Bylaws

ARTICLE XIII - GENERAL PROVISIONS

13.1         RULES AND REGULATIONS

The medical staff shall initiate and adopt such rules and regulations, as it may deem necessary for the proper conduct of its work and shall periodically review and revise its rules and regulations to comply with current medical staff practice. Recommended changes to the rules and regulations shall be submitted to the Medical Executive Committee for review and evaluation prior to presentation for consideration by the medical staff as a whole under such review or approval mechanism as the medical staff shall establish. Following adoption such rules and regulations shall become effective following approval of the Board of Directors, which approval shall not be withheld unreasonably, or automatically within 120 days if no action is taken by the Board of Directors. Applicants and members of the medical staff shall be governed by such rules and regulations as are properly initiated and adopted. If there is a conflict between the bylaws and the rules and regulations, the bylaws shall prevail. The mechanism described herein shall be the sole method for the initiation, adoption, amendment, or repeal of the medical staff rules and regulations.

13.2         DUES OR ASSESSMENTS

The Medical Executive Committee shall have the power to recommend the amount of annual dues or assessments, if any, for each category of medical staff membership, subject to the approval of the medical staff, and to determine the manner of expenditure of such funds received.

13.3         CONSTRUCTION OF TERMS AND HEADINGS

The captions or headings in these bylaws are for convenience only and are not intended to limit or define the scope of or affect any of the substantive provisions of these bylaws. These bylaws apply with equal force to both sexes wherever either term is used.

13.4         AUTHORITY TO ACT

Any member or members who act in the name of this medical staff without proper authority shall be subject to such disciplinary action as the Medical Executive Committee may deem appropriate.

13.5         DIVISION OF FEES

Any division of fees by members of the medical staff is forbidden and any such division of fees shall be cause for exclusion or expulsion from the medical staff.

13.6         NOTICES

Except where specific notice provisions are otherwise provided in these bylaws, any and all notices, demands, requests required or permitted to be mailed shall be in writing properly sealed, and shall be sent through United States Postal Service, first-class postage prepaid. An alternative delivery mechanism may be used if it is reliable, as expeditious, and if evidence of its use is obtained. Notice to the medical staff or officers or committees thereof, shall be addressed as follows:

Citrus Valley Medical Center
Inter-Community Campus
210 W. San Bernardino Road
Covina, CA  91723
c/o Director Medical Staff Services, Chief of Staff

Citrus Valley Medical Center
Queen of the Valley Campus
1115 So. Sunset Avenue
West Covina, CA 91790
c/o Director Medical Staff Services, Chief of Staff

Mailed notices to a member, applicant or other party shall be to the addressee at the address as it last appears in the official records of the medical staff or the hospital.

13.7         DISCLOSURE OF INTEREST

All nominees for election or appointment to medical staff offices, department chairships, or the Medical Executive Committee shall, at least 20 days prior to the date of election or appointment, disclose in writing to the Medical Executive Committee those personal, professional, or financial affiliations or relationships of which they are reasonably aware which could foreseeably result in a conflict of interest with their activities or responsibilities on behalf of the medical staff.

13.8         NOMINATION OF MEDICAL STAFF REPRESENTATIVES

Candidates for positions as medical staff representatives to local, state and national hospital medical staff sections should be filled by such selection process as the medical staff may determine. Nominations for such positions shall be made by a nominating committee appointed by the Medical Executive Committee.

13.9         MEDICAL STAFF CREDENTIALS FILES

13.9-1 INSERTION OF ADVERSE INFORMATION

The following applies to actions relating to requests for insertion of adverse information into the medical staff member's credentials file:

(a)       As stated previously, in Section 6.1-1, any person may provide information to the medical staff about the conduct, performance or competence of its members.

(b)       When a request is made for insertion of adverse information into the medical staff member's credentials file, the respective department chair and Chief of Staff shall review such a request.

(a)               After such a review a decision will be made by the respective department chair and Chief of Staff to:

(1)               not insert the information;

(2)               notify the member of the adverse information by a written summary and offer the opportunity to rebut this assertion before it is entered into the member's file; or

(3)               insert the information along with a notation that a request has been made to the MEC for an investigation as outlined in Section 6.1-2 of these bylaws.

(b)               This decision shall be reported to the MEC. The MEC, when so informed, may either ratify or initiate contrary actions to this decision by a majority vote.

