Bylaws

Table of Contents

Preamble & Definitions  ARTICLE I  ARTICLE II  ARTICLE III  ARTICLE IV  ARTICLE V  ARTICLE VI  ARTICLE VII  ARTICLE VIII  ARTICLE IX  ARTICLE X  ARTICLE XI  ARTICLE XII  ARTICLE XIII  ARTICLE XIV  ARTICLE XV

ARTICLE VI - CORRECTIVE ACTION

6.1             CORRECTIVE ACTION

6.1-1 CRITERIA FOR INITIATION

Any person may provide information to the medical staff about the conduct, performance, or competence of its members. When reliable information indicates a member may have exhibited acts, demeanor, or conduct reasonably likely to be (1) detrimental to patient safety or to the delivery of quality patient care within the hospital; (2) unethical; (3) contrary to the medical staff bylaws and rules and or regulations; or (4) below applicable professional standards, a request for an investigation or action against such member may be initiated by the chief of staff, a department chair, or the Medical Executive Committee.

6.1-2 INITIATION

A request for an investigation must be in writing, submitted to the Medical Executive Committee, and supported by reference to specific activities or conduct alleged. If the Medical Executive Committee initiates the request, it shall make an appropriate recordation of the reasons.

6.1-3 INVESTIGATION

If the Medical Executive Committee concludes an investigation is warranted, it shall direct an investigation to be undertaken. The Medical Executive Committee may conduct the investigation itself, or may assign the task to an appropriate medical staff officer, medical staff department, or standing or ad hoc committee of the medical staff. The Medical Executive Committee in its discretion may appoint practitioners who are not members of the medical staff as temporary members of the medical staff for the sole purpose of serving on a standing or ad hoc committee, and not for the purpose of granting these practitioners temporary privileges under Section 5.5, should circumstances warrant. If the investigation is delegated to an officer of committee other than the Medical Executive Committee, such officer or committee shall proceed with the investigation in a prompt manner and shall forward a written report of the investigation to the Medical Executive Committee as soon as practicable. The report may include recommendations for appropriate corrective action. The member shall be notified that an investigation is being conducted and shall be given an opportunity to provide information in a manner and upon such terms as the investigating body deems appropriate. The individual or body investigating the matter may, but is not obligated to, conduct interviews with persons involved; however, such investigation shall not constitute a 'hearing" as that term is used in Article VII, nor shall the procedural rules with respect to hearings or appeals apply. Despite the status of any investigation, at all times the Medical Executive Committee shall retain authority and discretion to take whatever action may be warranted by the circumstances, including summary suspension, termination of the investigative process, or other action.

6.1-4 EXECUTIVE COMMITTEE ACTION

As soon as practicable after the conclusion of the investigation, the Medical Executive Committee shall take action, which may include, without limitation:

(a)               determining no corrective action be taken and, if the Executive Committee determines there was no credible evidence for the complaint in the first instance, removing any adverse information from the member's file;

(b)               deferring action for a reasonable time where circumstances warrant;

(c)               issuing letters of admonition, censure, reprimand, or warning, although nothing herein shall be deemed to preclude department heads from issuing informal written or oral warnings outside of the mechanism for corrective action. In the event such letters are issued, the affected member may make a written response which shall be placed in the member's file;

(d)               recommending the imposition of terms of probation or special limitation upon continued medical staff membership or exercise of privileges, including, without limitation, requirements for co-admission, mandatory consultation, or monitoring;

(e)               recommending reduction, modification, suspension or revocation of privileges;

(f)                 recommending reductions of membership status or limitations of any prerogatives directly related to the member's delivery of patient care;

(g)               recommending suspension, revocation or probation of medical staff membership; and

(h)               taking other actions deemed appropriate under the circumstances.

6.1-5 SUBSEQUENT ACTION

(a)               All significant corrective actions recommended by the Medical Executive Committee shall be reported to the Board of Directors, provided the practitioner is not entitled to request a hearing in accordance with Article VII.

(b)               So long as the recommendation is supported by substantial evidence, the recommendation of the Medical Executive Committee shall be adopted by the Board of Directors as its final action. If the recommended action constitutes grounds for hearing, the practitioner is entitled to the hearing and appeal rights set forth in Article VII.

6.1-6 INITIATION BY BOARD OF DIRECTORS

If the Medical Executive Committee fails to investigate or take disciplinary action, contrary to the weight of the evidence, the Board of Directors may direct the Medical Executive Committee to initiate investigation or disciplinary action, but only after consultation with the Medical Executive Committee. if the Medical Executive Committee fails to take action in response to that Board of Directors direction, the Board of Directors may initiate corrective action, but this corrective action must comply with Articles VI and VII of these medical staff bylaws.

