Medical Staff Bylaws

Transcription

1 Medical Staff Bylaws Allen Hospital Waterloo, IA Revised/Reviewed: November 2015 Previous editions: March, 2015, December, 2013, November 2011, December 2009, November 2007, November 2006, May 2006, December 2005, March 2004, Supersedes all previous editions.

2 TABLE OF CONTENTS ARTICLE I NAME... 1 ARTICLE II PURPOSES OF THE MEDICAL STAFF PURPOSES RESPONSIBILITIES INTERPRETATION... 2 ARTICLE III DIRECT ACTION BY THE BOARD OF DIRECTORS COMPLIANCE WITH BYLAW REQUIREMENTS ASSUMPTION OF DUTIES BY THE BOARD DIRECT ACTION BY THE BOARD ON SPECIFIC MATTERS... 2 ARTICLE IV MEDICAL STAFF MEMBERSHIP NATURE OF MEMBERSHIP GENERAL QUALIFICATIONS RESPONSIBILITIES OF INDIVIDUAL PRACTITIONERS TERM OF APPOINTMENT SPECIALTY SPECIFIC BOARD CERTIFICATION REQUIREMENTS... 5 ARTICLE V CATEGORIES OF MEDICAL STAFF MEDICAL STAFF ACTIVE STAFF QUALIFICATIONS PREROGATIVES OBLIGATIONS AFFILIATE MEMBERSHIP QUALIFICATIONS PREROGATIVES OBLIGATIONS TELEMEDICINE (Including Teleradiology) QUALIFICATIONS PREROGATIVES PROVISIONAL PERIOD EFFECT ON APPOINTMENT OR EXERCISE OF PRIVILEGES FOCUSED PROFESSIONAL PRACTICE EVALUATION... 8 ARTICLE VI APPOINTMENT PROCEDURE APPLICATION ELIGIBILITY APPLICATION FEE EFFECT OF APPLICATION PROCESSING THE APPLICATION PROCEDURE SERVICE LINE LEADER REVIEW EFFECT OF CREDENTIALS COMMITTEE AND MEDICAL EXECUTIVE COMMITTEE ACTION BOARD ACTION BASIS FOR RECOMMENDATIONS AND ACTION ARTICLE VII CLINICAL PRIVILEGES EXERCISE OF PRIVILEGES DELINEATION OF PRIVILEGES IN GENERAL REQUESTS: BASIS FOR PRIVILEGES DETERMINATION: TEMPORARY PRIVILEGES i

3 7.3.1 CIRCUMSTANCES CONDITIONS TERMINATION OF TEMPORARY PRIVILEGES RIGHTS OF THE PRACTITIONER WITH TEMPORARY PRIVILEGES EMERGENCY PRIVILEGES DISASTER PRIVILEGES RECORDS OF CLINICAL PRIVILEGES ALTERNATE COVERAGE PRIVILEGES FOR NEW PROCEDURES MODIFICATION OF PRIVILEGES RECOMMENDATION OF SERVICE LINE ARTICLE VIII REAPPOINTMENT PROCEDURES QUALIFICATIONS INFORMATION COLLECTED AND VERIFICATION FROM STAFF APPOINTEES FROM INTERNAL AND/OR EXTERNAL SOURCES SERVICE LINE LEADER/MEDICAL DIRECTOR REVIEW CREDENTIALS COMMITTEE ACTION MEDICAL EXECUTIVE COMMITTEE ACTION FINAL PROCESSING AND BOARD ACTION BASIS FOR RECOMMENDATIONS AND ACTIONS REQUEST FOR MODIFICATION OF APPOINTMENT STATUS SPECIAL REQUIREMENTS REAPPOINTMENT ENTITLEMENT LEAVE OF ABSENCES RESIGNATION MEDICAL STUDENTS AND RESIDENTS STUDENTS RESIDENTS ARTICLE IX HISTORY & PHYSICAL ARTICLE X CORRECTIVE ACTION ROUTINE CORRECTIVE ACTION REQUESTS AND NOTICES INTERVIEWS PRIOR TO CORRECTIVE ACTION INVESTIGATION MEDICAL EXECUTIVE COMMITTEE ACTION DEFERRAL PROCEDURAL RIGHTS OTHER ACTION AUTOMATIC SUSPENSION STATE LICENSE DRUG ENFORCEMENT (DEA) PROFESSIONAL LIABILITY INSURANCE PROFESSIONAL REVIEW BODIES MEDICARE/MEDICAID EXCLUSION MEDICAL EXECUTIVE COMMITTEE RECOMMENDATION PRECAUTIONARY SUSPENSION SUMMARY SUSPENSION MEDICAL EXECUTIVE COMMITTEE ACTION PROCEDURAL RIGHTS OTHER ACTION ii

