Bylaws

ARTICLE IV - 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 privileges in the hospital unless and until that person applies 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 emeritus staff, by accepting an appointment to that category), the applicant acknowledges responsibility to first review these bylaws 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 privileges as have been granted in accordance with these bylaws. After the Medical Executive Committee fails to process an appointment or reappointment in a timely manner, without lawful cause, the Board of Directors may direct the Medical Executive Committee to process. If they do not, the Board may do so.

4.2             BURDEN OF PRODUCING INFORMATION

In connection with all applications for appointment, reappointment, advancement or transfer, the applicant shall have the burden of producing information for an adequate evaluation of the applicant's qualifications and suitability for the privileges and staff category requested, of resolving any reasonable doubts about these matters, and of satisfying requests for information, 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 Medical Executive Committee, which may select the examining physician.

4.3             APPOINTMENT AUTHORITY

Appointments, denials and revocations of appointments to the medical staff shall be made as set forth in these bylaws, but only after there has been a recommendation from the medical staff, or as set forth in Section 6.1-6.

4.4             DURATION OF APPOINTMENT AND REAPPOINTMENT

Except as otherwise provided in these bylaws, initial appointments to the medical staff shall be for a period not to exceed two years.

4.5             APPLICATION FOR INITIAL APPOINTMENT AND REAPPOINTMENT

4.5-1      APPLICATION FORM

An application form shall be developed by the Medical Executive Committee. The form shall require detailed information which shall include, but not be limited to, information concerning:

(a)               the applicant's qualifications, including, but not limited to, professional training and experience, current licensure, current DEA registration, certification or CPR training, and continuing medical education information related to the privileges to the exercised by the applicant;

(b)               peer references (from practitioners in the same professional discipline) familiar with the applicant's professional competence and ethical character;

(c)               requests for membership categories, departments, and privileges;

(d)               past or pending professional disciplinary action, voluntary or involuntary relinquishment of medical staff membership or privileges or any licensure or registration, licensure limitations, and related matters;

(e)               physical and mental health status; current physical and mental health status and ability to exercise the requested privileges safely;

(f)                 final judgments or settlements made against the applicant in professional liability cases, and any filed and served cases pending; and

(g)               professional liability coverage, if any is required.

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 available), and signed by the applicant. When an applicant requests an application form, that person shall be given a copy of these bylaws, the medical staff rules and regulations, and summaries of other applicable policies relating to clinical practice in the hospital, if any.

4.5-2      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)               signifies willingness to appear for interviews in regard to the application;

(b)               authorizes consultation with others who have been associated with the applicant and who may have information bearing on the applicant's competence, qualifications and performance, and authorizes such individuals and organizations to candidly provide all such information;

(c)               consents to inspection of records and documents that may be material to an evaluation of the applicant's qualifications and ability to carry out privileges requested, and authorizes all individuals and organizations in custody of such records and documents to permit such inspection and copying;

(d)               releases from any liability, to the fullest extent permitted by laws, all persons for their acts performed in connection with investigating and evaluation the applicant;

(e)               releases from any liability, to the fullest extent permitted by laws, all individuals and organizations who provide information regarding the applicant, including otherwise confidential information;

(f)                 consents to the disclosure to other hospitals, medical associations, licensing board, 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 and hospital from liability for so doing to the fullest extent permitted by laws;

(g)               if a requirement then exists for medical staff dues, acknowledges responsibility for timely payment;

(h)               pledges to provide for continuous quality care for patients;

(i)                 pledges to maintain an ethical practice, including refraining from illegal inducements for patient referral, providing for the continuous care of the applicant's patients, seeking consultation whenever necessary, refraining from providing "ghost" surgical or medical services, and refraining from delegating patient care responsibility to non-qualified or inadequately supervised practitioners.

(j)                  pledges to be bound by the medical staff bylaws, rules and regulations, and policies.

4.5-3      VERIFICATION OF INFORMATION

The applicant shall deliver a completed application to the appropriate medical staff officer and an advance payment of medical staff dues or fees, if any is required. The administrator shall be notified of the application. The application and all supporting materials then available shall be transmitted to the chair of each department in which the applicant seeks privileges. The administrator when requested to assist shall expeditiously seek to collect or verify the references, licensure status, and other evidence submitted in support of the application. The hospital's authorized representative shall query the National Practitioner Data Bank regarding the applicant or member and submit any resulting information for inclusion in the applicant's or member's credentials file. The applicant shall be notified of any problems in obtaining the information required, and it shall be the applicant's obligation to obtain the required information. When collection and verification is accomplished, all such information shall be transmitted to the appropriate department(s).

4.5-4      DEPARTMENT ACTION

After receipt of the application, the chair of each department to which the application is submitted, shall review the application and supporting documentation, and may conduct a personal interview with the applicant at the chair's or department's discretion. The chair shall evaluate all matters deemed relevant to a recommendation, including information concerning the applicant's provision of services within the scope of privileges granted, and the reapplicant's participation in relevant continuing education, and shall transmit to the clinical department a written report and recommendation as to appointment and, if appointment is recommended, as to membership category, department affiliation, privileges to be granted, and any special conditions to be attached. The chair may also request that the Medical Executive Committee defer action on the application.

