Bylaws

 ARTICLE V - PRIVILEGES

5.1             EXERCISE OF PRIVILEGES

Except as otherwise provided in these bylaws, a member providing clinical services at this hospital shall be entitled to exercise only those privileges specifically granted. Said privileges and services must be hospital specific, within the scope of any license, certificate or other legal credential authorizing practice in this state and consistent with any restrictions thereon, and shall be subject to the rules and regulations of the clinical department and the authority of the department chair and the medical staff. Privileges may be granted, continued, modified or terminated by the governing body of this hospital only upon recommendation of the medical staff, only for reasons directly related to quality of patient care and other provisions of the medical staff bylaws, and only following the procedures outlined in these bylaws.

5.2             DELINEATION OF PRIVILEGES IN GENERAL

5.2-1 REQUESTS

Each application for appointment and reappointment to the medical staff must contain a request for the specific privileges desired by the applicant. A request by a member for a modification of privileges may be made at any time, but such requests must be supported by documentation of training and/or experience supportive of the request.

5.2-2 BASES FOR PRIVILEGES DETERMINATION

Requests for privileges shall be evaluated on the basis of the member's education, training, experience, demonstrated professional competence and judgment, clinical performance, and the documented results of patient care and other quality review and monitoring which the medical staff deems appropriate. Privilege determinations may also be based on pertinent information concerning clinical performance obtained from other sources, especially other institutions and health care settings where a member exercises privileges.

5.3             PROCTORING

5.3-1 GENERAL PROVISIONS

Except as otherwise determined by the Medical Executive Committee, all initial appointees to the medical staff and all members granted new privileges shall be subject to a period of proctoring. Each appointee or recipient of new privileges shall be assigned to a department where performance on an appropriate number of cases and representative sample as established by the Medical Executive Committee, or the department as designee of the Medical Executive Committee, shall be observed by the chair of the department, or the chair's designee, during the period of proctoring specified in the department's rules and regulations, to determine suitability to continue to exercise the privileges granted in that department. The exercise of privileges in any other department shall also be subject to direct observation by that department's chair or the chair's designee. The member shall remain subject to such proctoring until the Medical Executive Committee has been furnished with:

(a)               a report signed by the chair of the department(s) to which the member is assigned describing the types and numbers of cases observed and the evaluation of the applicant's performance, a statement that the applicant appears to meet all of the qualifications for unsupervised practice in that department, has discharged all of the responsibilities of staff membership, and has not exceeded or abused the prerogatives of the category to which the appointment was made; and

(b)               a report signed by the chair of the other department(s) in which the appointee may exercise privileges, describing the types and number of cases observed and the evaluation of the applicant's performance and a statement that the member has satisfactorily demonstrated the ability to exercise the privileges initially granted in those departments.

5.3-2 FAILURE TO OBTAIN CERTIFICATION

If an initial appointee fails within the time of provisional membership to furnish the certification required, or if a member exercising new privileges fails to furnish such certification within the time allowed by the department, those specific privileges shall automatically terminate, and the member shall be entitled to a hearing, upon request, pursuant to Article VII.

5.3-3 MEDICAL STAFF ADVANCEMENT

The failure to obtain certification for any specific privileges shall not, of itself, preclude advancement in medical staff category of any member. If such advancement is granted absent such certification, continued proctorship on the uncertified procedure shall continue for the specified time period.

5.4             CONDITIONS FOR PRIVILEGES OF LIMITED LICENSE PRACTITIONERS

5.4-1 ADMISSIONS

As of the adoption date of these bylaws, when dentists, oral surgeons, and podiatrists who are members of the medical staff admit patients, a physician member of the medical staff must conduct or directly supervise the admitting history and physical examination (except the portion related to dentistry or podiatry), and assume responsibility for the care of the patient's medical problems present at the time of admission or which may arise during hospitalization which are outside of the limited license practitioner's lawful scope of practice. members of the Medical Staff who do not have admitting privileges must have a physician with admitting privileges conduct the history and physicals.

5.4-2 SURGERY

Surgical procedures performed by dentists and podiatrists shall be under the overall supervision of the chair of the department of surgery or the chair's designee.

5.4-3 MEDICAL APPRAISAL

All patients admitted for care in a hospital by a dentist or podiatrist shall receive the same basic medical appraisal as patients admitted to other services, and the dentists or podiatrists shall seek consultation with a physician member to determine the patient's medical status and need for medical evaluation whenever the patient's clinical status indicates the development of a new medical problem. Where a dispute exists regarding proposed treatment between a physician member and a limited license practitioner based upon medical or surgical factors outside of the scope of licensure of the limited license practitioner, the treatment proposed by the physician will prevail until dispute is resolved by the appropriate department(s).

5.5             TEMPORARY CLINICAL PRIVILEGES

5.5-1 CARE OF A SPECIFIC PATIENT

Temporary clinical privileges may be granted where good cause exists to a physician, dentist or podiatrist for the care of a specific patient (but not more than three (3) times during a calendar year) provided that the procedure described in Section 5.5-5 has been completed.

