medical Staff s Policies and Procedures, and to the extent approved by the Governing Body. Residents and Fellows shall be responsible and accountable at all times to a designated Member of the Medical Staff of this Hospital. Residents and Fellows shall be required to attend Medical Staff meetings when invited or as required and may be appointed to Medical Staff committees, but shall have no voting rights. The period of time served as a Resident or Fellow may not be considered in calculating the observational period required by Provisional Staff members. Resident and Fellow Staff membership automatically terminates with the Resident or Fellow s termination of the training program. As defined in the above paragraphs, Residents and Fellows are distinguished from practitioners who though currently enrolled in a graduate medical education program provide patient care services independently at the hospital (e.g. moonlighting or locum tenens coverage) and not as part of their educational program, such practitioners who provide independent services must meet 15

16 the qualifications for Medical Staff membership and privileges as provided in these Bylaws, and shall be credentialed in accordance with these Bylaws in the same manner as a practitioner seeking initial appointment to the Medical Staff. 3.7 HONORARY STAFF QUALIFICATIONS The Honorary Staff shall consist of physicians, dentists, podiatrists and clinical psychologists who either: (a) Do not actively practice at the Hospital but are deemed deserving of membership by virtue of their outstanding reputation, noteworthy contributions to the health and medical science or their previous longstanding service to the Hospital, and who continue to exemplify high standards of professional and ethical conduct; or Are retired from active practice and, at the time of their retirement, were members in good standing of the Medical Staff for a period of at least ten continuous years, and who continue to adhere to appropriate professional and ethical standards, and who request this appointment. Members of the Honorary Staff will not be required to pay Medical Staff dues PREROGATIVES Honorary Staff members are not eligible to admit patients to the Hospital or to exercise clinical privileges in the Hospital, or to vote or hold office in this Medical Staff organization, but they may serve upon committees with or without vote at the discretion of the MEC. They may attend staff and department meetings, including educational programs. 3.8 EXCEPTIONS AND LIMITATIONS TO PREROGATIVES LIMITED LICENSED PRACTITIONERS Regardless of the category of membership in the Medical Staff, Limited License Practitioners who are Members of the Medical Staff: (a) Shall only have the right to vote on matters within the scope of their licensure. In the event of a dispute over voting rights, that issue shall be determined by the chairman of the meeting, subject to final decision by the MEC; and Shall exercise clinical privileges only within the scope of their licensure and as set forth in Section 6.4 of these Bylaws LIMITATION OF PREROGATIVES IN INDIVIDUAL CASES The prerogatives set forth under each staff category are general in nature and may be subject to limitation by special conditions attached to a Practitioner's membership by other sections of these Bylaws, the Rules and Regulations of the Medical Staff and by other policies of the Hospital. 3.9 MODIFICATION OF MEMBERSHIP The MEC (a) on its own initiative, pursuant to a request by a Medical Staff Member pursuant to Section of these Bylaws or upon direction of the Board of Governors as set forth in Section of these Bylaws, may recommend a change in the Medical Staff category of a Member consistent with the requirements of the Bylaws PRIORITY ACCESS TO THE HOSPITAL FACILITIES At times of full occupancy or shortage of Hospital beds or other facilities, the elective patients of Active Staff members shall have priority over the elective admissions of other members. Members of the Provisional staff who have already admitted on average twelve (12) or more patients per year since their appointment and would otherwise be judged qualified for Active status shall have the next highest priority, followed by members of the Courtesy Staff, and then by members of the Provisional staff who have admissions on average of less than twelve (12) patients per year since their appointment. At all times, emergency patients shall have first priority based upon independent Medical Staff evaluation. Physicians who habitually abuse the emergency designation shall be subjected to corrective action under the terms of these Bylaws. Authority to implement these priority provisions shall rest with the Administrator of the Hospital on recommendation of the Chief of Staff. 16

