the quick brown fox jumps over the lazy dog€¦ · web view12) medical staff year means the...

Comparison of California Hospital Association Model Medical Staff Bylaws 2014

andCalifornia Medical Association Model Medical Staff Bylaws 2013

Prepared byAnn O'Connell, Esq.

Nossaman LLPSacramento, California

_________________

Note: This table is an updated version of a comparison last published by the California Hospital Association (CHA) in 2011 that compared the 2011 edition of CHA Model Medical Staff Bylaws with the 2010 edition of the California Medical Association (CMA) Model Medical Staff Bylaws. Both organizations have recently published updates to their Model Bylaws. The table also contains highlighting of portions of the Bylaws. The highlighting is to feature language within a section that is particularly relevant to the accompanying commentary (in the third column). Otherwise, commentary relates generally to the entire section. To facilitate comparison, the provisions of the CMA Model Bylaws have been reorganized to correlate with the comparable provisions of the CHA Model Bylaws.

CHA MODEL MEDICAL STAFF BYLAWS 2014

CMAMODEL MEDICAL STAFF BYLAWS 2013 COMMENTS

Preamble

These bylaws are adopted in recognition of the mutual accountability, interdependence and responsibility of the Medical Staff and the Governing Body of [insert name of hospital] in protecting the quality of medical care provided in the hospital and assuring the competency of the hospital’s Medical Staff. The bylaws provide a framework for self-government, assuring an organization of the Medical Staff that permits the Medical Staff to discharge its responsibilities in matters involving the quality of medical care, to govern the orderly resolution of issues and the conduct of Medical Staff functions supportive of those purposes, and to account to the Governing Body for the effective performance of Medical Staff responsibilities. These bylaws provide the professional and legal structure for Medical Staff operations, organized Medical Staff relations with the Governing Body, and relations with applicants to and members of the Medical Staff.

Accordingly, the bylaws address the Medical Staff’s responsibility to establish criteria and standards for Medical Staff membership and privileges, and to enforce those criteria and standards; they establish clinical criteria and standards to oversee and manage quality assurance, utilization review, and other Medical Staff activities, including, but not limited to, periodic meetings of the Medical Staff, its committees, and departments and review and analysis of patient medical records; they describe the standards and procedures for selecting and removing Medical Staff officers; and they address the respective rights and responsibilities of the Medical Staff and the Governing Body.

Finally, notwithstanding the provisions of these bylaws, the Medical Staff acknowledges that the Governing Body must act to protect the quality of medical care provided and the competency of the Medical Staff, and to ensure the responsible governance of the hospital. In adopting these bylaws, the Medical Staff commits to exercise its responsibilities with diligence and good faith; and in approving these bylaws, the Governing Body commits to allowing the Medical Staff reasonable independence in

1.1 PURPOSES OF THE BYLAWS

These bylaws are adopted in order to provide for the organization of the medical staff of [______________] hospital and to provide a framework for self-government in order to permit the medical staff to discharge its responsibilities in matters involving the quality of medical care, and to govern the orderly resolution of those purposes. These bylaws provide the professional and legal structure for medical staff operations, organized medical staff relations with the board of [trustees/directors], and relations with applicants to members of the medical staff. The organized medical staff both enforces and complies with these medical staff bylaws.

These bylaws recognize that the organized medical staff has the authority to establish and maintain patient care standards, including full participation in the development of hospital-wide policy, involving the oversight of care, treatment, and services provided by members and others in the hospital. The medical staff is also responsible for and involved with all aspects of delivery of health care within the hospital including, but not limited to, the treatment and services delivered by practitioners credentialed and privileged through the mechanisms described in these bylaws and the functions of credentialing and peer review.

These bylaws acknowledge that the provision of quality medical care in the hospital depends on the mutual accountability, interdependence, and responsibility of the medical staff and the hospital governing board for the proper performance of their respective obligations. To that end, the Medical Staff acknowledges that the Board of [Trustees/Directors] must act to protect the quality of medical care provided and the competency of the Medical Staff, and to ensure the responsible governance of the hospital. In adopting these Bylaws, the Medical Staff commits to exercise its responsibilities with diligence and good faith, and in approving these Bylaws, the Board of [Trustees/Directors] commits to supporting the Medical Staff's self- governance and independence in conducting the affairs of the Medical Staff. Accordingly, the Board of [Trustees/Directors] will not assume a duty or responsibility of the Medical Staff

CHA Preamble incorporates important provisions of Business & Professions Code 2282.5, particularly those embodied in the legislative findings that were part of the enacting legislation (SB 1325 (2004)).CMA’s Purpose Statement incorporates some, but not all, of these concepts.

CMA has added an important acknowledgement of the Governing Body’s responsibilities; of note, however, it is modulated by a statement of Medical Staff independence.

August 2013 Page 1



conducting the affairs of the Medical Staff. Accordingly, the Governing Body will not assume a duty or responsibility of the Medical Staff precipitously, unreasonably, or in bad faith; and will do so only in the reasonable and good faith belief that the Medical Staff has failed to fulfill a substantive duty or responsibility in matters pertaining to the quality of patient care.

precipitously, unreasonably, or in bad faith; and will do so only in the reasonable and good faith belief that the Medical Staff has failed to fulfill a substantive duty or responsibility in matters pertaining to the quality of patient care.

Definitions

1) Allied health professional or AHP means an individual, other than a licensed physician, dentist, [clinical psychologist] or podiatrist, who exercises independent judgment within the areas of his or her professional competence and the limits established by the Governing Body, the Medical Staff, and the applicable State Practice Act, who is qualified to render direct or indirect medical, dental, [psychological] or podiatric care under the supervision or direction of a Medical Staff member possessing privileges to provide such care in the hospital, and who may be eligible to exercise privileges and prerogatives in conformity with the policies adopted by the Medical Staff and Governing Body, these bylaws and the rules. AHPs are not eligible for Medical Staff membership.

2) Chief Executive Officer means the person appointed by the Governing Body to serve in an administrative capacity or his or her designee.

[3) Chief Medical Officer means a practitioner appointed by the Governing Body to serve as a liaison

1.2 DEFINITIONS

Membership and privileges shall be granted, revoked or otherwise restricted or modified based only on the professional training and experience criteria set forth in these bylaws.

1.2-2 AUTHORIZED REPRESENTATIVE or HOSPITAL’S AUTHORIZED REPRESENTATIVE means the individual designated by the hospital and approved by the medical executive committee to provide information to and request information from the National Practitioner Data Bank according to the terms of these Bylaws.

1.2-1 ADMINISTRATOR means the person appointed by the board of [trustees/directors] to serve in an administrative capacity.

1.2-4 CHIEF MEDICAL OFFICER (or Vice President of Medical Affairs) means a physician and surgeon appointed by

This addition to the CMA Bylaws appears to have been inadvertently placed amid the Definitions Section. Of note, it suggests that membership and privileges decisions may only be based on training and experience criteria, without mention of performance, conduct, character and other factors that also should be considered.

CMA Bylaws contain numerous provisions to control Data Bank reporting activities. CHA Bylaws do not impose these same constraints, and instead permit Data Bank reporting to be carried out as provided in applicable laws and regulations. See comment at pages 128-129.

CMA has added provisions relating to the selection of

August 2013 Page 2



between the Medical Staff and the administration.]

4) Chief of staff means the chief officer of the Medical Staff elected by the Medical Staff.

5) Date of receipt means the date any notice, special notice or other communication was delivered personally; or if such notice, special notice or communication was sent by mail, it shall mean 72 hours after the notice, special notice, or communication was deposited, postage prepaid, in the United States mail. [See also, the definitions of notice and special notice.]

6) Days means calendar days unless otherwise specified.7) Ex officio means service by virtue of office or position held. An ex officio appointment is with vote unless specified otherwise.

8) Governing Body means the [board of directors], [board of trustees], [district board]. As appropriate to the context and consistent with the hospital’s bylaws, it may also mean any Governing Body committee or individual authorized to act on behalf of the Governing Body.

9) Hospital means [insert name of hospital], and includes all inpatient and outpatient locations and services operated under the auspices of the hospital’s license.

the Chief Executive Officer and approved by the Medical Executive Committee to provide all necessary administrative support for the medical staff, communicate the views of the hospital administration to the medical staff, and serve as a liaison between the medical staff and the administration on particular issues. This position standing alone does not entitle its holder to vote on any matters of the medical staff or committee of the medical staff.

1.2-5 CHIEF OF STAFF means the chief officer of the medical staff elected by members of the medical staff.

1.2-3 BOARD OF [TRUSTEES/DIRECTORS] means the governing body of the hospital.

1.2-7 HOSPITAL means [______________] Hospital.

1.2-7 IN GOOD STANDING means a member is currently not under suspension or serving with any limitation of voting or other prerogatives imposed by operation of the bylaws, rules and regulations or policy of the medical staff.

1.2-8 INVESTIGATION means a process formally commenced by the medical executive committee to determine the validity, if any, to a concern or complaint raised against a member of the medical staff. An investigation is ongoing

the hospital’s Chief Medical Officer.

CHA includes clarification that hospital includes all locations of the hospital, including outpatient locations.

CMA’s definition of “in good standing” includes members who may be undergoing formal disciplinary action (including an ongoing hearing, for example). This may pose some dilemmas in responding to inquiries about a member’s current status (e.g., a member who is subject to a termination action [but who has not been summarily suspended] could be depicted as in good standing to an inquiring hospital.).

August 2013 Page 3



10) Medical Executive Committee or Executive Committee means the executive committee of the Medical Staff.

11) Medical Staff means the organizational component of the hospital that includes all physicians (M.D. or D.O.), dentists, [clinical psychologists], and podiatrists who have been granted recognition as members pursuant to these bylaws.

12) Medical Staff year means the period from [January 1 through December 31].

13) Member means any practitioner who has been appointed to the Medical Staff.

14) Notice means a written communication delivered personally to the addressee or sent by United States mail, first-class postage prepaid, addressed to the addressee at the last address as it appears in the official records of the Medical Staff or the hospital. (See also, the definitions of date of receipt and special notice.)

15) Physician means an individual with an M.D. or D.O. degree who is currently licensed to practice medicine.

16) Practitioner means, unless otherwise expressly limited, any currently licensed physician (M.D. or D.O.), dentist, [clinical psychologist] or podiatrist.

17) Privileges or clinical privileges means the

until either formal action is taken or the investigation is closed. An investigation does not include activity of the medical staff aid committee.

1.2-9 LIMITED LICENSE PRACTITIONERS means dentists, clinical psychologists, and podiatrists.

1.2-10 MEDICAL EXECUTIVE COMMITTEE means the executive committee of the medical staff which shall constitute the governing body of the medical staff as described in these bylaws.

1.2-11 MEDICAL STAFF or STAFF means those physicians (MD or DO or their equivalent as defined in Section 2.2-2(a)), [dentists] [podiatrists] [and clinical psychologists] who have been granted recognition as members of the medical staff pursuant to the terms of these bylaws.

1.2-12 MEDICAL STAFF YEAR means the period from [ ] to [ ].

1.2-13 MEMBER means, unless otherwise expressly limited, any physician (MD or DO or their equivalent as defined in Section 2.2-2(a)), [dentist] [podiatrist] [or clinical psychologist] holding a current license to practice within the scope of that license who is a member of the medical staff.

1.2-14 PHYSICIAN means an individual with an MD or DO degree1 or the equivalent degree (i.e., foreign) as recognized by the Medical Board of California (MBC) or the Board of Osteopathic Examiners (BOE), who is licensed by either the MBC or the BOE.

1.2-15 PRACTITIONER means an individual licensed to practice one of the professions eligible for membership in the medical staff.

CHA has added a definition of Investigation that encompasses a more complete statement of when a formal investigation may be undertaken.

1

August 2013 Page 4



permission granted to a Medical Staff member or AHP to render specific patient services.

18) Rules refers to the Medical Staff [and/or department] rules adopted in accordance with these bylaws unless specified otherwise.

19) Special notice means a notice sent by certified or registered mail, return receipt requested. (See also, the definitions of date of receipt and notice above.)

[20) System means the [insert name of health system.]

[21) System member means a facility or entity (such as an affiliated hospital, urgent care center, surgery center, foundation or other entity) that is part of the system.]

22) "Telehealth" is defined by California Business & Professions Code §2290.5 to mean the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient's health care while the patient is at the originating site and the health care provider is at a distant site. Telehealth includes synchronous (a real-time interaction between a patient and a health care provider located at a distant site interactions and asynchronous (the transmission of a patient's medical information from an originating site to the health care provider at a distant site without the presence of the patient) store and forward

1.2-6 CLINICAL PRIVILEGES or PRIVILEGES means the permission granted to medical staff members to provide patient care and include unrestricted access to those hospital resources (including equipment, facilities and hospital personnel) which are necessary to effectively exercise those privileges. [FN - The phrase “access … to hospital resources” is included to allow a member to retain access to the equipment and personnel necessary to exercise clinical privileges after a hospital decision to enter into an exclusive contract arrangement with another provider. Such language is intended to prevent the hospital from using the convenient fiction that a member continues to have privileges after entering into an exclusive contract with a different provider, and thus is not entitled to a hearing under the bylaws, but cannot use the privileges because the contract and bylaws work together to bar the member from using any hospital lab equipment or operating room. Rather, loss of privileges due to an exclusive contract and any resulting hearing rights should be addressed directly. (See these Bylaws, Sections 7.6 EXCEPTIONS TO HEARING RIGHTS and 14.9 MEDICAL STAFF ROLE IN EXCLUSIVE CONTRACTING.)

This CMA definition may be problematic – i.e., “unrestricted access” may be inconsistent with exclusive contracting arrangements in certain hospital departments. CMA’s footnote explains its reasoning – namely requiring a hearing to modify privileges even when the privilege loss is due to a change in the exclusive contractor. Hospitals should assess whether this is a necessary and appropriate use of resources. CHA agrees that a straightforward bylaw provision is most advisable. The most efficient way to address these issues is to automatically terminate privileges of physicians who are no longer part of the contracted group. Nonetheless, some hospitals choose to allow physicians who are no longer part of an exclusive contract group (either because the individual left the group or the group contractor changed), to remain on staff with modified conditions on their exercise of privileges. See additional discussion accompanying CHA Bylaws Section 14.13.

CHA Bylaws include provisions to accommodate health systems that elect to coordinate some medical staff functions.

CHA has modified its Telemedicine definition to reflect changes to Business & Professions 2290.5 (AB 415 [2011]).

(CMA Bylaws now include Telemedicine provisions as well [see CMA Section 5.5].)

August 2013 Page 5



transfers. For purposes of these Bylaws, “Telemedicine” is that subset of Telehealth services delivered to hospital patients by practitioners who have been granted privileges by this hospital to provide services via Telehealth modalities (“Telemedicine Providers”).

Article 1

NAME AND PURPOSES

1.1 NAME

The name of this organization shall be the Medical Staff of [insert name of hospital].

1.3 NAME

The name of this organization is the medical staff of [ ] Hospital.

1.2 Description

1.2-1 The Medical Staff organization is structured as follows: The members of the Medical Staff are assigned to a Staff category depending upon nature and tenure of practice at the hospital. All new members are assigned to the Provisional Staff. Upon satisfactory completion of the provisional period, the members are assigned to one of the Staff categories described in Article III.

1.2-2 Members are also assigned to departments, depending upon their specialties, as follows: Insert list of departments – this will be the same as the list for your hospital at Section 10.2-1]. Each department is organized to perform certain functions on behalf of the department, such as credentials review and peer review. This is accomplished by the department [committees,] / [members functioning as a "committee of the whole,"] as described at Article ___ of these Bylaws.

1.2-3 There are also Medical Staff committees, which perform staff-wide responsibilities, and which oversee related activities being performed by the [departments] / [department committees].

1.2-4 Overseeing all of this is the Medical Executive Committee, comprising the elected officials of the Medical Staff,[ the department chairpersons], representatives elected at large, and [______________ ].

CHA includes a summary description of the structure of the Medical Staff, in response to TJC Standard requiring the bylaws to include “the structure of the Medical Staff.” TJC, MS.01.01.01, EP 12.

August 2013 Page 6



1.3 Purposes and Responsibilities

1.3-1 The Medical Staff’s purposes are:

a. To assure that all patients admitted or treated in any of the hospital services receive a uniform standard of quality patient care, treatment and efficiency consistent with generally accepted standards attainable within the hospital’s means and circumstances.

b. To provide for a level of professional performance that is consistent with generally accepted standards attainable within the hospital’s means and circumstances.

c. To organize and support professional education and community health education and support services.

d. To initiate and maintain rules for the Medical Staff to carry out its responsibilities for the professional work performed in the hospital.

e. To provide a means for the Medical Staff, Governing Body and administration to discuss issues of mutual concern and to implement education and changes intended to continuously improve the quality of patient care.

f. To provide for accountability of the Medical Staff to the Governing Body.

g. To exercise its rights and responsibilities in a manner that does not jeopardize the hospital’s license, Medicare and Medi-Cal provider status, accreditation, [or tax exemption status.]

CHA Bylaws provide these specific Sections describing the purposes and responsibilities of the Medical Staff Organization. Incorporated within these provisions are key requirements of TJC, CMS, and key concepts articulated in SB 1325 (2004).

CMA Bylaws do not have a comparable Section that summarizes these purposes and responsibilities; however, they do address some, but certainly not all, of these concepts through other provisions in their Bylaws.

The CHA Bylaws provision aligning the Medical Staff’s purposes to those consistent with maintaining the hospital’s license, Medicare and Medi-Cal provider status, accreditation, and if applicable tax exempt status are important articulations, especially in light of certain provisions of SB 1325 (e.g., those provisions that permit the Medical Staff to collect and spend their funds, without governing body interference, for the purposes of the Medical Staff).

1.3-2 The Medical Staff’s responsibilities are:

a. To provide quality patient care.

b. To account to the Governing Body for the quality of patient care provided by all members authorized to practice in the hospital through the following measures:

1) Review and evaluation of the quality of patient care provided through valid and reliable patient care

August 2013 Page 7



evaluation procedures;

2) An organizational structure and mechanisms that allow on-going monitoring of patient care practices;

3) A credentials program, including mechanisms of appointment, reappointment and the matching of clinical privileges to be exercised or specified services to be performed with the verified credentials and current demonstrated performance of the Medical Staff applicant or member;

4) A continuing education program based at least in part on needs demonstrated through the medical care evaluation program.

5) A utilization review program to provide for the appropriate use of all medical services.

c. To recommend to the Governing Body action with respect to appointments, reappointments, staff category [and department assignments], clinical privileges and corrective action.

d. To establish and enforce, subject to the Governing Body approval, professional standards related to the delivery of health care within the hospital.

e. To account to the Governing Body for the quality of patient care through regular reports and recommendations concerning the implementation, operation, and results of the quality review and evaluation activities.

f. To initiate and pursue corrective action with respect to members where warranted.

g. To provide a framework for cooperation with other community health facilities and/or educational institutions or efforts.

h. To establish and amend from time to time as needed Medical Staff bylaws, rules and policies for the effective performance of Medical Staff responsibilities, as

August 2013 Page 8



further described in these bylaws.

i. To select and remove Medical Staff officers.

j. To assess Medical Staff dues and utilize Medical Staff dues as appropriate for the purposes of the Medical Staff.

1.4 Health System Affiliation

This hospital is part of or affiliated with the system. One of the purposes of the system is to maintain comparably high professional standards among its patient care facilities and to strive to provide efficient patient care and support services. In keeping with the foregoing, cooperative credentialing, peer review, corrective action, and procedural rights are hereby authorized, in accordance with the guidelines in these bylaws.

1.4-1 Credentialing

The Medical Staff may enter into arrangements with other system members to assist it in credentialing activities. This may include, without limitation, relying on information in other system members’ credentials and peer review files in evaluating applications for appointment and reappointment, and utilizing the other system members’ medical or professional staff support resources to process or assist in processing applications for appointment and reappointment.

1.4-2 Peer Review

The Medical Staff may enter into arrangements with other system members to assist it in peer review activities. This may include, without limitation, relying on information in other system members’ credentials and peer review files, and utilizing the other system members’ medical or professional staff support resources to conduct or assist in conducting peer review activities.

1.4-3 Corrective Action

The Medical Staff may work cooperatively with any other system member at which a Medical Staff member holds

CHA Bylaws contain optional provisions for Health Systems that want to engage in cooperative Medical Staff activities, such as credentialing, peer review, and corrective actions.

August 2013 Page 9



privileges to develop and impose coordinated, cooperative, or joint corrective action measures as deemed appropriate to the circumstances. This may include, but is not limited to, giving timely notice of emerging or pending problems, as well as notice of corrective actions imposed and/or reciprocal effectiveness of such corrective actions as provided in Section 13.6, Systemwide Corrective Action, of these bylaws.

1.4-4 Joint Hearings and Appeals

The Medical Staff and Governing Body are authorized to participate in joint hearings and appeals provided the applicable procedures are substantially comparable to those set forth in Article14, Hearings and Appellate Reviews, of these bylaws.]

Article 2

MEDICAL STAFF MEMBERSHIP

2.1 NATURE OF MEDICAL STAFF MEMBERSHIP

Membership on the Medical Staff and/or privileges may be extended to and maintained by only those professionally competent practitioners who continuously meet the qualifications, standards, and requirements set forth in these bylaws and the rules. A practitioner, including one who has a contract with the hospital to provide medical-administrative services, may admit or provide services to patients in the hospital only if the practitioner is a member of the Medical Staff or has been granted temporary privileges in accordance with these bylaws and the rules. Appointment to the Medical Staff shall confer only such privileges and prerogatives as have been established by the Medical Staff and granted by the Governing Body in accordance with these bylaws.

2.1 NATURE OF MEMBERSHIP

No physician, [dentist] [podiatrist] [clinical psychologist] including those in a medical administrative position by virtue of a contract with the hospital, shall admit or provide medical or health-related services to patients in the hospital unless the physician is a member of the medical staff or has been granted temporary privileges in accordance with the procedures set forth in these bylaws. Medical staff membership shall confer only such clinical privileges and prerogatives as have been granted in accordance with these bylaws.

2.2 QUALIFICATIONS FOR MEMBERSHIP 2.2 QUALIFICATIONS FOR MEMBERSHIP

Membership and privileges shall be granted, revoked or otherwise restricted or modified based only on professional training, experience and current competence criteria as set forth in these bylaws.

August 2013 Page 10



2.2-1 General Qualifications

Membership on the Medical Staff and privileges shall be extended only to practitioners who are professionally competent and continuously meet the qualifications, standards, and requirements set forth in the Medical Staff bylaws and rules. Medical Staff membership (except honorary Medical Staff) shall be limited to practitioners who are currently licensed or qualified to practice medicine, podiatry, [clinical psychology] or dentistry in California.

2.2-1 GENERAL QUALIFICATIONS

Only physicians, [dentists] [podiatrists] [clinical psychologists] shall be deemed to possess basic qualifications for membership in the medical staff, except for the honorary and retired staff categories in which case these criteria shall only apply as deemed individually applicable by the medical staff, and who

(a) document their (1) current licensure, (2) adequate experience, education, and training, (3) current professional competence, (4) good judgment, and (5) current adequate physical and mental health status, so as to demonstrate to the satisfaction of the medical staff that they are professionally and ethically competent and that patients treated by them can reasonably expect to receive quality medical care;

(b) are determined (1) to adhere to the ethics of their respective professions, (2) to be able to work cooperatively with others so as not to adversely affect patient care, (3) to keep as confidential, as required by law, all information or records received in the physician-patient relationship, and (4) to be willing to participate in and properly discharge those responsibilities determined by the medical staff;

[(c) maintain in force professional liability insurance in not less than the minimum amounts, if any, as from time to time may be jointly determined by the board of [trustees/directors] and medical executive committee. The medical executive committee, for good cause shown may waive this requirement with regard to a member as long as such a waiver is not granted or withheld on an arbitrary, discriminatory or capricious basis. In determining whether an individual exception is appropriate, the following facts may be considered:

(1) Whether the member has applied for the requisite insurance;

(2) Whether the member has been refused insurance, and if so, the reasons for such refusal; and

(3) Whether insurance is reasonably available to the member, and if not, the reasons for its unavailability.]

CHA approaches credentialing in a two-pronged manner, as follows:

Practitioners must meet objective criteria (i.e. the “Basic Qualifications”) in order to qualify to apply (if unable to meet these objective criteria, the application is deemed incomplete and need not be processed – and no procedural rights would apply).

Practitioners who meet objective criteria must also demonstrate compliance with subjective criteria (i.e., the “Additional Qualifications”). If unable to meet these criteria, procedural rights would apply.

CMA, on the other hand, combines all of these criteria such that more hearing rights may apply.

CMA Bylaws permit the MEC to waive insurance requirements. (This does not appear to require Board approval.)

August 2013 Page 11



2.2-2 Basic Qualifications

A practitioner must demonstrate compliance with all the basic standards set forth in this Section 2.2-2 in order to have an application for Medical Staff membership accepted for review. The practitioner must:

a. Qualify under California law to practice with an out-of-state license or be licensed as follows:

1) Physicians must be licensed to practice medicine by the Medical Board of California or the Board of Osteopathic Examiners of the State of California;

2) Telemedicine providers who are not licensed in California must be registered as a telemedicine provider with the Medical Board of California.

3) Dentists must be licensed to practice dentistry by the California Board of Dental Examiners;

4) Podiatrists must be licensed to practice podiatry by the California Board of Podiatric Medicine;

[5) Clinical psychologists must be licensed to practice clinical psychology by the California Board of Psychology and Division of Allied Health Professions of the Medical Board of California.]

b. If practicing clinical medicine, dentistry, or podiatry, have a federal Drug Enforcement Administration (DEA) number.

c. Be certified by or currently qualify to take the board certification examination of a board recognized by the American Board of Medical Specialties, the American Board of Podiatric Surgery, the American Board of Orthopedic Podiatric Medicine, or a board or association with equivalent requirements approved by the Medical Board of California in the specialty that the practitioner will practice at the hospital, or have completed a residency approved by the Accreditation Council for Graduate Medical Education that provided complete training in the specialty or subspecialty that the practitioner will practice at the hospital. This Section shall not apply to dentists or

2.2-2 PARTICULAR QUALIFICATIONS

(a) Physicians. An applicant for physician membership in the medical staff, except for the honorary staff, must hold an MD or DO degree or their equivalent and a valid and unsuspended certificate to practice medicine issued by the Medical Board of California or the Board of Osteopathic Examiners of the State of California. For the purpose of this section, “or their equivalent” shall mean any degree (i.e., foreign) recognized by the Medical Board of California or the Board of Osteopathic Examiners.

[(b) Limited License Practitioners.]

[(1) Dentists. An applicant for dental membership in the medical staff, except for the honorary staff, must hold a DDS or equivalent degree and a valid and unsuspended certificate to practice dentistry issued by the Board of Dental Examiners of California.]

[(2) Podiatrists. An applicant for podiatric membership on the medical staff, except for the honorary staff, must hold a DPM degree and a valid and unsuspended certificate to practice podiatry issued by the Board of Podiatric Medicine.]

[(3) Clinical Psychologists. An applicant for clinical psychologist membership on the medical staff, except for the honorary staff, must hold a clinical psychologist degree, have not less than two years clinical experience in a multi-disciplinary facility licensed or operated by this or another state or by the United States to provide health care or be listed in the latest edition of the National Register of Health Service Providers in Psychology, and hold a valid and unsuspended certificate to practice clinical psychology issued by the Board of Psychology.]

CHA Bylaws more specifically accommodate out-of-state telemedicine providers.

August 2013 Page 12



[clinical psychologists].

d. [Be eligible to receive payments from the federal Medicare and state Medicaid (Medi-Cal) programs.]

e. Have liability insurance or equivalent coverage meeting the standards specified [in the rules] [by the Governing Body].

f. Have actively practiced for an average of at least 20 hours per week in the specialty he or she will practice at the hospital for 12 of the previous 24 months (or have completed a residency within the previous 18 months).

g. Be located close enough (office and residence) to the hospital to be able to provide continuous care to his or her patients. The distance to the hospital may vary depending upon the Medical Staff category and privileges that are involved and the feasibility of arranging alternative coverage, and may be defined in the rules.

h. Pledge to provide continuous care to his or her patients.

i. If requesting privileges only in [departments] [services] operated under an exclusive contract, be a member, employee or subcontractor of the group or person that holds the contract.

A practitioner who does not meet these basic standards is ineligible to apply for Medical Staff membership, and the application shall not be accepted for review, except that applicants for the honorary Medical Staff do not need to comply with any of the basic standards [and applicants for the affiliate Medical Staff need not comply with paragraphs (c), (d) and (f), and applicants for the telemedicine affiliate staff need not comply with paragraph (g) of this Section 2.2-2.] If it is determined during the processing that an applicant does not meet all of the basic qualifications, the review of the application shall be discontinued. An applicant who does not meet the basic standards is not entitled to the procedural rights set forth in these bylaws, but may submit comments and a request for reconsideration of the specific standards which adversely affected such practitioner. Those

CHA Bylaws specify eligibility for Medicare and Medi-Cal as a condition of membership. For most hospitals, this is essential. The requirement could be waived pursuant to Section 2.2-4.

August 2013 Page 13



comments and requests shall be reviewed by the Medical Executive Committee and the Governing Body, which shall have sole discretion to decide whether to consider any changes in the basic standards or to grant a waiver as allowed by Section 2.2-4, Waiver of Qualifications.

2.2-3 Additional Qualifications for Membership

In addition to meeting the basic standards, the practitioner must:

a. Document his or her:

1) Adequate experience, education, and training in the requested privileges;

2) Current professional competence;

3) Good judgment; and

4) Adequate physical and mental health status (subject to any necessary reasonable accommodation) to demonstrate to the satisfaction of the Medical Staff that he or she is sufficiently healthy and professionally and ethically competent so that patients can reasonably expect to receive the quality and safety generally recognized professional level of quality of care for this community. Without limiting the foregoing, with respect to communicable diseases and other conditions that could affect ability to provide safe and quality care, practitioners are expected to know their own health status, to take such precautionary measures as may be warranted under the circumstances to protect patients and others present in the hospital, and to comply with all reasonable precautions established by hospital and/or Medical Staff policy respecting safe provision of care and services in the hospital.

b. Be determined to:

1) Adhere to the lawful ethics of his or her profession;

2) Be able to work cooperatively with others in the hospital setting so as not to adversely affect patient care or

As noted above, the CHA Bylaws segregate the kinds of qualifications that must be subjectively evaluated (such that failure to meet the qualifications should be grounds for a hearing) from those that are objective (and should not be grounds for a hearing).