4.5-5      AD HOC CREDENTIALS COMMITTEE ACTION

Credentialing will be performed at the Department level, but whenever necessary, the Ad Hoc Credentials Committee shall review the application, evaluate and verify the supporting documentation, the department chair's report and recommendations, and other relevant information. The Ad Hoc Credentials Committee may elect to interview the applicant and seek additional information. As soon as practicable, the Ad Hoc Credentials Committee shall transmit to the Medical Executive Committee a written report and its recommendations as to appointment and, if appointment is recommended, as to membership category, department affiliation, privileges to be granted, and any special conditions to be attached to the appointment. The committee may also recommend that the Medical Executive Committee defer action on the application.

4.5-6      MEDICAL EXECUTIVE COMMITTEE ACTION

At its next regular meeting after receipt of the clinical department's report and recommendation, or as soon thereafter as is practicable, the Medical Executive Committee shall consider the report and any other relevant information. The Medical Executive Committee may request additional information, return the matter to the clinical department for further investigation, and/or elect to interview the applicant. The Medical Executive Committee shall forward to the Administrator, for prompt transmittal to the Board of Directors, a written report and recommendation as to medical staff appointment and, if appointment is recommended, as to membership category, department affiliation, privileges to be granted, and any special conditions to be attached to the appointment. The committee may also defer action on the application. The reasons for each recommendation shall be stated.

4.5-7      EFFECT OF MEDICAL EXECUTIVE COMMITTEE ACTION

(a)               Favorable Recommendation: When the recommendation of the Medical Executive Committee is favorable to the applicant, it shall be promptly forwarded, together with supporting documentation, to the Board of Directors.

(b)               Adverse Recommendation: When a final recommendation of the Medical Executive Committee is adverse to the applicant, the Administrator and the applicant shall be promptly informed by written notice. The applicant shall then be entitled to the procedural rights as provided in Article VII.

4.5-8      ACTION ON THE APPLICATION

The Board of Directors may accept the recommendation of the Medical Executive Committee or may refer the matter back to the Medical Executive Committee for further consideration, stating the purpose for such referral and setting a reasonable time limit for making a subsequent recommendation.  The following procedures shall apply with respect to action on the application:

(a)               If the Medical Executive Committee issues a favorable recommendation, the Board of Directors shall affirm the recommendation of the Medical Executive Committee if the Medical Executive Committee's decision is supported by substantial evidence.

(1)               If the Board of Directors concurs in that recommendation, the decision of the Board shall be deemed final action.

(2)               If the tentative final action of the Board of Directors is unfavorable, the Administrator shall give the applicant written notice of the tentative adverse recommendation and the applicant shall be entitled to the procedural rights set forth in Article VII. If procedural rights are waived by the applicant, the decision of the Board of Directors shall be deemed final action.

(b)               In the event the recommendation of the Medical Executive Committee, or any significant part of it, is unfavorable to the applicant the procedural rights set forth in Article VII shall apply.

(1)               If procedural rights are waived by the applicant, the recommendations of the Medical Executive Committee shall be forwarded to the Board of Directors for final action, which shall affirm the recommendation of the Medical Executive Committee if the Medical Executive Committee's decision is supported by substantial evidence.

(2)               If the applicant requests a hearing following the adverse Medical Executive Committee recommendation pursuant to Section 4.5-8(b) or an adverse Board of Directors tentative final action pursuant to 4.5-8(a) (2), the Board of Directors shall take final action only after the applicant has exhausted all procedural rights as established by Article VII. After exhaustion of the procedures set forth in Article VII, the Board shall make a final decision and shall affirm the decision of the Judicial Review Committee if the Judicial Review Committee's decision is supported by substantial evidence, following a fair procedure. The Board's decision shall be in writing and shall specify the reasons for the action taken.

4.5-9      NOTICE OF FINAL DECISION

(a)               Notice of the final decision shall be given to the Chief of Staff, the Medical Executive Committee and the chair of each department concerned, the applicant, and the Administrator.

(b)               A decision and notice to appoint or reappoint shall include, if applicable: (1) the staff category to which the applicant is appointed; (2) the department to which that person is assigned; (3) the privileges granted; and (4) any special conditions attached to the appointment.

4.5-10   REAPPLICATION AFTER ADVERSE APPOINTMENT DECISION

An applicant who has received a final adverse decision regarding appointment shall not be eligible to reapply to the medical staff for a period of one year. Any such reapplication shall be processed as an initial application, and the applicant shall submit such additional information as may be required to demonstrate that the basis for the earlier adverse action no longer exists.

4.5-11   TIMELY PROCESSING OF APPLICATIONS

Applications for staff appointments shall be considered in a timely manner by all persons and committees required by these bylaws to act thereon. While special or unusual circumstances may constitute good cause and warrant exceptions, the following maximum time periods provide a guideline for routine processing of applications:

(a)               evaluation, review, and verification of application and all supporting documents by the medical staff office: 90 days from receipt of all necessary documentation;

(b)               review and recommendation by department(s): At the next scheduled meeting: 30 days after receipt of all necessary documentation;

(c)               review and recommendation by the Executive Committee: 30 days after receipt of all necessary documentation from the department; and

(d)               final action: 180 days after receipt of all necessary documentation by the Medical Staff Office or seven (7) days after conclusion of hearing.