4 ARTICLE XI FAIR HEARING PLAN STATEMENT OF POLICY DEFINITIONS INITIATION OF A HEARING NOTICE OF ADVERSE RECOMMENDATION OR ACTION REQUEST FOR A HEARING HEARING COMMITTEE HEARING PROCESS HEARING COMMITTEE REPORT EFFECT OF FAVORABLE RESULTS EFFECT OF ADVERSE RESULT APPELLATE REVIEW APPELLATE REVIEW PROCEDURE FINAL DECISION OF THE BOARD GENERAL PROVISIONS AMENDMENT ARTICLE XII PRACTIONER HEALTH GENERAL REQUIREMENTS IMPAIRED PHYSICIAN ARTICLE XIII CONFIDENTIALITY, IMMUNITY AND RELEASES AUTHORIZATIONS AND CONDITIONS CONFIDENTIALITY IMMUNITY FROM LIABILITY ACTIVITIES AND INFORMATION COVERED ACTIVITIES AND INFORMATION RELEASES CUMULATIVE EFFECT ARTICLE XIV OFFICERS OFFICERS QUALIFICATIONS NOMINATION AND ELECTION OF OFFICERS PRESIDENT OF THE MEDICAL STAFF PRESIDENT-ELECT PAST PRESIDENT VACANCIES AND REMOVAL OF OFFICERS VACANCIES REMOVAL OF OFFICERS INDEMNIFICATION OF OFFICERS ARTICLE XV SERVICE LINES DELINEATION OF SERVICE LINE CRITERIA FOR CLINICAL PRIVILEGES FUNCTIONS OF SERVICE LINES SERVICE LINE LEADER/MEDICAL DIRECTOR QUALIFICATIONS SELECTION DUTIES OF THE SERVICE LINE LEADER/MEDICAL DIRECTOR REMOVAL OF A SERVICE LINE LEADER/MEDICAL DIRECTOR ARTICLE XVI COMMITTEES STANDING AND SPECIAL COMMITTEES THE MEDICAL EXECUTIVE COMMITTEE MEMBERSHIP iii

5 OFFICERS MEDICAL STAFF REPRESENTATION FUNCTIONS ACTIONS MEETINGS MINUTES CREDENTIALS COMMITTEE FUNCTIONS MEMBERSHIP MEETINGS REPORTS PERFORMANCE IMPROVEMENT COMMITTEE CHAIR MEMBERS FUNCTIONS REPORTS MINUTES MEETINGS TRAUMA SERVICES COMMITTEE CHAIR MEMBERSHIP FUNCTIONS MEETINGS MINUTES REPORTS PERINATAL COMMITTEE CHAIR MEMBERSHIP FUNCTIONS MEETINGS MINUTES ETHICS COMMITTEE MEMBERSHIP FUNCTIONS MEETINGS MINUTES ARTICLE XVII MEDICAL STAFF MEETINGS MEETINGS SPECIAL MEETING WITH HOSPITAL BOARD OF DIRECTORS CLOSED MEETINGS QUORUM SPECIAL APPEARANCES ARTICLE XVIII MEDICAL STAFF AND DEPARTMENTAL POLICIES, RULES, AND REGULATIONS ARTICLE XIX AMENDMENTS TO BYLAWS ARTICLE XX ADOPTION iv

6 ALLEN HOSPITAL MEDICAL STAFF BYLAWS ARTICLE I NAME The Name of the Organization shall be the Medical Staff of Allen Hospital. ARTICLE II PURPOSES OF THE MEDICAL STAFF 2.1 PURPOSES A. Provide an organization of Hospital Medical Staff members for prescribed interrelationships with the Hospital Board of Directors and the various departments within the Hospital. B. Promote excellent patient care. C. Recognize and define qualifications for granting practice privileges in the Hospital. D. Oversee and regulate the practice of healing arts within the Hospital. E. Inform the Board of Directors of the Hospital concerning the appropriateness of patient care and practitioner conduct. F. Provide a means by which members of the Medical Staff can formulate recommendations for the Hospital s policy-making and planning processes. G. Better quality, better patient experience, at an affordable cost 2.2 RESPONSIBILITIES To accomplish the above purposes, it is the obligation and responsibility of the organized Medical Staff to: A. The Organized Medical Staff has a leadership role in hospital performance improvement activities to improve quality of care, treatment, and services and patient safety. B. Make recommendations to the Hospital Board of Directors regarding Medical Staff appointment, service line assignments, clinical privileges and criteria for reappointment. C. Enforce compliance with medical and Hospital staff regulations. D. Cooperate with the Board of Directors of the Hospital in long-range planning to meet future health care needs of the community. E. Provide a continuing program of professional education, or give evidence of participation in such a program. There may be a program of continuing medical education designed to keep the Medical Staff informed of significant new developments and new skills in medicine. Medical Staff education should include Hospital-based programs as well as educational opportunities outside of the Hospital. Documentation of these activities should be kept in order to evaluate the scope, effectiveness, attendance and amount of time spent at such efforts. 1