CHA Bylaws include provisions relating to health status – requiring the practitioner to be aware of health status and take precautions as needed to protect others.

August 2013 Page 14



hospital operations; and

3) Be willing to participate in and properly discharge Medical Staff responsibilities.

2.2-4 Waiver of Qualifications

Insofar as is consistent with applicable laws, the Governing Body has the discretion to deem a practitioner to have satisfied a qualification, after consulting with the Medical Executive Committee, if it determines that the practitioner has demonstrated he or she has substantially comparable qualifications and that this waiver is necessary to serve the best interests of the patients and of the hospital. There is no obligation to grant any such waiver, and practitioners have no right to have a waiver considered and/or granted. A practitioner who is denied a waiver or consideration of a waiver shall not be entitled to any hearing and appeal rights under these bylaws.

CHA Bylaws contain authorization for waiver of qualifications in appropriate circumstances.

2.3 EFFECT OF OTHER AFFILIATIONS

No practitioner shall be entitled to Medical Staff membership merely because he or she holds a certain degree, is licensed to practice in this or in any other state, is a member of any professional organization, is certified by any clinical board, or because he or she had, or presently has, staff membership or privileges at another health care facility.

2.3 EFFECT OF OTHER AFFILIATIONS

No person shall be entitled to membership in the medical staff merely because that person holds a certain degree, is licensed to practice in this or in any other state, is a member of any professional organization, is certified by any clinical board, or because such person had, or presently has, staff membership or privileges at another health care facility. Medical staff membership or clinical privileges shall not be conditioned or determined on the basis of an individual’s participation or non-participation in a particular medical group, surgery center or other outpatient service facility, IPA, PPO, PHO, hospital-sponsored foundation, or other organization or in contracts with a third party which contracts with this hospital. Medical staff membership or clinical privileges shall not be revoked, denied, or otherwise infringed based on the member’s professional or business interests. Neither the existence of an actual or potential conflict of interest, nor the disclosure thereof, shall affect a member's medical staff membership or clinical privileges.

CMA includes these provisions apparently out of concerns about “economic credentialing.” Governing Bodies should carefully assess this in determining whether to approve the Bylaws.

2.4 NONDISCRIMINATION 2.4 NONDISCRIMINATION

August 2013 Page 15



Medical Staff membership or particular privileges shall not be denied on the basis of age, gender, religion, race, creed, color, national origin, or any physical or mental impairment if, after any necessary reasonable accommodation, the applicant complies with the bylaws or rules of the Medical Staff or the hospital.

No aspect of medical staff membership or particular clinical privileges shall be denied on the basis of sex, race, age, color, religion, ancestry, national origin, disability, physical or mental impairment, marital status, or sexual orientation that does not pose a threat to the quality of patient care.

2.5 ADMINISTRATIVE AND CONTRACT PRACTITIONERS

2.5-1 Contractors with No Clinical Duties

A practitioner employed by or contracting with the hospital in a purely administrative capacity with no clinical duties or privileges is subject to the regular personnel policies of the hospital and to the terms of his or her contract or other conditions of employment and need not be a member of the Medical Staff. . [Nonetheless, with respect to any contracts with practitioners whose duties involve formal liaison with or advising the Medical Staff, hospital administration, or the Governing Body about Medical Staff activities or performance, the hospital shall first consult with the Medical Executive Committee and provide reasonable opportunity to review and comment on the scope of responsibilities and qualifications of the proposed candidate; and at least bi-annually thereafter shall provide reasonable opportunity to participate in reviewing performance of the contracted practitioner.]

2.5-2 Contractors Who Have Clinical Duties

a. A practitioner with whom the hospital contracts to provide services which involve clinical duties or privileges must be a member of the Medical Staff, achieving his or her status by the procedures described in these bylaws. Unless a written contract or agreement executed after this provision is adopted specifically provides otherwise, or unless otherwise required by law, those privileges made exclusive or semi-exclusive pursuant to a closed-staff or limited-staff specialty policy will automatically terminate, without the right of access to the review, hearing, and appeal procedures of Article 14, Hearings and Appellate Reviews, of these bylaws, upon termination or expiration of such practitioner’s contract or agreement with the hospital.

3.8 ADMINISTRATIVE STAFF (INCLUDING CHIEF MEDICAL OFFICERS)

3.8-1 Selection, Review and Removal of Chief Medical Officer (Vice President of Medical Staff Affairs)

The Medical Executive Committee and Board of [Trustees/Directors] shall jointly determine if there is a need to employ a Chief Medical Officer. In addition, the job description for the Chief Medical Officer must be reviewed and approved by the Medical Executive Committee prior to the position being fulfilled in order to prevent encroachment upon medical staff self- governance and to maximize effectiveness of the administrative position and cooperation between administrative staff and the medical staff. The Chief Executive Officer shall coordinate candidate interviews with representatives of medical staff leadership, who shall participate in the interview and review of candidates for position of Chief Medical Officer in the hospital. The Medical Executive Committee shall also approve or veto the selection of any such candidate, with any veto being binding upon the hospital.

The Medical Executive Committee shall provide the Chief Medical Officer and the Board of [Trustees/Directors] with an annual performance review of its Chief Medical Officer within sufficient time to permit the Chief Medical Officer to discuss the results of such review with each administrative staff member.

An individual in a chief medical officer position shall be terminated upon the request of the Medical Executive Committee or by a majority vote of the entire medical staff for cause. Prior to removing an individual from a member of the administrative staff, the CEO shall meet and discuss the action with the Medical Executive Committee.

The CMA Bylaws provide for very significant MEC role (including a veto and termination powers) with respect to hospital contracting decisions. Also, they require Medical Staff appointment (to the Administrative Staff category) in order to hold a hospital administrative position.

CHA Bylaws, on the other hand, permit the hospital to contract as deemed appropriate; but do require Medical Staff appointment IF the administrative practitioner will be exercising clinical privileges. Additionally, CHA has added optional provision for MEC input into administrative practitioner contracting decisions.

CHA Bylaws provide for automatic termination if exclusive contract physicians’ contracts terminate (except as otherwise required by law or the CHA Medical Staff Bylaws).

CMA requires Medical Staff action to terminate privileges of exclusive contracting physicians (see

August 2013 Page 16



b. Contracts between practitioners and the hospital shall prevail over these bylaws and the rules, except that the contracts may not reduce any hearing rights granted when an action will be taken that must be reported to the Medical Board of California or the federal National Practitioner Data Bank.

2.5-3 Subcontractors

Practitioners who subcontract with practitioners or entities who contract with the hospital may lose any privileges granted pursuant to an exclusive or semi-exclusive arrangement (but not their Medical Staff membership) if their relationship with the contracting practitioner or entity is terminated, or the hospital and the contracting practitioner’s or entity’s agreement or exclusive relationship is terminated. The hospital may enforce such an automatic termination even if the subcontractor’s agreement fails to recognize this right.

3.8-2 Selection, Review and Removal of Medical Directorships

A listing of all medical directorship positions in the hospital shall be made available to any medical staff member upon request.

The Medical Executive Committee shall review the job descriptions (e.g., qualifications, responsibilities and reporting relationships) for all medical directorships in the hospital to both assure their adequacy for medical staff purposes and to avoid a conflict of duties between the medical director and any medical staff leader. The Medical Executive Committee shall also participate in the interview and review of candidates for the position of a medical director and approve or veto the selection of any such candidate, with any veto being binding upon the hospital. In addition, the Medical Executive Committee shall review the performance of each of the medical directors periodically and transmit the results of that review to the hospital board [of trustees/directors] for its consideration.

An individual in a medical director position shall be terminated upon the request of the Medical Executive Committee or by a majority vote of the entire medical staff for cause. Prior to removing an individual from a member of the administrative staff, the CEO shall meet and discuss the action with the Medical Executive Committee.

3.8-3 QUALIFICATIONS

Administrative staff category membership shall be held by any physician, who is not otherwise eligible for another staff category and who is retained by the hospital or medical staff solely to perform ongoing medical administrative activities.

The administrative staff shall consist of members who:

(a) are charged with assisting the medical staff in carrying out medical-administrative functions;

(b) document their (1) current licensure, (2) adequate experience, education and training, (3) current professional competence, (4) good judgment, and (5) current physical and mental health status, so as to demonstrate to the satisfaction of

Section 7.6 of CMA Bylaws.)

CMA Bylaws include an extensive role for the MEC and Medical Staff with respect to medical directorships.

August 2013 Page 17



the medical staff that they are professionally and ethically competent to exercise their duties;

(c) are determined (1) to adhere to the ethics of their respective professions, (2) to be able to work cooperatively with others so as not to adversely affect their judgment in carrying out the quality assessment and improvement functions, and (3) to be willing to participate in and properly discharge those responsibilities determined by the medical staff.

3.8-4 PREROGATIVES

All administrative staff shall be entitled to:

Attend open meetings of the medical staff and various departments and educational programs.

Administrative staff members shall not be eligible to hold office in the medical staff organization, admit patients or exercise clinical privileges.

CMA Bylaws appear to provide that the Medical Staff determines the responsibilities of all administrative staff physicians (including those engaged by the hospital).

CMA Bylaws restrict administrative staff members’ access to meetings (i.e., they may not attend executive sessions unless invited).

2.6 BASIC RESPONSIBILITIES OF MEDICAL STAFF MEMBERSHIP

Except for honorary members (see Rule 1, Appendix 1E), each Medical Staff member and each practitioner exercising temporary privileges shall continuously meet all of the following responsibilities:

2.5 BASIC RESPONSIBILITIES OF MEDICAL STAFF MEMBERSHIP

Except for the honorary and retired staff, the ongoing responsibilities of each member of the medical staff include:

(a) providing patients with the quality of care meeting the professional standards of the medical staff of this hospital;

CHA Bylaws contain more details (derived from TJC and CMS requirements).

August 2013 Page 18



2.6-1 Provide his or her patients with care of the generally recognized professional level of quality and efficiency.

2.6-2 Abide by the Medical Staff bylaws and rules and all other lawful standards, policies and rules of the Medical Staff and the hospital.

2.6-3 Abide by all applicable laws and regulations of governmental agencies [and comply with applicable standards of [The Joint Commission] [DNV]].

2.6-4 Discharge in a responsible and cooperative manner such Medical Staff, [department, section,] committee and service functions for which he or she is responsible by appointment, election or otherwise.

2.6-5 Abide by all applicable requirements for timely completion and recording of a physical examination and medical history, as further described at Section 5.4-3.

2.6-6 Abide by all applicable requirements for appropriately informing patients and obtaining consent, as further described in [Section 15.4.3] /[the Hospital’s Informed Consent Policy].

2.6-7 Prepare and complete in timely and accurate manner the medical and other required records for all patients to whom the practitioner in any way provides services in the hospital [, including compliance with such electronic health record (EHR) policies and protocols as have been implemented by the hospital].

2.6-8 Abide by the ethical principles of his or her profession.

2.6-9 Refrain from unlawful fee splitting or unlawful inducements relating to patient referral.

2.6-10 Refrain from any unlawful harassment or discrimination against any person (including any patient, hospital employee, hospital independent contractor, Medical Staff member, volunteer, or visitor) based upon the person’s age, sex, religion, race, creed, color, national origin, health status, ability to pay, or source of payment.

(b) abiding by the medical staff bylaws, medical staff rules and regulations, and policies;

(c) discharging in a responsible and cooperative manner such reasonable responsibilities and assignments imposed upon the member by virtue of medical staff membership, including committee assignments;

(d) preparing and completing in timely fashion medical records for all the patients to whom the member provides care in the hospital;

(e) abiding by the lawful ethical principles of the California Medical Association or member’s professional association;

(f) aiding in any medical staff approved educational programs for medical students, interns, resident physicians, resident dentists, staff physicians and dentists, nurses and other personnel;

(g) working cooperatively with members, nurses, hospital administration and others so as not to adversely affect patient care;

(h) making appropriate arrangements for coverage of that member’s patients as determined by the medical staff;

(i) refusing to engage in improper inducements for patient referral;

(j) participating in continuing education programs as determined by the medical staff;

(k) participating voluntarily in such emergency service coverage or consultation panels as may be determined by the medical staff;

CMA Bylaws do not require Medical Staff adherence to hospital standards, policies, and rules.

CMA specifies the applicability of CMA principles; CHA Bylaws are more generic (see CHA 2.6-8).

Medicare Conditions of Participation require these H&P provisions to be stated in the Medical Staff Bylaws. CHA addresses this here and at Section 5.4-3. CMA addresses this at CMA Bylaws Section 5.8.

The Medicare Conditions of Participation no longer require that the Medical Staff specify those procedures requiring informed consent. Accordingly, the Medical Staff may opt to move such specifics out of the Bylaws and place them into an Informed Consent Policy.

CMA limits the “working cooperatively” requirement to only those situations adversely affecting patient care; whereas CHA requires cooperation so as not to adversely affect patient care or hospital operations. (See CHA 2.6-18.)

See comments below regarding CHA Section 2.6-19 and CMA Section 2.6.

August 2013 Page 19



2.6-11 Refrain from delegating the responsibility for diagnosis or care of hospitalized patients to a practitioner or AHP who is not qualified to undertake this responsibility or who is not adequately supervised.

2.6-12 Coordinate individual patients’ care, treatment and services with other practitioners and hospital personnel, including, but not limited to, seeking consultation whenever warranted by the patient’s condition or when required by the rules or policies and procedures of the Medical Staff [or applicable department].

2.6-13 Actively participate in and regularly cooperate with the Medical Staff in assisting the hospital to fulfill its obligations related to patient care, including, but not limited to, continuous organization-wide quality measurement, assessment, and improvement, peer review, utilization management, quality evaluation, ongoing and focused professional practice evaluations and related monitoring activities required of the Medical Staff, and in discharging such other functions as may be required from time to time.

2.6-14 Upon request, provide information from his or her office records or from outside sources as necessary to facilitate the care of or review of the care of specific patients.

2.6-15 Recognize the importance of communicating with appropriate [department officers and/or] Medical Staff officers when he or she obtains credible information indicating that a fellow Medical Staff member may have engaged in unprofessional or unethical conduct or may have a health condition which poses a significant risk to the well-being or care of patients and then cooperate as reasonably necessary toward the appropriate resolution of any such matter.

2.6-16 Accept responsibility for participating in Medical Staff proctoring in accordance with the rules and policies and procedures of the Medical Staff.

2.6-17 Complete continuing medical education (CME) that meets all licensing requirements and is appropriate to the practitioner’s specialty.

(l) serving as a proctor or other peer reviewer, and otherwise participating in medical staff peer review as reasonably requested;

(m) discharging such other staff obligations as may be lawfully established from time to time by the medical staff or medical executive committee; and

(n) providing information to and/or testifying on behalf of the medical staff or an accused practitioner regarding any matter under an investigation pursuant to paragraph 6.1-3, and those which are the subject of a hearing pursuant to Article VII.

CHA Bylaws provide for access to office records as needed to review care.

CHA Bylaws impose specific communication requirements relating to professional conduct.

CMA ER call coverage is completely voluntary;

August 2013 Page 20



2.6-18 Adhere to the Medical Staff Standards of Conduct (as further described at Section 2.7), so as not to adversely affect patient care or hospital operations.

2.6-19 Participate in emergency service coverage and consultation panels as allowed and as required by the rules.

2.6-20 Cooperate with the Medical Staff in assisting the hospital to meet its uncompensated or partially compensated patient care obligations.

2.6-21 Participate in patient and family education activities, as determined by the [department or] Medical Staff rules, or the Medical Executive Committee.

2.6-22 Notify the Medical Staff office in writing promptly, and no later than 14 calendar days, following any action taken regarding the member’s license, DEA registration, privileges at other facilities, changes in liability insurance coverage, any report filed with the National Practitioner Data Bank, or any other action or change in circumstances that could affect his/her qualifications for Medical Staff membership and/or clinical privileges at the hospital.

2.6-23 Continuously meet the qualifications for and perform the responsibilities of membership as set forth in these bylaws. A member may be required to demonstrate continuing satisfaction of any of the requirements of these bylaws upon the reasonable request of the Medical Executive Committee. This shall include, but is not limited to, mandatory health or psychiatric evaluation and mandatory drug and/or alcohol testing, the results of which shall be reportable to the Medical Executive Committee, the Well-Being Committee, [and/or the Professional Conduct Committee].

2.6-24 Discharge such other Staff obligations as may be lawfully established from time to time by the Medical Staff or Medical Executive Committee.

2.6 VOLUNTARY PARTICIPATION ON EMERGENCY DEPARTMENT BACKUP CALL PANELS

Participation on the emergency department backup call panel shall be voluntary. Membership on the medical staff shall not in any way be contingent on an applicant’s willingness to participate on the emergency department’s backup call panel.

whereas CHA’s ER call responsibilities are as determined by the Medical Staff Rules – which may be voluntary or mandatory, depending upon the circumstances at each hospital.

CHA Bylaws note the Medical Staff role in assisting the hospital to meet uncompensated care obligations. While no specific requirement is stated, there is still a general obligation to cooperate.

CHA Bylaws impose specific notification requirements relating to other adverse actions involving Medical Staff members.

CHA Bylaws clearly state that mandatory health or psychiatric evaluations may be required.

2.7 STANDARDS OF CONDUCT

Members of the Medical Staff are expected to adhere to the Medical Staff Standards of conduct, including but not

2.7 MEMBERS’ CONDUCT REQUIREMENTS

As a condition of membership and privileges, a medical staff member shall continuously meet the requirements for

CHA Bylaws provisions relating to Standards of Conduct are derived from the Settlement Agreement in the Medical Staff of Community Memorial Hospital v.

August 2013 Page 21



limited to the following:

2.7-1 General

a. It is the policy of the Medical Staff to require that its members fulfill their Medical Staff obligations in a manner that is within generally accepted bounds of professional interaction and behavior. The Medical Staff is committed to supporting a culture and environment that values integrity, honesty and fair dealing with each other, and to promoting a caring environment for patients, practitioners, employees and visitors.

b. Rude, combative, obstreperous behavior, as well as willful refusal to communicate or comply with reasonable rules of the Medical Staff and the hospital may be found to be disruptive behavior. It is specifically recognized that patient care and hospital operations can be adversely affected whenever any of the foregoing occurs with respect to interactions at any level of the hospital, in that all personnel play an important part in the ultimate mission of delivering quality patient care.

c. In assessing whether particular circumstances in fact are affecting quality patient care or hospital operations, the assessment need not be limited to care of specific patients, or to direct impact on patient health. Rather, it is understood that quality patient care embraces—in addition to medical outcome—matters such as timeliness of services, appropriateness of services, timely and thorough communications with patients, their families, and their insurers (or third party payors) as necessary to effect payment for care, and general patient satisfaction with the services rendered and the individuals involved in rendering those services.

2.7-2 Conduct Guidelines

a. Upon receiving Medical Staff membership and/or privileges at the hospital, the member enters common goal with all members of the organization to endeavor to maintain the quality of patient care and appropriate professional conduct.

b. Members of the Medical Staff are expected to behave in a professional manner at all times and with all

professional conduct established in these bylaws. Non-members with privileges will be held to the same conduct requirements as members. Except as provided in these bylaws, no other codes or policy restricting or defining conduct apply to the medical staff and its members.

2.7-1 Acceptable Conduct

Acceptable medical staff member conduct is not restricted by these bylaws and includes, but is not limited to:

(a). advocacy on medical matters;

(b). making recommendations or criticism intended to improve care;

(c). exercising rights granted under the medical staff bylaws, rules and regulations, and policies;

(d). fulfilling duties of medical staff membership or leadership;

(e). engaging in legitimate business activities that may or may not compete with the hospital.

2.7-2 Disruptive and Inappropriate Conduct

Disruptive and inappropriate medical staff member conduct affects or could affect the quality of patient care at the hospital and includes:

(a). Harassment by a medical staff member against any individual involved with the hospital; (e.g., against another medical staff member, house staff, hospital employee or patient) on the basis of race, religion, color, national origin, ancestry, physical disability, mental disability, medical disability, marital status, sex or sexual orientation.

(b). “Sexual harassment” defined as unwelcome verbal or physical conduct of a sexual or gender-based nature which may include verbal harassment (such as epithets, derogatory comments or slurs), physical harassment (such as unwelcome touching, assault, or interference with movement or work), and visual harassment (such as the display of derogatory cartoons, drawings, or posters). Sexual harassment includes

Community Memorial Hospital case.

CMA has updated its conduct requirements. While in theory all of the conduct described as “Acceptable” is indeed generally acceptable when done in a civilized and professional manner, the wording of the CMA provision is such that one might conclude it immunizes all conduct that can be said to be in furtherance of these listed activities.

CMA’s description of disruptive and inappropriate conduct is notably limited and per the lead paragraph of this Section, no other codes or policies restricting or defining conduct apply.

See also CHA Rule 3.

August 2013 Page 22



people—patients, professional peers, hospital staff, visitors, and others in and affiliated with the hospital.

c. Interactions with all persons shall be conducted with courtesy, respect, civility and dignity. Members of the Medical Staff shall be cooperative and respectful in their dealings with other persons in and affiliated with the hospital.

d. Complaints and disagreements shall be aired constructively, in a nondemeaning manner, and through official channels.

e. Cooperation and adherence to the reasonable rules of the hospital and the Medical Staff is required.

f. Members of the Medical Staff shall not engage in conduct that is offensive or disruptive, whether it is written, oral or behavioral.

2.7-3 Adoption of Rules

The Medical Executive Committee may promulgate rules further illustrating and implementing the purposes of this Section, including but not limited to, procedures for investigating and addressing incidents of perceived misconduct, and, where appropriate, progressive or other remedial measures. These measures may include [establishing a Professional Conduct Committee to oversee practitioner conduct issues,] alternative avenues for medical or administrative disciplinary action, which in turn may include but are not limited to conditional appointments and reappointments, requirements for behavioral contracts, mandatory counseling, practice restrictions, and/or suspension or revocation of Medical Staff membership and/or privileges.

unwelcome advances, requests for sexual favors, and any other verbal, visual, or physical conduct of a sexual nature when (1) submission to or rejection of this conduct by an individual is used as a factor in decisions affecting hiring, evaluation, retention, promotion, or other aspects of employment; or (2) this conduct substantially interferes with the individual's employment or creates and/or perpetuates an intimidating, hostile, or offensive work environment. Sexual harassment also includes conduct which indicates that employment and/or employment benefits are conditioned upon acquiescence in sexual activities.

(c) Deliberate physical, visual or verbal intimidation or challenge, including disseminating threats or pushing, grabbing or striking another person involved in the hospital;

(e) Carrying a gun or other weapon in the hospital;

(f) Refusal or failure to comply with these member conduct requirements.

2.7-3 Medical Staff Conduct Complaints

2.7-3 Medical Staff Conduct Complaints

All complaints or reports will be discussed and decisions made in executive session. Complaints or reports of disruptive and inappropriate conduct by medical staff members are subject to review whether or not the witness or complainant requests or desires action to be taken. Complaints or reports must be in writing, and will be transmitted to the Department Chair and Chief of the Medical Staff, or to the medical staff officer designated by either the Chief of Staff or Medical Executive Committee. Complaints are shared with the subject member, who will be given the opportunity to respond in writing. The Department Chair, in consultation with the Chief of Staff shall refer the matter immediately to the Medical Staff Aid Committee for evaluation, and monitoring and treatment if needed, if there is any indication that the member's health is implicated and the conduct at issue can be addressed by the Medical Staff Aid Committee without jeopardizing quality care or patient safety.

CMA has added explicit instructions about executive sessions, which per their Section 12.8 specifically excludes all but voting members of the Medical Staff who are not also employed by the Hospital. Such restrictions can significantly undermine CEO and medical executives’ abilities to fully perform their duties.

CHA has introduced a new committee, the Professional Conduct Committee, and provisions for “administrative discipline” as new tools for dealing with these difficult issues. See additional comments at Rule 2.3 and Rule 4J.

CHA Rules contain additional provisions for processing conduct issues.

August 2013 Page 23



The Department Chair, in consultation with the Chief of Staff shall determine if the complaint or report is obviously specious and warrants no further action. If the Department Chair, in consultation with the Chief of Staff determines no action is warranted, the decision is reported at the next Medical Executive Committee. This decision may be discussed and acted upon at the request of any Medical Executive Committee member with the support of the majority of the Medical Executive Committee members present at that meeting. Complaints not referred to the Medical Staff Aid Committee or nor dismissed by the Department Chair, in consultation with the Chief of Staff are referred to the appropriate department for peer review committee evaluation and investigation, if needed. The decision will be forwarded to the Medical Executive Committee. Any action taken shall be commensurate with the nature and severity of the conduct in question. If corrective action is decided by the Medical Executive Committee, the members will be afforded hearing rights per Article VIII. If the Medical Executive Committee decides no further action is necessary, the complaint will be closed and filed for up to two years and discarded thereafter.

2.7-4 Hospital Staff Conduct Complaints

Medical staff members' reports or complaints about the conduct of any hospital administrators, nurses or other employees, contractors, board members or others affiliated with the hospital must be reduced to writing and submitted to the Chief of Staff or any medical staff officer. The Chief of Staff shall forward the complaint or report to the appropriate hospital authority for action. Reports and complaints regarding hospital staff conduct will be tracked through the medical staff office, which will report results of such results and complaints to the Medical Executive Committee.

2.7-5 Abuse of Process

Retaliation or attempted retaliation against complainants or those who are carrying out medical staff duties regarding conduct will be considered inappropriate and disruptive conduct, and could give rise to evaluation and corrective action pursuant to the medical staff bylaws.

CMA Bylaws appear to require majority MEC “support” to even discuss a referred conduct issue.

See comments accompanying CMA Section 14.8.2 regarding purging of complaint records.

August 2013 Page 24



Article 3

CATEGORIES OF THE MEDICAL STAFF

3.1 CATEGORIES

Each Medical Staff member shall be assigned to a Medical Staff category based upon the qualifications defined in the rules. The members of each Medical Staff category shall have the prerogatives and carry out the duties defined in the bylaws and rules. Action may be initiated to change the Medical Staff category or terminate the membership of any member who fails to meet the qualifications or fulfill the duties described in the bylaws or rules. Changes in Medical Staff category shall not be grounds for a hearing unless they adversely affect the member’s privileges.

ARTICLE III CATEGORIES OF MEMBERSHIP

3.1 CATEGORIES

The categories of the medical staff shall include the following: active, courtesy, consulting, provisional, honorary, retired, [resident], temporary, and administrative. Each time membership is granted or renewed, the member’s staff category shall be determined.

CMA Bylaws contain most of their provisions relating to Medical Staff Categories in the Bylaws; CHA on the other hand, contains the basic provision in the Bylaws, with details in the rules. To facilitate substantive comparison, and reduce redundancy, the CMA provisions have been moved along-side the relevant CHA Rule 1.

3.2 GENERAL EXCEPTIONS TO PREROGATIVES

Regardless of the category of membership in the Medical Staff, podiatrists, [clinical psychologists], dentists, and limited license members:

3.2-1 May not hold any general Medical Staff office.

3.2-2 Shall have the right to vote only on matters within the scope of their licensure. Any disputes over voting rights shall be determined by the chair of the meeting, subject to final decision by the Medical Executive Committee.

3.2-3 Shall exercise privileges only within the scope of their licensure and as limited by the Medical Staff bylaws and rules.

3.10 LIMITATION OF PREROGATIVES

The prerogatives set forth under each membership category are general in nature and may be subject to limitation by special conditions attached to a particular membership, by other sections of these bylaws and by the medical staff rules and regulations.

3.11 GENERAL EXCEPTIONS TO PREROGATIVES

Regardless of the category of membership in the medical staff, limited license members:

(a) shall only have the right to vote on matters within the scope of their licensure. In the event of a dispute over voting rights, that issue shall be determined by the chair of the meeting, subject to final decision by the medical executive committee; and

(b) shall exercise clinical privileges only within the scope of their licensure and as set forth in Section 5.4.

3.12 MODIFICATION OF MEMBERSHIP

On its own, upon recommendation of the credentials committee, or pursuant to a request by a member under Section 4.6, the medical executive committee may

August 2013 Page 25



recommend a change in the medical staff category of a member consistent with the requirements of the bylaws.

3.3 SUMMARY OF PREROGATIVES AND RESPONSIBILITIES OF THE MEDICAL STAFF

[See table at CHA Bylaws §3.3.]

CHA has added a table summarizing the prerogatives and responsibilities of each category of the Medical Staff to ensure compliance with TJC Standard MS.01.01.01. That table is not replicated here because it would not fit within the format of this comparison.

Article 4

PROCEDURES FOR APPOINTMENT AND REAPPOINTMENT

4.1 GENERAL

The Medical Staff shall consider each application for appointment, reappointment and privileges, and each request for modification of Medical Staff category using the procedure and the criteria and standards for membership and clinical privileges set forth in the bylaws and the rules. The Medical Staff shall perform this function also for practitioners who seek temporary privileges and for AHPs. The Medical Staff shall investigate each applicant for appointment or reappointment and make an objective, evidence-based decision based upon assessment of the applicant vis-à-vis the hospital’s “general competencies,” (as further described at Section 5.2 of these bylaws, before recommending action to the Governing Body. The Governing Body shall ultimately be responsible for granting membership and privileges (provided, however, that these functions may be delegated to the Chief of Staff and Chief Executive Officer with respect to requests for temporary privileges). By applying to the Medical Staff for appointment or reappointment (or by accepting honorary Medical Staff appointment), the applicant agrees that regardless of whether he or she is appointed or granted the requested privileges, he or she will comply with the responsibilities of Medical Staff membership and with the Medical Staff bylaws and rules as they exist and as they may be modified from time to time.