17 ARTICLE FOUR APPOINTMENT AND REAPPOINTMENT 4.1 GENERAL Except as otherwise specified herein, no person (including persons engaged by the Hospital in administratively responsible positions) shall exercise clinical privileges in the Hospital unless and until that person has applied for and receives appointment to the Medical Staff or is granted temporary privileges as set forth in these Bylaws. By applying to the Medical Staff for appointment or reappointment (or, in the case of members of the Honorary or Non- Clinical staff, by accepting an appointment to that category), the applicant acknowledges responsibility to first review these Bylaws and Rules and Regulations and agrees that throughout any period of membership that person will comply with the responsibilities of Medical Staff membership and with the Bylaws and Rules and Regulations of the Medical Staff as they exist and as they may be modified from time to time. Appointment to the Medical Staff shall confer on the appointee only such clinical privileges as have been granted in accordance with these Bylaws and Rules and Regulations. 4.2 BURDEN OF PRODUCING INFORMATION In connection with all applications for appointment, reappointment, or advancement, the applicant shall have the burden of producing information and documents for an adequate evaluation of the applicant's qualifications and suitability for the clinical privileges and staff category requested, of resolving any reasonable doubts about these matters, and of satisfying requests for information and documents. The applicant's failure to sustain this burden shall be grounds for denial of the application. This burden may include submission to a medical or psychological examination, at the applicant's expense, if deemed appropriate by the MEC that may select the examining physician. 4.3 DURATION OF APPOINTMENT AND REAPPOINTMENT Except as otherwise provided in these Bylaws, initial appointments to the Medical Staff shall be for a period of up to two years. Reappointments shall be for a period of up to two years. 4.4 APPLICATION FOR INITIAL APPOINTMENT An applicant for initial appointment shall complete written application forms that have been recommended by the MEC and approved by the Board of Governors. The application forms shall request information regarding the applicant and document the applicant s agreement to abide by the Medical Staff Bylaws and Rules and Regulations. Copies of the Bylaws and Rules and Regulations shall be provided to the applicant or may be made available electronically or otherwise. The information shall be verified and evaluated by the Medical Staff using the procedure and standards set forth in these Bylaws and Rules and Regulations. Following its investigation, the MEC shall recommend to the Board of Governors whether to appoint, reappoint and grant specific privileges APPLICATION FORM An application form shall be recommended by the MEC, and shall require detailed information concerning at least the following: (a) The applicant's qualifications, including but not limited to, professional training and experience, demonstrated current clinical competence, current licensure, current DEA registration, and continuing medical education information related to the clinical privileges to be exercised by the applicant; (e) (f) (g) Peer reference(s) familiar with the applicant's professional competence and ethical character; Requests for membership categories and clinical privileges; Past and pending professional disciplinary actions, licensure limitations and related matters; Physical and mental health that could affect the applicant s ability to perform the privileges requested. Professional liability insurance, plus a list of any pending professional liability actions and any settlements or adverse judgments occurring within the past seven (7) years prior to the application; and Continuing education. Each application for initial appointment to the Medical Staff shall be in writing, submitted on the prescribed form with all provisions completed (or accompanied by an explanation of why answers are unavailable), and signed by the applicant. Each applicant shall be given a copy of, or access to a copy of, these Bylaws and the Rules and Regulations, both of which the applicant has the responsibility of reading. Each applicant must submit a current picture hospital ID card or a valid picture ID issued by a State or Federal agency (e.g. 17

18 drivers license or passport) to verify that the applicant is the person identified in the credentialing documents EFFECT OF APPLICATION In addition to the matters set forth in Section 4.1, by applying for appointment to the Medical Staff, each applicant: (a) Agrees to appear for interviews in regard to his/her application; Authorizes Medical Staff and Hospital representatives to consult with other hospitals, persons or entities who have been associated with him or her and/or may have information bearing on his/her competence and qualifications or that is otherwise relevant to the pending review and authorizes such persons to provide all information that is requested orally or in writing; Agrees to provide copies of and consents to inspection of records and documents that may be material, or may lead to the discovery of information that may be material, to an evaluation of the applicant's qualifications and ability to carry out the clinical privileges requested, and authorizes all individuals and organizations in custody of such records and documents to permit such inspections and copying; Certifies that he will immediately report and fully disclose to the Chief of Staff, via the Medical Staff Services Office, any subsequent changes in the information submitted on the application including without limitation any of the following: (I) Stayed and un-stayed suspension, revocation, restriction, modification or non-renewal of his license to practice medicine in California; (ii) (iii) (iv) (v) (vi) (vii) (viii) (ix) Any suspension, revocation, restriction, modification or non-renewal of his DEA or other controlled substances certificate; Any cancellation, material reduction or non-renewal of his/her professional liability insurance coverage; Receipt of written notice of any adverse action against him or her by the Medical Board of California taken or pending; Any adverse action against him or her by any Medical Staff health care facility or other organization which has resulted in the filing of a Section 805 report with the Medical Board of California, or a report with the National Practitioner Data Bank; The denial, revocation, suspension, reduction, limitation, non-renewal or voluntary relinquishment by resignation of his Medical Staff membership or clinical privileges at any hospital, health care facility or other Healthcare Organization; His receipt of written notice of any legal action against him or her, including without limitation any filed and served malpractice suit or arbitration action; His conviction, guilty plea, or no contest plea of any criminal law (excluding minor traffic violations); His receipt of written notice of any adverse action against him or her under the Medicare or Medicaid programs, including but not limited to, false claims, fraud and abuse proceedings or convictions; (e) (f) (g) Releases from any liability, to the fullest extent permitted by law, all persons and entities for acts performed in connection with investigating and evaluating the applicant; Releases from any liability, to the fullest extent permitted by law, all individuals and organizations who provide information regarding the applicant, including otherwise confidential information; Consents to the disclosure to other hospitals, medical associations, licensing boards, and to other similar organizations as required by law, any information regarding the applicant's professional or ethical standing that the Hospital or Medical Staff may have, and releases the Medical Staff, its representatives, the Hospital and its representatives from liability for so doing to the fullest extent permitted by law; 18