6.2             SUMMARY RESTRICTION OR SUSPENSION

6.2-1 CRITERIA FOR INITIATION

Whenever a member's conduct appears to require that immediate action be taken to protect the life or well-being of patient(s) or to reduce a substantial and imminent likelihood of significant impairment of the life, health, safety of any patient, prospective patient, or other person, or that danger to patients, prospective patients or other person may result if immediate restraint is not imposed, the Chief of Staff, the Medical Executive Committee, or the head of the department or designee in which the member holds privileges may summarily restrict or suspend the medical staff membership or privileges of such member. Unless otherwise stated, such summary restriction or suspension shall become effective immediately upon imposition, and the person or body responsible shall promptly give written notice to the Board of Directors, the Medical Executive Committee and the Administrator. In addition, the affected medical staff member shall be provided with a written notice of the action which notice fully complies with the requirements of Section 6.2-2 below. The summary restriction or suspension may be limited in duration and shall remain in effect for the period stated or, if none, until resolved as set forth herein. Unless otherwise indicated by the terms of the summary restriction or suspension, the member's patients shall be promptly assigned to another member by the department chair or by the chief of staff, considering where feasible, the wishes of the patient in the choice of a substitute member.

6.2-2 WRITTEN NOTICE OF SUMMARY SUSPENSION

Within one working day of imposition of a summary suspension, the affected medical staff member shall be provided with written notice of such suspension. This initial written notice shall include a statement of facts demonstrating that the suspension was necessary because failure to suspend or restrict the practitioner's privileges summarily could reasonably result in an imminent danger to the health of an individual. The statement of facts provided in this initial notice shall also include a summary of one or more particular incidents giving rise to the assessment of imminent danger. This initial notice shall not substitute for, but is in addition to, the notice required under Section 7.3-1 (which applies in all cases where the MEC does not immediately terminate the summary suspension). The notice under Section 7.3-1 may supplement the initial notice provided under this section, by including any additional relevant facts supporting the need for summary suspension or other corrective action.

6.2-3 MEDICAL EXECUTIVE COMMITTEE ACTION

Within one week after such summary restriction or suspension has been imposed, a meeting of the Medical Executive Committee or a subcommittee appointed by the Chief of Staff shall be convened to review and consider the action, Upon request, the member may attend and make a statement concerning the issues under investigation, on such terms and conditions as the Medical Executive Committee may impose, although in no event shall any meeting of the Medical Executive Committee, with or without the member, constitute a "hearing" within the meaning of Article VII, nor shall any procedural rules apply. The medical Executive Committee may modify, continue, or terminate the summary restriction or suspension, but in any event it shall furnish the member with notice of its decision within two working days of the meeting,

6.2-4 PROCEDURAL RIGHTS

Unless the Medical Executive Committee promptly terminates the summary restriction or suspension, the member shall be entitled to the procedural rights afforded by Article VII. In addition, the affected practitioner shall have the following rights:

(a)               Any affected practitioner shall have the right to challenge imposition of the summary suspension, particularly on the issue of whether or not the facts stated in the notice present a reasonable possibility of "imminent danger" to an individual. Initially, the practitioner may present this challenge to the Medical Executive Committee at the meeting held within one week of imposition of the suspension. If the MEC's decision is to continue the summary suspension, then any practitioner who has properly requested a hearing under the medical staff bylaws may request that the hearing be bifurcated, with the first part of the hearing being devoted exclusively to procedural matters, including the propriety of summary suspension. Along with any other appropriate requests for rulings, the affected practitioner may request that the hearing officer (or hearing panel) stay the summary suspension, pending the final outcome of the hearing and any appeal.

(b)               At the conclusion of the procedural portion of the hearing, the hearing officer or hearing panel shall issue a written opinion on the issues raised, including whether or not the facts stated in the written notice to the affected practitioner adequately support a determination that failure to summarily restrict or suspend could reasonably result in imminent danger to an individual. Such written opinion shall be transmitted to both the affected practitioner and the MEC within one week of the date of the procedural hearing,

(c)               If the hearing officer's or hearing panel's determination is that the facts stated in the notice required by Section 6.2-2 do not support a reasonable determination that failure to summarily restrict or suspend the practitioner's privileges could result in imminent danger, the summary suspension shall be immediately stayed pending the outcome of the hearing and any appeal.