13.9-2 REVIEW OF ADVERSE INFORMATION AT THE TIME OF REAPPRAISAL AND REAPPOINTMENT     

The following applies to the review of adverse information in the medical staff member's credentials file at the time of reappraisal and reappointment.

(a)               Prior to recommendation on reappointment, the Clinical Department, as part of its reappraisal function, shall review any adverse information in the credentials file pertaining to a member.

(b)               Following this review, the Clinical Department shall determine whether documentation in the file warrants further action.

(c)               With respect to such adverse information, if it does not appear that an investigation and/or adverse action on reappointment is warranted, the Clinical Department shall so inform the MEC.

(d)               However, if an investigation and/or adverse action on reappointment is warranted, the Clinical Department shall so inform the MEC.

(e)               No later than 60 days following final action on reappointment, the MEC shall, except as provided in (g):

(1)               initiate a request for corrective action, based on such adverse information and on the Clinical Department's recommendation relating thereto, or

(2)       cause the substance of such adverse information to be summarized and disclosed to the member.

(f)                 The member shall have the right to respond thereto in writing, and the MEC may elect to remove such adverse information on the basis of such response.

(g)               in the event that adverse information is not utilized as the basis for a request for corrective action, or disclosed to the member as provided herein, it shall be removed from the file and discarded, unless the MEC, by a majority vote, determines that such information is required for continuing evaluation of the member's:

(1)               character;

(2)               competence; or

(3)               professional performance.

13.9-3 CONFIDENTIALITY

The following applies to records of the medical staff and its Committees responsible for the evaluation and improvement of patient care:

(a)               The records of the medical staff and its committees responsible for the evaluation and improvement of the quality of patient care rendered in the hospital shall be maintained as confidential.

(b)               Access to such records shall be limited to duly appointed officers and committees of the medical staff for the sole purpose of discharging medical staff responsibilities and subject to the requirement that confidentiality be maintained.

(c)               Information which is disclosed to the governing body of the hospital or its appointed representatives -- in order that the governing body may discharge its lawful obligations and responsibilities -- shall be maintained by that body as confidential.

(d)               Information contained in the credentials file of any member may be disclosed with the member's consent, or at any medical staff or professional licensing board, or as required by law. However, any disclosure outside of the medical staff shall require the authorization of the Chief of Staff and the concerned Department Chair and notice to the member.

(e)               A medical staff member shall be granted access to the individual's credentials file, subject to the following provisions;

(1)               timely notice of such shall be made by the member to the chief of staff or the chief of staff's designee;

(2)               the member may review, and receive a copy of, only those documents provided by or addressed personally to the member. A summary of all other information -- including peer review committee findings, letters of reference, proctoring reports, complaints, etc. -- shall be provided to the member, in writing, by the designated officer of the medical staff, (at the time the member reviews the credentials file) / (within a reasonable period of time, as determined by the medical staff). Such summary shall disclose the substance, but not the source, of the information summarized;

(3)               the review by the member shall take place in the Medical Staff Office, during normal work hours, with an officer or designee of the medical staff present.

(f)                 In the event a Notice of Charges is filed against a member, access to that member's credentials file shall be governed by Section 7.4-1.

13.9-4 MEMBER'S OPPORTUNITY TO REQUEST CORRECTION/DELETION OF AND TO MAKE ADDITION TO INFORMATION IN FILE

(a)               After review of the file as provided under Section 13.9-3(e) the member may address to the Chief of Staff a written request for correction or deletion of information in the credentials file. Such request shall include a statement of the basis for the action requested.

(b)               The Chief of Staff shall review such a request within a reasonable time and shall recommend to the MEC, after such review, whether or not to make the correction or deletion requested. The MEC, when so informed, shall either ratify or initiate action contrary to this recommendation, by a majority vote.

(c)               The member shall be notified promptly, in writing, of the decision of the MEC.

(d)               In any case, a member shall have the right to add to the individual's credentials file, upon written request to the MEC, a statement responding to any information contained in the file.

13.10    MEDICAL STAFF ROLE IN EXCLUSIVE CONTRACTING

The Medical Executive Committee shall review and make recommendations to the Board of Directors regarding quality of care issues related to exclusive arrangements for physician and/or professional services, prior to any decision being made, in the following situations:

(a)               the decision to execute an exclusive contract in a previously open department or service;

(b)               the decision to renew or modify an exclusive contract in a particular department or service;

(c)               the decision to terminate an exclusive contract in a particular department or service.