7 2.3 INTERPRETATION These Bylaws do not constitute a contract. They represent a formal policy of the Medical Staff as recommended by the Medical Staff and adopted by the Board for the purpose of discharging the responsibilities delegated by the Board and stated above. These Bylaws and industry custom afford substantial substantive and procedural protection to individuals in connection with membership and privilege issues, and the Medical Staff and the Hospital are committed to respecting the rights of those individuals. ARTICLE III DIRECT ACTION BY THE BOARD OF DIRECTORS 3.1 COMPLIANCE WITH BYLAW REQUIREMENTS The procedures set forth in these Bylaws will be followed to the extent reasonably possible. 3.2 ASSUMPTION OF DUTIES BY THE BOARD If the Board of Directors of the Hospital determines, after consultation with the Medical Staff officers, that the Medical Staff Executive Committee is unwilling or unable to effectively discharge its responsibilities under the Medical Staff Bylaws in a particular case, the Board of Directors of the Hospital itself may assume and carry out the responsibilities of the Medical Staff Executive Committee under these Bylaws. In such case the Board may appoint any individuals it deems appropriate to assume and carry out the specific powers and responsibilities which would otherwise be assigned to the President of the Medical Staff and/or Medical Staff Executive Committee, under the provisions of these Bylaws. The persons so appointed, while acting in such capacity, shall have all privileges, immunities and other protections available pursuant to these Bylaws. 3.3 DIRECT ACTION BY THE BOARD ON SPECIFIC MATTERS The Board reserves the right to enforce the Medical Staff Bylaws, Standard Operating Procedures (SOPs) and general health and safety standards of Hospital-wide significance, with or without prior notice to the Medical Staff. This may be particularly appropriate where the Bylaw, rule or standard is outside the responsibility delegated by the Board to the Medical Staff, or is within an area of shared responsibility, and concerns behavior which can be evaluated as well by Board members or by health professionals. The Chair of the Board or the President/CEO shall first attempt to notify the Medical Staff President or designee before undertaking direct action. In the case of direct action under this section, the Board or the President/CEO shall establish a procedure for considering and implementing direct action. When the proposed action is one which would have entitled the practitioner to a fair hearing, the direct action shall include the provision for a hearing before a committee appointed by the Board. 2

8 The hearing shall be prosecuted by a representative of the Medical Staff designated by the Medical Staff Executive Committee. The hearing panel shall solicit the position and opinion of the Medical Staff through its appointed representative. The provisions of the Fair Hearing Plan shall apply whenever a practitioner has the right to request a hearing under this Plan. ARTICLE IV MEDICAL STAFF MEMBERSHIP 4.1 NATURE OF MEMBERSHIP Membership to the Medical Staff of Allen Hospital is a privilege extended only to professional, competent practitioners who continuously meet the qualifications, standards and requirements as set forth in these Bylaws and the Rules and Regulations of the Medical Staff. 4.2 GENERAL QUALIFICATIONS The following qualifications constitute the basic requirements for appointment to the Medical Staff. A. A valid current license issued by the State of Iowa for the practice of medicine, dentistry or podiatry. B. Have successfully completed one year of postgraduate training in a hospital-affiliated program accredited by the ACGME, AOA, Royal College of Physicians and Surgeons of Canada, and the College of Family Physicians of Canada. C. Documented education, training and clinical experience to indicate professional competence. D. Board certification as detailed in Section 4.5. E. Proof of current malpractice liability insurance is required for membership in amounts jointly agreed upon by the Medical Executive Committee and the Board of Directors of the Hospital. (Staff Rules & Regulations Article XXIII) This coverage must be provided by a Company licensed or approved to do business in the State of Iowa. Members will submit to the hospital annually a certificate of insurance that verifies compliance with this requirement. Failure to maintain the amount of professional liability insurance or its equivalent, if any, as required by a Practitioner s membership and clinical privileges, after written warning of delinquency, shall be automatic suspension for that Practitioner, and he or she shall remain so suspended until he or she provides evidence to that professional liability coverage has been secured in the amount required. Failure to provide such evidence within one (1) month after the expiration of such coverage shall automatically cause voluntary resignation of the Practitioner s Medical Staff membership. F. Adherence to recognized standards of professional ethics and responsibility in the care of patients. G. Freedom from, or adequate control of (including any accommodations which can be reasonably made by the Hospital to the extent required by law), any significant physical, mental or behavioral impairment that interferes with satisfactory professional performance in the Hospital. H. Any person seeking membership or reappointment to the Medical Staff shall be 3

9 considered individually. Appointment to the Medical Staff shall not be automatically granted because of membership in other organizations or because of educational accomplishments alone. I. Applicants for appointment or reappointment to the Medical Staff must demonstrate a willingness to participate in the orderly functioning of the Medical Staff and of the Hospital. J. Granting of Medical Staff privileges or membership shall not be denied regardless of an individual s race, color, creed, age, sex, sexual orientation, national origin or religion. K. An applicant for Active Staff membership should reside within a 30 minutes of the Hospital, or be affiliated with physicians with appropriate privileges who reside within 30 minutes, so as to provide continuous care for patients as indicated in Article I-Admission in the Rules and Regulations of the Medical Staff. See also Section 7.7 Alternate Coverage. L. Practitioner must practice a healthcare specialty which is consistent with the purposes, treatment philosophy, methods and resources of the Hospital and its medical and professional staff and for which the Hospital has a demonstrated need for additional practitioner. 4.3 RESPONSIBILITIES OF INDIVIDUAL PRACTITIONERS Each member of the Medical Staff and each practitioner granted temporary privileges shall: A. Provide patients with care at generally recognized standards. B. Abide by the Medical Staff Bylaws and all other lawful standards, policies, procedures, rules, and regulations of the Medical Staff and Hospital and all applicable Iowa and federal laws and regulations; C. Prepare and complete medical and other records for patients cared for in the Hospital as prescribed by these Bylaws. D. Abide by recognized standards of professional ethics. E. Satisfy continuing education requirements established by State law. F. Comply with reporting of immunizations as required by Federal, State and regulatory requirements. G. Adhere to the Red Rules H. Notify the Hospital President or designee within twenty-four (24) hours of each of the following events and provide such additional information as may be requested regarding: 1. Voluntary or involuntary revocation, limitation, or suspension of his/her professional license, Drug Enforcement Administration (DEA) registration, or Iowa Controlled Substances Act (CSA) certificate (if applicable); any reprimand or other disciplinary action taken by any state or federal government agency relating to his/her professional license; or the imposition of terms of probation or limitation by any state; 2. Voluntary or involuntary loss or restriction of staff membership or privileges at any hospital or other health care institution, whether temporary or permanent, including all suspensions; 4