(d)               If the hearing officer or hearing panel determines that the facts stated in the notice required by Section 6.2-2 support a reasonable determination that summary suspension was necessary to avoid imminent danger to an individual, the summary suspension shall remain in effect pending conclusion of the hearing and any appellate review.

6.2-5 INITIATION BY BOARD OF DIRECTORS

If the Chief of Staff, members of the Medical Executive Committee and the head of the department (or designee) in which the member holds privileges are not available to summarily restrict or suspend the member's membership or privileges, the Board of Directors (or designee) may immediately suspend a member's privileges if a failure to suspend those privileges is likely to result in an imminent danger to the health of any patient, prospective patient, or other person, provided that the Board of Directors (or designee) made reasonable attempts to contact the Chief of Staff, members of the Medical Executive Committee and the head of the department (or designee) before the suspension.

Such a suspension is subject to ratification by the Medical Executive Committee. If the Medical Executive Committee does not ratify such a summary suspension within two working days, excluding weekends and holidays, the summary suspension shall terminate automatically. If the Medical Executive Committee does ratify the summary suspension, all other provisions under Section 6.2 of these bylaws will apply. In this event, the date of imposition of the summary suspension shall be considered to be the date of ratification by the Medical Executive Committee for purposes of compliance with notice and hearing requirements.

6.3             AUTOMATIC SUSPENSION OR LIMITATION

In the following instances, the member's privileges or membership may be suspended or limited as described, and a hearing, if requested, shall be limited to the question of whether the grounds for automatic suspension as set forth below have occurred.

6.3-1 LICENSURE

(a)               Revocation, Suspension and Expiration: Whenever a member's license or other legal credential authorizing practice in this state is revoked, suspended, or expired, medical staff membership and privileges shall be automatically revoked as of the date such action becomes effective.

(b)       Restriction: Whenever a member's license or other legal credential authorizing practice in this state is limited or restricted by the applicable licensing or certifying authority, any privileges which the member has been granted at the hospital which are within the scope of said limitation or restriction shall be automatically limited or restricted in a similar manner, as of the date such action becomes effective and throughout its term.

6.3-3 FAILURE TO SATISFY SPECIAL APPEARANCE REQUIREMENT

Failure of a member without good cause to appear and satisfy the requirements of Section 11.6-3 shall be a basis for corrective action.

6.3-4 MEDICAL RECORDS

Members of the medical staff are required to complete medical records within such reasonable time as may be prescribed by the Medical Executive Committee. A limited suspension in the form of withdrawal of admitting and other related privileges until medical records are completed, shall be imposed by the Chief of Staff, or the Chief of Staff's designee, after notice of delinquency for failure to complete medical records within such period.

For the purpose of this Section, "related privileges" means voluntary on-call service for the emergency room, scheduling  surgery, (including but not limited to all operating room procedures, all cardiac procedures, bronchoscopy and GI procedures), assisting in surgery, consulting on hospital cases, and providing professional services within the hospital for future patients. Bone fide vacation or illness may constitute an excuse subject to approval by the Medical Executive Committee. Members whose privileges have been suspended for delinquent records shall loose all privileges. The suspension shall continue until lifted by the chief of staff or the chief of staff's designee.

Physicians under medical record suspension may continue to treat medically any existing hospital patients that they are participating in at the time of suspension (either as admitting doctor or consultant) until that treatment is completed.

6.3-5 FAILURE TO PAY DUES/ASSESSMENTS

Failure without good cause as determined by the Medical Executive Committee, to pay dues or assessments, as required under Section 13.2, shall be ground for automatic suspension of a member's privileges, and if within six months after written warnings of the delinquency the member does not pay the required dues or assessments, the member's membership shall be automatically terminated.

6.3-6 EXECUTIVE COMMITTEE DELIBERATION

As soon as practicable after action is taken or warranted as described in Section 6.3-1(b) or (c), Section 6.3-2, 6.3-3, 6.3-4, 6.3-5, or 6.3-6, the Medical Executive Committee shall convene to review and consider the facts, and may recommend such further corrective action as it may deem appropriate following the procedure generally set forth commencing at Section 7.3-1.

6.3-7 PROFESSIONAL LIABILITY INSURANCE

Failure to maintain professional liability insurance, if any is required, shall be ground for automatic suspension of a member's privileges, and if within 90 days after written warnings of the delinquency the member does not provide evidence of required professional liability insurance, the member's membership shall be automatically terminated.