ARTICLE IV MEMBERSHIP AND MEMBERSHIP RENEWAL

4.1 GENERAL

Except as otherwise specified herein, no person (including persons engaged by the hospital in administratively responsible positions) shall exercise clinical privileges in the hospital unless and until that person applies for and obtains membership on the medical staff and is granted privileges as set forth in these bylaws, or, with respect to allied health practitioners, has been granted a service authorization or privileges under applicable medical staff policies. By applying to the medical staff for initial membership or renewal of membership (or, in the case of members of the honorary staff, by accepting membership in that category), the applicant acknowledges responsibility to first review these bylaws and medical staff rules, regulations and policies, and agrees that throughout any period of membership that person will comply with the responsibilities of medical staff membership and with the bylaws, rules and regulations and policies of the medical staff as they exist and as they may be modified from time to time. Membership on the medical staff shall confer on the member only such clinical privileges as have been granted in accordance with these bylaws.

August 2013 Page 26



4.2 OVERVIEW OF THE PROCESS

The following chart depicts the basic steps of the appointment, reappointment, and temporary privileges processes. Details of each step are described in Rules 2.2 through 2.9.

CHA has added a table summarizing the appointment, reappointment, and privileging processes to ensure compliance with TJC Standard MS.01.01.01. That table is not replicated here because it would not fit within the format of this comparison.

4.3 APPLICANT’S BURDEN

4.3-1 An applicant for appointment, reappointment, advancement, transfer, and/or privileges shall have the burden of producing accurate and adequate information for a thorough evaluation of the applicant’s qualifications and suitability for the requested status or privileges, resolving any reasonable doubts about these matters and satisfying requests for information. The provision of information containing significant misrepresentations or omissions and/or a failure to sustain the burden of producing information shall be grounds for denying an application or request. This burden may include submission to a physical or mental health examination at the practitioner’s expense, if deemed appropriate by the Medical Executive Committee. The applicant may select the examining physician from an outside panel of three physicians chosen by the Medical Executive Committee.

4.3-2 Any committee or individual charged under these bylaws with responsibility of reviewing the appointment or reappointment application and/or request for clinical privileges may request further documentation or clarification. If the practitioner or member fails to respond within one month, the application or request shall be deemed withdrawn, and processing of the application or request will be discontinued. Unless the circumstances are such that a report to the Medical Board of California is required, such a withdrawal shall not give rise to hearing and appeal rights pursuant to Article 14, Hearings and Appellate Reviews.

4.2 BURDEN OF PRODUCING INFORMATION

In connection with all applications for initial membership, membership renewal, 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 clinical 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. To the extent consistent with law, 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. The applicant may select the examining physician from an outside panel of three physicians chosen by the medical executive committee.

CHA Bylaws Section 4.3-2 contains an option whereby the applicant may withdraw an incomplete application – in appropriate circumstances this may avert need for a MBOC 805 report. (However, as noted in the CHA Model, in some circumstances a withdrawn application must still be reported.)

4.4 APPLICATION FOR INITIAL APPOINTMENT AND REAPPOINTMENT

4.4-1 A practitioner applying for appointment and reappointment shall complete written application forms that

4.3 AUTHORITY TO GRANT, DENY AND REVOKE MEMBERSHIP

Approvals, denials and revocations of medical staff membership and/or privileges shall be made as set forth in

See comments accompanying CMA Section 6.3-6.

August 2013 Page 27



seeks information regarding the applicant and documents the applicant’s agreement to abide by the Medical Staff bylaws and rules (including the standards and procedures for evaluating applicants contained therein) and to release all persons and entities from any liability that might arise from their investigating and/or acting on the application. The information shall be verified and evaluated by the Medical Staff using the procedure and standards set forth in the bylaws and rules. Following its investigation, the Medical Executive Committee shall recommend to the Governing Body whether to appoint, reappoint and/or grant specific privileges.

these bylaws, but only after there has been a recommendation from the medical staff, or as set forth in Section 6.1-6 [sic 6.3-6?].

4.4-2 Basis for Appointment

a. Except as next provided with respect to telemedicine practitioners, recommendations for appointment to the Medical Staff and for granting privileges shall be based upon appraisal of all information provided in the application, (including but not limited to health status and written peer recommendations regarding the practitioner’s current proficiency with respect to the hospital’s general competencies [as further described at Section 5.2], the practitioner’s training, experience, and professional performance at this hospital, if applicable, and in other settings, whether the practitioner meets the qualifications and can carry out all of the responsibilities specified in these bylaws and the rules, and upon the hospital’s patient care needs and ability to provide adequate support services and facilities for the practitioner. Recommendations from peers in the same professional discipline as the practitioner, and who have personal knowledge of the applicant, are to be included in the evaluation of the practitioner’s qualifications.

b. The initial appointment of practitioners to the Telemedicine Staff may be based upon

1) The practitioner’s full compliance with this hospital’s credentialing and privileging standards;

2) By using this hospital’s standards but relying in whole or in part on information provided by the [Joint Commission] [DNV]-accredited hospital(s) at which the August 2013 Page 28



practitioner routinely practices;

[Option: for Medicare participating hospitals]

[[i) If the hospital where the practitioner normally practices is a Medicare participating hospital, this Medical Staff may use a copy of that hospital’s credentialing packet for privileging purposes. This pack must include a list of all privileges granted by that hospital and an attestation signed by an authorized representative at that hospital indicating that the packet is complete, accurate, and up-to-date].

4.4-3 Basis for Reappointment

Recommendation for reappointment to the Medical Staff and for renewal of privileges shall be based upon a reappraisal of the member’s health status, current proficiency in the hospital’s general competencies (as further described at Section 5.2) in light of his/her performance at this hospital and in other settings. The reappraisal is to include confirmation of adherence to Medical Staff membership requirements as stated in these bylaws, the Medical Staff rules, the Medical Staff, and hospital policies [and the applicable department rules]. Such reappraisal should also include relevant member-specific information from ongoing performance evaluations, focused professional performance evaluations (if any), performance improvement activities and, where appropriate, comparisons to aggregate information about performance, judgment and clinical or technical skills, and reappraisal of the hospital’s patient care needs and ability to provide adequate support services and facilities for the practitioner. Where applicable, the results of specific peer review activities shall also be considered. If sufficient review data are unavailable, peer recommendations may be used instead; or in the case of reappointment of a member of the Telemedicine Staff, reappointment may be based upon information provided by the hospital(s) where the

CHA Bylaws more specifically articulate the criteria for evaluating applications for reappointment in accordance with TJC and CMS standards.

August 2013 Page 29



practitioner routinely practices.

4.4-4 Limitations on Extension of Appointment If the reappointment application has not been fully processed before the member’s appointment expires, the Medical Staff member’s membership status and privileges shall be automatically suspended until the review is completed, unless: (i) good cause exists for the care of a specific patient or patients and no other health professional currently privileged possesses the necessary skills and is available to provide care to the specific patient(s), in which case the member’s privileges may be temporarily extended while his or her full credentials information is verified and approved; or (ii) the delay is due to the member’s failure to timely return the reappointment application form or provide other documentation or cooperation, in which case the appointment shall terminate as provided in the next section. An extension of an appointment does not create a vested right for the member to be reappointed. Time period for submission and resulting effect are in the rules.

CMA Footnote to Section 4.6-3 states that: Joint Commission Standard MS.06-02-07, EP 8, requires that privileges are granted, renewed, or revised and do not exceed a period of two years. The Joint Commission permits no exceptions to the two-year re-credentialing rule. This issue routinely makes the list of the most commonly violated Standards. As an acceptable alternative, temporary privileges may be granted to complete the credentialing process. This recommendation protects the individual staff member by providing that, when delays are due to causes other than the fault of the individual member, the member may continue to exercise membership and privileges until the process has been completed. See Section 5.5-1(c).

CHA Bylaws address the TJC limitation on extension of privileges.

Query regarding CMA Bylaws: Can temporary privileges be granted in these circumstances? TJC says: “There are two circumstances in which temporary privileges may be granted. Each circumstance has different criteria for granting privileges. The circumstances for which the granting of temporary privileges is acceptable are:- To fulfill an important patient care, treatment, and service need.- When an applicant for new privileges with a complete application that raises no concerns is awaiting review and approval by the medical staff executive committee and the governing body.

“Note: ‘Applicant for new privileges’ includes an individual applying for clinical privileges at the hospital for the first time; an individual currently holding clinical privileges who is requesting one or more additional privileges; and an individual who is in the reappointment/reprivileging process and is requesting one or more additional privileges.” TJC Standard MS.06.01.03.

4.4-5 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 and other privileges and prerogatives at the end of the current Medical Staff appointment, unless otherwise extended by the Medical Executive Committee with the approval of the Governing Body, pursuant to Section 4.3-4. If the member fails to submit a completed application for reappointment within the time specified in the rules, the practitioner shall be deemed to have resigned membership in the Medical Staff. In the event membership terminates for the reasons set forth

4.6-4 FAILURE TO FILE REAPPOINTMENT APPLICATION [repeated in Rule 2 below]

If the member in good standing fails to submit a completed application for renewal of membership within [ ] days past the date it was due, the member shall be deemed to have resigned membership in the medical staff, unless otherwise extended by the Medical Executive Committee with the approval of the board of [trustees/directors] so long as processing the member’s application is completed prior to the expiration of the privileges. In the event membership terminates for the reasons set forth herein, the procedures set forth in Article VII shall not apply. If a member subsequently submits a new

CMA’s inclusion of a “good standing” requirement, coupled with its definition of “good standing” [see

August 2013 Page 30



herein, the practitioner shall not be entitled to any hearing or review.

application for medical staff membership within [90] days of resigning membership, the member shall be subject to the procedures set forth in Sections 4.5-3 through 4.5-11, except that the member will not be required to undergo initial proctoring requirements for clinical privileges that were previously granted by the medical staff.

Section 1.2-7], might limit the Medical Staff’s ability to impose proctoring on a physician who may be under investigation or otherwise undergoing a yet-to-be completed corrective action process (e.g., if such physician were to not timely submit a reappointment application, then resubmit within 90 days).

4.5 APPROVAL PROCESS FOR APPOINTMENTS AND REAPPOINTMENTS

4.5-1 Recommendations and Approvals

The [Department Chair][Department Committee] shall review applications, engage in further consideration if appropriate, as further described in the rules, and make a recommendation to the [Credentials Committee][Medical Executive Committee] regarding staff appointments, reappointments and clinical privileges. [The Credentials Committee shall then review the application and make a recommendation to the Medical Executive Committee] The Medical Executive Committee shall make a recommendation to the Governing Body that is either favorable, adverse or defers the recommendation. If the Medical Executive Committee’s recommendation to the practitioner is adverse, the Medical Executive Committee shall also assess and determine whether the adverse recommendation is for a “medical disciplinary” cause or reason. A medical disciplinary action is one taken for cause or reason that involves that aspect of a practitioner’s competence or professional conduct that is reasonably likely to be detrimental to patient safety or to the delivery of patient care. All other actions are deemed administrative disciplinary actions. In some cases, the reason may involve both medical disciplinary and administrative disciplinary cause or reason, in which case, the matter shall be deemed medical disciplinary for Bylaws, Article 14 hearing purposes.

4.5-2 The Governing Body’s Action

The Governing Body shall review any favorable recommendation from the Medical Executive Committee and take action by adopting, rejecting, modifying or sending

[CMA Bylaws Sections 4.5-4.6 have been moved to CHA Rule 2]

CHA has consolidated the appointment and reappointment approval processes, as they are essentially the same.

The CHA Bylaws Section 4.5 generally describes the approval steps for appointments and reappointments, as well as in the new table added at Section 3.3. Additional detail about these steps is provided in the CHA Rules. To facilitate a comparative analysis of the CHA and CMA Provisions, the CMA Provisions have been moved along-side CHA Rule 2, describing the appointment and reappointment steps.

CHA includes a provision that distinguishes “medical disciplinary” from “administrative disciplinary” actions, as an added tool for dealing with conduct and other infractions that may not directly involve safety or quality of patient care.

See comments accompanying CMA Section 4.3.

August 2013 Page 31



the recommendation back for further consideration.

a. After notice, the Governing Body may also take action on its own initiative if the Medical Executive Committee does not give the Governing Body a recommendation in the required time. The Governing Body may also receive and take action on a recommendation following any applicable procedural rights described at Article 14, Hearings and Appellate Reviews.

b. The Governing Body shall make its final determination giving great weight to the actions and recommendations of the Medical Executive Committee. Further, the Governing Body determination shall not be arbitrary or capricious, and shall be in keeping with its legal responsibilities to act to protect the quality of medical care provided and the competency of the Medical Staff, and to ensure the responsible governance of the hospital.

4.5-3 Expedited Review

The Governing Body may use an expedited process for appointment, reappointment or when granting Privileges when criteria for that process are met, as further described in the rules.

4.5-4 Notice of Final Decision

The Chief Executive Officer shall give notice of the Governing Body’s final decision to the Medical Executive Committee and to the applicant.

4.6 LEAVE OF ABSENCE

4.6-1 Routine Leave of Absence.Except as next provided with respect to military leave of absence, members may request a leave of absence, which must be approved by the Medical Executive Committee and cannot exceed [two years]. Reinstatement at the end of the leave must be approved in accordance with the standards and procedures set forth in the rules for reappointment review. The member must provide information regarding his or her professional activities during the leave of absence. During the period of the leave, the member shall not

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 [ ]. During the period of the leave, the member shall not exercise clinical privileges at the hospital, and membership rights and responsibilities shall be inactive, but the obligation to pay

August 2013 Page 32



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 Executive Committee.

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. 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 membership.

4.7-4 MEDICAL LEAVE OF ABSENCE

The medical executive committee shall determine the circumstances under which a particular medical staff member shall be granted a leave of absence for the purpose of obtaining treatment for a medical condition or disability. In the discretion of the medical executive committee, unless accompanied by a reportable restriction of privileges, the leave shall be deemed a “medical leave” which is not granted for a medical disciplinary cause or reason.

Under the CHA Bylaws, Medical Leaves are subsumed within the general Leave of Absence provisions – again to avoid members from using the Leave of Absence (or Medical Leave of Absence) to avoid disciplinary matters. (CHA Bylaws do provide means for members to participate in well-being activities in appropriate circumstances. See CHA Rule 4.)

4.6-2 Military Leave of Absence.Requests for leave of absence to fulfill military service

4.7-5 MILITARY LEAVE OF ABSENCE

August 2013 Page 33



obligations shall be granted upon notice and review by the Medical Executive committee. Reactivation of membership and clinical privileges previously held shall be granted, notwithstanding the provisions of Sections 4.6-1, but may be granted subject to focused professional practice evaluation, as determined by the Medical Executive Committee.

Requests for leave of absence to fulfill military service obligations shall be granted upon notice and review by the medical executive committee. Reactivation of membership and clinical privileges previously held shall be granted, notwithstanding the provisions of Sections 4.7-2 and 4.7-3, but may be granted subject to monitoring and/or proctoring as determined by the medical executive committee.

4.7 WAITING PERIOD AFTER ADVERSE ACTION

4.7-1 Who Is Affected

a. A waiting period shall apply to the following practitioners:

1) An applicant who

i) Has received a final adverse decision regarding appointment; or

ii) Withdrew his or her application or request for membership or privileges following an adverse recommendation by the Medical Executive Committee or the Governing Body

2) A former member who has

i) Received a final adverse decision resulting in termination of Medical Staff membership and/or privileges; or

ii) Resigned from the Medical Staff or relinquished privileges while an investigation was pending or following the Medical Executive Committee or Governing Body issuing an adverse recommendation

3) A member who has received a final adverse decision resulting in

i) Termination or restriction of his or her privileges; or

ii) Denial of his or her request for additional privilegesAugust 2013 Page 34



b. An action is considered adverse only if it is based on the type of occurrences which might give rise to corrective action. An action is not considered adverse if it is based upon reasons that do not pertain to medical or ethical conduct, such as actions based on a failure to maintain a practice in the area (which can be cured by a move), to pay dues (which can be cured by paying dues), or to maintain professional liability insurance (which can be cured by obtaining the insurance).

CHA Bylaws contain more detail regarding the waiting period, and also provide a basis for waiving the 24 month period in appropriate circumstances.

4.7-2 Commencement Date of the Waiting Period

a. Ordinarily the duration of the waiting period shall be the longer of (i) [24 months] or (ii) completion of all judicial proceedings pertinent to the action served within two years after completion of the hospital proceedings described in Bylaws, Section 4.7-2. However, for practitioners whose adverse action included a specified period or conditions of retraining or additional experience, the Medical Executive Committee may exercise its discretion to allow earlier reapplication upon completion of the specified conditions. Similarly, the Medical Executive Committee may exercise its discretion, with approval of the Governing Body, to waive the [24-month] period in other circumstances where it reasonably appears, by objective measures, that changed circumstances warrant earlier consideration of an application.

b. The action is considered final on the latest date on which the application or request was withdrawn, a member’s resignation became effective, or upon final Governing Body action following completion or waiver of all Medical Staff and hospital hearings and appellate reviews.

4.7-3 Effect of the Waiting Period

Except as otherwise allowed (per Section 4.6-1(b)), practitioners subject to waiting periods cannot reapply for Medical Staff membership or the privileges affected by the adverse action for at least [24 months] after the action became final. After the waiting period, the practitioner may reapply. The application will be processed like an initial application or request, plus the practitioner shall document that the basis for the adverse action no longer exists, that he

4.5-10 REAPPLICATION AFTER ADVERSE MEMBERSHIP DECISION

An applicant who has received a final adverse decision regarding membership shall not be eligible to reapply to the medical staff for a period of [ ]. 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.

CHA Bylaws have been amended to clarify the waiting period, consistent with the California appellate court ruling in Smith v. Adventist Health System (2010) 190 Cal.App.4th 40.

August 2013 Page 35



or she has corrected any problems that prompted the adverse action, and/or he or she has complied with any specific training or other conditions that were imposed.

4.8 CONFIDENTIALITY; IMPARTIALITY

To maintain confidentiality and to assure the unbiased performance of appointment and reappointment functions, participants in the credentialing process shall limit their discussion of the matters involved to the formal avenues provided in the bylaws and rules for processing applications for appointment and reappointment.

CHA Bylaws articulate important confidentiality and impartiality provision associated with the credentialing process. This serves as a reminder to those involved in the credentialing processes of this important requirement.

[4.9 SYSTEMWIDE COOPERATION

4.9-1 General Rules for Systemwide Cooperation for Appointments and Reappointments

Practitioners desiring to exercise privileges through more than one system member are subject to the following provisions regarding systemwide appointments and reappointments.

CHA Bylaws contain optional provisions relating to systemwide credentialing activities.

4.9-2 System Application Form

A single application form shall be developed for all participating system members to use, and the applicant shall indicate those system members in which he or she desires to exercise privileges together with the privileges desired.

a. An applicant requesting appointment and privileges with an affiliated medical foundation must first demonstrate a contractual or employment relationship with such medical foundation.

b. An applicant requesting privileges in a facility [or department or section] subject to an exclusive contracting arrangement must first demonstrate a contractual or employment relationship with the party holding the exclusive contract.

c. In addition to the provisions of subparagraphs 4.8-2(a) and (b) above, privileges at any system member shall

August 2013 Page 36



be hospital-specific and limited by the scope of privileges normally available at that system member.

4.9-3 System Investigation

a. A coordinated investigation shall be conducted in accordance with the system’s credentialing program rules. Such program may delegate investigatory responsibility to one or more participants in the program.

Option 1

b. The results of the investigation shall be reported to the System Credentials Committee for processing in substantially the same manner as described in Rule 2, Appointment and Reappointment, (except that references throughout this Article 4, Procedures for Appointment and Reappointment, and Rule 2 to Credentials Committee shall be deemed to read System Credentials Committee). The System Credentials Committee shall render its recommendations to this hospital’s Medical Executive Committee, as well as to each participating system member’s Medical Executive Committee or equivalent committee, or if there is no such committee then directly to each system member’s Governing Body for independent determination of appointment and/or privileges in accordance with each system member’s bylaws or other applicable credentialing policies and procedures.

OR

Option 2

b. The results of the investigation shall be reported to this hospital’s Credentials Committee for processing in accordance with Sections 4.1 to 4.7 and Rule 2].

Article 5

PRIVILEGES

5.1 EXERCISE OF PRIVILEGES

Except as otherwise provided in these bylaws or the rules, every practitioner or allied health professional (AHP)

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 clinical privileges specifically granted. Said privileges and services must be hospital specific, within the scope of any license, certificate or other legal credential

August 2013 Page 37



providing direct clinical services at this hospital shall be entitled to exercise only those setting-specific privileges granted to him or her. Practitioners who wish to provide telemedicine services (whether to patients of this hospital, or to patients of another facility that this hospital is assisting via telemedicine technology) must apply for and be granted setting and procedure-specific telemedicine privileges. (Additionally, practitioners who are not otherwise members of this hospital’s Medical Staff who wish to provide services via telemedicine technology must apply for and be granted membership and privileges as part of the telemedicine staff (per Rule 1, Appendix 1I) in order to provide services to patients of this hospital.)

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. 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.

This CMA provision appears to curtail the Board’s rights pursuant to Business & Professions Code Section 809, which permits the Board to act in the absence of a Medical Staff recommendation in certain circumstances. . (Note, CMA did add a provision, at Section 6.3-6 that arguably modifies this section [although CMA did not include a deferential reference to 6.3-6 (as it did in its comparable amendments to Section 4.3), leading to possible interpretation that 6.3-6 is not intended to apply in these 5.1 circumstances).

5.2 CRITERIA FOR PRIVILEGES/GENERAL COMPETENCIES

5.2-1 Criteria for Privileges

Subject to the approval of the Medical Executive Committee and Governing Body, [each department] [the Medical Staff] will be responsible for developing criteria for granting setting-specific privileges (including but not limited to identifying and developing criteria for any privileges that may be appropriately performed via telemedicine). These criteria shall address the hospital’s general competencies (as described below) and assure uniform quality of patient care, treatment, and services. Insofar as feasible, affected categories of AHPs shall participate in developing the criteria for privileges to be exercised by AHPs. Such criteria shall not be inconsistent with the Medical Staff bylaws, rules or policies. [Each department’s approved criteria for granting privileges shall be included in the department’s rules.]

5.2-2 General Competencies

The Medical Staff shall assess all practitioners’ current proficiency in the hospital’s general competencies, which shall be established by the [departments] [Medical Staff]

CHA’s credentialing criteria specifically address the TJC general competencies requirements

August 2013 Page 38



and shall include assessment of [patient care, medical/clinical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice]. [Each department] [The Medical Staff] shall define how to measure these general competencies as applicable to the privileges requested, and shall use them to regularly monitor and assess each practitioner’s current proficiency.

5.3 DELINEATION OF PRIVILEGES IN GENERAL

5.3-1 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 for a modification of privileges must be supported by documentation of training and/or experience supportive of the request. The basic steps for processing requests for privileges are described at Section 4.2.

5.2 DELINEATION OF PRIVILEGES IN GENERAL

5.2-1 REQUESTS

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

5.3-2 Basis for Privilege Determinations

Requests for privileges shall be evaluated on the basis of the hospital’s needs and ability to support the requested privileges and assessment of the applicant’s general competencies with respect to the requested privileges, as evidenced by the applicant’s license, education, training, experience, demonstrated professional competence, judgment and clinical performance, (as confirmed by peers knowledgeable of the applicant’s professional performance), health status, the documented results of patient care and other quality improvement review and monitoring, performance of a sufficient number of procedures each year to develop and maintain the applicant’s skills and knowledge, and compliance with any specific criteria applicable to the privileges requested. Privilege determinations shall also be based on pertinent information concerning clinical performance obtained from other sources, especially other institutions and health care

5.2-2 BASES FOR PRIVILEGES DETERMINATION

(a) Requests for clinical privileges shall be evaluated on the basis of the member’s education, training, experience, current demonstrated professional competence and judgment, clinical performance, current health status, 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 clinical privileges.

(b) No specific privilege may be granted to a member if the task, procedure or activity constituting the privilege is not available within the hospital despite the member’s qualifications or ability to perform the requested privilege.

5.2-3 CRITERIA FOR “CROSS-SPECIALTY” PRIVILEGES WITHIN THE HOSPITAL

This CMA provision appears to be a good way to address privileges that cross departmental lines, to assure the same general standard of care is maintained

August 2013 Page 39



settings where an applicant exercises privileges. Any request for clinical privileges that are either new to the Hospital or that overlap more than one department shall initially be reviewed by the appropriate departments, in order to establish the need for, and appropriateness of, the new procedure or services. The MEC shall facilitate the establishment of hospital-wide credentialing criteria for new or trans-specialty procedures, with the input of all appropriate departments, with a mechanism designed to ensure that quality patient care is provided for by all individuals with such clinical privileges. In establishing the criteria for such clinical privileges, the MEC may establish an ad-hoc committee with representation from all appropriate Departments.

across departments, and may be useful in refining exclusivity provisions of exclusive service departments.

5.3-3 Telemedicine Privileges

a. The initial appointment of telemedicine privileges may be based upon a Medical Executive Committee recommendation that is based upon either:

1) The practitioner’s full compliance with this hospital’s privileging standards and processes; or

2) Information provided by the distant-site hospital or telemedicine entity, subject to compliance with 42 CFR 482.12, as further described in the Rules.

b. Reappointment of a Telemedicine Staff member’s privileges may be based upon performance at this hospital, and/or (and subject to compliance with 42 CFR §482.12) upon information from the distant-site hospital(s) where the practitioner routinely practices.

5.5 TELEMEDICINE PRIVILEGES

5.5-1 DEFINITION OF TELEMEDICINE

Telemedicine involves the use of electronic communication or other communication technologies to provide or support clinical care by a practitioner at a distant site to patients located at an originating site. Practitioners who render a diagnosis or otherwise provide clinical treatment to a patient at this hospital by telemedicine are subject without exception to the Medical Staff credentialing and privileging processes in these Bylaws and Rules.

5.5-2 SERVICES

Services provided by telemedicine shall be identified by each specific department.

5.5-3 QUALIFICATION FOR PRIVILEGES TO PROVIDE SERVICES VIA TELEMEDICINE

In order to qualify for telemedicine privileges, the practitioner must meet all the requirements set forth in the Bylaws and Rules for privileges (either temporary or granted in connection with membership)

August 2013 Page 40



5.4 ADMISSIONS; RESPONSIBILITY FOR CARE; HISTORY AND PHYSICAL REQUIREMENTS; AND OTHER GENERAL RESTRICTIONS ON EXERCISE OF PRIVILEGES BY LIMITED LICENSE PRACTITIONERS

5.4-1 Admitting Privileges

Option 1

a. Only Medical Staff members with admitting privileges may independently admit patients to the hospital. The following categories of licensees are eligible to independently admit patients to the hospital:

1) Physicians (MDs or DOs);2) Dentists;3) Podiatrists; 4) Clinical Psychologists.

Option 2

a. The following categories of licensees are eligible to independently admit patients to the hospital:

1) Physicians (MDs or DOs).

b. The following categories of licensees are eligible to co-admit patients to the hospital:

1) Dentists;2) Podiatrists; 3) Clinical Psychologists.

[c. Additionally, AHPs with admitting privileges may admit patients upon order of a member of the Medical Staff who has admitting privileges and who maintains responsibility for the overall care of the patient:

1) Physician Assistants;2) Nurse Practitioners; 3) Certified Nurse Midwives.]

5.4 CONDITIONS FOR PRIVILEGES OF LIMITED LICENSE PRACTITIONERS

5.4-1 ADMISSIONS

When dentists and any oral surgeons [podiatrists] [clinical psychologists] who do not hold history and physical privileges who are members of the medical staff admit patients, a physician member of the medical staff with history and physical privileges must document and conduct or directly supervise the admitting history and physical examination (except the portion related to dentistry [podiatry or clinical psychology]), 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.

CHA has reorganized and consolidated provisions relating to admitting, responsibility for care, H&Ps and other general restrictions on exercise of privileges.

CHA Bylaws provide more specific options for admitting privileges.

August 2013 Page 41



5.4-2 Responsibility for Care of Patients

a. All patients admitted to the hospital must be under care of a member of the Medical Staff.

b. The admitting member of the Medical Staff shall establish, at the time of admission, the patient’s condition and provisional diagnosis.

c. For patients admitted by or upon order of a dentist, oral surgeon, [clinical psychologist] or podiatrist members, a physician member must assume responsibility for the care of the patient’s medical or psychiatric problems that are 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.

CHA Bylaws address these Title 22 hospital licensing requirements.

5.4-4 Surgery and High Risk Interventions by Limited License Practitioners

a. Surgical procedures performed by dentists and podiatrists shall be under the overall supervision of the [chair of the designated department or the chair’s designee.]

b. Additionally, the findings, conclusions, and assessment of risk must be confirmed or endorsed by a physician member with appropriate privileges, prior to major high-risk (as defined by the [responsible department] [Medical Staff]) diagnostic or therapeutic interventions.

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 Histories and Privileges and Medical Appraisals

a. Members of the Medical Staff, with appropriate privileges, may perform history and physical examinations.

b. All patients admitted for care in a hospital by a dentist, oral surgeon, [clinical psychologist] or podiatrist shall receive the same basic medical appraisal as patients admitted to other services, and a physician member or a limited license practitioner with appropriate privileges shall

5.4-3 MEDICAL APPRAISAL

All patients admitted for care in a hospital by a dentist or oromaxillofacial surgeon [podiatrist] [clinical psychologist] shall receive the same basic medical appraisal as patients admitted to other services, and the dentists or oromaxillofacial surgeons [podiatrists] [clinical psychologists] 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 presence of

August 2013 Page 42



determine the risk and effect of any proposed treatment or surgical procedure on the general health status of the patient. 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 will be suspended insofar as possible while the dispute is resolved by the [appropriate department(s)] [Chief of Staff].

c. When evidence of appropriate training and experience is documented, a limited license practitioner may perform the history or physical on his or her own patient. Otherwise, a physician member must conduct or directly supervise the admitting history and physical examination (except the portion related to dentistry, [clinical psychology] or podiatry).

d. The admitting or referring member of the Medical Staff shall assure the completion of a physical examination and medical history on all patients within 24 hours after admission (or registration for a surgery or procedure requiring anesthesia or moderate or deep sedation), or immediately before. This requirement may be satisfied by a complete history and physical that has been performed within the 30 days prior to admission or registration (the results of which are recorded in the hospital’s medical record) so long as an examination for any changes in the patient’s condition is completed and documented in the hospital’s medical record within 24 hours after admission or registration.

e. Additionally, the history and physical must be updated within 24 hours prior to any surgical procedure or other procedure requiring general anesthesia or moderate or

a 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 will be suspended insofar as possible while the dispute is resolved by the appropriate department(s).