10 3. Voluntary or involuntary cancellation or change of professional liability insurance coverage; 4. Receipt of a quality inquiry letter, an initial sanction notice, notice of proposed sanction or of the commencement of a formal investigation or the filing of charges relating to health care matters by a Medicare peer review organization, the Department of Health and Human Services, or any law enforcement agency or health regulatory agency of the United States or the State of Iowa; 5. Receipt of notice of the filing of any suit against the Practitioner alleging professional liability in connection with the treatment of any patient in or at the Hospital; and 6. Receipt of notice of any state or federal felony charges or convictions. Failure to provide the above information within 24 hours may constitute grounds for automatic withdrawal of an Applicant s application or automatic termination of a Member s Clinical Privileges and Medical Staff membership. Applicants whose applications are deemed withdrawn pursuant to this provision and Members whose Clinical Privileges and membership are terminated pursuant to this provision are not entitled to fair hearing and appeal rights. 4.4 TERM OF APPOINTMENT All appointments will not exceed two (2) years. 4.5 SPECIALTY SPECIFIC BOARD CERTIFICATION REQUIREMENTS Members of the Medical Staff will have completed an approved AOA or ACGME medical residency program; CPME approved podiatric residency program, or an ADA accredited dentistry program. Board certification must be obtained prior to the end of the fifth year of medical staff membership. Members of the Medical Staff in good standing prior to January 1, 1993 and general dentists are exempt from the Specialty Board Certification requirement. If a physician has not achieved Board Certification within a five-year period, he/she may be allowed to continue membership and privileges upon the recommendations of both the Credentials Committee, the Medical Staff Executive Committee, and at the sole discretion of the Board of Directors of the Hospital. Re-certification must be obtained as established by the certifying board relevant to the clinical practice application. Failure to re-certify in a previously certified medical specialty will be considered by the Credentials Committee on an individual basis but may constitute a voluntary relinquishment of privileges and membership. The certifying agency shall be recognized by one of the following organizations: A. American Board of Medical Specialties B. American Osteopathic Association C. American Board of Oral and Maxillofacial Surgery D. American Board of Physician Specialties 5

11 E. American Board of Podiatric Surgery F. Royal College of Physicians and Surgeons of Canada G. College of Family Physicians of Canada ARTICLE V CATEGORIES OF MEDICAL STAFF 5.1 MEDICAL STAFF The Medical Staff membership shall be divided into Active and Affiliate. 5.2 ACTIVE STAFF QUALIFICATIONS An Active Staff member must: A. Meet the general qualifications for membership set forth in these Medical staff bylaws and specifically in Article IV. B. Be involved in the care of patients in the Hospital (including Hospital owned clinics or outpatient services) PREROGATIVES An Active Staff member shall be able to: A. Admit and care for patients as provided in the Medical Staff Rules and Regulations. B. Vote on all matters presented at general and special meetings of the Medical Staff and of the service line and committees of which the Practitioner is a member. C. Hold any office in the Medical Staff organization and be chair of committees. (must have completed Focused Professional Practice Evaluation (FPPE)) D. Exercise clinical privileges granted as provided herein OBLIGATIONS An Active Staff member must: A. Participate in the affairs of the Medical Staff, faithfully performing the duties of any office or position to which elected or appointed. B. Participate in the peer review, utilization review, and other performance evaluation and monitoring activities required of the Medical Staff. C. Discharge the recognized functions of Medical Staff membership by giving consultation to other Staff members consistent with the Practitioner s delineated privileges, providing backup coverage for the emergency department consistent with the Practitioner s training, supervising practitioners during the FPPE (Medical Staff Rules and Regulations Focused Professional Practice Evaluation article) and fulfilling other Medical Staff functions as may reasonably be required of Medical Staff members. D. May attend regular and special meetings of the Medical Staff and of the service line and committees of which the Practitioner is a member. E. Work with others within his or her specialty to ensure constant coverage for the community in that specialty. 6