4.6       REAPPOINTMENTS AND REQUESTS FOR MODIFICATIONS OF STAFF STATUS OR PRIVILEGES

            4.6-1 APPLICATION

(a)               At least six months prior to the expiration date of the current staff appointment (except for temporary appointments), a reapplication form developed by the Medical Executive Committee shall be mailed or delivered to the member. If an application for reappointment is not received at least 60 days prior to the expiration date, written notice shall be promptly sent to the applicant advising that the application has not been returned. At least 45 days prior to the expiration date, each medical staff member shall submit to the department the completed application form for renewal of appointment to the staff for the coming year, and for renewal or modification of privileges. The reapplication form shall include all information necessary to update and evaluate the qualifications of the applicant including, but not limited to, the matters set forth in Section 4.5-1, as well as other relevant matters. Upon receipt of the application, the information shall be processed as set forth commencing at Section 4.5-3.

(b)               A medical staff member who seeks a change in medical staff status or modification of privileges may submit such a request at any time upon a form developed by the Medical Executive Committee, except that such application may not be filed within one year of the time a similar request has been denied.

4.6-2 EFFECT OF APPLICATION

The effect of an application for reappointment or modification of staff status or privileges is the same as that set forth in Section 4.5-2.

4.6-3 STANDARDS AND PROCEDURE FOR REVIEW

When a staff member submits the first application for reappointment, and every two years thereafter, or when the member submits an application for modification of staff status or privileges, the member shall be subject to an in-depth review generally following the procedures set forth in Sections 4.5-3 through 4.5-11.

4.6-4 EXTENSION OF APPOINTMENT

If it appears that an application for reappointment will not be fully processed by the expiration date of the member's appointment, for reasons other than due to the reapplicant's failure to return documents or otherwise timely cooperate in the reappointment process, the Medical Executive Committee and the Board of Directors shall approve a time-and-member-specific extension of the member's status and clinical privileges. With respect to such delays not caused by the staff member, if for any reasons the Medical Executive Committee and/or Board of Directors fails to approve an extension or the extension time runs out prior to completion of the reappointment procedures, the member's membership and privileges shall nonetheless continue until processing of the reapplication is completed. Any extension of an appointment pursuant to this Section does not create a vested right in the member for continued appointment through the entire next term but only until such time as processing of the application is concluded.  The member shall continue to be subject to the reapplication review process as outlined in Sections 4.5-3 through 4.5-11. Failure by the member to timely complete and return the reappointment application form or provide other documentation or cooperation will result in termination of the member's appointment.

4.6-5 FAILURE TO FILE REAPPOINTMENT APPLICATION

Failure without good cause to timely file a completed application for reappointment shall result in the automatic suspension of the member's admitting privileges and expiration of other practice privileges and prerogatives at the end of the current staff appointment, unless otherwise extended by the Medical Executive Committee with the approval of the Board of Directors. If the member fails to submit a completed application for reappointment within 30 days past the date it was due, the member shall be deemed to have resigned membership in the medical staff. In the event membership terminates for the reasons set forth herein, the procedures set forth in Article VII shall not apply.

4.7       LEAVE OF ABSENCE

4.7-1 LEAVE STATUS

At the discretion of the Medical Executive Committee, a medical staff member may obtain a voluntary leave of absence from the staff upon submitting a written request to the Medical Executive Committee stating the approximate period of leave desired, which may not exceed one year. If a physician is at a residency or training program that is beyond one year, the leave of absence will be extended an additional year. During the period of the leave, the member shall not exercise privileges at the hospital, and membership rights and responsibilities shall be inactive, but the obligation to pay dues, if any, shall continue, unless waived by the medical staff.

4.7-2 TERMINATION OF LEAVE

At least 30 days prior to the termination of the leave of absence, or at any earlier time, the medical staff member may request reinstatement of privileges by submitting a written notice to that effect to the Medical Executive Committee. The staff member shall submit a summary of relevant activities during the leave, if the Executive Committee so requests. Physicians on leave for health shall be required to submit evidence of fitness and the medical staff has the authority to order an appropriate examination by an independent physician as necessary (pursuant to Section 2.2-1(a). The Medical Executive Committee shall make a recommendation concerning the reinstatement of the member's privileges and prerogatives, and the procedure provided in Sections 4.1 through 4.5-11 shall be followed.

4.7-3 FAILURE TO REQUEST REINSTATEMENT

Failure, without good cause, to request reinstatement shall be deemed a voluntary resignation from the medical staff and shall result in automatic termination of membership, privileges, and prerogatives. A member whose membership is automatically terminated shall be entitled to the procedural rights provided in Article VII for the sole purpose of determining whether the failure to request reinstatement was unintentional or excusable, or otherwise. A request for medical staff membership subsequently received from a member so terminated shall be submitted and processed in the manner specified for applications for initial appointments.