5.5-2 LOCUM TENENS

Locum tenens privileges may be granted in cases of personal emergency or vacation, to a person serving as a locum tenens for a current member of the medical staff, provided that the procedure described in Section 5.5-5 has been completed. Such person may attend only patients of the member(s) for whom that person is providing coverage, for a period not to exceed thirty (30) consecutive days, in a twelve month period, unless the Medical Executive Committee recommends a longer additional period for good cause.

5.5-3 PENDING APPLICATION FOR PERMANENT MEDICAL STAFF MEMBERSHIP

Temporary clinical privileges may be granted to a person during pendency of that person's application for permanent medical staff membership and privileges, provided that the procedure described in Section 5.5-5 has been completed.

5.5-4 TEMPORARY MEMBERSHIP AND TEMPORARY CLINICAL PRIVILEGES NOT CO-EXTENSIVE

Temporary members of the medical staff pursuant to Section 6.1-3 are not, by virtue of such membership, granted temporary clinical privileges.

5.5-5 APPLICATION AND REVIEW

(a)               Upon receipt of a completed application and supporting documentation from a physician, dentist or podiatrist authorized to practice in California, the Board of Directors or its designee may grant temporary clinical privileges to a member who appears to have qualifications, ability and judgment consistent with Section 2.2-1, but only after:

(1)               the hospital's authorized representative has queried the National Practitioner Data Bank regarding the applicant for temporary clinical privileges.

(2)               the applicant's file, including the recommendation of the department chair, is forwarded to the department and the Medical Executive Committee.

(3)               reviewing the applicant's file and attached materials, the Medical Executive Committee through the chief of staff or another designee recommends granting temporary clinical privileges.

In the event of a disagreement between the Board of Directors and the Medical Executive Committee regarding the granting of temporary clinical privileges, the matter shall be resolved as set forth in Section 4.5-8.

(b)               If the applicant requests temporary clinical privileges in more than one department, interviews shall be conducted and written concurrence shall first be obtained from the appropriate department chairs and forwarded to the Medical Executive Committee.

5.5-6 GENERAL CONDITIONS

(a)       If granted temporary clinical privileges, the applicant shall act under the supervision of the department chair to which the applicant has been assigned, and shall ensure that the chair, or the chair's designee, is kept closely informed as to the applicant's activities within the hospital.

(b)       Temporary clinical privileges shall automatically terminate at the end of the designated period, unless earlier terminated or suspended under Articles VI and/or VII of these bylaws or unless affirmatively renewed following the procedure as set forth in Section 5.5-5. As necessary, the appropriate department chair or, in the chair's absence, the chair of the Medical Executive Committee, shall assign a member of the medical staff to assume responsibility for the care of such member's patient(s). The wishes of the patient shall be considered in the choice of a replacement  medical staff member.

(c)               Requirements for proctoring and monitoring, including but not limited to those in Section 5.3, shall be imposed on such terms as may be appropriate under the circumstances upon any member granted temporary clinical privileges by the chief of staff after consultation with the departmental chair or the chair's designee.

(d)               Temporary clinical privileges may at any time be suspended or terminated under these bylaws. In such cases, the appropriate department chair or, in the chair's absence, the chair of the Medical Executive Committee, shall assign a member of the medical staff to assume responsibility for the care of such member's patient(s). The wishes of the patient shall be considered in the choice of a replacement medical staff member.

(e)               All persons requesting or receiving temporary clinical privileges shall be bound by the bylaws and rules and regulations of the medical staff.

5.6             EMERGENCY PRIVILEGES

(a)               In the case of an emergency, any member of the medical staff, to the degree permitted by the scope of the applicant's license and

regardless of department, staff status, or privileges, shall be permitted to do everything reasonably possible to save the life of a patient or to save a patient from serious harm. The member shall make every reasonable effort to communicate promptly with the department chair concerning the need for emergency care and assistance by members of the medical staff with appropriate privileges, and once the emergency has passed or assistance has been made available, shall defer to the department chair with respect to further care of the patient at the hospital.

(b)               In the event of an emergency, any person shall be permitted to do whatever is reasonably possible to save the life of a patient or to save a patient from serious harm. Such persons shall promptly yield such care to qualified members of the medical staff when it becomes reasonably available.

5.7             MODIFICATION OF PRIVILEGES OR DEPARTMENT ASSIGNMENT

On its own, upon recommendation of the department, or pursuant to a request under Section 4.6-1(b), the Medical Executive Committee may recommend a change in the privileges or department assignment(s) of a member. The Executive Committee may also recommend that the granting of additional privileges to a current medical staff member be made subject to monitoring in accordance with procedures similar to those outlined in Section 5.3-1.

5.8             LAPSE OF APPLICATION

If a medical staff member requesting a modification of privileges or department assignments fails to timely furnish the information necessary to evaluate the request, the application shall automatically lapse, and the applicant shall not be entitled to a hearing as set forth in Article VI.