12 F. Pay Medical Staff fees and fines. G. Be able to personally provide patient coverage at the Hospital within a 30 minute time-frame, or submit in writing from an equivalent specialist that back-up coverage is provided. H. Comply with all mandatory Federal and State requirements related to patient care. I. Provide primary and secondary means of communication. J. Notify President of Medical Staff or designee of any mental or physical impairment or other form of exclusion or discrimination that may affect your practice of medicine or place patients at risk. This could include chemotherapy, central nervous system diseases, cardiac disease, major trauma or infectious disease. 5.3 AFFILIATE MEMBERSHIP QUALIFICATIONS A. Meet the general qualifications for membership set forth in these Medical staff bylaws and specifically in Article IV. B. Does not actively admit or provide consultation for patients at Allen Hospital, but may refer patients to active members of the Medical Staff PREROGATIVES A. A physician who does not actively admit or provide consultation for patients at Allen Hospital, but may refer patients to members of the Medical Staff. B. May hold the position of a medical director for a physician or hospital organization, but does not actively practice. C. May make courtesy calls on his/her specific hospitalized patients, but may not write orders for care. D. May attend Medical Staff, service line or committee meetings. E. May not hold office, does not have voting privileges. F. May participate in the peer review, utilization review, and other performance evaluation and monitoring activities required of the Medical Staff. G. Receive copies of operative reports, discharge summaries, or other pertinent information for his/her patients OBLIGATIONS A. Pay Medical Staff fees and fines. 5.4 TELEMEDICINE (Including Teleradiology) QUALIFICATIONS A. Meet the general qualifications for membership set forth in these Medical staff bylaws and specifically in Article IV Items A-J and Item K. B. Are contracted by the hospital to provide services,, to hospital patients solely by telemedicine link C. Are credentialed in accordance with the processes described in these bylaws Or D. Are credentialed by the hospital through verification of privileges held by the practitioner at the distant site, if the practitioner is credentialed at a distant site that is 7

13 Joint Commission accredited and meets the CMS Conditions of Participation PREROGATIVES A. not eligible to vote, to hold office or to serve on Medical Staff Committees and B. not permitted to admit patients to the hospital. 5.5 PROVISIONAL PERIOD EFFECT ON APPOINTMENT OR EXERCISE OF PRIVILEGES During the provisional period, a practitioner must demonstrate all of the qualifications, may exercise all of the prerogatives, must fulfill all of the obligations of the staff category, and may exercise all of the clinical privileges granted to the practitioner FOCUSED PROFESSIONAL PRACTICE EVALUATION During the first 6 months of a new members appointment (or for a new privilege), the practitioner performance is reviewed as part of a collegial process of evaluation and performance improvement by the Service Line Leader/Medical Director or their designee. The Service Line Leader/Medical Director or designee is expected to report to the Credentials Committee their findings and recommendations. Successful completion of this period of review will grant to the practitioner the right to advance to medical staff leadership positions including Service Line Leader/Medical Director, department chair, or medical staff officer, as appointed by the President of the Medical Staff. If, after review, the Credentials committee makes a negative recommendation to Medical Executive Committee, the procedural rights to Fair Hearing are available to the practitioner. (Refer to Medical Staff Rules and Regulations Focused Professional Practice Evaluation Article) ARTICLE VI APPOINTMENT PROCEDURE 6.1 APPLICATION An application for staff appointment and/or for the granting of clinical privileges will be provided to eligible applicants upon receipt of adequate preliminary information confirming the applicant s eligibility for staff appointment. The application for appointment is to be submitted by the applicant. The application must be in writing and on such form as designated by the Credentials Committee and approved by the Medical Executive Committee. The applicant will be provided access to a copy of the Medical Staff Bylaws and its accompanying manuals and the applicable policies prior to the application being submitted. The application will include a notification of the scope and extent of authorization, confidentiality, immunity and release provisions of the Medical Staff Bylaws. 6.2 ELIGIBILITY If an applicant is denied Medical Staff appointment or the granting of clinical privileges requested, or if a practitioner s appointment or privileges are terminated as a result of an adverse recommendation by the staff, the applicant is ineligible to reapply for appointment to the Medical Staff or for the granting of the clinical privileges for a period of two years from the date 8

14 that the denial or adverse recommendation is final, unless, for good cause, the Credentials Committee waives the period of ineligibility. 6.3 APPLICATION FEE Applicants to the medical staff shall be required to pay an application fee. The fee must be submitted with the application. Reapplication after withdrawal constitutes a new application. 6.4 EFFECT OF APPLICATION The applicant must sign the application and in so doing: Consents and agrees that the Hospital or Medical Staff representatives may consult with others who have information bearing on the applicant s competence and qualifications and receive copies of documents that relate to an evaluation of the applicant s 1) professional qualifications and competence, 2) ability to perform and 3) professional and ethical reputation to carry out the clinical privileges requested. Agrees to release from liability, expense or cost: 1) the Hospital and Hospital or Medical Staff representatives for their acts performed in good faith and without malice in connection with evaluation of the applicant and 2) individuals and organizations who provide information to the Hospital or Medical Staff representatives in good faith and without malice. Consents and agrees to the Hospital or Medical Staff representatives providing other hospitals, medical associations, licensing boards, the National Practitioner Data Bank and other organizations concerned with provider performance and the quality and efficiency of patient care with information relevant to such matters that the Hospital may have relating to the applicant if the information is required to be provided by law or regulation or if a release for the information is obtained; and releases the Hospital or Medical Staff and its representatives from liability, expense or cost for so doing, provided that the furnishing of information is done in good faith and without malice. Agrees to abide by the current Medical Staff Bylaws, Medical Staff Rules & Regulations, Allied Health Manual, Credentialing Criteria Manual and Medical Staff Policies. Agrees to appear for interviews in regard to the application. Certifies that the information provided in the application is true, complete and accurate to the best of the applicant s knowledge and belief and, if found to be false or materially inaccurate, may subject the applicant to disciplinary proceedings or revocation of appointment and/or clinical privileges. For purposes of this Section, the term Hospital representatives or Hospital or Medical Staff representatives includes the board of directors, its directors and committees; the President/CEO or designee; and other employees or officers of the Hospital; the Medical Staff and all Medical Staff appointees or representatives; service line and committees which have responsibility for 1) collecting or evaluating the applicant s credentials, experience, or other qualifications or background information or 2) acting upon the application. 9