5.9 HISTORY AND PHYSICAL PRIVILEGES

Histories and physicals can be conducted or updated and documented only pursuant to specific privileges granted upon request to qualified physicians [and other practitioners] who are members of the medical staff or seeking temporary privileges, acting within their scope of practice.

Oromaxillofacial surgeons who have successfully completed a postgraduate program in oromaxillofacial surgery accredited by a nationally recognized accrediting body approved by the U.S. Office of Education and have been determined by the medical staff to be competent to do so, may be granted the privileges to perform a history and physical examination related to oromaxillofacial surgery. For patients with existing medical conditions or abnormal findings beyond the surgical indications, a physician member of the medical staff with history and physical privileges must conduct or directly supervise the admitting history and physical examination, except the portion related to oromaxillofacial surgery, 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 oromaxillofacial surgeon’s lawful scope of practice.

Every patient receives a history and physical within twenty-four hours of admission, unless a previous history and physical performed within thirty days of admission (or registration if an outpatient procedure) is on record, in which case that history and physical will be updated within twenty-four hours of admission. Every patient admitted for surgery must have a history and physical within 24 hours prior to surgery, unless a previous history and physical performed within thirty days prior to the surgery is on record, in which case that history and physical will be updated within twenty-

CHA Bylaws clarify that these H&P requirements also apply to outpatients and to procedures involving certain anesthetics.

August 2013 Page 43



deep sedation. The practitioner responsible for administering anesthesia may, if granted clinical privileges, perform this updating history and physical.

four hours of the surgery.

5.5 TEMPORARY PRIVILEGES

5.5-1 Circumstances

a. Temporary privileges may be granted after appropriate application:

1) For [30]-day periods, subject to renewal during the pendency of an application, not to exceed a total of 120 days;

2) For the care of up to [4] specific patients each consecutive [12] months;

3) For practitioners who will serve as locum tenens for a Medical Staff member for up to [30] days at a time, subject to renewal to a total of [120] days in any consecutive [12] months (if a locum tenens serves more than [4] times in a calendar year, or for greater than [120] days in a calendar year, he or she shall be required to apply for regular membership on the Medical Staff if he or she desires to exercise privileges at the hospital); or

4) As otherwise necessary to fulfill an important patient care need.

b. Temporary members of the Medical Staff who are granted temporary membership for purposes of serving on standing or ad hoc committees for investigation proceedings, are not, by virtue of such membership, granted temporary clinical privileges.

5.6 TEMPORARY CLINICAL PRIVILEGES

Temporary privileges are allowed under two circumstances only: to address a patient care need and to permit patient care to be provided while an application is pending. Temporary privileges for applicants may be granted for no more than 120 days.

5.6-1 PATIENT CARE NEEDS

(a) Care of Specific Patient

Temporary clinical privileges may be granted where good cause exists to allow a physician, [dentist] [podiatrist] [clinical psychologist] to provide care to a specific patient (but not more than [ ] during a calendar year) provided that the procedure described in Section 5.6-5(a)(1) has been completed.

(b) Locum Tenens

Temporary clinical privileges may be granted to a person serving as a locum tenens for a current member of the medical staff to meet the care needs of that member's patients in that member’s absence, provided that the procedure described in Section 5.5-5 [sic 5.6-5?] 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 [ ], unless the medical executive committee recommends a longer period for good cause.

(c) Other Important Patent Care Needs

Temporary clinical privileges may be granted to allow a physician, [dentist] [podiatrist] [clinical psychologist] to fulfill an important patient care treatment or service need provided that the procedure described in Section 5.6-4 has been completed.

August 2013 Page 44



5.6-2 PENDING APPLICATION FOR MEDICAL STAFF MEMBERSHIP

Temporary clinical privileges may be granted to an applicant while that person’s application for medical staff membership and privileges is completed and awaiting review and approval of the medical executive committee or the board of [trustees/directors], provided that the procedure described in Section 5.6-4 (a) (2) has been completed, and that the applicant has no current or previously successful challenge to professional licensure or registration, no involuntary termination of medical staff membership at any other organization, and no involuntary limitation, reduction, denial or loss of clinical privileges. Such persons may only attend patients for a period not to exceed [120] days.

5.6-3 TEMPORARY MEMBERSHIP AND TEMPORARY PRIVILEGES NOT CO-EXTENSIVE

Temporary members of the medical staff pursuant to Section 5.6 are not, by virtue of such membership, granted temporary clinical privileges.

5.5-2 Application and Review

a. Temporary privileges may be granted after the applicant completes the application procedure and the Medical Staff office completes the application review process. The following conditions apply:

1) There must first be verification of:

i) Current licensure;

ii) Relevant training or experience;

iii) Current competence;

iv) Ability to perform the privileges requested.

2) The results of the National Practitioner Data Bank and Medical Board of California queries have been obtained and evaluated.

3) The applicant has:

5.6-4 APPLICATION AND REVIEW

(a) Upon receipt of a completed application and supporting documentation from a physician, [dentist] [podiatrist] [clinical psychologist] authorized to practice in California, the chief executive officer on the recommendation of either the applicable clinical department chairperson or the chief of staff, may grant temporary privileges to a member who appears to have qualifications, ability and judgment consistent with Section 2.2-1, but only:

(1) With respect to applications by a locum tenens, or to fulfill an important patient care need, after verification of current licensure and current competence; or

(2) With respect to a new applicant awaiting review and approval of the medical staff executive committee and the governing body in compliance with the requirements in Section 5.6-2, after the following has been completed:

(i) the National Practitioner Data Bank report regarding the applicant for temporary privileges has been received and

August 2013 Page 45



i) Filed a complete application with the medical staff office;

ii) No current or previously successful challenge to licensure or registration;

iii) Not been subject to involuntary termination of Medical Staff membership at another organization; and

iv) Not been subject to involuntary limitation, reduction, denial, or loss of clinical privileges.

b. There is no right to temporary privileges. Accordingly, temporary privileges should not be granted unless the available information supports, with reasonable certainty, a favorable determination regarding the requesting applicant’s or AHP’s qualifications, ability and judgment to exercise the privileges requested.

c. If the available information is inconsistent or casts any reasonable doubts on the applicant’s qualifications, action on the request for temporary privileges may be deferred until the doubts have been satisfactorily resolved.

d. Temporary privileges may be granted by the Chief Executive Officer (or his or her designee) on the recommendation of the Chief of Staff [or the department chair where the privileges will be exercised, or either’s designee].

e. A determination to grant temporary privileges shall not be binding or conclusive with respect to an applicant’s pending request for appointment to the Medical Staff.

evaluated and current California licensure has been verified.

(ii) the appropriate department chair has interviewed the applicant and has contacted at least one person who

(a) has recently worked with the applicant;

(b) has directly observed the applicant’s professional performance over a reasonable time; and

(c) provides reliable information regarding the applicant’s current professional competence to perform the privileges requested, ethical character, and ability to work well with others so as not to adversely affect patient care, or other criteria required by medical staff bylaws.

(iii) the applicant’s file, including the recommendation of the department chair of the applicable department when available, or the chief of staff in all other cases, is forwarded to the credentials committee and the medical executive committee.

(iv) the medical executive committee through the chief of staff, after reviewing the applicant’s file and attached materials, recommends granting temporary privileges.

(b) If the applicant requests temporary 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 credentials committee. In the event of a disagreement between the chief executive officer or a designee 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.

CHA Bylaws provide for deferral if information is missing or casts doubts. This is an important provision in that it provides a means to avoid unnecessary reporting to MBOC and consequent hearing rights.

By virtue of this provision (5.6-4(b)), CMA Bylaws appear to grant hearing rights where it may not be necessary.

5.5-3 General Conditions and Termination

a. Members granted temporary privileges shall be subject to the proctoring and supervision in accordance with the focused professional practice evaluation requirements specified in the rules.

b. Temporary privileges shall automatically terminate at the end of the designated period, unless affirmatively renewed as provided at Section 5.5-1(a), or earlier

5.6-5 GENERAL CONDITIONS

(a) If granted temporary 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 privileges shall automatically terminate at the end of the designated period, unless earlier terminated

August 2013 Page 46



terminated as provided at Section 5.5-3(c).

c. Temporary privileges may be terminated with or without cause at any time by the Chief of Staff, [the responsible department chair], or the Chief Executive Officer after conferring with the Chief of Staff [or the responsible department chair]. A person shall be entitled to the procedural rights afforded by bylaws Article 14, Hearings and Appellate Reviews, only if a request for temporary privileges is refused based upon, or if all or any portion of temporary privileges are terminated or suspended for, a medical disciplinary cause or reason. In all other cases (including a deferral in acting on a request for temporary privileges), the affected practitioner shall not be entitled to any procedural rights based upon any adverse action involving temporary privileges.

d. Whenever temporary privileges are terminated, [the appropriate department chair or, in the chair’s absence,] the Chief of Staff shall assign a member to assume responsibility for the care of the affected practitioner’s patient(s). The wishes of the patient and affected practitioner shall be considered in the choice of a replacement member.

e. All persons requesting or receiving temporary privileges shall be bound by the bylaws and rules.

or suspended under Articles VI and/or VII of these bylaws or unless affirmatively renewed following the procedure as set forth in Section 5.6-5. A medical staff applicant’s temporary privileges shall automatically terminate if the applicant’s initial membership application is withdrawn. 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 privileges by the chief of staff after consultation with the departmental chair or the chair’s designee.

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

CMA clarifies the effect of withdrawal of application.

CMA also clarifies that proctoring applies in these circumstances.

5.6 DISASTER PRIVILEGES

5.6-1 Disaster Privileges may be granted when the hospital’s disaster plan has been activated and the organization is unable to handle the immediate patient needs. The following provisions apply:

a. Disaster Privileges may be granted on a case-by-case basis by the Chief Executive Officer, based upon recommendation of the Chief of Staff, [or in his or her absence, the recommendation of the responsible department chair,] upon presentation of a valid government-issued photo identification issued by a state or federal agency and

5.8 DISASTER PRIVILEGES

(a) In the case of a disaster in which the disaster plan has been activated and the hospital is unable to handle the immediate patient needs, the Chief of Staff, or in the absence of the Chief of Staff, the Vice-Chief of Staff, may grant disaster privileges. In the absence of the Chief of Staff and Vice-Chief of Staff and Department Chair(s), the Chief Executive Officer or the CEO’s designee may grant the disaster privileges consistent with this subsection. The grant of privileges under this subsection shall be on a case-by-case basis at the sole discretion of the individual authorized to

August 2013 Page 47



any of the following:

1) A current picture hospital identification card;

2) A current license to practice and primary source verification of the license (as further described in the Rules);

3) Identification indicating that the practitioner is a member of a Disaster Medical Assistance Team (DMAT) the Medical Reserve Corps (MRC), the Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP), or other recognized state state or federal response organization or group;

4) Identification indicating that the practitioner has been granted authority to render patient care in emergency circumstances, such authority having been granted by a federal, state, or municipal entity;

5) Presentation by current hospital or Medical Staff member(s) with personal knowledge regarding the practitioner’s identity.

b. Persons granted Disaster Privileges shall wear identification badges denoting their status as a DMAT member.

c. The Medical Staff office shall begin the process of verification of credentials and privileges as soon as the immediate situation is under control, using a process identical to that described as Section 5.5-2 (except that the individual is permitted to begin rendering services immediately, as needed).

d. The [responsible department chair] [Chief of Staff] shall arrange for appropriate concurrent or retrospective monitoring of the activities of practitioners granted Disaster Privileges.

e. Based on the Medical Staff’s oversight of each practitioner granted disaster privileges, the Chief Executive Officer, upon recommendation of the Chief of Staff, [or in his or her absence, the recommendation of the responsible department chair,] shall determine within 72 hours of the

grant such privileges. An initial grant of disaster privileges is reviewed by a person authorized to grant disaster privileges within 72 hours to determine whether the disaster privileges should be continued.

(b) The verification process of the credentials and privileges of individuals who receive disaster privileges under this subsection shall be developed in advance of a disaster situation. This process shall begin as soon as the immediate disaster situation is under control, and shall meet the following requirements in order to fulfill important patient care needs:

(1) The medical staff identifies in writing the individual(s) responsible for granting disaster privileges.

(2) The medical staff describes in writing the responsibilities of the individual(s) responsible for granting disaster privileges.

(3) The medical staff describes in writing a mechanism to manage the activities of individuals who receive disaster privileges. There is a mechanism to allow staff to readily identify these individuals.

(4) The medical staff addresses the verification process as a high priority. The medical staff has a mechanism to ensure that the verification process of the credentials and privileges of individuals who receive disaster privileges begins as soon as the immediate situation is under control. This privileging process is identical to the process established under the medical staff bylaws for granting temporary privileges to fulfill an important patient care need.

(5) Those authorized under subsection (a) may grant disaster privileges upon presentation of a valid picture ID issued by a state, federal or regulatory agency and at least one of the following:

(i) A current picture hospital ID card clearly identifying professional designation.

(ii) A current license to practice.

(iii) Identification indicating that the individual August 2013 Page 48



practitioner’s arrival if granted disaster privileges shall continue.

5.6-2 Volunteers who are not licensed independent practitioners may be permitted to provide disaster services as described in the Rules.

5.7 Emergency PrivilegesIn the event of an emergency, any member of the

is a member of a Disaster Medical Assistance Team (DMAT) or MRC, ESAR-VHP, or other recognized state or federal organizations or groups.

(iv) Identification indicating that the individual has been granted authority by a federal, state, or municipal entity to render patient care in disaster circumstances.

(v) Identification by current hospital or medical staff member(s) with personal knowledge regarding the volunteer's ability to act as a licensed independent practitioner during a disaster.

a)[sic (c)?] Current professional licensure of those providing care under disaster privileges is verified from the primary source as soon as the immediate emergency situation is under control or within 72 hours from the time the volunteer licensed independent practitioner presents to the hospital, whichever comes first. If primary source verification cannot be completed within 72 hours of the practitioner's arrival due to extraordinary circumstances, the hospital documents all of the following:

(1) The reason[s] verification could not be performed within 72 hours of the practitioner's arrival,

(2) Evidence of the licensed independent practitioner's demonstrated ability to continue to provide adequate care, treatment and services.

(3) Evidence of an attempt to perform primary source verification as soon as possible.

b) [sic (d)?] Members of the medical staff shall oversee those granted disaster privileges.

5.7 EMERGENCY PRIVILEGES

(a) In the case of an emergency involving a particular patient, any member of the medical staff with clinical privileges, to the degree permitted by the scope of the

August 2013 Page 49



Medical Staff or credentialed AHP shall be permitted to do everything reasonably possible, within the scope of their licensure, to save the life of a patient or to save a patient from serious harm. The member or AHP shall promptly yield such care to a qualified member when one becomes available.

applicant’s license and regardless of department, staff status, or clinical privileges, shall be permitted to do everything reasonably possible to save the life of the patient or to save the patient from serious harm provided that the care provided is within the scope of the individual’s license. 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 clinical 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 under subsection (a), 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.

(c) Emergency privileges under subsection (a) shall not be used to force members to serve on emergency department call panels providing services for which they do not hold delineated clinical privileges.

CMA Bylaws provide that emergency privileges may not be invoked to compel call coverage.

5.8 TRANSPORT AND ORGAN HARVEST TEAMS

Properly licensed practitioners who individually, or as members of a group or entity, have contracted with the hospital to participate in transplant and/or organ harvesting activities may exercise clinical privileges within the scope of their agreement with the hospital.

CHA Bylaws contain provisions relating to Transport and Organ Harvest Teams, per TJC standards.

[5.9 Proctoring]

CHA Bylaws provisions relating to proctoring have been moved to a new Article on Performance Evaluations – See Article 7.

To facilitate comparison, CMA’s § 5.9 Proctoring provisions have been moved along-side CHA’s Section 7.4-4.

August 2013 Page 50



5.9 Dissemination of Privilege List

Documentation of current privileges (granted, modified, or rescinded) shall be disseminated to the hospital admissions/registration office and such other scheduling and health information services personnel as necessary to maintain an up-to-date listing of privileges for purposes of scheduling and monitoring to assure that practitioners are appropriately privileged to perform all services rendered.

Added to CHA Bylaws to comply with TJC Standard MS.06.01.09, EP 4.

5.10 MODIFICATION OF CLINICAL PRIVILEGES OR DEPARTMENT ASSIGNMENT

On its own, upon recommendation of the credentials committee, or pursuant to a request under Section 4.6-1(b), the medical executive committee may recommend a change in the clinical 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.

5.11 LAPSE OF APPLICATION

If a medical staff member requesting a modification of clinical privileges or department assignments fails to timely furnish the information reasonably 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 VII.

Article 6

ALLIED HEALTH PROFESSIONALS

6.1 QUALIFICATIONS OF ALLIED HEALTH PROFESSIONALS

Allied health professionals (AHPs) are not eligible for Medical Staff membership. They may be granted practice privileges if they hold a license, certificate or other credentials in a category of AHPs that the Governing Body (after securing Medical Executive Committee comments) has identified as eligible to apply for practice privileges, and

8.1 DEFINITIONS

“Allied Health Practitioner (AHP)” means a health care professional, other than a physician, who holds a license or other legal credential, as required by California law, to provide certain professional services.

“Allied Health Staff” means those Allied Health Practitioners who are neither employees of the hospital nor, pursuant to the terms of these bylaws, eligible for medical staff membership, but have been granted a service authorization to provide certain clinical services.

August 2013 Page 51



only if the AHPs are professionally competent and continuously meet the qualifications, standards and requirements set forth in the Medical Staff bylaws and rules.

“Service authorization” means the permission granted to an Allied Health Staff member to provide specified patient care services within the member’s qualifications and scope of practice.

CMA Footnote to "Service Authorization" The term “service authorization” as used in these bylaws, is intended to mean the same thing as “clinical privileges” when used with respect to AHPs who may provide services independently. This term is utilized for purposes of distinguishing the permission to perform certain services, which is granted to AHPs, from the clinical privileges granted to medical staff members, given that procedures applicable to AHPs will often differ substantially from the procedures applicable to medical staff members. Medical staffs that are uncertain regarding which AHPs may practice independently should seek legal advice from an attorney who is an expert in this area of the law.

CMA distinguishes the privileges given to AHPs from those given to medical staff members.

CMA further distinguishes the service authorizations, to say it means the same as clinical privileges when granted to an AHP who can practice independently (and presumably it means something else when granted to an AHP who cannot practice independently). See also CMA Section 8.4-1(b).

6.2 CATEGORIES

The Governing Body shall determine, based upon comments of the Medical Executive Committee and such other information as it has before it, those categories of AHPs that shall be eligible to exercise privileges in the hospital. Such AHPs shall be subject to the supervision requirements developed [in each department] and approved by the Interdisciplinary Practice Committee, the Medical Executive Committee, and the Governing Body.

8.3 CATEGORIES OF AHPS ELIGIBLE TO APPLY FOR SERVICE AUTHORIZATIONS [repeated in CHA Rule 6]

The categories of AHPs, based on occupation or profession, which shall be eligible to apply for Allied Health Staff membership and for service authorization in the hospital and the corresponding service authorization prerogatives, terms, and conditions for each such AHP category shall be designated by the Board of [Trustees/Directors], upon the recommendation of the Executive Committee, and when approved by the Board of [Trustees/Directors], shall be set forth in the medical staff rules and regulations. Such actions by the Executive Committee and the Board of [Trustees/Directors] shall be based upon the recommendations of the relevant departments for the designation of categories of AHPs eligible to apply for service authorization and the delineation of corresponding service authorization prerogatives, terms, and conditions for each such AHP category. The Board of [Trustees/Directors] shall review the designation of categories of AHPs eligible to apply for service authorizations at least annually and at other times, within its discretion or upon the recommendation of the Executive Committee.

CMA Bylaws contain all of their provisions relating to AHP Categories in the Bylaws; CHA on the other hand, contains the basic provision in the Bylaws, with details in the rules. To facilitate substantive comparison, and reduce redundancy, the CMA provisions have been moved along-side the relevant CHA Rule 6.

August 2013 Page 52



6.3 PRIVILEGES [AND DEPARTMENT ASSIGNMENT]

6.3-1 AHPs may exercise only those setting-specific privileges granted them by the Governing Body. The range of privileges for which each AHP may apply and any special limitations or conditions to the exercise of such privileges shall be based on recommendations of the Interdisciplinary Practice Committee, subject to approval by the Medical Executive Committee and the Governing Body.

6.3-2 An AHP must apply and qualify for practice privileges, and practitioners who desire to supervise or direct AHPs who provide dependent services must apply and qualify for privileges to supervise approved AHPs. Applications for initial granting of practice privileges and biennial renewal thereof shall be submitted and processed in a similar manner to that provided for practitioners, unless otherwise specified in the rules.

6.3-3 Each AHP shall be [assigned to the department or departments appropriate to his or her occupational or professional training and, unless otherwise specified in these bylaws or the rules, shall be] subject to terms and conditions similar to those specified for practitioners as they may logically be applied to AHPs and appropriately tailored to the particular AHP.

8.4 PROCEDURE FOR GRANTING SERVICE AUTHORIZATION [see also Rule 6]

8.4-1 (a) An AHP whose scope of practice allows independent practice must apply and qualify for a service authorization and must designate a physician member of the active medical staff who, concurrently with the AHP’s application, applies for and is granted privileges to be responsible, to the extent necessary, for the general medical condition of patients for whom the AHP proposes to render services in the hospital.

(b) An AHP whose scope of practice does not allow independent practice must apply and qualify for a service authorization and must provide services under the supervision of an active medical staff member who has applied for, qualified for, and been granted specific privileges in accordance with the Medical Staff Bylaws, rules and regulations, to supervise and direct the exercise of service authorizations by the same category of AHP as that of the applicant. An AHP under this subsection may apply to work under the supervision of one active medical staff member or, within the Medical Executive Committee’s discretion, a group of medical staff members so long as each of the medical staff members has separately applied for and been granted privileges to supervise the AHP or the category of AHPs to which the applicant belongs. Whenever an AHP will be supervised by more than one active staff member, such supervision must be in strict accordance with rules and regulations developed by the appropriate department/division and approved by the Medical Executive Committee.

(c) AHP applications for initial granting and renewal of service authorizations respecting nurses in expanded roles and physician’s assistants who are eligible for Allied Health Staff membership shall be submitted to the Interdisciplinary Practice Committee. AHP applications for all other categories of AHPs who are eligible for membership on the Allied Health Staff shall be submitted to the Committee on Allied Health Practitioners. All such applications shall be processed in a parallel manner to that provided in Articles [IV] and [V] for medical staff members, except that the IDP Committee or

As noted above, the detailed CHA provisions relating to AHPs appear in Rule 6 – accordingly, the CMA provisions are repeated there, and compared.

Here, CMA clarifies that AHPs who cannot practice independently must be supervised.

August 2013 Page 53



Committee on Allied Health Professions shall perform the function which would otherwise be preformed by the Credentials Committee, unless otherwise specified in the medical staff rules and regulations.

8.4-2 Except as is provided under Section 8.7-2(a), an AHP who (a) has received an final adverse decision regarding their [sic] application for a service authorization or (b) withdrew their [sic] application for a service authorization following an adverse recommendation by the Executive Committee, or (c) after having been granted a service authorization has received a final adverse decision resulting in termination of the authorization or (d) has relinquished their [sic] service authorization following the issuance of a Medical Staff or Board of [Trustees/Directors] recommendation adverse to their [sic] service authorization, shall not be eligible to reapply for the service authorization affected by such decision or recommendation for a period of at least [ ] months from the date that the adverse decision became final, the application was withdrawn, or the AHP relinquished their [sic] service authorization.

8.4-3 An AHP who does not have licensure or certification in an AHP category identified as eligible for service authorizations pursuant to Section 8.3 may not apply for a service authorization but may submit a written request to the Administrator, asking the Board of [Trustees/Directors] to consider designating the appropriate category of AHPs as eligible to apply for service authorizations. Upon receipt of such a request, the Board of [Trustees/Directors] shall forward a copy of the request to the Executive Committee for its recommendation, and shall also request the recommendation of any affected department or division. The Board of [Trustees/Directors] shall consider such request and the Executive Committee’s recommendation, as well as the recommendation of any affected department or division, either before or at the time of its annual review of the categories of AHPs, in accordance with Section 8.3.

8.4-4 Each AHP who is granted a service authorization shall be assigned to the clinical [department] [division] appropriate to their [sic] occupational or professional training and, unless otherwise specified in the medical staff rules and

August 2013 Page 54



regulations, shall be subject to terms and conditions that parallel those specified in Article [II-membership], as they may logically apply to AHPs and may be appropriately tailored to the particular category of AHPs. Each AHP who practices independently must maintain communication with the relevant physician under Section 8.4-1 in order to enable the physician to assume responsibility, to the extent it is indicated, for the general medical condition of the patient. Each AHP who does not practice independently shall be subject to the supervision of one or more members of the active medical staff who have been granted privileges to provide such supervision or direction by the Board of [Trustees/Directors] upon recommendation of the Executive Committee.

6.4 PREROGATIVES

The prerogatives which may be extended to an AHP shall be defined in the rules and/or hospital policies. Such prerogatives may include:

6.4-1 Provision of specified patient care services; which services may be provided independently or under the supervision or direction of a Medical Staff member and consistent with the practice privileges granted to the AHP and within the scope of the AHP’s licensure or certification, as specified in the Rules.

6.4-2 Service on the Medical Staff[, department] and hospital committees.

6.4-3 Attendance [at the meetings of the department to which the AHP is assigned, as permitted by the department rules, and attendance at] hospital education programs in the AHP’s field of practice.

8.5 PREROGATIVES

The prerogatives which may be extended to a member of a particular category of AHP shall be defined in the medical staff rules and regulations. Such prerogatives may include:

(a) Provision of specified patient care services subject to a medical staff member’s responsibility, to the extent indicated, for the patient’s general medical condition and under the general oversight of the medical staff, and, where the AHP does not practice independently, also under the supervision and direction of a member of the active medical staff who has been granted specific privileges to supervise that category of AHP. AHP services must be consistent with the service authorization granted to the AHP and within the scope of the AHP’s licensure or certification.

(b) Service on medical staff and hospital committees except as otherwise expressly provided in the medical staff bylaws, rules and regulations. An AHP may not serve as chair of medical staff committees.

Attendance at meetings of the department to which the AHP is assigned, as permitted by the [department] [division] rules and regulations, and attendance at medical staff educational programs in the AHP’s field of practice. An AHP may not vote at department/division meetings.

Additional details applicable to each category of AHP are presented in the CHA Rules.

August 2013 Page 55



6.5 RESPONSIBILITIES

Each AHP shall:

6.5-1 Meet those responsibilities required by the rules and as specified for practitioners in Section 2.6, Basic Responsibilities of Medical Staff Membership, as they may be logically applied to reflect the more limited practice of the AHP.

6.5-2 Retain appropriate responsibility within the AHP’s area of professional competence for the care and supervision of each patient in the hospital for whom the AHP is providing services.

6.5-3 Participate in peer review and quality improvement and in discharging such other functions as may be required from time to time.

8.6 RESPONSIBILITIES

Each AHP shall:

(a) Meet those responsibilities required by the medical staff rules and regulations and if not so specified, meet those responsibilities specified in [Section 2.5 of Article II] as are generally applicable to the more limited practice of the AHP.

(b) Retain appropriate responsibility within the AHP’s area of professional competence for the care of each patient in the hospital for whom the AHP is providing services.

(c) Participate, when requested, in patient care audit and other quality review, evaluation, and monitoring activities required of AHPs, in evaluating AHP applicants, in supervising initial AHP appointees of the AHP’s same occupation or profession or of an occupation or profession which is governed by a more limited scope of practice statute, and in discharging such other functions as may be required by the medical staff from time to time.

6.6 PROCEDURAL RIGHTS OF ALLIED HEALTH PROFESSIONALS

Option 1

6.6-1 Fair Hearing and Appeal

Denial, revocation, or modification of Allied Health Professionals’ Privileges shall be the prerogative of the Interdisciplinary Practices Subcommittee, subject to approval by the Credentials Committee, the Medical Executive Committee, and the Governing Body. The procedural rights described at Article 14, Hearings and Appellate Reviews, shall apply.

OR

Option 2

6.6-1 Fair Hearing and Appeal

[a. Clinical psychologists, marriage and family

8.7 TERMINATION, SUSPENSION OR RESTRICTION OF SERVICE AUTHORIZATIONS

8.7-1 GENERAL PROCEDURES

(a) At any time, the Chief of Staff or Chief of the Department or Division to which the AHP has been assigned may recommend to the Medical Executive Committee that an AHP’s service authorization be terminated, suspended or restricted. After investigation (including, if appropriate, consultation with the Interdisciplinary Practice Committee or the Committee on Allied Health Practitioners), if the Medical Executive Committee agrees that corrective action is appropriate, the MEC shall recommend specific corrective action to the hospital’s Board of Trustees. A Notification Letter regarding the recommendation shall be sent by certified mail to the subject AHP. The Notification Letter shall inform the AHP of the recommendation and the circumstances giving rise to the recommendation.

(b) Nothing contained in the Medical Staff Bylaws shall be interpreted to entitle an Allied Health Staff member, except

CHA provides three alternative procedures for satisfying TJC requirement that there be a mechanism for addressing adverse decisions for AHPs holding clinical privileges.

CMA provides one alternative.