15 6.5 PROCESSING THE APPLICATION PROCEDURE Upon request, eligible applicants will be given an application for appointment to the Medical Staff, a request form for the granting of clinical privileges and a detailed list of requirements for completion of the application. The applicant will be provided access to a copy of the complete set of Medical Staff Bylaws and manuals. The applicant has the responsibility and burden to complete the application and to provide all documentation requested in the application or in the application process. Documentation necessary to complete an application shall consist of the following: an accurately completed, signed application form and request for privileges; a copy of current Iowa license and, where applicable, a copy of the applicant s DEA number or certificate, State of Iowa Controlled Substances Registration Certificate; evidence of current professional liability insurance with limits of liability in accordance with that stipulated by the Board of Directors of the Hospital; copies of certificates or letters confirming satisfactory completion of an approved residency/training program or other educational curriculum; documentation of Board certification or of eligibility for Board Certification. names of three persons who have recently worked with the applicant, and have directly observed professional performance for at least one year, and who can and will provide complete, reliable information regarding current clinical activity and skill, professional and ethical character and ability to work with others; sufficient evidence of verification of identity, including a current photograph; previously successful or currently pending challenges to any licensure or registration (state or district, Drug Enforcement Administration) or the voluntary relinquishment of such licensure or registration; voluntary or involuntary termination of Medical Staff membership or voluntary or involuntary limitation, reduction, or loss of clinical privileges at another hospital; or any investigations related to Medical Staff membership or clinical privileges; final judgments or settlements in a professional liability action involving the individual or any pending professional liability lawsuits; evidence of appropriate personal qualifications to include a record of applicant s observance of ethical standards including, without limitation: abstinence from any participation in fee splitting or other payment, receipt or remuneration with respect to referral or patient service opportunities a record of professionally and harmoniously working with others within an institutional setting information regarding Medicare/Medicaid sanctions including both current and pending investigations and challenges information regarding any removal from a managed care organization s panel for quality of care reasons or unprofessional conduct disclosure of any current clinical charges pending and any past charges and any convictions of misdemeanors or felonies Confirmation that the applicant has the physical and mental ability to perform the privileges requested. 10

16 Documentation of tuberculosis screening as required by Allen Hospital policies and procedures. Certification and re-certification in life saving techniques as required by each service line. Documentation of attendance at mandatory education programs as required by state and federal law, i.e. HIPAA. Continuing Medical Education credits for the previous two (2) years with part of them related to privileges requested. Upon receipt of a completed application, the Medical Staff Office will seek to verify its contents and collect additional information including but not limited to: completed reference questionnaires from significant past practice settings; completed reference questionnaires from three peer references given by applicant; verification of licensure status; A criminal history check shall be performed Confirmation with the Office of Inspector General (OIG) of eligibility for participation in the Medicare/Medicaid programs will be performed. Information from recognized physician reference or data banks concerning the applicant s educational or professional history or record. NOTE: In the event of undue delay in obtaining required information, the Medical Staff Office will request assistance from the applicant. During this time period, the time periods for processing the application will be appropriately modified. Failure of an applicant to adequately respond to a request for assistance will, after thirty days, result in termination of the application process and the Hospital will deem the application withdrawn, unless, for good cause, the applicant requests an additional thirty days to respond to the request for information. 6.6 SERVICE LINE LEADER REVIEW When verification is completed, within sixty (60) days after receipt of the application containing the above information, the application shall be reviewed by the specialty representative(s) and/or Service Line Leader(s)/Medical Director(s). The Service Line Leader(s)/Medical Director(s) may request interviews, additional information as needed. The application is then submitted to the Credentials Committee for membership and privilege consideration, along with comments for additional information, etc. 6.7 EFFECT OF CREDENTIALS COMMITTEE AND MEDICAL EXECUTIVE COMMITTEE ACTION 1. The Credentials Committee shall examine the submitted evidence, along with comments from the reviewer(s) and determine whether to accept the recommendations, request additional information or continue an investigation. When all concerns/questions have been completed, the Credentials Committee will forward its recommendation to the Medical Staff Executive Committee for privileges within sixty (60) days. 11

17 2. Inadequate information: If the service line leader/medical director, the Credentials Committee, or the Medical Staff Executive Committee, has not received all requested information, the application may be deemed withdrawn. Withdrawal of an application does not trigger the practitioner rights available under the Medical Staff Fair Hearing Plan. 3. Medical Staff Executive Committee: At its next regular meeting after receiving the report of the Credentials Committee, the Medical Staff Executive Committee shall formulate a recommendation to the Board of Directors of the Hospital. If unfavorable, the procedure specified below shall be followed. 4. Reconsideration: When the Medical Staff Executive Committee determines that the application should be deferred for further consideration, it must be followed within thirty (30) days by a subsequent recommendation for appointment with specified clinical privileges or for rejection of membership. The applicant shall have fifteen (15) days following receipt of the written notice of the initial adverse recommendations in which to submit his/her written request for reconsideration, failing which the applicant shall be deemed to have accepted the initial adverse recommendation of the Medical Staff Executive Committee, and it shall be treated as the final recommendation and transmitted to the Board. 6.8 BOARD ACTION 1. Final action by the Board: The President of the Medical Staff shall forward all recommendations, along with all supporting documents to the Board of Directors of the Hospital. 2. Within thirty (30) days after receipt of all recommendations, the Board of Directors of the Hospital shall make the final decision concerning appointment. 3. If the decision of the Board is favorable, the President/CEO of the Hospital will so notify the practitioner in writing. 4. If the decision of the Board is negative, the President/CEO of the Hospital will notify the practitioner in writing. 5. The practitioner may, if unwilling to adhere to the Board s decision, exercise the rights available under the Medical Staff Fair Hearing Plan. 6. Withdrawal: By submission of a written notice, an applicant may at any time withdraw his/her application from further consideration in which case the application shall not be transmitted to the Board of Directors of the Hospital for action. 6.9 BASIS FOR RECOMMENDATIONS AND ACTION The report of each individual or group, including the Board, required to act on an application must state the reasons for each recommendation or action taken, with specific reference to the completed application and all other documentation considered. Any dissenting views at any point in the process must also be documented, supported by reasons and references, and transmitted with the majority report. 12

18 ARTICLE VII CLINICAL PRIVILEGES 7.1 EXERCISE OF PRIVILEGES Members of the Medical Staff shall limit their professional activities in the Hospital to the exercise of those privileges granted by the Board of Directors of the Hospital after review and recommended by the Medical Staff Executive Committee. Consultation must be obtained when required for the welfare of a patient and when required by Medical Staff or Hospital rules. 7.2 DELINEATION OF PRIVILEGES IN GENERAL REQUESTS: Each application for appointment or reappointment to the Medical Staff or for the granting of clinical privileges must contain a request for specific clinical privileges desired by the applicant. Specific requests must also be submitted for temporary privileges and for modification of privileges in the interim between reappointments BASIS FOR PRIVILEGES DETERMINATION: Requests for clinical privileges will be evaluated on the basis of education, training, experience and demonstrated competence, ability and judgment. Also considered will be the ability of the Hospital to provide adequate facilities and support services and the Hospital s patient care needs for additional professionals with the person s skill and training. The basis for privileges determination to be made in connection with periodic reappointment or a requested change in privileges must include evaluation of clinical performance and documented results by the staff s quality assessment program activities. Privileges determinations will also be based on pertinent information from other sources, especially other institutions and healthcare settings where a professional exercises clinical privileges. The information will be added to and maintained in the Medical Staff file established for the staff appointee or clinical privilege grantee. 7.3 TEMPORARY PRIVILEGES CIRCUMSTANCES Temporary privileges may be granted under these circumstances: (a) fulfill an important patient care need (b) when an applicant with a complete, clean application is awaiting review and approval of the medical staff executive committee and the governing body The President /CEO of the Hospital and the President of the Medical Staff or in the absence of the President of the Medical Staff the President-Elect or Immediate Past President may grant temporary privileges for a limited period of time in the following circumstances: Pendency of Application: When an applicant with a complete, clean application is awaiting review and approval of the Medical Executive Committee and the governing body for a limited period of time not to exceed 120 days. A clean application means the applicant must have a complete application, no challenges to his or her licensure or registration, not been involuntarily terminated from the medical staff at another organization and no history of limited, reduced, denied or lost clinical privileges. Successful candidates will be granted core privileges within 13

19 their specialty. Special requests may be granted on an individual basis by the Credentials Committee. Care of Specific Patients: When there is an important patient care need that mandates an immediate authorization to practice. Such cases would include, but are not limited to, the following: A practitioner becomes ill or takes a leave of absence and needs another practitioner to cover his or her practice. A practitioner has specific medical skills to fulfill a particular patient need that no other practitioner on staff possesses. Appropriate information regarding the individual must be obtained as outlined in Section CONDITIONS Temporary privileges may be granted only in the circumstances described in this Section and only: to an eligible and appropriately-licensed practitioner otherwise qualified under the Bylaws; when available information supports a favorable determination regarding the requesting practitioner s qualifications, ability and judgment to exercise the privileges requested; and After the practitioner has satisfied the professional liability insurance requirement of the Bylaws and the Board of Directors of the Hospital. Requirements for observation, consultation and/or reporting may be imposed on the temporary practitioner by the Credentials Committee and/or Medical Executive Committee responsible for supervision. Temporary privileges will not be granted unless the practitioner has agreed in writing to abide by the Bylaws, manuals and policies of the staff and the Hospital in all matters related to his or her temporary privileges TERMINATION OF TEMPORARY PRIVILEGES The President of the Medical Staff or the President/CEO of the Hospital shall, on the discovery of any information or the occurrence of any event of a nature which raises questions about a practitioner s professional qualifications or ability to exercise any or all of the temporary privileges granted, and may, at any other time, terminate any or all of a practitioner s temporary privileges. Where the life or well-being of a patient is determined to be endangered, the termination may be affected by any person entitled to impose summary suspension under the Bylaws. In the event of any such termination, the practitioner s patients then in the Hospital will be assigned to another practitioner by the President of the Medical Staff responsible for supervision. The wishes of the patient shall be considered, where feasible, in choosing a substitute practitioner. 14