CHA Bylaws also have clarified that Business & Professions Section 809 hearing rights are now

August 2013 Page 56



therapists, and clinical social workers shall be entitled to the procedural rights set forth at Article 14, Hearings and Appellate Reviews.]

b. [Except as provided at Section 6.6-1(a), with respect to clinical psychologists, marriage and family therapists, and clinical social workers,] there shall be no formal hearing and appeal rights with respect to decisions to deny initial applications for AHP clinical privileges. However, an AHP applicant shall have the right to challenge any such action by filing a written grievance with the Medical Executive Committee within 15 days of such action. Upon receipt of such a grievance, the Medical Executive Committee or its designee shall conduct a review that shall afford the AHP an opportunity for an interview concerning the grievance. Any such interview shall not constitute a hearing as established by Article 14, Hearings and Appellate Reviews, of the bylaws and shall not be conducted according to the procedural rules applicable to such hearings. Before the interview, the AHP shall be informed of the general nature and circumstances giving rise to the action, and the AHP may present information relevant thereto at the interview. A record of the interview shall be made. The Medical Executive Committee or its designee shall make a decision based on the interview and all other information available to it.

c. Whenever an AHP holding clinical privileges is subject to an action that would constitute grounds for a hearing under Section 14.2-2 through 14.2-6 of the bylaws, the AHP shall be entitled to the procedural rights set forth at Article 14, Hearings and Appellate Reviews.]

OR

Option 3

[6.6-1 Fair Hearing and Appeal

AHPs shall be entitled to certain fair hearing and appeal rights, as described below:

[a. Clinical psychologists, marriage and family therapists, and clinical social workers shall be entitled to

for a clinical psychologist, to the hearing rights set forth in Articles VI and VII. However, an AHP shall have the right to challenge any recommendation which would constitute grounds for a hearing under Section 7.2 of the Bylaws (to the extent that such grounds are applicable by analogy to the Allied Health Staff) by filing a written request for an AHP Health Staff hearing with the Medical Executive Committee within fifteen (15) days of receipt of the Notification Letter. Upon receipt of a request, the Medical Executive Committee or its designee, shall afford the AHP an opportunity for an AHP Health Staff hearing concerning the grievance. The hearing need not be conducted according to the procedural rules applicable to member hearings; however the purpose of the AHP Health Staff hearing is to allow both the AHP and the party recommending the action the opportunity to discuss the situation and to produce evidence in support of their respective positions. A record of the AHP Health Staff hearing shall be made.

(c) Within [ ] days following the AHP Health Staff hearing, the Medical Executive Committee, based on the AHP Health Staff hearing and all other aspects of the investigation, shall make a final recommendation to the Board of [Trustees/Directors], which shall be communicated in writing, sent by certified mail, to the subject AHP. The final recommendation shall discuss the circumstances giving rise to the recommendation any pertinent information from the interview. Prior to acting on the matter, the Board of [Trustees/Directors] may, in its discretion, offer the affected practitioner the right to appeal to the Board or a subcommittee thereof. The Board of [Trustees/Directors] shall adopt the Medical Executive Committee’s recommendation, so long as it is reasonable, appropriate under the circumstances and supported by substantial evidence. The final decision by the Board of [Trustees/Directors] shall become effective upon the date of its adoption. The AHP shall be provided promptly with notice of the final action, sent by certified mail.

8.7-2 SUMMARY SUSPENSION

(a) Notwithstanding Section 8.7-1, an Allied Health Practitioner’s service authorization may be immediately suspended or restricted where the failure to take such action

extended to marriage and family therapists and clinical social workers.

The CMA Bylaws require the Board to adopt the MEC decision if reasonable, appropriate and supported by substantial evidence. (See additional comments accompanying CHA Bylaws Sections 13.1-9 and 14.6-18.)

August 2013 Page 57



the procedural rights set forth at Article 14, Hearings and Appellate Reviews.]

b. [Other] AHP applicants shall have the right to challenge a recommendation of the interdisciplinary practice committee to deny or restrict requested privileges by filing a written grievance with the Medical Executive Committee within 15 days of such action. Upon receipt of such a grievance, the Medical Executive Committee or its designee shall conduct a review that shall afford the AHP an opportunity for an interview concerning the grievance. Any such interview shall not constitute a hearing as established by Article 14, Hearings and Appellate Reviews, of the bylaws and shall not be conducted according to the procedural rules applicable to such hearings. Before the interview, the AHP shall be informed of the general nature and circumstances giving rise to the action, and the AHP may present information relevant thereto at the interview. A record of the interview shall be made. The Medical Executive Committee or its designee shall make a decision based on the interview and all other information available to it.

c. An AHP [other than a clinical psychologist, marriage and family therapists, and clinical social workers] holding clinical privileges who is subject to a recommendation of the Interdisciplinary Practice Committee to revoke, restrict or not renew any or all of such AHP’s privileges shall be entitled to the rights set forth below.

1) The affected AHP shall be given written notice of the recommended action.

2) The affected AHP shall have 10 days within which to request a Medical Executive Committee review hearing of the action.

3) If review is requested, the affected AHP shall be given written notice of the general reasons for the action, and the date, time and place that the Medical Executive Committee review hearing is scheduled. Such date shall afford the AHP at least 14 calendar days’ notice.

may result in an imminent danger to the health of any individual. Such summary suspension or restriction may be imposed by the Chief of Staff, the Medical Executive Committee, or the head of the department or designee to which the Allied Health Practitioner has been assigned (or a designee). Unless otherwise stated, the summary action shall become effective immediately upon imposition, and the person responsible for taking such action shall promptly give written notice of the action to the Board of [Trustees/Directors], the Medical Executive Committee, and the Administrator. The notice shall also inform the practitioner of the right to file a grievance. The practitioner’s right to file a grievance and subsequent interview procedures shall be in accordance with Section 8.7-1, except that all reasonable efforts shall be made to ensure that the practitioner is given an interview and that final action is taken within (_____) days or as promptly thereafter as practicable.

(b) Within one (1) working day of the summary action, the affected practitioner shall be provided with written notice of the action. The notice shall include the reasons for the action and that such action was necessary because of a reasonable probability that failure to take the action could result in imminent danger to the health of an individual.

(c) Within five (5) working days following the action, the Interdisciplinary Practice Committee (or the Committee on Allied Health Practitioners, as appropriate) shall meet to consider the matter and make a recommendation to the Executive Committee as to whether the summary suspension should be vacated or continued pending the outcome of any interview with the affected practitioner. Within eight (8) days following the imposition of the action, the Medical Executive Committee shall meet and consider the matter in light of any recommendation forwarded from the Interdisciplinary Practice Committee or the Committee on Allied Health Practitioners. Within two (2) working days following the Medical Executive Committee’s meeting, the Medical Executive Committee shall provide written notice to the affected practitioner regarding its determination on whether the summary action should be vacated or continued pending the outcome of any interview proceeding.

This one-day requirement can be very difficult to comply with.

August 2013 Page 58



4) The affected AHP and the Interdisciplinary Practice Committee, through its designated representative, shall each have 10 days to submit written information and argument in support of their positions.

5) The affected AHP shall have a right to appear at the Medical Executive Committee hearing, to hear such evidence as the Interdisciplinary Practice Committee representative may present in support of the committee’s recommended action, and to present evidence in support of the AHP’s challenge to that recommendation. Neither party shall be represented by legal counsel in the hearing.

6) The Medical Executive Committee may then, at a time convenient to itself, deliberate outside the presence of the parties.

7) The Medical Executive Committee decision following such a hearing shall be effective immediately, but shall be subject to appeal to the Governing Body (or, in the discretion of the Governing Body, to an Appeal Board appointed by the Governing Body).

8) The affected AHP shall be promptly informed, in writing, of the Medical Executive Committee’s decision, and of his or her right to appeal the decision.

9) The affected AHP shall have 10 days to request an appeal hearing. The request for appeal shall state, with specificity, the basis for the appeal.

10) The appeal hearing shall be conducted within 30 days. The parties to the appeal shall be the Medical Executive Committee (which shall be represented by a member of the Medical Staff, who may, but need not be a member of the Medical Executive Committee or the Interdisciplinary Practice Committee) and the affected AHP.

11) Each party shall have the right to present a written statement in support of his, her or its position on appeal. The Governing Body (or appeal board, if applicable) chair may establish reasonable time frames for the appealing party to submit a written statement and for the responding

August 2013 Page 59



party to respond. Each party has the right to personally appear and make oral argument. The Governing Body (or appeal board, if applicable) may then, at a time convenient to itself, deliberate outside the presence of the parties.

12) The Governing Body (or appeal board, if applicable) shall issue a final decision, in writing.]

6.6-2 Automatic Termination

a. Notwithstanding the provisions of Section 6.6-1, an AHP’s privileges shall automatically terminate, without review pursuant to Section 6.6-1 or any other section of the Medical Staff bylaws, in the event:

1) The Medical Staff membership of the supervising practitioner is terminated, whether such termination is voluntary or involuntary;

2) The supervising practitioner no longer agrees to act as the supervising practitioner for any reason, or the relationship between the AHP and the supervising practitioner is otherwise terminated, regardless of the reason therefore; or

3) The AHP’s certification or license expires, is revoked, or is suspended.

b. Where the AHP’s service authorization is automatically terminated for reasons specified in Section 6.6-2a 1) or 2), above, the AHP may apply for reinstatement as soon as the AHP has found another supervising practitioner who agrees to supervise the AHP and receives privileges to do so. In this case, the Medical Executive Committee may, in its discretion, expedite the reapplication process.

c. Additionally, AHPs are subject to the automatic action provisions of Section 13.3 of these Bylaws.

8.7-3 AUTOMATIC SUSPENSION, TERMINATION OR RESTRICTION

(a) Notwithstanding subsection 8.7-1, above, an AHP’s service authorization shall automatically terminate in the event that:

(1) The AHP’s certification, license, or other legal credential expires or is revoked.

(2) With respect to an AHP who must practice under physician supervision:

(i) The medical staff membership or privileges to supervise the AHP of the supervising physician is terminated, whether such termination is voluntary or involuntary; or

(ii) The supervising physician no longer agrees to act in such capacity for any reason, or the relationship between the AHP and the supervising physician is otherwise terminated, regardless of the reason therefore;

Where the AHP’s service authorization is automatically terminated for reasons specified in (2)(A) [sic] or (2)(B) [sic] above, the AHP may apply for reinstatement as soon as the AHP has found another physician active medical staff member who agrees to supervise the AHP and receives privileges to do so. In this case, the Medical Executive Committee may, in its discretion, expedite the reapplication process.

(b) Notwithstanding subsection 8.7-1, above, in the event that the AHP’s certification or license is restricted, suspended, or made the subject of an order of probation, the AHP’s service authorization shall automatically be subject to

August 2013 Page 60



the same restrictions, suspension, or conditions of probation.

(c) Where the AHP’s privileges are automatically terminated, suspended, or restricted pursuant to this subsection, the notice and interview procedures under subsection 8.7-1 shall not apply and the AHP shall have no right to an interview except, within the discretion of the Medical Executive Committee, regarding any factual dispute over whether or not the circumstances giving rise to the automatic termination, suspension, or restriction actually exist.

6.6-3 Review of Category Decisions

The rights afforded by this section shall not apply to any decision regarding whether a category of AHP shall or shall not be eligible for practice privileges and the terms, prerogatives, or conditions of such decision. Those questions shall be submitted for consideration to the Governing Body, which has the discretion to decline to review the request or to review it using any procedure the Governing Body deems appropriate.

8.7-4 APPLICABILITY OF SECTION

The rights afforded by this section shall not apply to any decision regarding whether a category of AHP shall be eligible for a service authorization and the terms or conditions of such decision pursuant to Section 8.3 of this Article.

8.8 REAPPLICATION

Every _____ [ ] years, each AHP on the Allied Health Staff must reapply for a renewed service authorization in accordance with Section 8.4.

Article 7

PERFORMANCE EVALUATION AND MONITORING

7.1 General Overview of Performance Evaluation and Monitoring Activities

The credentialing and privileging processes described in Articles 4 and 5 require that the Medical Staff develop ongoing performance evaluation and monitoring activities to ensure that decisions regarding appointment to membership on the Medical Staff and granting or renewing of privileges are, among other things, detailed, current, accurate, objective and evidence-based. Additionally, performance evaluation and monitoring activities help assure timely identification of problems that may arise in the ongoing provision of services in the hospital. Problems

Article VIEVALUATION AND CORRECTIVE ACTION

Peer review, fairly conducted, is essential to preserving the highest standards of medical practice.

6.1 PEER REVIEW OF APPLICANTS

All applicants are evaluated for membership and privileges using only those medical staff peer review criteria adopted consistent with these bylaws, and applied exclusively through the processes established in these bylaws.

6.2 ONGOING PEER REVIEW

All members are subject to evaluation based on medical staff peer review criteria, adopted consistent with these bylaws. Evaluation results are used in privileging, system improvement, and when warranted, corrective action.

CHA has consolidated all of its performance evaluation and monitoring – including proctoring – in Article 7.

CMA bylaws address some of these issues in their Article V (relating to appointment and reappointment) and others in their Article VI (relating to evaluation and corrective action). Thus, for comparative purposes, portions of CMA’s Chapter VI (relating to Evaluation) have been placed here, and other portions (Corrective Action) have been aligned with CHA’s Article 13.

August 2013 Page 61



identified through performance evaluation and monitoring activities are addressed via the appropriate performance improvement and/or remedial actions as described in Article 13.

7.2 Performance Monitoring Generally

7.2-1 Except as otherwise determined by the Medical Executive Committee and Governing Body, the Medical Staff shall regularly monitor all members' privileges in accordance with the provisions set forth in these bylaws and such performance monitoring policies as may be developed by the Medical Staff and approved by the Medical Executive Committee and the Governing Body.

7.2-2 Performance monitoring is not viewed as a disciplinary measure, but rather is an information-gathering activity. Performance monitoring does not give rise to the procedural rights described in Article 14 (unless the form of monitoring is Level III proctoring and its imposition becomes a restriction of privileges because procedures cannot be done unless a proctor is present and proctors are not available after reasonable attempts to secure a proctor).

7.2-3 The Medical Staff shall clearly define how information gathered during performance monitoring shall be shared in order to effectuate change and additional action, if determined necessary.

7.2-4 Performance monitoring activities and reports shall be integrated into other quality improvement activities.

7.2-5 The results of any practitioner-specific performance monitoring shall be considered when granting, renewing, revising or revoking clinical privileges of that practitioner.

7.3 Ongoing Professional Performance Evaluations

7.3-1 [Each department] [The Medical Staff] shall recommend, for Medical Executive Committee and Governing Body approval, the criteria to be used in the conduct of ongoing professional performance evaluations for its practitioners.

6.2-1 Peer Review Criteria

Departments shall develop and routinely update peer review criteria based on current practices and standards of care, which shall be the sole criteria used in evaluating those applying for membership and privileges and the performance of members and privileges holders. "Patient satisfaction" survey responses shall not be used to evaluate professionals for membership or privileging unless the methodology used is considered reliable by the medical staff. Included in the departmental peer review criteria are the types of data to be collected for evaluation. At a minimum, departments shall, where relevant, collect and evaluate department members’ data pertaining to:

a) Operative and other clinical procedure(s) performed and their outcomes.

b) Pattern of blood and pharmaceutical usage

c) Requests for tests or procedures

d) Patterns of length of stay

e) Use of consultants and

f) Morbidity and mortality

In addition, each department shall add and update department-specific criteria [quarterly but] at least [annually] for ongoing peer review of department members.

Department criteria are subject to the approval of the Medical Executive Committee. Approved criteria as updated are made known and accessible to all members.

Note CMA provision for exclusion of patient satisfaction survey responses.

August 2013 Page 62



7.3-2 Methods that may be used to gather information for ongoing professional performance evaluations include, but are not limited to:

a. Periodic chart review;

b. Direct observation;

c. Monitoring of diagnostic and treatment techniques;

d. Discussion with other individuals involved in the care of each patient including consulting physicians, assistants at surgery, nursing and administrative personnel.

7.3-3 Ongoing performance reviews shall be factored into the decision to maintain, revise or revoke a practitioner’s existing privilege(s).

7.4 Focused Professional Practice Evaluation

7.4-1 The Medical Staff is responsible for developing a focused professional practice evaluation process that will be used in predetermined situations to evaluate, for a time-limited period, a practitioner's competency in performing specific privilege(s). The Medical Staff may supplement these bylaws with policies, for approval by the Medical Executive Committee and the Governing Body, that will clearly define the circumstances when a focused evaluation will occur, what criteria and methods should be used for conducting the focused evaluation, the duration of the evaluation period, requirements for extending the evaluation period, and how the information gathered during the evaluation process will be analyzed and communicated.

7.4-2 Information for a focused evaluation process may be gathered through a variety of measures, including but not limited to:

1) Retrospective or concurrent chart review;

2) Monitoring clinical practice patterns;

3) Simulation;

6.2-2 Focused Peer Review of Initial Members

All initial grants of privileges shall be subject to proctoring under these bylaws and otherwise reviewed for compliance with the relevant departmental peer review criteria.

6.2-3 Focused Peer Review of Members

All members and privilege holders not otherwise subject to initial review are reviewed for compliance with the relevant department peer review criteria on an on-going basis. In addition to information gathered under routine screening, determined by the department, such as periodic chart review, proctoring on a rotational basis, monitoring of diagnostic and treatment techniques, and discussions with other professionals, complaints and concerns are analyzed in light of the department peer review criteria. Peer review analysis shall be [conducted and reported [quarterly] by the department chair] [conducted and reported at quarterly department meetings] [conducted by the department peer review committee for reporting quarterly to the department meeting for action],[conducted by the credentials committee for reporting monthly to the medical executive committee.] [using mechanisms determined by the department to review collected date no less frequently than semi-annually]. Members are kept apprised of reviews of their performance. Performance monitoring, corrective action or other measurements are implemented or recommended.

6.2-4 Results of Review

Information resulting from ongoing peer review of members

Note: CHA’s focused review generally includes Level I proctoring; but it is possible to use other methods to evaluate new appointees and/or new privileges. (See CHA 7.4-3.)

August 2013 Page 63



4) External peer review;

5) Discussion with other individuals involved in the care of each patient;

6) Proctoring, as more fully described at Section 7.4-4.

7.4-3 A focused professional practice evaluation shall be used in at least the following situations:

a. All initial appointees to the Medical Staff and all members granted new privileges shall be subject to a period of focused professional practice evaluation in accordance with these bylaws [and the rules of the department in which the applicant or member will be exercising those privileges]. Such focused evaluation will generally include a period of Level I proctoring in accordance with Section 7.4-4(a), unless additional circumstances appear to warrant a higher level of proctoring, as described below.

b. In special instances, focused evaluation will be imposed as a condition of renewal of privileges (for example, when a member requests renewal of a privilege that has been performed so infrequently that it is difficult to assess the member's current competency in that area). Such evaluation will generally consist of Level I proctoring in accordance with Section 7.4-4(a)(1), unless additional circumstances appear to warrant a higher proctoring level, as described below.

c. When questions arise regarding a practitioner's competency in performing specific privilege(s) at the hospital as a result of specific concerns or circumstances, a focused evaluation may be imposed. Such evaluations may include either Level II or III proctoring, in accordance with these Sections 7.4-4(a)(2) or (3).

d. As otherwise defined in these bylaws or applicable focused professional practice evaluation policies.

e. Nothing in the foregoing precludes the use of other focused professional practice evaluation tools, in addition to or in lieu of proctoring, as deemed warranted by the circumstances.

according to the relevant department criteria and analyzed by the process established in these bylaws must be acted upon. Resulting action can be but is not limited to:

a) documenting in the member’s credentials file that the member is performing well or within desired expectations;

b) identifying issues that require a focused evaluation;

c) determining that the privilege should be continued because the hospital's mission is to be able to provide the privilege to its patients;

d) recommending to the medical executive committee needed changes in hospital systems to improve patient safety or the quality of patient care;

e) recommending limiting a privilege or privileges or other corrective action under these bylaws.

The fact of the peer review and any recommendations and determinations pertaining to the member shall be included in the member’s credentials file and dealt with according to these bylaws.

6.2-5 External Peer Review

External peer review may be used to inform medical staff peer review as delineated under these bylaws. The Credentials Committee or the Medical Executive Committee, upon request from a Department or upon its own motion, in evaluating or investigating an applicant, privileges holder, or member, shall obtain external peer review in the following circumstances: (a) Committee or department review(s) that could affect an individual’s membership or privileges do not provide a sufficiently clear basis for action; (b) No current Medical Staff member can provide the necessary expertise in the clinical procedure or area under review; (c) to promote impartial peer review; (d) Upon the request of the practitioner.

Note CMA requirement for “action” upon ongoing peer review.

Query regarding CMA 6.2-4(c): Does this imply that privilege should be continued regardless of performance if there is need?

CMA 6.2-4(d) is a constructive provision.

CMA Bylaws have been modified to require external review in all of these circumstances. Query: Does failure to automatically obtain an external review indicate that the MEC did not “promote impartial peer review”? Also, does this permit the member to request further outside review if one has already been obtained?

August 2013 Page 64



7.4-4 Proctoring

a. Overview of Proctoring Levels

1) Level I proctoring shall be considered routine and is generally implemented as a means to review initially requested privileges in accordance with Section 7.4-3(a), and for review of infrequently used privileges in accordance with Section 7.4-3(b).

2) Level II proctoring is appropriate in situations where a practitioner's competency or performance is called into question, in accordance with Section 7.4-3(c), but where the circumstances do not involve a “medical disciplinary” cause or reason or where the proctoring does not constitute a restriction on the practitioner's privilege(s) [i.e., the practitioner is required to participate in proctoring, and to notify either the proctor or other designated individual(s) prior to providing services, but is permitted to proceed without the proctor if one is not available].

3) Level III proctoring is appropriate in situations where a practitioner's competency or performance is called into question due to a “medical disciplinary” cause or reason in accordance with Section 7.4-3(c) and where the form of proctoring is a restriction on the practitioner's privilege(s) [because the practitioner may not perform a procedure or provide care in the absence of the proctor]. Upon imposition of Level III proctoring, that practitioner is afforded such procedural rights as provided at Article 14.

b. Overview of Proctoring Procedures

1) Whenever proctoring is imposed, the number (or duration) and types of procedures to be proctored shall be delineated.

2) During the proctoring, the practitioners must demonstrate they are qualified to exercise the privileges that

5.3 PROCTORING

5.3-1 GENERAL PROVISIONS

Except as otherwise determined by the medical executive committee, all initial members to the medical staff and all members requesting new clinical privileges shall be subject to a period of proctoring. Each member or recipient of new clinical privileges shall be assigned to a department where performance on an appropriate number of cases 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 clinical privileges granted in that department. The exercise of clinical privileges in any other department shall also be subject to direct observation by that department’s chair or the chair’s designee….[see below]

(CHA provision for external review is noted at CHA Section 7.4-2.)

CHA has developed a three-tier proctoring scheme, distinguishing between routine proctoring (that is not medical disciplinary) and other proctoring (some of which may be medical disciplinary).

August 2013 Page 65



were granted and are carrying out the duties of their Medical Staff category.

3) In the event that the new applicant has privileges at a neighboring hospital where members of this hospital’s Medical Staff are familiar with the member to be proctored, and familiar with that neighboring hospital's peer review standards, privileging and proctoring information from the neighboring hospital may, at the discretion of [the appropriate department chair], be acceptable to satisfy a portion of the focused professional practice evaluation required for this hospital.

c. Proctor: Scope of Responsibility

1) All members who act as proctors of new appointees and/or members of the Medical Staff are acting at the direction of and as an agent for [the department], the Medical Executive Committee and the Governing Body. When possible, no business relationship shall exist between proctor and proctoree.

2) The intervention of a proctor shall be governed by the following guidelines:

i) A member who is serving as a proctor does not act as a supervisor of the member or practitioner he or she is observing. His or her role is to observe and record the performance of the member or practitioner being proctored, and report his or her evaluation to the [department and/or the Credentials Committee].

ii) A proctor is not mandated to intervene when he or she observes what could be construed as deficient performance on the part of the practitioner or member being proctored.

iii) In an emergency situation, a proctor may intervene, even though he or she has no legal obligation to do so.

d. Completion of Proctoring

The member shall remain subject to such proctoring until the Medical Executive Committee has been furnished with:

[5.3-1 cont’d] 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

August 2013 Page 66



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

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

e. Effect of Failure to Complete Proctoring

1) Failure to Complete Necessary Volume

Any practitioner or member undergoing Level I or Level II proctoring who fails to complete the required number of proctored cases within the time frame established in the bylaws and rules shall be deemed to have voluntarily withdrawn his or her request for membership (or the relevant privileges), and he or she shall not be afforded the procedural rights provided in Article 14, Hearings and Appellate Reviews. However, [the department] [other responsible official or committee] has the discretion to extend the time for completion of proctoring in appropriate cases subject to ratification by the Medical Executive Committee. The inability to obtain such an extension shall not give rise to procedural rights described in Article 14 Hearings and Appellate Reviews.

2) Failure to Satisfactorily Complete Proctoring

If a practitioner completes the necessary volume of proctored cases but fails to perform satisfactorily during proctoring, he or she may be terminated (or the relevant privileges may be revoked), and he or she shall be afforded the procedural rights as provided in Article 14, Hearings

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 membership was granted; and

(b) a report signed by the chair of the other department(s) in which the member may exercise clinical 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 clinical privileges initially granted in those departments.

5.3-2 FAILURE TO OBTAIN CERTIFICATION

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

CHA distinguishes the hearing rights, depending upon the reason proctoring is not completed. If the reason is not completing enough cases, this is deemed a voluntary withdrawal (because this is a matter within the member’s control) note there is provision to extend the time)), and there are no hearing rights. If the reason is poor performance, then hearing rights apply.

CMA extends hearing rights in either case.

August 2013 Page 67



and Appellate Reviews.

3) Effect on Advancement

The failure to complete proctoring for any specific privilege shall not, by itself, preclude advancement from Provisional Staff. If advancement is approved prior to completion of proctoring, the proctoring will continue for the specified privileges. The specific privileges may be voluntarily relinquished or terminated, pursuant to Section 7.4-4(e)(1) or (2), if proctoring is not completed thereafter within a reasonable time.

5.3-3 MEDICAL STAFF ADVANCEMENT

The failure to obtain certification for any specific clinical 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.

Article 8

MEDICAL STAFF OFFICERS [AND MEDICAL DIRECTOR]

8.1 MEDICAL STAFF OFFICERS—GENERAL PROVISIONS

8.1-1 Identification

a. There shall be the following general officers of the Medical Staff:

1) Chief of Staff

2) Vice Chief of Staff

3) Secretary-Treasurer

b. In addition, the Medical Staff’s [department and section officers] and committee chairs shall be deemed Medical Staff officers within the meaning of California law.

9.1 OFFICERS OF THE MEDICAL STAFF

9.1.-1 IDENTIFICATION

The officers of the medical staff shall be the chief of staff, vice chief of staff [or chief of staff-elect], immediate past chief of staff, and secretary-treasurer.

8.1-2 Qualifications

All Medical Staff officers shall:

a. Understand the purposes and functions of the Medical Staff and demonstrate willingness to assure that patient welfare always takes precedence over other concerns;

b. Understand and be willing to work toward attaining the hospital’s lawful and reasonable policies and


Officers must be members of the active medical staff at the time of their nominations and election, and must remain members in good standing during their term of office. Failure to maintain such status shall create a vacancy in the office involved. All officers must be licensed as physicians and surgeons, given the nature of their duties in office. In addition to exercising their responsibilities pursuant to Section 14.6, officers shall verbally disclose all actual or potential conflicts

CHA Bylaws articulate more specific qualifications for Medical Staff officers.

Note CMA provision regarding conflict of interest.

August 2013 Page 68



requirements;

c. Have administrative ability as applicable to the respective office;

d. Be able to work with and motivate others to achieve the objectives of the Medical Staff and hospital;

e. Demonstrate clinical competence in his or her field of practice;

f. Be an active Medical Staff member (and remain in good standing as an active Medical Staff member while in office); and

g. Not have any significant conflict of interest.

of interest in the course of each medical staff meeting or other event where such a disclosure may be relevant. Any potential conflicts so disclosed shall be resolved as set forth in Section 14.6.

Compare CHA Bylaws Section 8.1-3.

8.1-3 Disclosure of Conflict of Interest

a. All nominees for election or appointment to Medical Staff offices (including those nominated by petition of the Medical Staff pursuant to Section 8.2-3, Nomination by Petition) 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 that could foreseeably result in a conflict of interest with their activities or responsibilities on behalf of the Medical Staff. Generally, a conflict of interest arises when there is a divergence between an individual’s private interests and his/her professional obligations, such that an independent observer might reasonably question whether the individual’s professional actions or decisions are determined by those private interests. A conflict of interest depends on the situation and not on the character of the individual. The fact that an individual practices in the same specialty as a practitioner who is being reviewed does not by itself create a conflict of interest. The evaluation of whether a conflict of interest exists shall be interpreted reasonably by the persons involved, taking into consideration common sense and objective principles of fairness. The Medical Executive Committee shall evaluate the significance of such disclosures and discuss any significant conflicts with the nominee. If a nominee with a

14.6 DISCLOSURE OF INTEREST AND CONFLICT OF INTEREST RESOLUTION

For the purposes of these bylaws, CONFLICT OF INTEREST means a personal or financial interest or conflicting fiduciary obligation that makes it impossible, as a practical matter, for the individual to act in the best interests of the medical staff without regard to the individual's private or personal interest. Such an interest may also be held by an immediate family member of that individual, including that individual's spouse, domestic partner, child or parent.

The disclosure of an interest, as set forth in these bylaws, does not automatically mean that an actual conflict of interest exists. Whether a disclosed interest constitutes a conflict is determined as set forth below.

14.6-1 Application

(a) In order to encourage unbiased, responsible management and decisionmaking, all medical staff leaders, including officers, department chiefs, division chairs, medical staff representatives, and medical staff members serving on committees shall comply with the disclosure of interest and conflict of interest requirements as relevant to the position held and the circumstances, consistent with these bylaws.

Compare definitions. CMA’s definition (with its “impossible” criterion) is arguably a more liberal provision (i.e., allowing members with apparent or potential conflicts to continue to participate).

CMA’s provisions regarding conflict of interest are much more detailed and broad-ranging. The scope of required disclosures could unnecessarily discourage participation in Medical Staff activities.