20 7.3.4 RIGHTS OF THE PRACTITIONER WITH TEMPORARY PRIVILEGES A practitioner is not entitled to the procedural rights afforded by the Bylaws and the Fair Hearing Plan because his or her request for temporary privileges is refused or because all or any part of his or her temporary privileges are terminated or suspended. 7.4 EMERGENCY PRIVILEGES In case of an emergency, any Medical Staff appointee is authorized to do everything possible to save the patient s life or to save the patient from serious harm, to the degree permitted by the appointee s license, but regardless of service line affiliation, staff category, or level of privileges. A Medical Staff appointee exercising emergency privileges is obligated to summon all consultative assistance deemed necessary and to arrange appropriate follow-up. 7.5 DISASTER PRIVILEGES Disaster privileges may be granted by the chief executive officer, medical staff president or his or her designee(s) when the emergency management plan has been activated and the organization is unable to handle the immediate patient needs. The CEO, medical staff president or designee is not required to grant privileges to any individual and is expected to make such decisions on a case-by-case basis at his or her discretion. The chief executive officer or president of the medical staff or his or her designee(s) may grant disaster privileges upon presentation of any of the following: A current picture hospital ID card. A current license to practice and a valid picture ID issued by a state, federal or regulatory agency. Identification indicating that the individual is a member of a Disaster Medical Assistance Team (DMAT). Identification indicating that the individual has been granted authority to render patient care in emergency circumstances. Such authority having been granted by a federal, state or municipal entity. Presentation by current hospital or medical staff member(s) with personal knowledge regarding practitioner s identity. Verification of the above information is a priority and will be done by the Medical Staff Office or designee as soon as the immediate situation is under control, in addition to all other verifications required for privileges as outlined in Section of these Bylaws. A record of this information will be retained in the Medical Staff Office. A practitioner s disaster privileges will be immediately terminated in the event that any information received through the verification process indicates any adverse information or suggests the person is not capable of rendering services in an emergency. The practitioner will be paired with a currently credentialed medical staff member, will be identified to others by a medical staff member and should act only under the direct supervision of a medical staff member. The practitioner s privileges will be for the period needed during the duration of the disaster only and will automatically be canceled at the end of needed services. 15

21 7.6 RECORDS OF CLINICAL PRIVILEGES The records of all practitioners who have been granted clinical privileges at the Hospital shall be maintained in the Medical Staff Office and shall be readily made available to Medical Staff officers and service line leader/medical directors in the performance of their responsibilities and obligations provided in the Medical Staff Bylaws or supporting manuals. 7.7 ALTERNATE COVERAGE Each appointee to the Medical Staff shall file with the Medical Staff Office the name(s) of an appointee who shall be in the active category with appropriate clinical privileges and similar clinical training whom the appointee has authorized and who have agreed to provide prompt and continuous care for the Medical Staff appointee s patients when he or she cannot be reached or is detained. 7.8 PRIVILEGES FOR NEW PROCEDURES A privileged member of the Medical Staff may apply for new or additional privileges. The member must apply in writing and present documentation of background, education and current skill commensurate with the requested privileges. Application: The application shall be submitted to the Administrative Offices and is then forwarded to the Credentials Committee. The Credentials Committee may request a meeting with the applicant and will review the submitted documents. The Credentials Committee shall request the appropriate service line leader/medical director to review and make recommendations for privileges. If the new procedure or activity will be further considered, the Credentials Committee will establish guidelines or standards which must be satisfied by an applicant before the privilege or activity may occur in the Hospital. These standards may include: Documented participation at a recognized continuing medical education course teaching the new procedure. Hands-on laboratory involvement where appropriate. Subsequent supervision by a physician previously trained in the new procedure for a minimum number of actual human cases. Documentation of performance during a conditional period of time. Documentation may include the number of cases done, indications, outcomes and any complications so that regular privileges for the procedure can be granted. The standards or guidelines for a new procedure or activity will apply to requests received after the Credentials Committee begins consideration and development of the standards or guidelines. All future reappointment decisions will be based upon the standards recommended by the Credentials Committee. Executive Committee: When approved by the Credentials Committee, the recommendation is submitted, via the minutes to the Medical Staff Executive Committee. If the report is adverse, the applicant will be entitled to a hearing pursuant to the Fair Hearing Plan. 16