August 2013 Page 69



significant conflict remains on the ballot, the nature of his or her conflict shall be disclosed in writing and circulated with the ballot.

b. [A person nominated from the floor shall be asked to verbally disclose conflicts to those in attendance at the meeting, and the Medical Executive Committee or its representative shall have an opportunity to comment thereon, prior to the vote.]

(b) These bylaws shall be the unique and exclusive mechanism for discerning and acting upon conflicts of interest applicable to medical staff members. Only those medical staff members who also serve on the governing body may be required to adhere to a disclosure and conflict of interest policy, if any, of the governing body.

14.6-2 General Requirements

(a) No member may exercise any leadership or committee role unless or until the member completes the Disclosure of Interest form approved by the medical executive committee as consistent with these bylaws. This form shall be updated by such members within thirty (30) days of the occurrence of any changes relating to statements on that form. This form shall be available for viewing by any member of the medical staff, but may only be used for bona fide medical staff purposes and not for individual personal use. Nor may the information be shared with non¬medical staff members.

(b) Members holding any leadership or committee role must disclose their potential conflict of interest relevant to the subject under discussion when they address a medical staff body or prior to voting upon the subject where a potential conflict of interest exists.

14.6-3 Information to be Disclosed

Potential conflicts include, but are not limited to current or impending:

(1) Competitive or personal relationships, activities, or interests that may influence a member's decisions or actions;

(2) Grants or other financial, academic or professional relationships involving research relating to decisions under review;

(3) Ownership or investment interests in excess of $5,000 or 5% of the whole, whichever is less, in any hospital, hospital system, and/or ambulatory health facility;

(4) Ownership or investment interests in excess of $5,000 or 5% of the whole, whichever is less, in any company that furnishes goods or services to the hospital or is seeking to

CMA precludes Governing Body imposition of any conflict of interest policy not approved by the Medical Staff. This well illustrates the confrontational possibilities of CMA’s self-governance parameters.

August 2013 Page 70



provide goods or services to the hospital;

(5) Employment, consulting or other personal compensation agreement with any hospital or ambulatory health facility;

(6) Ownership or investment interests in excess of $5,000 or 5% of the whole, whichever is less, or a director, trustee, officer or key employee in, a managed care company that contracts with or could contract with the hospital;

(7) Receipt of gifts including goods, services, or honoraria from the hospital or any company or person who contracts with or otherwise sells to the hospital, in excess of $100;

(8) Employment, consulting or other personal compensation agreement with any quality assurance, credentialing, and/or utilization review entity, including but not limited to any third party payor, quality improvement organization, or the Medical Board of California.

(9) Any other personal or financial interest or conflicting fiduciary obligation that may raise a conflict of interest.

14.6-4 Conflict Resolution

(1) Not all disclosures of a potential conflict of interest require the member’s abstention or recusal, however, a member may abstain from voting on any issue. A member shall recuse if the member reasonably believes that the member’s ability to render a fair and independent decision is or may be affected by a conflict of interest. A recused member shall not be counted in determining the quorum for that vote but may answer questions or otherwise provide information about the matter after disclosing the conflict. A recused member must not be present for the remainder of the deliberations or the vote.

(2) If a member has not voluntarily recused and a majority of voting members of the committee or in the staff meeting vote that the member should be excused from discussion or voting due to conflict of interest, the chair shall excuse the member.

August 2013 Page 71



(3) If a member discloses a potential conflict of interest and requests a vote regarding excusing that member, the member shall leave the room while the issue is being discussed and voted upon.

(4) The minutes of the meeting shall include the names of those who disclosed potential conflicts and those who abstained and/or recused themselves.

14.6-4 Corrective Action

Medical staff members who fail to comply with all provisions of these bylaws concerning actual or potential conflicts of interest shall be subject to corrective action under these bylaws, including but not limited to removal from the medical staff position.

CMA Bylaws include rigorous conflict of interest enforcement provisions.

8.2 METHOD OF SELECTION—GENERAL OFFICERS

Option 1

[8.2-1 Succession of Vice Chief of Staff to Chief of Staff

The Vice Chief of Staff shall accede to the position of Chief of Staff upon the Chief of Staff’s completion of his or her term.

8.2-2 Nominating Committee

An ad hoc nominating committee composed of the Chief of Staff, two staff members elected by the Medical Executive Committee, and two staff members appointed by the Chief of Staff shall develop a slate of candidates meeting the qualifications of office, as described in Section 8.1-2 above. This slate shall be developed at least 45 days prior to the scheduled election. At least one candidate shall be nominated for each of the following positions:

a. Vice Chief of Staff and

b. Secretary-Treasurer]

Option 2

[8.2-1 Nominating Committee

9.1-3 NOMINATIONS

(a) The medical staff election year shall be each [even or odd] numbered medical staff year. A nominating committee shall be appointed by the medical executive committee not later than [120] days prior to the annual staff meeting to be held during the election year or at least [45] days prior to any special election. The nominating committee shall consist of the immediate past chief of staff, and one other member of the medical executive committee, [2] members of the bylaws committee from among the active medical staff who are not members of the medical executive committee and the CMA/AMA representative [with/without vote]. The nominating committee shall formally request names of potential candidates from members of the medical staff at least [65] days prior to the annual meeting. Such a request shall be made electronically to each medical staff member through the medical staff's Internet-based bulletin board and electronically to those medical staff members that have provided their e-mail address and/or fax numbers. Such requests shall also be posted in medical staff common areas, such as medical staff offices, dining room, and lounges. The nominations of the committee shall be reported to the medical executive committee at least [60] days prior to the annual meeting and shall be delivered or mailed to the voting members of the medical staff at least [40] days prior to the election. The hospital shall have no right to approve the slate

CHA Bylaws provide several options for selecting Medical Staff officers (including succession of officers through the ranks – which adds to continuity and building of experience).

August 2013 Page 72



An ad hoc nominating committee composed of the Chief of Staff, two staff members elected by the Medical Executive Committee, and two staff members appointed by the Chief of Staff shall develop a slate of candidates meeting the qualifications of office, as described in Section 8.1-2 above. This slate shall be developed at least 45 days prior to the scheduled election. At least one candidate shall be nominated for each of the following positions:

a. Chief of Staff

b. Vice Chief of Staff, and

c. Secretary-Treasurer]

8.2-3 Nomination by Petition

The Medical Staff may nominate candidates for office by a petition signed by at least ten members who are eligible to vote and a statement from the candidate signifying willingness to run. Such nominations must be received by the Chief of Staff at least 30 days prior to the scheduled elections.

[8.2-4 Governing Body Review

The slate of candidates (including those nominated by petition), together with the disclosure information provided pursuant to Section 8.1-3, will be presented to the Governing Body for its review and comment. The Governing Body may issue written comments about any or all candidate, which comments must be communicated to all voting Medical Staff prior to the election.]

of candidates or otherwise participate in the activities of the nominating committee.

(b) Further nominations may be made for any office by any voting member of the medical staff, provided that the name of the candidate is submitted in writing to the chair of the nominating committee, is endorsed by the signature of at least [10%] of other members who are eligible to vote, and bears the candidate’s written consent. These nominations shall be delivered to the chair of the nominating committee as soon as reasonably practicable, but at least [20] days prior to the date of election. If any nominations are made in this manner, the voting members of the medical staff shall be advised by notice delivered or mailed at least [10] days prior to the meeting. Nominations from the floor will be recognized if the nominee is present and consents.

CMA Bylaws Section 9.1-4 has been amended to address disclosure of potential conflicts in the case of nominations from the floor.

CHA Bylaws contain an option for Board review of nominees. This is not intended to serve as a veto power; but rather as a means to flush out possible problems before elections occur.

8.2-5 Election

The election shall be by mail ballot, and the outcome shall be determined by a majority of the votes cast by mail ballots that are returned to the Medical Staff office within 15 days after the ballots were mailed to the voting Medical Staff members.

9.1-4 ELECTIONS

The vice chief of staff and secretary-treasurer shall be elected at the annual meeting of the medical staff which falls during the election year. In accordance with Section 14.6, all nominees for election shall disclose in writing to the medical staff those current or impending personal, professional, or financial affiliations or relationships of which they are reasonably aware, including contractual, employment or other relationships with the hospital, which could foreseeably result in a conflict of interest with their activities or responsibilities

CHA Bylaws provide only for mail ballots.

CMA has included a provision regarding conflict of interest disclosure.

Compare with CHA Bylaws Section 8.1-3.

August 2013 Page 73



on behalf of the medical staff. Such disclosure statement shall accompany the ballot. Voting shall be by secret written ballot, and authenticated sealed mail ballots may be counted. Written ballots shall include handwritten signatures on the envelope for comparison with signatures on file, when necessary. A nominee shall be elected upon receiving a majority of the valid votes cast. If no candidate for the office receives a majority vote on the first ballot, a run-off election shall be held promptly between the two candidates receiving the highest number of votes. In the case of a tie on the second ballot, the majority vote of the medical executive committee shall decide the election by secret written ballot at its next meeting or a special meeting called for that purpose.

8.2-6 Term of Office

a. Officers shall be elected in the fall of odd-numbered years and shall take office the following January.

b. The term of office shall be two years. No officer shall serve consecutive terms in the same position.

9.1-5 TERM OF ELECTED OFFICE

Each officer shall serve a [2] year term, commencing on the first day of the medical staff year following the election. Each officer shall serve in each office until the end of that officer’s term, or until a successor is elected, unless that officer shall sooner resign or be removed from office. At the end of that officer’s term, the chief of staff shall automatically assume the office of immediate past chief of staff and the vice chief of staff shall automatically assume the office of chief of staff.

8.3 RECALL OF OFFICERS

A general Medical Staff officer may be recalled from office for any valid cause, including, but not limited to, failure to carry out the duties of his or her office. Except as otherwise provided, recall of a general Medical Staff officer may be initiated by the Medical Executive Committee or by a petition signed by at least 33-1/3 percent of the Medical Staff members eligible to vote for officers; but recall itself shall require a 66-2/3 percent vote of the Medical Executive Committee or 66-2/3 percent vote of the Medical Staff members eligible to vote for general Medical Staff officers.

9.1-6 RECALL OF OFFICERS

Any medical staff officer may be removed from office for valid cause, including, but not limited to, gross neglect or misfeasance in office, or serious acts of moral turpitude. Recall of a medical staff officer may be initiated by the medical executive committee or shall be initiated by a petition signed by at least [one-third] of the members of the medical staff eligible to vote for officers. Recall shall be considered at a special meeting called for that purpose. Recall shall require a [two-thirds] vote of the medical staff members eligible to vote for medical staff officers who actually cast votes at the special meeting in person or by mail ballot.

8.4 FILLING VACANCIES

Vacancies created by resignation, removal, death, or disability shall be filled as follows:

9.1-7 VACANCIES IN ELECTED OFFICE

Vacancies in office occur upon the death or disability, resignation, or removal of the officer, or such officer’s loss of

August 2013 Page 74



8.4-1 A vacancy in the office of Chief of Staff shall be filled by the Vice Chief of Staff.

8.4-2 A vacancy in the office of Vice Chief of Staff shall be filled by special election held in general accordance with Bylaws, Section 8.2.

8.4-3 A vacancy in the office of secretary-treasurer shall be filled by appointment by the Medical Executive Committee.

membership in the medical staff. Vacancies, other than that of the chief of staff, shall be filled by appointment by the medical executive committee until the next regular election. If there is a vacancy in the office of chief of staff, then the vice chief of staff shall serve out that remaining term and shall immediately appoint an ad hoc nominating committee to decide promptly upon nominees for the office of vice chief of staff. Such nominees shall be reported to the medical executive committee and to the medical staff. A special election to fill the position shall occur at the next regular staff meeting. If there is a vacancy in the office of vice chief of staff, that office need not be filled by election, but the medical executive committee shall appoint an interim officer to fill this office until the next regular election, at which time the election shall also include the office of chief of staff.

8.5 DUTIES OF OFFICERS

8.5-1 Chief of Staff

The Chief of Staff shall serve as the chief officer of the Medical Staff. The duties of the Chief of Staff shall include, but not be limited to:

a. Enforcing the Medical Staff bylaws and rules, promoting quality of care, implementing sanctions when indicated, and promoting compliance with procedural safeguards when corrective action has been requested or initiated;

b. Calling, presiding at, and being responsible for the agenda of all meetings of the Medical Staff;

c. Serving as chair of the Medical Executive Committee, and in that capacity shall be deemed the individual responsible for the organization and conduct of the Medical Staff;

d. Serving as an ex-officio member of all other Staff committees without vote, unless his or her Membership in a particular committee is required by these bylaws;

e. Appointing, in consultation with the Medical Executive Committee, committee members for all standing, ad hoc, and special Medical Staff, liaison, or multi-disciplinary committees except where otherwise provided

9.2 DUTIES OF OFFICERS

9.2-1 CHIEF OF STAFF

The chief of staff shall serve as the chief officer of the medical staff. The duties required of the chief of staff shall include, but not be limited to:

(a) enforcing the medical staff bylaws and rules and regulations, implementing sanctions where indicated, and promoting compliance with procedural safeguards where corrective action has been requested or initiated;

(b) calling, presiding at, and being responsible for the agenda of all meetings of the medical staff;

(c) serving as chair of the medical executive committee and calling, presiding at, and being responsible for the agenda of all meetings thereof;

(d) serving as an ex officio member of all other staff committees without vote, unless chief of staff membership in a particular committee is required by these bylaws;

(e) interacting with the administrator in all matters of mutual concern within the hospital;

(f) appointing, in consultation with the medical executive committee, committee members for all standing

CHA includes Section 8.5-1c to address the CMS requirement that an individual must be responsible for the organization and conduct of the Medical Staff.

August 2013 Page 75



by these bylaws and, except where otherwise indicated, designating the chairs of these committees;

f. Being a spokesperson for the Medical Staff in external professional and public relations;

g. Serving on liaison committees with the Governing Body and administration, as well as outside licensing or accreditation agencies;

h. Appointing members of the Medical Staff to participate, as a Medical Staff liaison, in the development of hospital policies;

i. Regularly reporting to the Governing Body on the performance of Medical Staff functions and communicating to the Medical Staff any concerns expressed by the Governing Body;

j. In the interim between Medical Executive Committee meetings, performing those responsibilities of the committee that, in his or her reasonable opinion, must be accomplished prior to the next regular or special meeting of the committee;

k. Interacting with the Chief Executive Officer and Governing Body in all matters of mutual concern within the hospital;

l. Representing the views and policies of the Medical Staff to the Governing Body and to the Chief Executive Officer and serving as an ex-officio member of the Governing Body;

m. Serving on the Joint Conference Committee;

n. Being accountable to the Governing Body, in conjunction with the Medical Executive Committee, for the effective performance, by the Medical Staff, of its responsibilities with respect to quality and efficiency of

committees other than the medical executive committee and all special medical staff, liaison, or multi-disciplinary committees, except where otherwise provided by these bylaws and, except where otherwise indicated, designating the chairs of these committees;

(g) representing the views and policies of the medical staff to the board of [trustees/directors] at every board of [trustees/directors] meeting;

(h) being a spokesperson for the medical staff in external professional and public relations;

(i) performing such other functions as may be assigned to the chief of staff by these bylaws, the medical staff, or by the medical executive committee;

(j) serving on liaison committees with the board of [trustees/directors] and administration, as well as outside licensing or accreditation agencies.

CMA Bylaws provide that the Chief of Staff (or Vice Chief – see 9.2-2 below) may participate in every meeting of the Board (whether or not the Chief of Staff/Vice Chief is a member of the Board). (They do not, however, provide comparable participation to the CEO/Board representatives in meetings of the Medical Staff – see CMA Bylaws Section 12.8.)

CHA Bylaws clarify the Chief of Staff’s authority to act in between meetings of the MEC.

August 2013 Page 76



clinical services within the hospital and for the effectiveness of the quality assurance and utilization review programs; and

o. Performing such other functions as may be assigned to him or her by these bylaws, the Medical Staff or the Medical Executive Committee.

8.5-2 Vice Chief of Staff

The Vice Chief of Staff shall assume all duties and authority of the Chief of Staff in the absence of the Chief of Staff. The Vice Chief of Staff shall be a member of the Medical Executive Committee and of the Joint Conference Committee, and shall perform such other duties as the Chief of Staff may assign or as may be delegated by these bylaws or the Medical Executive Committee.

9.2-2 VICE CHIEF OF STAFF [OR CHIEF OF STAFF-ELECT]

The vice chief of staff shall assume all duties and authority of the chief of staff in the absence of the chief of staff. The vice chief of staff shall be a member of the medical executive committee and of the joint conference committee, shall attend and represent, at the direction of and in the absence of the chief of staff, the views and policies of the medical staff to the board of [trustees/directors] at every board of [trustees/directors] meeting and shall perform such other duties as the chief of staff may assign or as may be delegated by these bylaws, or by the medical executive committee.

9.2-3 IMMEDIATE PAST CHIEF OF STAFF

The immediate past chief of staff shall be a member of the medical executive committee and a member of the joint conference committee and shall perform such other duties as may be assigned by the chief of staff or delegated by these bylaws, or by the medical executive committee.

8.5-3 Secretary-Treasurer

The Secretary-Treasurer shall be a member of the Medical Executive Committee. The duties shall include, but not be limited to:

a. Maintaining a roster of members;

b. Keeping accurate and complete minutes of all Medical Executive Committee and Medical Staff meetings;

c. Calling meetings on the order of the Chief of Staff or Medical Executive Committee;

d. Attending to correspondence and notices on behalf

9.2-4 SECRETARY-TREASURER

The secretary-treasurer shall be a member of the executive committee. The duties shall include, but not be limited to:

(a) maintaining a roster of members;

(b) keeping accurate and complete minutes of all medical executive committee and general medical staff meetings;

(c) calling meetings on the order of the chief of staff or medical executive committee;

(d) attending to all appropriate correspondence and

August 2013 Page 77



of the Medical Staff;

e. Receiving and safeguarding all funds of the Medical Staff;

f. Excusing absences from meetings on behalf of the Medical Executive Committee; and

g. Performing such other duties as ordinarily pertain to the office or as may be assigned from time to time by the Chief of Staff or Medical Executive Committee.

notices on behalf of the medical staff;

(e) receiving and safeguarding all funds of the medical staff, preparing an annual proposed budget of anticipated income and expenditures, for approval by the medical staff, and preparing on a quarterly basis a financial statement in accordance with generally accepted accounting principles (GAAP), and recommending, where needed, the creation of a finance subcommittee to assist in these duties;

(f) excusing absences from meetings on behalf of the medical executive committee; and

(g) performing such other duties as ordinarily pertain to the office or as may be assigned from time to time by the chief of staff or medical executive committee.

Note CMA responsibility for the Secretary- Treasurer.

9.3 COMPENSATION OF MEDICAL STAFF OFFICERS

Medical staff officers should be compensated for their work spent representing and leading the medical staff. Such compensation shall come from the medical staff bank account, for which the medical staff has sole responsibility. The payment to individual physicians should be in the amount determined by the MEC. If the hospital provides any funds specifically earmarked for such compensation, those funds should be requested and accounted for in the medical staff budget for hospital approval. Payment to each physician under this provision shall be contingent upon each physician’s proper performance of those duties, and the evaluation and determination of the quality of that performance is in the sole determination of the MEC.

9.4 MEDICAL STAFF REPRESENTATIVES TO THE BOARD

The medical staff shall elect [ ] members from the active staff to serve as voting members of the board of [trustees/directors] of the hospital, and, where applicable, system in which the hospital is affiliated, representing the interests of the medical staff organization in the same manner and at the same time as provided in sections 9.1-3 through 9.1-4 for the nomination

CMA Bylaws address compensation for Medical Staff officers, and significant other provisions relating to the management of funds earmarked for the Medical Staff.

CMA Bylaws provide for election of Medical Staff representatives on the Governing Body – including the Governing Body at the system level, and provide that this appointment is not to be made by the Governing Body.

This is in addition to the participation of the Chief of Staff. Note: The CMA Bylaws do not specifically

August 2013 Page 78



and election of officers. The representatives shall report to the medical executive committee. The hospital shall have no right to appoint a medical staff member to serve as a member of the board.

9.5 [CMA/AMA] OMSS REPRESENTATIVE

The medical staff shall elect physician members of the active medical staff to serve as [CMA/AMA] Organized Medical Staff Section representative [and alternate] in the same manner and at the same time as provided in sections 9.1-3 through 9.1-4 for the nomination and election of officers. Such representative[s] shall serve on the Medical Executive Committee and the nominating committee, and attend the annual meeting of the CMA Organized Medical Staff Section, shall work with the medical staff in understanding its responsibilities to be self-governing, alert the bylaws committee to potential infringements on medical staff self-governance, and when needed, shall contact the CMA for information and assistance.

provide for Chief of Staff membership on the Governing Body. If a hospital’s corporate Bylaws do provide for Chief of Staff membership on the Governing Body, and if the Governing Body were to also approve a provision such as this one, it is possible that the Medical Staff would be entitled to representation via both provisions, resulting in two (or more) representatives on the Governing Body.

CMA Bylaws ensure CMA OMSS representation on the MEC, providing a means to ensure CMA OMSS oversight of medical staff operations. See also, CMA Section 11.3-1c, assuring OMSS representation on the MEC.

[8.6 CHIEF MEDICAL OFFICER

8.6-1 Appointment

The Chief Medical Officer shall be appointed by the Governing Body and approved by the Medical Executive Committee.

8.6-2 Responsibilities

a. The Chief Medical Officer’s duties shall be delineated by the Governing Body in keeping with the general provisions set forth in subparagraph (b) below. The Medical Executive Committee approval shall be required for any Chief Medical Officer duties that relate to authority to perform functions on behalf of the Medical Staff or directly affect the performance or activities of the Medical Staff.

b. In keeping with the foregoing, the Chief Medical Officer shall:

1) Serve as administrative liaison among hospital administration, the Governing Body, outside agencies and

CHA Bylaws include specific provisions relating to a Chief Medical Officer.

August 2013 Page 79



the Medical Staff;

2) Assist the Medical Staff in performing its assigned functions and coordinating such functions with the responsibilities and programs of the hospital; and

3) In cooperation and close consultation with the Chief of Staff and the Medical Executive Committee, supervise the day-to-day performance of the Medical Staff office and the hospital’s quality improvement personnel.

8.6-3 Participation in Medical Staff Committees

The Chief Medical Officer:

a. Shall be an ex officio member––without vote––of all Medical Staff Committees, except the Joint Conference Committee (which the Chief Medical Officer shall attend as a resource person) and any hearing committee.

b. May attend any meeting of any department or section.]

Article 9

COMMITTEES

9.1 General

9.1-1 Designation

The Medical Executive Committee and the other committees described in these bylaws and the rules shall be the standing committees of the Medical Staff. Special or ad hoc committees may be created by the Medical Executive Committee [or a department] to perform specified tasks. Any committee––whether Medical Staff-wide or [department or] other clinical unit, or standing or ad hoc––that is carrying out all or any portion of a function or activity required by these bylaws is deemed a duly appointed and authorized committee of the Medical Staff.

11.1 DESIGNATION

Medical staff committees shall include but not be limited to, the medical staff meeting as a committee of the whole, meetings of departments and divisions, meetings of committees established under this Article, and meetings of special or ad hoc committees created by the medical executive committee (pursuant to this Article) or by departments (pursuant to Sections 10.4(i) and (l)). The committees described in this Article shall be the standing committees of the medical staff. Special or ad hoc committees may be created by the medical executive committee to perform specified tasks. Unless otherwise specified, the chair and members of all committees shall be appointed by and may be removed by the chief of staff, subject to consultation with and approval by the medical executive committee. In accordance with Section 14.6, all nominees for appointment to medical staff committees shall, at least [20] days prior to the date of appointment, disclose in writing to the medical executive committee and the Chief of Staff those current or impending personal, professional, or financial affiliations or relationships of which they are reasonably aware, including contractual,

Note CMA’s extensive Conflict of Interest language. (Compare CHA 9.1-10.)

August 2013 Page 80



employment or other relationships with the hospital, which could foreseeably result in a conflict of interest with their activities or responsibilities on behalf of the committee. Medical staff committees shall be responsible to the medical executive committee.


In addition to exercising the responsibilities pursuant to Section 14.6, committee members shall verbally disclose all actual or potential conflicts of interest in the course of each medical staff meeting or other event where such a disclosure may be relevant. Any potential conflicts so disclosed shall be resolved as set forth in Section 14.6.

9.1-2 Appointment of Members

a. Unless otherwise specified, the chair and members of all committees shall be appointed by, and may be removed by, the Chief of Staff, subject to consultation with and approval by the Medical Executive Committee. Medical Staff committees shall be responsible to the Medical Executive Committee.

b. A Medical Staff committee created in these bylaws is composed as stated in the description of the committee in these bylaws or the rules. Except as otherwise provided in the bylaws, committees established to perform Medical Staff functions required by these bylaws may include any category of Medical Staff members; allied health professionals; representatives from hospital departments such as administration, nursing services, or health information services; representatives of the community; and persons with special expertise, depending upon the functions to be discharged. Each Medical Staff member who serves on a committee participates with votes unless the statement of committee composition designates the position as nonvoting.

c. The Chief Executive Officer, or his or her designee, in consultation with the Chief of Staff, shall appoint any non-Medical Staff members who serve in non-ex officio capacities.

d. The committee chair, after consulting with the

The CHA Bylaws contain more detailed general provisions relating to Medical Staff committees.

August 2013 Page 81



Chief of Staff and Chief Executive Officer, may call on outside consultants or special advisors.

e. Each committee chair shall appoint a vice chair to fulfill the duties of the chair in his or her absence and to assist as requested by the chair. Each committee chair or other authorized person chairing a meeting has the right to discuss and to vote on issues presented to the committee.

9.1-3 Representation on Hospital Committees and Participation in Hospital Deliberations

The Medical Staff may discharge its duties relating to accreditation, licensure, certification, disaster planning, facility and services planning, financial management and physical plant safety by providing Medical Staff representation on hospital committees established to perform such functions.

9.1-4 Ex Officio Members

The Chief of Staff and the Chief Executive Officer, or their respective designees [and the Chief Medical Officer] are ex officio members of all standing and special committees of the Medical Staff and shall serve with vote unless provided otherwise in the provision or resolution creating the committee.

9.1-5 Action Through Subcommittees

Any standing committee may use subcommittees to help carry out its duties. The Medical Executive Committee shall be informed when a subcommittee is appointed. The committee chair may appoint individuals in addition to, or other than, members of the standing committee to the subcommittee after consulting with the Chief of Staff regarding Medical Staff members, and the Chief Executive Officer regarding hospital staff.

CHA Section 9.1-3 provides an efficient way to accommodate this TJC requirement.

9.1-6 Terms and Removal of Committee Members

Unless otherwise specified, a committee member shall be appointed for a term of [one year; two years], subject to unlimited renewal, and shall serve until the end of this

11.2 GENERAL PROVISIONS

11.2-1 TERMS OF COMMITTEE MEMBERS

Unless otherwise specified, committee members shall be

August 2013 Page 82



period and until his or her successor is appointed, unless he or she shall sooner resign or be removed from the committee. Any committee member who is appointed by the Chief of Staff may be removed by a majority vote of the Medical Executive Committee. [Any committee member who is appointed by the department chair may be removed by a majority vote of his or her department committee or the Medical Executive Committee]. The removal of any committee member who is automatically assigned to a committee because he or she is a general officer or other official shall be governed by the provisions pertaining to removal of such officer or official.

appointed for a term of [ ], and shall serve until the end of this period or until the member’s successor is appointed, unless the member shall sooner resign or be removed from the committee.

11.2-2 REMOVAL

If a member of a committee ceases to be a member in good standing of the medical staff, or loses employment or a contract relationship with the hospital, suffers a loss or significant limitation of practice privileges, or if any other good cause exists, that member may be removed by the medical executive committee.

9.1-7 Vacancies

Unless otherwise specified, vacancies on any committee shall be filled in the same manner in which an original appointment to such committee is made; provided however, that if an individual who obtains membership by virtue of these bylaws is removed for cause, a successor may be selected by the Medical Executive Committee

9.1-8 Conduct and Records of Meetings

Committee meetings shall be conducted and documented in the manner specified for such meeting in Article 11, Meetings.

9.1-9 Attendance of Nonmembers

Any Medical Staff member who is in good standing may ask the chair of any committee for permission to attend a portion of that committee’s meeting dealing with a matter of importance to that practitioner. The committee chair shall have the discretion to grant or deny the request and shall grant the request only if the member’s attendance will reasonably aid the committee to perform its function. If the request is granted, the invited member shall abide by all bylaws and rules applicable to that committee.

9.1-10 Conflict of Interest

11.2-3 VACANCIES

Unless otherwise specifically provided, vacancies on any committee shall be filled in the same manner in which an original appointment to such committee is made; provided however, that if an individual who obtains membership by virtue of these bylaws is removed for cause, a successor may be selected by the medical executive committee.

[SEE CMA Section 14.6] See additional comments regarding CMA Conflict of Interest accompanying CHA Bylaws Section 8.1-3

August 2013 Page 83



a. In any instance where a Medical Staff member has or reasonably could be perceived to have a conflict of interest, as defined below, such individual shall not participate in the discussion or voting on the matter, and shall be excused from any meeting during that time. However, the individual with a conflict may be asked, and may answer, any questions concerning the matter before leaving. Any dispute over the existence of a conflict of interest shall be resolved by the chairperson of the committee, or, if it cannot be resolved at that level, by the Chief of Staff.

b. A conflict of interest arises when there is a divergence between an individual’s private interests and his/her professional obligations, such that an independent observer might reasonably question whether the individual’s professional actions or decisions are determined by those private interests. A conflict of interest depends on the situation and not on the character of the individual. The fact that an individual practices in the same specialty as a practitioner who is being reviewed does not by itself create a conflict of interest. The evaluation of whether a conflict of interest exists shall be interpreted reasonably by the persons involved, taking into consideration common sense and objective principles of fairness. The fact that a committee member or Medical Staff leader chooses to refrain from participation, or is excused from participation, shall not be interpreted as a finding of actual conflict.

9.1-11 Accountability

All committees shall be accountable to the Medical Executive Committee.

(CMA Section 14.6).

9.2 JOINT CONFERENCE COMMITTEE

9.2-1 Composition

The Joint Conference Committee shall be composed of [eight] members: [the Chief of Staff, the Vice Chief of Staff, the immediate-past Chief of Staff, the Secretary-Treasurer, three members of the hospital’s Governing Body, and the Chief Executive Officer]. All members are voting members. The person serving as the Joint Conference Committee chair

11.5 JOINT CONFERENCE COMMITTEE

11.5-1 COMPOSITION

The joint conference committee shall be composed of an equal number of members of the board of [trustees/directors] and of the medical executive committee, but the medical staff members shall at least include the chief of staff, the chief of

TJC no longer requires a Joint Conference Committee, and it is not required by California or federal laws or regulations. However, many hospitals retain the committee since it can help fulfill the TJC requirement for a mechanism to assure effective communication

August 2013 Page 84



shall alternate annually between the Chief of Staff and one of the Governing Body representatives.

9.2-2 Duties and Meeting Frequency

a. This committee shall serve as a focal point for furthering an understanding of the roles, relationships, and responsibilities of the Governing Body, administration, and the Medical Staff. It may also serve as a forum for discussing any hospital matters regarding the provision of patient care. It shall meet at least quarterly or as often as necessary to fulfill its responsibilities. Any member of the committee shall have the authority to place matters on the agenda for consideration by the committee.

b. The committee [shall/may] also serve as the initial forum for exercise of the meet and confer provisions contemplated by Section 15.7 of these bylaws; provided, however, that upon request of at least four committee members (which four must be comprised of at least three Medical Staff representatives and one Governing Body representative, or of at least three Governing Body representatives and one Medical Staff representative), a neutral mediator, acceptable to both contingents, shall be engaged to assist in dispute resolution.

staff-elect, and the immediate past chief of staff. A quorum shall consist of an equal number of trustees/directors and MEC members. The chairship of the committee shall alternate every other meeting between the board of [trustees/directors] and the medical staff. In no event shall the chair representing the medical staff have a personal compensation agreement with the hospital or hospital system for administrative services that constitutes in excess of [__%] of such member's annual compensation.

11.5-2 DUTIES

The joint conference committee shall constitute a forum for the discussion of matters of hospital and medical staff policy, practice, and planning, and the exclusive forum for interaction between the board of [trustees/directors] and the medical staff on such matters as may be referred by the medical executive committee or the board of [trustees/directors]. Except where there is a resource allocation committee, the joint conference committee shall serve as the review body for hospital strategic planning, reviewing all strategic plans before the plans are sent to the governing board. The committee may request additional information from management before acting to approve or disapprove such plans. Joint Conference Committee approval shall be required before the implementation of any strategic plan. The Joint Conference Committee shall serve as the body to handle medical staff and board of [trustees/directors] disputes, shall gather information concerning the dispute and shall meet and confer, as early as possible, in good faith to resolve such disputes. The joint conference committee shall exercise any other responsibilities set forth in these bylaws.

11.5-3 MEETINGS

The joint conference committee shall meet [at least semi-annually], and shall transmit written reports of its activities to the executive committee and to the board of [trustees/directors].

among the Medical Staff, hospital administration and the Governing Body, and it fits well with TJC’s Shared Vision – New Pathways philosophy. Additionally, the Joint Conference Committee represents an effective forum for operationalizing the interdependence of the Medical Staff and Governing Body, and may also be an appropriate forum for the meet and confer provisions that are expressed in Business & Professions Code Section 2282.5.

The CMA Bylaws provide that this is the exclusive forum for interaction with the Board; as well as a provision for requesting additional information, and a requirement that, in certain circumstances, JCC approval is required before the hospital can implement a strategic plan. Given the equal representation on the JCC, this could result in a stalemate with respect to hospital strategic planning.

9.2-3 Accountability

August 2013 Page 85



The Joint Conference Committee is directly accountable to the Medical Executive Committee and to the Governing Body.

9.3 MEDICAL EXECUTIVE COMMITTEE

9.3-1 Composition

The Medical Executive Committee shall be composed of the Medical Staff officers listed in Article 8, Medical Staff Officers and Chief Medical Officers, at least one at-large representative, [the Chief Medical Officer as an ex officio member without vote, and (insert others who will be Medical Executive Committee members)]. The Chief Executive Officer [and the hospital’s chief nursing executive or designee] shall serve as an ex officio member. The Chief of Staff shall chair the Medical Executive Committee. A majority of the committee shall be physicians.

11.3 MEDICAL EXECUTIVE COMMITTEE

11.3-1 COMPOSITION

The medical executive committee shall consist of the following persons:

(a) the officers of the medical staff;

(b) the department chairs;

(c) the [CMA/AMA] OMSS Representative [with/without] vote who are physician members of the active medical staff who shall be nominated and elected for a [two-year] term in the same manner at the same time as provided in Sections 9.1-3 through 9.1-4 for the nomination and election of officers; and

(d) [ ] at-large members of the active medical staff [one at-large member for every [ ] medical staff members] who shall be nominated and elected for a [two-year] term in the same manner and at the same time as provided in Sections 9.1-3 through 9.1-4 for the nomination and election of officers.

A medical executive committee member can be removed from the committee only if the medical staff acts to remove that member from the position held as an officer, OMSS representative or at-large member, in the same manner as provided in Section 9.1-6 for the recall of officers, or, in the case of department chair, if the department acts to remove the member from the department chair as provided in Section 10.6-4.

CMA Bylaws afford MEC membership to the OMSS Representative.

CMA Bylaws do not recognize the CEO or CMO as a member [or attendee] of the MEC. This does not appear to comply with TJC Standard MS.02.01.01, EP 2, which requires: “The chief executive officer (CEO) of the hospital or his or her designee attends each medical staff executive committee meeting on an ex-officio basis, with or without a vote.” See CMA Footnote 243, which notes appropriate circumstances where a CEO should be excluded. But see also, CMA Section 12.3, which seems to extend these executive session exclusions to a much broader scope of activities.

CHA has also added an optional provision, for those hospital’s using DNV accreditation, regarding CNO participation on the MEC.

CHA Bylaws at Section 9.1-6 and 10.5-4 address removal of committee members.

9.3-2 Duties

The Medical Staff delegates to the Medical Executive Committee broad authority to oversee the operations of the Medical Staff. With the assistance of the Chief of Staff, and

11.3-2 DUTIES

The medical executive committee shall be accountable to the organized medical staff. The duties of the medical executive committee, as delegated by the medical staff, are:

CHA Bylaws articulate broad authority of the MEC. CMA Bylaws appear to limit MEC authority to just what is listed.

August 2013 Page 86



without limiting this broad delegation of authority, the Medical Executive Committee shall perform in good faith the duties listed below.

a. Supervise the performance of all Medical Staff functions, which shall include:

1) Requiring regular reports and recommendations from the [departments,] committees and officers of the Medical Staff concerning discharge of assigned functions;

2) Issuing such directives as appropriate to assure effective performance of all Medical Staff functions; and

3) Following up to assure implementation of all directives.

b. Coordinate the activities of the committees [and departments].

c. Assure that the Medical Staff adopts bylaws and rules establishing the structure of the Medical Staff, the mechanism used to review credentials and to delineate individual privileges, the organization of the quality assessment and improvement activities of the Medical Staff as well as the mechanism used to conduct, evaluate, and revise such activities, the mechanism by which membership on the Medical Staff may be terminated, and the mechanism for hearing procedures.

d. Based on input and reports from [the departments and the Credentials Committee], assure that the Medical Staff adopts bylaws, rules or regulations establishing criteria and standards, consistent with California law, for Medical Staff membership and privileges (including but not limited to any privileges that may be appropriately performed via telemedicine), and for enforcing those criteria and standards in reviewing the qualifications, credentials, performance, and professional competence and character of applicants and Staff members.

e. Assure that the Medical Staff adopt bylaws, rules or regulations establishing clinical criteria and standards to oversee and manage quality assurance, utilization review,

(a) seeking out the views of the medical staff on all appropriate issues;

(b) conveying accurately to the board of [trustees/directors] the views of the medical staff on all issues, including those relating to safety and quality;

(c) representing and acting on behalf of the medical staff in the intervals between medical staff meetings within the scope of its responsibilities as defined by the medical staff and subject to such limitations as may be imposed by these bylaws;

(d) coordinating and implementing the professional and organizational activities and policies of the medical staff;

(e) receiving and acting upon reports and recommendations from medical staff departments, divisions, committees, and assigned activity groups;

(f) recommending actions to the board of [trustees/directors] on matters of a medical-administrative nature;

(g) developing and adopting appropriate policies to enable privileges holders to maintain the level of practice required under, and to more specifically implement, these Bylaws;

(h) establishing appropriate criteria for cross-specialty privileges in accordance with Section 5.2-3;

(i) making recommendations directly to the board of [trustees/directors] based on medical staff membership the organized medical staff organization’s structure, the process used to review credentials and delineate privileges, the delineation of privileges for each practitioner privileges through the medical staff process, and the executive committee's review of and actions on reports of medical staff committees, departments, and other assigned activity groups;

(j) evaluating the medical care rendered to patients in the hospital;

(k) participating in the development of all hospital policy, practice, and planning;

August 2013 Page 87



and other Medical Staff activities including, but not limited to, periodic meetings of the Medical Staff and its committees [and departments] and review and analysis of patient medical records.

f. Evaluate the performance of practitioners exercising clinical privileges whenever there is doubt about an applicant’s, member’s, or AHP’s ability to perform requested privileges.

g. Based upon input from [the departments and Credentials Committee], make recommendations regarding all applications for Medical Staff appointment, reappointment and privileges.

h. When indicated, initiate focused professional practice evaluations and/or pursue disciplinary or corrective actions affecting Medical Staff members.

i. With the assistance of the Chief of Staff, supervise the Medical Staff’s compliance with:

1) The Medical Staff bylaws, rules, and policies;

2) The hospital’s bylaws, rules, and policies;

3) State and federal laws and regulations; and

4) [Joint Commission][DNV] accreditation requirements.

j. Oversee the development of Medical Staff policies, approve (or disapprove) all such policies, and oversee the implementation of all such policies.

k. Implement, as it relates to the Medical Staff, the approved policies of the hospital.

l. [With the department chairs,] set [departmental] objectives for establishing, maintaining and enforcing professional standards within the hospital and for the continuing improvement of the quality of care rendered in the hospital; assist in developing programs to achieve these objectives, including but not limited to ongoing professional practice evaluations, as further described at Article 7,

(l) reviewing the qualifications, credentials, performance and professional competence, and character of applicants and staff members, and making recommendations to the board of [trustees/directors] at least quarterly regarding staff membership and renewals of membership, assignments to departments, clinical privileges, and corrective action;

(m) taking reasonable steps to promote ethical conduct and competent clinical performance on the part of all members including the initiation of and participation in medical staff corrective or review measures when warranted;

(n) taking reasonable steps to develop continuing education activities and programs for the medical staff;

(o) designating such committees as may be appropriate or necessary to assist in carrying out the duties and responsibilities of the medical staff and approving or rejecting appointments to those committees by the chief of staff;

(p) reporting to the medical staff at each regular staff meeting;

(q) assisting in the obtaining and maintenance of accreditation;

(r) developing and maintenance of methods for the protection and care of patients and others in the event of internal or external disaster;

(s) appointing such special or ad hoc committees as may seem necessary or appropriate to assist the medical executive committee in carrying out its functions and those of the medical staff;

(t) reviewing the quality and appropriateness of services provided by contract physicians;

(u) reviewing and approving the designation of the hospital’s authorized representative for National Practitioner Data Bank purposes;

(v) establishing a mechanism for dispute resolution between medical staff members (including limited license practitioners) involving the care of a patient;

CMA Bylaws give the MEC approval authority over the hospital’s representative for NPDB reporting purposes.

The CMA Bylaws consolidate rights conferred via August 2013 Page 88



Performance Evaluation and Monitoring.

m. Regularly report to the Governing Body through the Chief of Staff and the Chief Executive Officer on at least the following:

1) the outcomes of Medical Staff quality improvement programs with sufficient background and detail to assure the Governing Body that quality of care is consistent with professional standards; and

2) the general status of any Medical Staff disciplinary or corrective actions in progress.

n. Review and make recommendations to the Chief Executive Officer regarding quality of care issues related to exclusive contract arrangements for professional medical services. In addition, the Medical Executive Committee shall assist the hospital in reviewing and advising on sources of clinical services provided by consultation, contractual arrangements or other agreements, in evaluating the levels of safety and quality of services provided via consultation, contractual arrangements, or other agreements, and in providing relevant input to notice-and-comment proceedings or other mechanisms that may be implemented by hospital administration in making exclusive contracting decisions.

o. Prioritize and assure that hospital-sponsored educational programs incorporate the recommendations and results of Medical Staff quality assessment and improvement activities.

p. Establish, as necessary, such ad hoc committees that will fulfill particular functions for a limited time and will report directly to the Medical Executive Committee.

q. Establish the date, place, time and program of the regular meetings of the Medical Staff.

(w) affirmatively implementing, enforcing and safeguarding the self-governance rights of the medical staff to the fullest extent permitted by law, such rights of the medical staff including but not limited to the following:

(1) initiating, developing and adopting medical staff bylaws, rules and regulations, and amendments thereto, subject to the approval of the hospital governing board, which approval shall not be unreasonably withheld;

(2) selecting and removing medical staff officers;

(3) assessing medical staff dues and utilizing the medical staff dues as appropriate for the purposes of the medical staff;

(4) the ability to retain and be represented by independent legal counsel at the expense of the medical staff;

(5) establishing, in medical staff bylaws, rules or regulations, criteria and standards for medical staff membership and privileges, and for enforcing those criteria and standards;

(6) establishing in medical staff bylaws, rules or regulations, clinical criteria and standards to oversee and manage quality assurance, utilization review and other medical staff activities including, but not limited to, periodic meetings of the medical staff and its committees and departments and review and analysis of patient medical records;

(7) taking such action as appropriate to enforce Section 14.9 of these bylaws regarding the prohibition against retaliation directed towards a member;

(x) taking such other steps as appropriate to meet and confer in good faith to resolve disputes with the governing body, or any other person or entity, regarding any self-governance rights of the medical staff.

(y) after having met and conferred in good faith to remedy any dispute under subsection(s) of this section, exercising its discretion as appropriate to resolve the dispute, up to and including resort to resolution of the matter in the courts as

Business & Professions Code Section 2282.5 as MEC responsibilities, and charges the MEC with enforcement of these rights. (The CHA Model addresses these statutory provisions throughout the Bylaws.)

The CHA Model describes the role of the MEC in reviewing quality of care issues relating to exclusive contracts; and reviewing and advising about clinical services procures via contracts.

CMA’s dispute resolutions provisions appear to render the MEC as the ultimate dispute decision-making authority, and specifically contemplate legal action to resolve disputes with the Governing Body (including disputes not specifically relating to Medical Staff self-governance rights as specified in the California Business & Professions Code § 2282.5) .

Compare CHA Bylaws 15.1-6, describing an extensive internal process for resolving disputes with the Governing Body (which process does not foreclose the

August 2013 Page 89



r. Represent and act on behalf of the Medical Staff between meetings of the Medical Staff

s. To take such other actions as may reasonably be deemed necessary in the best interests of the Medical Staff and the hospital.

The authority delegated pursuant to this Section 9.3-2 may removed by amendment of these Bylaws [, or may be temporarily removed by Resolution of the Medical Staff, approved by a 2/3 vote of the voting Medical Staff, taken at a general or special meeting noticed to include the specific purpose of removing specifically-described authority of the Medical Executive Committee, which resolution is thereafter approved by the Governing Body].

permitted by law;

(z) reviewing the job description (e.g. qualifications, responsibilities, and reporting relationships) of medical directorships in the hospital both to assure their adequacy for medical staff purposes, and to avoid a conflict of duties between the medical director and any medical staff leader;

(aa) participating in the interview and review of candidates for position of medical director in the hospital, and in approving or vetoing the selection of any such candidate, with any veto being binding upon the hospital;

(bb) reviewing the performance of the hospital’s medical directors periodically and transmitting the results of that review to the hospital board for its consideration;

(cc) fulfilling such other duties as the medical staff has delegated to the medical executive committee in these bylaws.

By action of [2/3 of ] the medical staff members [present and ] entitled to vote, the medical staff may, at a regular or special meeting at which a quorum is achieved, remove and reassign a duty or duties delegated to the Medical Executive Committee for a stated period of time, for a reason identified and supported by the meeting.

statutorily-provided resort to the courts in the event the Governing Body is infringing on protected Medical Staff rights).

CMA Bylaws provide an extensive role for the MEC with respect to medical directorships.

CHA Bylaws assure that MEC authority will only be removed at a meeting specifically noticed for this purpose.

CMA Bylaws provide for removal of authority at any meeting of the Medical Staff. By virtue of the notice provisions at CMA Section 12.1-3, it appears that removal intent would need to be noticed, although the details relating thereto need not be.

9.3-3 Meetings

The Medical Executive Committee should be scheduled to meet on a monthly basis and shall meet at least [10] times during the calendar year. A permanent record of its proceedings and actions shall be maintained.

11.3-3 MEETINGS

The medical executive committee shall meet as often as necessary, but at least [once a month] and shall maintain a record of its proceedings and actions. The record shall also contain for each action taken, whether, and if so, how, each member of the committee voted on policy and procedure issues of interest to the general membership that do not raise peer review or other sensitive issues involving specific medical staff members. The administrator or designee shall be invited to attend all meetings in a non-voting capacity.

To facilitate comparison and minimize redundancy, the CMA provisions pertaining to other Medical Staff committees have been moved along-side the CHA Rules for Medical Staff Committees. (See CHA Rule 4.)

August 2013 Page 90



[CMA LISTS ALL OTHER MEDICAL STAFF COMMITTEES IN THIS SECTION. THESE PROVISIONS HAVE BEEN MOVED AS NOTED.]

Article 10

DEPARTMENTS AND SECTIONS

10.1 ORGANIZATION OF CLINICAL DEPARTMENTS

Each department shall be organized as an integral unit of the Medical Staff and shall have a chair and a vice chair who are selected and shall have the authority, duties, and responsibilities specified in the rules. Additionally, each department may appoint a department committee and such other standing or ad hoc committees as it deems appropriate to perform its required functions. The composition and responsibilities of each standing department committee shall be specified in the rules. Departments may also form sections as described below.

10.1 ORGANIZATION OF CLINICAL DEPARTMENTS AND DIVISIONS

The medical staff shall be organized into clinical departments. Each department shall be organized as a separate component of the medical staff and shall have a chair selected and entrusted with the authority, duties, and responsibilities specified in Section 10.6. A department may be further divided, as appropriate, into divisions which shall be directly responsible to the department within which it functions, and which shall have a division chief selected and entrusted with the authority, duties and responsibilities specified in Section 10.7. When appropriate, the medical executive committee may recommend to the medical staff the creation, elimination, modification, or combination of departments or divisions.

The CHA provisions detailing the responsibilities of the departments are set out in the rules. (See CHA Rule 5.)

10.2 DESIGNATION

10.2-1 Current Designation

The current departments are:

Check all applicable departments

Anesthesia

Emergency

Medicine

Obstetrics and Gynecology

Pathology

Pediatrics

Psychiatry

Radiology

10.2 CURRENT DEPARTMENTS AND DIVISIONS

The current departments and divisions are: [ ]

August 2013 Page 91



Surgery

10.2-2 Future Departments

The Medical Executive Committee will periodically restudy the designation of the departments and recommend to the Governing Body what action is desirable in creating, eliminating, or combining departments for better organizational efficiency and improved patient care. Action shall be effective upon approval by the Medical Executive Committee and the Governing Body.

10.3 ASSIGNMENT TO DEPARTMENTS

Each member shall be assigned membership in at least one department, but may also be granted membership and/or clinical privileges in other departments consistent with the practice privileges granted.

10.3 ASSIGNMENT TO DEPARTMENTS AND DIVISIONS

Each member shall be assigned membership in at least one department, and to a division, if any, within such department, but may also be granted membership and/or clinical privileges in other departments or divisions consistent with practice privileges granted.

10.4 FUNCTIONS OF DEPARTMENTS

The departments shall fulfill the clinical, administrative, quality improvement/risk management/utilization management, and collegial and education functions described in the rules. When the department or any of its committees meets to carry out the duties described below, the meeting body shall constitute a peer review committee, which is subject to the standards and entitled to the protections and immunities afforded by federal and state law for peer review committees. Each department or its committees, if any, must meet regularly to carry out its duties.

10.4 FUNCTIONS OF DEPARTMENTS [repeat at CHA Rule 5]

The general functions of each department shall include:

(a) Conducting patient care reviews for the purpose of analyzing and evaluating the quality and appropriateness of care and treatment provided to patients within the department. The number of such reviews to be conducted during the year shall be as determined by the medical executive committee in consultation with other appropriate committees. The department shall routinely collect information about important aspects of patient care provided in the department, periodically assess this information, and develop objective criteria for use in evaluating patient care. Patient care reviews shall include all clinical work performed under the jurisdiction of the department, regardless of whether the member whose work is subject to such review is a member of that department.

(b) Recommending to the medical executive committee criteria for the granting of clinical privileges and the performance of specified services within the department.

(c) Evaluating and making appropriate

CHA Bylaws contain general description of the departments’ functions in the Bylaws, and provide additional details in the Rules. To facilitate comparison, CMA’s department functions are repeated along-side the CHA Rules for the departments. (CHA Rule 5.)

August 2013 Page 92



recommendations regarding the qualifications of applicants seeking membership or renewal of membership and clinical privileges within that department.

(d) Conducting, participating and making recommendations regarding continuing education programs pertinent to departmental clinical practice.

(e) Reviewing and evaluating departmental adherence to: (1) medical staff policies and procedures and (2) sound principles of clinical practice.

(f) Coordinating patient care provided by the department’s members with nursing and ancillary patient care services.

(g) Submitting written reports to the medical executive committee concerning: (1) the department’s review and evaluation activities, actions taken thereon, and the results of such action; and (2) recommendations for maintaining and improving the quality of care provided in the department and the hospital.

(h) Meeting at least monthly for the purpose of considering patient care review findings and the results of the department’s other review and evaluation activities, as well as reports on other department and staff functions.

(i) Establishing such committees or other mechanisms as are necessary and desirable to perform properly the functions assigned to it, including proctoring protocols.

(j) Taking appropriate action when important problems in patient care and clinical performance or opportunities to improve care are identified.

(k) Accounting to the medical executive committee for all professional and medical staff administrative activities within the department.

(l) Appointing such committees as may be necessary or appropriate to conduct department functions.

(m) Formulating recommendations for departmental rules and regulations reasonably necessary for the proper discharge

August 2013 Page 93



of its responsibilities subject to the approval by the medical executive committee and the medical staff.

10.5 DEPARTMENT CHAIR AND VICE CHAIR


Each department chair and department vice chair shall be active Medical Staff members, shall have demonstrated ability in at least one of the clinical areas covered by the department, shall be Board certified, and shall be willing and able to faithfully discharge the functions of his or her office. Specific qualifications shall be set forth in the rules.

10.6 DEPARTMENT CHAIRS [Repeat at Rule 5]


Each department shall have a chair and vice-chair who shall be members of the active staff and shall be qualified by licensure, training, experience and demonstrated ability in at least one of the clinical areas covered by the department. Department chairs must be certified by an appropriate specialty board or must demonstrate comparable competence. In addition to exercising their responsibilities pursuant to Section 14.6, all department chairs and vice chairs shall verbally disclose all actual or potential conflicts of interest in the course of each department meeting or other event where such a disclosure may be relevant. Any potential conflicts so disclosed shall be resolved as set forth in Section 14.6.

Note CMA conflict of interest provisions. (Compare CHA 8.1-3.)

10.5-2 Selection

Department officers shall be elected by a majority of the votes cast by the voting Medical Staff members of the department. Candidates shall be selected by the nominating and elections procedures described in the rules.

10.6-2 SELECTION

Department chairs and vice-chairs shall be elected every [2] years by those members of the department who are eligible to vote for general officers of the medical staff. For the purpose of this election, each department chair shall appoint a nominating committee of [3] members at least [60] days prior to the meeting at which election is to take place. The recommendations of the nominating committee of one or more nominees for chair and vice-chair positions shall be circulated to the voting members of each department at least [20] days prior to the election. Nominations also may be made from the floor when the election meeting is held, as long as the nominee is present and consents to the nomination. [Election of department chairs and vice-chairs shall be subject to ratification by the medical executive committee.] In accordance with Section 14.6, all nominees for election for department chair or vice-chair shall disclose in writing to each voting member of the department those current or impending personal, professional, or financial affiliations or relationships of which they are reasonably aware, including contractual, employment or other relationships with the hospital, which could foreseeably result in a conflict of interest with their activities or responsibilities on behalf of the medical staff.


August 2013 Page 94



Such disclosure statement shall accompany the ballot. Vacancies due to any reason shall be filled for the unexpired term through special election by the respective department with such mechanisms as that department may adopt.

10.5-3 Term of Office

Each department chair and vice chair shall serve a two-year term, the expiration of which coincides with the Medical Staff year or until their successors are chosen, unless they shall sooner resign, be removed from office, or lose their Medical Staff membership or privileges in that department. Department officers are eligible to succeed themselves.

10.6-3 TERM OF OFFICE

Each department chair and vice-chair shall serve a [2] year term which coincides with the medical staff year or until their successors are chosen, unless they shall sooner resign, be removed from office, or lose their medical staff membership or clinical privileges in that department. Department officers shall be eligible to succeed themselves.

10.5-4 Removal

A department officer may be removed for failure to cooperatively and effectively perform the responsibilities of his or her office. Removal may be initiated by the Medical Executive Committee or by written request from 20 percent of the members of the department who are eligible to vote on department matters. Such removal may be effected by a 66-2/3 percent vote of the Medical Executive Committee members or by a 66-2/3 percent vote of the department members eligible to vote on department matters. The procedures for effecting removal shall be as described in the rules.

10.6-4 REMOVAL

After election [and ratification], removal of department chairs and vice-chairs from office may occur for cause by a [two-thirds] vote of the medical executive committee and a [two-thirds] vote of the department members eligible to vote on departmental matters who cast votes.

CHA Bylaws provide alternative means to remove a department chair; whereas CMA Bylaws require a combined action.

10.5-5 Roles and Responsibilities of Department Officers

Specific roles and responsibilities of department officers shall be as set forth in the rules.

THESE ROLES AND RESPONSIBILITIES INCLUDE AT LEAST THE FOLLOWING:

a. Clinically related activities of the department.

b. Administratively related activities of the department, unless otherwise provided by the hospital.

c. Continuing surveillance of the professional

10.6-5 DUTIES [repeated at CHA Rule 5]

Each chair shall have the following authority, duties and responsibilities, and the vice-chair, in the absence of the chair, shall assume all of them and shall otherwise perform such duties as may be assigned:

(a) act as presiding officer at departmental meetings;

(b) report to the medical executive committee and to the chief of staff regarding all professional and administrative

CHA Bylaws now list the TJC’s requirements relating to departments, to assure compliance with MS.01.01.01, EP 36. See also CHA Rule 5.

August 2013 Page 95



performance of all individuals in the department who have delineated clinical privileges.

d. Recommending to the medical staff the criteria for clinical privileges that are relevant to the care provided in the department.

e. Recommending clinical privileges for each member of the department.

f. Assessing and recommending to the relevant hospital authority off-site sources for needed patient care, treatment, and services not provided by the department or the organization.

g. Integration of the department or service into the primary functions of the organization.

h. Coordination and integration of interdepartmental and intradepartmental services.

i. Development and implementation of policies and procedures that guide and support the provision of care, treatment, and services.

j. Recommendations for a sufficient number of qualified and competent persons to provide care, treatment, and services.

k. Determination of the qualifications and competence of department or service personnel who are not licensed independent practitioners and who provide patient care, treatment, and services.

l. Continuous assessment and improvement of the quality of care, treatment, and services.

m. Maintenance of quality control programs, as appropriate.

n. Orientation and continuing education of all persons in the department.

activities within the department;

(c) generally and continuously monitor the quality of patient care and professional performance rendered by members with clinical privileges in the department through a planned and systematic process; oversee and maintain the effective conduct of the patient care, evaluation, and monitoring functions delegated to the department by the medical executive committee in coordination and integration with organization-wide quality assessment and improvement activities;

(d) develop and implement departmental programs for retrospective patient care review, ongoing monitoring of practice, credentials review and privilege delineation, medical education, utilization review, and quality assessment and improvement; and all other clinically related activities of the department;

(e) be a member of the medical executive committee, be responsible for all clinically related activities of the department, give guidance on the overall medical policies of the medical staff and hospital and make specific recommendations and suggestions regarding the department;

(f) transmit to the medical executive committee the department’s recommendations concerning practitioner membership and classification, renewal of membership, criteria for clinical privileges, monitoring of specified services, and corrective action with respect to persons with clinical privileges in the department;

(g) endeavor to enforce the medical staff bylaws, rules, policies and regulations within the department;

(h) implement within the department appropriate actions taken by the medical executive committee;

(i) participate in every phase of administration of the department, including maintaining a quality control program, as appropriate, recommending a sufficient number of qualified and competent persons to provide care, treatment, and services, and space and other resources needed by the department; cooperation with the nursing service and the

August 2013 Page 96



hospital administration in matters such as personnel (including assisting in determining the qualifications and competence of department/service personnel who are not licensed independent practitioners and who provide patient care services), supplies, special regulations, standing orders and techniques;

(j) assist in the preparation of such annual reports, including budgetary planning, pertaining to the department as may be required by the medical executive committee;

(k) assess and recommend to the board of [trustees/directors] off-site sources for needed patient care, treatment, and services not provided by the department or the hospital;

(l) integrate the department or service into the primary functions of the hospital, and coordinate and integrate interdepartmental and intradepartmental services;

(m) develop and implement departmental policies and procedures that guide and support the provision of care, treatment, and services in the department;

(n) provide orientation and continuing education of all persons in the department or service;

(o) recommend delineated clinical privileges for each member of the department;

(p) recommend space and other resources needed by department; and

(q) perform such other duties commensurate with the office as may from time to time be reasonably requested by the chief of staff or the medical executive committee.

10.6 SECTIONS

Within each department, the practitioners of the various specialty groups may organize themselves as a clinical section. Each section may develop rules specifying the purpose, responsibilities and method of selecting officers.

10.5 FUNCTIONS OF DIVISIONS

Subject to approval of the medical executive committee, each division shall perform the functions assigned to it by the department chair. Such functions may include, without limitation, retrospective patient care reviews, evaluation of

CHA Bylaws permit these details to be developed by each hospital, as deemed necessary.

August 2013 Page 97



These rules shall be effective when approved as required by Article 15, General Provisions. While sections may assist departments in performance of departmental functions, responsibility and accountability for performance of departmental functions shall remain at the departmental level.

patient care practices, credentials review and privileges delineation, and continuing education programs. The division shall transmit regular reports to the department chair on the conduct of its assigned functions.

10.7 DIVISION CHIEFS


Each division shall have a chief who shall be a member of the active medical staff and a member of the division, and shall be qualified by training, experience, and demonstrated current ability in the clinical area covered by the division. In addition to exercising their responsibilities pursuant to Section 14.6, division chiefs shall verbally disclose all actual or potential conflicts of interest in the course of each division meeting or other event where such a disclosure may be relevant. Any potential conflicts so disclosed shall be resolved as set forth in Section 14.6.

10.7-2 SELECTION

Each division chief shall be selected or elected with such mechanism as the medical staff may adopt. Regardless of the mechanism utilized, in accordance with Section 14.6, all nominees for appointment or election shall disclose in writing to the medical executive committee and department chair those current or impending personal, professional, or financial affiliations or relationships of which they are reasonably aware, including contractual, employment or other relationships with the hospital, which could foreseeably result in a conflict of interest with their activities or responsibilities on behalf of the medical staff. Vacancies due to any reason shall be filled for the unexpired term by the department chair.


Each division chief shall serve a [one-year] term which coincides with the medical staff year or until a successor is chosen, unless the division chief shall sooner resign or be removed from office or lose medical staff membership or clinical privileges in that division. Division chiefs shall be


August 2013 Page 98



eligible to succeed themselves.

10.7-4 REMOVAL

After appointment and ratification, a division chief may be removed by the department chair and the medical executive committee.

10.7-5 DUTIES

Each division chief shall:

(a) act as presiding officer at division meetings;

(b) assist in the development and implementation, in cooperation with the department chair, of programs to carry out the quality review, and evaluation and monitoring functions assigned to the division;

(c) evaluate the clinical work performed in the division;

(d) conduct investigations and submit reports and recommendations to the department chair regarding the clinical privileges to be exercised within the division by members of or applicants to the medical staff; and

(e) perform such other duties commensurate with the office as may from time to time be reasonably requested by the department chair, the chief of staff, or the medical executive committee.

Article 11

MEETINGS

11.1 MEDICAL STAFF MEETINGS

11.1-1 Medical Staff Meetings

There shall be at least one meeting of the Medical Staff during each Medical Staff year. The date, place and time of the meeting(s) shall be determined by the Chief of Staff. The Chief of Staff shall present a report on significant actions taken by the Medical Executive Committee during the time since the last Medical Staff meeting and on other matters believed to be of interest and value to the

12.1 MEETINGS

12.1-1 ANNUAL MEETING

There shall be an annual meeting of the medical staff. The chief of staff, or such other officers, department or division heads, or committee chairs the chief of staff or medical executive committee may designate, shall present reports on actions taken during the preceding year and on other matters of interest and importance to the members. Notice of this meeting and its agenda items shall be given to the members at

CMA Bylaws include more details of Medical Staff meetings.

August 2013 Page 99



membership. No business shall be transacted at any Medical Staff meeting except that stated in the notice calling the meeting.

least [ ] days prior to the meeting.

12.1-2 REGULAR MEETINGS

Regular meetings of the members shall be held [each quarter], except that the annual meeting shall constitute the regular meeting during the [quarter] in which it occurs. The date, place and time of the regular meetings shall be determined by the medical executive committee, and at least 10 days prior notice of the meetings, and their agenda items (except for items to be discussed in executive session), shall be given to the members. Notice of any meeting and its agenda items shall be provided electronically to each medical staff member through the medical staff Internet-based bulletin board, and via e-mail to those medical staff members that have provided their e-mail addresses, and via facsimile to those who have not. Such notices shall also be posted in medical staff common areas such as medical staff offices, dining rooms, and lounges.

12.1-3 AGENDA

The order of business at a meeting of the medical staff shall be determined by the chief of staff and medical executive committee. The agenda shall include, insofar as feasible:

(a) reading and acceptance of the minutes of the last regular and all special meetings held since the last regular meeting;

(b) administrative reports from the chief of staff, departments, and committees, and the administrator;

(c) election of officers and others when required by these bylaws;

(d) reports by responsible officers, committees and departments on the overall results of patient care audits and other quality review, evaluation, and monitoring activities of the staff and on the fulfillment of other required staff functions;

(d) reports by responsible officers, committees and departments on the overall results of patient care audits and other quality review, evaluation, and monitoring activities of

Included among these details are extensive notice distribution provisions.

August 2013 Page 100



the staff and on the fulfillment of other required staff functions;

(e) adoption and amendment of bylaws and other medical staff documents, as needed.

(f) old business; and

(g) new business. Any item of new business that is not urgent or emergent, as determined by the medical staff, shall be placed on the agenda for the next meeting.

Where the medical staff is being asked to consider or review a document, a copy of the document shall be appended to the agenda. Drafts of any documents considered or to be considered at any medical staff meeting shall be available to any medical staff member upon request. Further, any proposal considered at the meeting shall be accompanied by a clear explanation as to the source of the proposal and why that proposal is needed.

Except as stated below, no business shall be transacted at any medical staff meeting unless it is identified in the agenda to the notice calling the meeting. In the event an emergent or urgent issue arises after the agenda is set, and action on that issue is necessary, any action taken shall be ratified by the medical staff at the next properly constituted meeting.

CMA specifically requires distribution of all documents under consideration, and explanation of the reasons for the proposal.

11.1-2 Special Meetings

Special meetings of the Medical Staff may be called at any time by the Chief of Staff, Medical Executive Committee, or Governing Body, or upon the written request of ten percent of the voting members. The meeting must be called within 30 days after receipt of such request. No business shall be transacted at any special meeting except that stated in the notice calling the meeting.

12.1-4 SPECIAL MEETINGS

Special meetings of the medical staff may be called at any time by the chief of staff or the medical executive committee, or shall be called upon the written request of [10%] of the members of the active medical staff. The person calling or requesting the special meeting shall state the purpose of such meeting in writing. The meeting shall be scheduled by the medical executive committee within [30] days after receipt of such request. No later than [10] days prior to the meeting, notice shall be mailed or delivered to the members of the staff which includes the stated purpose of the meeting. No business shall be transacted at any special meeting except that stated in the notice calling the meeting.

11.1-3 Combined or Joint Medical Staff Meetings CHA Bylaws provide for combined or joint meetings of




The Medical Staff may participate in combined or joint Medical Staff meetings with staff members from other hospitals, healthcare entities, or the County Medical Society; however, precautions shall be taken to assure that confidential Medical Staff information is not inappropriately disclosed, and to assure that this Medical Staff (through its authorized representative(s)) maintains access to and approval authority of all minutes prepared in conjunction with any such meetings.

the Medical Staff with other organizations.

11.2 [DEPARTMENT AND] COMMITTEE MEETINGS

11.2-1 Regular Meetings

[Departments and] committees, by resolution, may provide the time for holding regular meetings and no notice other than such resolution shall then be required. [Each department shall meet regularly, at least quarterly, to review and discuss patient care activities and to fulfill other departmental responsibilities.]

11.2-2 Special Meetings

A special meeting of any [department or] committee may be called by, or at the request of, the chair thereof, the Medical Executive Committee, Chief of Staff, or by [33-1/3] percent of the group’s current members, but not fewer than three members. No business shall be transacted at any special meeting except that stated in the notice calling the meeting.

12.2 COMMITTEE AND DEPARTMENT MEETINGS

12.2-1 REGULAR MEETINGS

Except as otherwise specified in these bylaws, the chairs of committees, departments and divisions may establish the times for the holding of regular meetings. Notice of all meetings and their agenda items shall be given to the members at least [ ] days prior to the meeting (except for items to be discussed in executive session). Notice of any meeting and its agenda items shall be provided electronically to each medical staff member through a medical staff Internet- based bulletin board, and via e-mail to those medical staff members that have provided their e-mail addresses, and via facsimile to those who have not. Such notices shall also be posted in medical staff common areas such as medical staff offices, dining rooms, and lounges. Where the members are being asked to consider or review a document, a copy of the document shall be appended to the agenda. Drafts of any documents considered or to be considered at any meeting shall be available to any medical staff member upon request and such members shall have the right to comment on such documents in writing to the respective committee. Further, any proposal considered at the meeting shall be accompanied by a clear explanation as to the source of the proposal and why that proposal is needed.

Except as stated below, no business shall be transacted at any medical staff meeting unless it is identified in the agenda to the notice calling the meeting. In the event an emergent or urgent issue arises after the agenda is set, and action on that issue is necessary, any action taken shall be ratified by the

CMA Bylaws contain more details of committee and department meetings.

CMA Bylaws also require extensive notice and document dissemination provisions for committees and department activities.




respective committee, department or division at the next properly constituted meeting.

12.2-2 SPECIAL MEETINGS

A special meeting of any medical staff committee, department or division may be called by the chair thereof, the medical executive committee, or the chief of staff, and shall be called by written request of [one-third] of the current members, eligible to vote, but not less than [ ] members.

11.2-3 Combined or Joint [Department or] Committee Meetings

The [departments or] committees may participate in combined or joint [department or] committee meetings with staff members from other hospitals, health care entities or the County Medical Society; however, precautions shall be taken to assure that confidential Medical Staff information is not inappropriately disclosed, and to assure that this Medical Staff (through its authorized representative(s)) maintains access to and approval authority of all minutes prepared in conjunction with any such meetings.

11.3 NOTICE OF MEETINGS

Written notice stating the place, day and hour of any regular or special Medical Staff meeting or of any regular or special [department or] committee meeting not held pursuant to resolution shall be delivered either personally or by mail to each person entitled to be present not fewer than [two] working days nor more than [45] days before the date of such meeting. Personal attendance at a meeting shall constitute a waiver of notice of such meeting.

CHA Bylaws provide for combined or joint meetings of Departments and Committees with other organizations.

11.4 QUORUM

11.4-1 Medical Staff Meetings

The presence of [25] percent of the voting Medical Staff members at any regular or special meeting shall constitute a quorum.

12.3 QUORUM

12.3-1 STAFF MEETINGS

The presence of [two-thirds] of the total members of the active medical staff at any regular or special meeting in person or through written ballot shall constitute a quorum for

A 2/3 quorum requirement makes it very difficult to effect amendments, and, in essence, allows the minority




the purpose of amending these bylaws or the rules and regulations of the medical staff or for the election or removal of medical staff officers. The presence of [ ] percent of such members shall constitute a quorum for all other actions.

of the Medical Staff to control the bylaws and rules.

The CMA Bylaws do not specify the vote requirement for adoption of policies.

11.4-2 Committee Meetings

The presence of [50] percent of the voting members shall be required for Medical Executive Committee meetings. For other committees, a quorum shall consist of [30] percent of the voting members of a committee but in no event less than three voting committee members.

11.4-3 Department Meetings

The presence of [25] percent of the voting Medical Staff members at any regular or special department meeting shall constitute a quorum.

11.5 MANNER OF ACTION

Except as otherwise specified, the action of a majority of the members present and voting at a meeting at which a quorum is present shall be the action of the group. A meeting at which a quorum is initially present may continue to transact business notwithstanding the withdrawal of members, if any action taken is approved by at least a majority of the required quorum for such meeting, or such greater number as may be required by these bylaws. Committee action may be conducted by telephone or internet conference, which shall be deemed to constitute a meeting for the matters discussed in that telephone or internet conference. Valid action may be taken without a meeting if at least [10] days’ notice of the proposed action has been given to all members entitled to vote, and it is subsequently approved in writing setting forth the action so taken, which is signed by at least [66-2/3] percent of the members entitled to vote. The meeting chair shall refrain from voting except when necessary to break a tie, except that the Joint Conference Committee chair may vote.

12.3-2 DEPARTMENT AND COMMITTEE MEETINGS

A quorum of [ ] percent of the voting members shall be required for medical executive and credentials committee meetings. For other committees, a quorum shall consist of [ ] of the voting members of a committee but in no event less than [ ] voting members. For department and division meetings, a quorum shall consist of [ ] of the voting members.

12.4 VOTING AND MANNER OF ACTION

12.4-1 VOTING

Unless otherwise specified in these bylaws, only members of the medical staff may vote in medical staff departmental or staff elections, and at department and medical staff meetings and all duly appointed members of medical staff committees are entitled to vote on committee matters, except as may otherwise be specified in these bylaws. With the exception for matters voted upon by the medical executive committee, voting may be accomplished by email or other electronic and/or telephone means where permitted by the chair of the meeting on either an individual or group basis, so long as adequate precautions are in place to ensure authentication and security.

12.4-2 MANNER OF ACTION

Except as otherwise specified, the action of a majority of the members present and voting at a meeting at which a quorum is present shall be the action of the group. A member may be present at a meeting by electronic or telephonic means where permitted by the chair of the meeting on either an individual or group basis. A meeting at which a quorum is initially present may continue to transact business notwithstanding the withdrawal of members, if any action taken is approved by at least a majority of the required quorum for such meeting, or such greater number as may be specifically required by these

CHA Bylaws provide for telephone or internet conference and vote.

CMA Bylaws provide for telephone or electronic vote, but it is not clear whether they require attendance (electronically or by phone) at the meeting at which the matter is discussed.

Query: Is this a prerequisite to the voting permitted at CMA Section 12.4-1 or do these Sections operate independently?




bylaws. Committee action may be conducted by telephone conference or other electronic communication which shall be deemed to constitute a meeting for the matters discussed in that telephone or virtual conference. Valid action may be taken without a meeting by a committee if it is acknowledged by a writing setting forth the action so taken which is signed by at least [two-thirds] of the members entitled to vote.

11.6 MINUTES

Minutes of all meetings shall be prepared and shall include a record of the attendance of members and the vote taken on each matter. The minutes shall be signed by the presiding officer or his or her designee and forwarded to the Medical Executive Committee or other designated committee and Governing Body. Each committee shall maintain a permanent file of the minutes of each meeting. When meetings are held with outside entities, access to minutes shall be limited as necessary to preserve the protections from discovery, as provided by California law.

12.5 MINUTES

Except as otherwise specified herein, minutes of meetings shall be prepared and retained. They shall include, at a minimum, a record of the attendance of members and the vote taken on significant matters. Further, the minutes shall include the names of those who disclosed potential conflicts of interest and those who abstained and/or recused themselves. Minutes of all medical staff meetings (except the minutes relating to peer review and matters discussed in executive session), shall be available to any staff member upon request. A copy of the minutes shall be signed by the presiding officer of the meeting and forwarded to the medical executive committee.

CMA Bylaws specifically require recording of conflict of interest disclosures, and wide access to minutes.

11.7 ATTENDANCE REQUIREMENTS

11.7-1 Regular Attendance Requirements

Each member of a Medical Staff category required to attend meetings under Rule 1.3, Prerogatives and Responsibilities, shall be required to attend [two] general staff meetings [and [six] department or section meetings] during the two-year reappointment period.

12.6 ATTENDANCE REQUIREMENTS

12.6-1 REGULAR ATTENDANCE

Except as stated below, each member of the active and provisional staff shall be required to attend:

(a) The annual medical staff meeting;

(b) At least [ ] percent of all other general staff meetings duly convened pursuant to these bylaws; and

(c) At least [ ] percent of all meetings of each department, division, and committee to which the member is assigned.

(d) [Attendance via web conferencing, email or electronic means shall be accepted.]

Each member of the temporary, consulting or courtesy staff




and members of the provisional staff who qualify under criteria applicable to courtesy or consulting members shall be required to attend such meetings as may be determined by the medical executive committee. Temporary members of the medical staff under Section 6.1-4 are excluded from meetings requirements.

11.7-2 Failure to Meet Attendance Requirements

Medical Staff members will be notified semi-annually if they have not yet met the full attendance requirements. Practitioners who have not met meeting attendance requirements before the end of the appointment/reappointment period will be reappointed for a maximum of two years on probationary status. Practitioners who do not meet the meeting attendance requirements during the reappointment period will [be demoted in status] [not be reappointed].

12.6-2 ABSENCE FROM MEETINGS

Any member who is compelled to be absent from any medical staff, department, division, or committee meeting shall promptly provide to the regular presiding officer thereof the reason for such absence. Unless excused for good cause by the presiding officer of the department, division, or committee, or the secretary-treasurer for medical staff meetings, failure to meet the attendance requirements may be grounds for removal from such committee or for corrective action.

This CMA provision regarding absences seems unnecessarily onerous – i.e., having to provide a reason for all absences and obtain an excuse seems nonproductive and unnecessary.

11.7-3 Special Appearance

A committee, at its discretion, may require the appearance of a practitioner during a review of the clinical course of treatment regarding a patient. If possible, the chair of the meeting should give the practitioner at least ten days’ advance written notice of the time and place of the meeting. In addition, whenever an appearance is requested because of an apparent or suspected deviation from standard clinical practice, special notice shall be given and shall include a statement of the issue involved and that the practitioner’s appearance is mandatory. Failure of a practitioner to appear at any meeting with respect to which he or she was given special notice shall (unless excused by the Medical Executive Committee upon a showing of good cause) result in an automatic suspension of the practitioner’s privileges for at least two weeks, or such longer period as the Medical Executive Committee deems appropriate. The practitioner shall be entitled to the procedural rights described at Article 14, Hearings and Appellate Reviews.

12.6-3 SPECIAL ATTENDANCE

At the discretion of the chair or presiding officer, when a member’s practice or conduct is scheduled for discussion at a regular department, division, or committee meeting, the member may be requested to attend. If a suspected deviation from standard clinical practice is involved, the notice shall be given at least [7] days prior to the meeting and shall include the time and place of the meeting and a general indication of the issue involved. Failure of a member to appear at any meeting to which notice was given, unless excused by the medical executive committee upon a showing of good cause, shall be a basis for corrective action.

11.8 CONDUCT OF MEETINGS 12.7 CONDUCT OF MEETINGS




Unless otherwise specified, meetings shall be conducted according to [Robert’s Rules of Order]; however, technical failures to follow such rules shall not invalidate action taken at such a meeting.

Unless otherwise specified, meetings shall be conducted according to [Robert’s Rules of Order; Sturgis Standard Code of Parliamentary Procedure] however, technical or non-substantive departures from such rules shall not invalidate action taken at such a meeting.

12.8 EXECUTIVE SESSION

Executive session is a meeting of a medical staff committee, department, or division, or of the medical staff as a whole which only voting medical staff members who are not also employed by the hospital may attend, unless others are expressly requested by the member presiding at the meeting to attend. Executive session may be called by the presiding member at the request of any medical staff committee member, and shall be called by the presiding member pursuant to a duly adopted motion. Executive session may be called to discuss peer review issues, personnel issues, or any other sensitive issues requiring confidentiality.

CMA Bylaws exclude the CEO from the voting membership of the MEC; accordingly, the CEO may be excluded from participation in any executive session. CMA extends this exclusion to any hospital employee – thereby providing a means to exclude medical directors and others from executive sessions of the MEC.

Query: Does this comport with TJC Standard MS.02.02.01, EP2?

See CMA Footnote 243.

While there may be appropriate circumstances for CEO or other hospital administrative or medical-administrative staff exclusion at some meetings (such as those noted in CMA Footnote 243), the CMA provisions more extensive (and exclusive).

Article 12

CONFIDENTIALITY, IMMUNITY, RELEASES, AND INDEMNIFICATION

13.1 AUTHORIZATION AND CONDITIONS

By applying for or exercising clinical privileges within this hospital, an applicant:

(a) authorizes representatives of the hospital and the medical staff to solicit, provide, and act upon information bearing upon, or reasonably believed to bear upon, the applicant’s professional ability and qualifications;

(b) authorizes persons and organizations to provide information concerning such practitioner to the medical staff;

(c) agrees to be bound by the provisions of this Article and to waive all legal claims against any representative of the medical staff or the hospital who would be immune from liability under Section 13.3 of this Article; and




(d) acknowledges that the provisions of this Article are express conditions to an application for medical staff membership, the continuation of such membership, and to the exercise of clinical privileges at this hospital.

12.1 GENERAL

Medical Staff[, department, section] or committee minutes, files and records––including information regarding any member or applicant to this Medical Staff––shall, to the fullest extent permitted by law, be confidential. Such confidentiality shall also extend to information of like kind that may be provided by third parties. This information shall become a part of the Medical Staff committee files and shall not become part of any particular patient’s file or of the general hospital records. Dissemination of such information and records shall be made only where expressly required by law or as otherwise provided in these bylaws.

13.2 CONFIDENTIALITY OF INFORMATION

13.2-1 GENERAL

Records and proceedings of all medical staff committees having the responsibility of evaluation and improvement of quality of care rendered in this hospital, including, but not limited to, meetings of the medical staff meeting as a committee of the whole, meetings of departments and divisions, meetings of committees established under Article XI, and meetings of special or ad hoc committees created by the medical executive committee or by departments and including information regarding any member or applicant to this medical staff shall, to the fullest extent permitted by law, be confidential.

12.2 BREACH OF CONFIDENTIALITY

Inasmuch as effective credentialing, quality improvement, peer review and consideration of the qualifications of Medical Staff members and applicants to perform specific procedures must be based on free and candid discussions, and inasmuch as practitioners and others participate in credentialing, quality improvement, and peer review activities with the reasonable expectations that this confidentiality will be preserved and maintained, any breach of confidentiality of the discussions or deliberations of Medical Staff [departments, sections, or] committees, except in conjunction with another [system member], health facility, professional society or licensing authority peer review activities, is outside appropriate standards of conduct for this Medical Staff and will be deemed disruptive to the operations of the hospital. If it is determined that such a breach has occurred, the Medical Executive Committee may undertake such corrective action as it deems appropriate.

13.2-2 BREACH OF CONFIDENTIALITY

As effective peer review and consideration of the qualifications of medical staff members and applicants to perform specific procedures must be based on free and candid discussions, any breach of confidentiality of the discussions or deliberations of medical staff departments, divisions, or committees, except in conjunction with other hospital, professional society, or licensing authority, is outside appropriate standards of conduct for this medical staff, violates the medical staff bylaws, and will be deemed disruptive to the operations of the hospital. If it is determined that such a breach has occurred, the medical executive committee may undertake such corrective action as it deems appropriate.

12.3 ACCESS TO AND RELEASE OF CONFIDENTIAL INFORMATION

14.8-3 CONFIDENTIALITY

The following applies to records of the medical staff and its August 2013 Page 108



12.3-1 Access for Official Purposes

Medical Staff records, including confidential committee records and credentials files, shall be accessible by:

a. Committee members, and their authorized representatives, for the purpose of conducting authorized committee functions.

b. Medical Staff [and department] officials, and their authorized representatives, for the purpose of fulfilling any authorized function of such official.

departments and committees responsible for the evaluation and improvement of patient care:

(a) The records of the medical staff and its departments and 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. The Chief Executive Officer, the Governing Body, and their authorized representatives, for the purpose of enabling them to discharge their lawful obligations and responsibilities.

d. Upon approval of the Chief Executive Officer and Chief of Staff, the peer review bodies of System Affiliates, as reasonably necessary to facilitate review of an applicant or member of such Affiliate’s professional staff.

e. Information which is disclosed to the Governing Body or its appointed representatives and to peer review bodies of System Affiliates shall be maintained as confidential.

12.3-2 Member’s Access

a. A Medical Staff member shall be granted access to his or her own credentials file, subject to the following provisions:

1) Notice of a request to review the file shall be given by the member to the Chief of Staff (or his or her designee) at least three days before the requested date for review

2) The member may review and receive a copy of only those documented, provided by or addressed personally to the member. A summary of all other information, including peer review committee findings, letter of reference, proctoring reports, complaints, etc., shall

(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 to 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;

The CMA authorization and notice requirements of all disclosures seem administratively onerous – i.e., routine disclosures occur regularly among peer review bodies in connection with regular appointments and reappointment cycles. Requiring these specific approvals and notices may be an administrative burden.




be provided to the member, in writing, by the designated officer of the Medical Staff within a reasonable period of time (not to exceed two weeks). 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 Chief of Staff present.

4) In the event a Notice of Charges is filed against a member, access to that member’s credentials file shall be governed by Section 14.6-9

b. A member may be permitted to request correction of information as follows:

1) After review of his or her file, a member may address to the Chief of Staff a written request for correction of information in the credentials file. Such request shall include a statement of the basis for the action requested.

2) The Chief of Staff shall review such a request within a reasonable time and shall recommend to the Medical Executive Committee whether to make the correction as requested, and the Medical Executive Committee shall make the final determination.

3) The member shall be notified promptly, in writing, of the decision of the Medical Executive Committee.

4) In any case, a member shall have the right to add to his or her credentials file a statement responding to any information contained in the file. Any such written statement shall be addressed to the Medical Executive Committee, and shall be placed in the credentials file immediately following review by the Medical Executive

(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 action or proposed action is filed against a member, access to that member’s credentials file shall be governed by Section 7.4-1.

14.8-4 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 14.8-3(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 medical executive committee, after such review, whether or not to make the correction or deletion requested. The medical executive committee, 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 medical executive committee.

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

14.8 MEDICAL STAFF CREDENTIALS FILES

14.8-1 INSERTION OF ADVERSE INFORMATION

The following applies to actions relating to requests for

The CMA Bylaws are more explicit about handling of the credentials files.




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.

(c) After such a review a decision will be made by the respective department chair and chief of staff to:

(1) not insert the information;

CMA Bylaws require department chair and chief of staff review of each request to insert adverse information in the file.

(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 medical executive committee for an investigation as outlined in Section 6.1-2 of these bylaws

CMA Bylaws require notice to the member of any decision to insert adverse information (unless an investigation has been initiated (per 14-8-1(3)); and

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

CMA requires MEC notice and action on all decisions (including decisions not to insert information into the file). While certainly protective of the members, these provisions can be administratively onerous.

14.8-2 REVIEW OF ADVERSE INFORMATION AT THE TIME OF REAPPRAISAL AND RENEWAL OF MEMBERSHIP

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

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

(b) Following this review, the credentials committee 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 at the time of membership renewal is warranted, the credentials committee shall so inform the medical executive committee.(d) However, if an investigation and/or adverse action at the time of membership renewal is warranted, the credentials committee shall so inform the medical executive committee.(e) No later than 60 days following final action on the request for renewal of membership, the medical executive committee shall, except as provided in (g):(1) initiate a request for corrective action, based on such adverse information and on the credentials committee’s recommendation relating thereto, or

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

The CMA Bylaws requirement to summarize and disclose (again – i.e., it was required to be disclosed upon initial entry) may be administratively burdensome.

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

The CMA Bylaws provide for expunction of adverse information. (CHA Bylaws do not provide for expunction of any information in the credentials file; they do, however, require notations to be made of information found to be unsubstantiated. See CHA Bylaws Section 12.1-7.)

(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 medical executive committee, 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.

This CMA Bylaws provision requiring removal of adverse information unless a corrective action has been initiated can easily result in loss of important evidence of a building problem. It can readily be expected that evidence of early problems, not acted upon because they’ve not yet accumulated enough concern, will be destroyed. When and if the problems continue, important records of the growth of the problem will be lost. While the CMA Bylaws do provide for retention of this information, this requires an affirmative action of the MEC. Not only can this be onerous, the MEC’s decisions may be influenced by a variety of factors that are not necessarily conducive to ongoing peer review – i.e., friendship, wanting to give benefit of doubt, acrimony, etc. Regardless of the reasons, retention of




important information is jeopardized by such provisions.

12.4 IMMUNITY AND RELEASES

12.4-1 Immunity from Liability for Providing Information or Taking Action

Each representative of the Medical Staff and hospital and all third parties shall be exempt from liability to an applicant, member or practitioner for damages or other relief by reason of providing information to a representative of the Medical Staff, hospital [system member] or any other health-related organization concerning such person who is, or has been, an applicant to or member of the Medical Staff or who did, or does, exercise privileges or provide services at this hospital or by reason of otherwise participating in a Medical Staff or hospital credentialing, quality improvement, or peer review activities.

13.3 IMMUNITY FROM LIABILITY

13.3-1 FOR ACTION TAKEN

Each representative of the medical staff and hospital shall be immune, to the fullest extent provided by law, from liability to an applicant or member for damages or other relief for any action taken or statements or recommendations made within the scope of duties exercised as a representative of the medical staff or hospital.

13.3-2 FOR PROVIDING INFORMATION

Each representative of the medical staff and hospital and all third parties shall be immune, to the fullest extent provided by law, from liability to an applicant or member for damages or other relief by reason of providing information to a representative of the medical staff or hospital concerning such person who is, or has been, an applicant to or member of the staff or who did, or does, exercise clinical privileges or provide services at this hospital.

12.4-2 Activities and Information Covered

a. Activities

The immunity provided by this Article shall apply to all acts, communications, reports, recommendations or disclosures performed or made in connection with this or any other health-related institution’s or organization’s activities concerning, but not limited to:

1) Applications for appointment, privileges, or specified services;

2) Periodic reappraisals for reappointment, privileges, or specified services;

3) Corrective action;

4) Hearings and appellate reviews;

5) Quality improvement review, including patient

13.4 ACTIVITIES AND INFORMATION COVERED

The confidentiality and immunity provided by this Article shall apply to all acts, communications, reports, recommendations or disclosures performed or made in connection with this or any other health care facility’s or organization’s activities concerning, but not limited to:

(a) application for membership, renewal of membership, or clinical privileges;

(b) corrective action;

(c) hearings and appellate reviews;

(d) utilization reviews;

(e) other department, or division, committee, or medical staff activities related to monitoring and maintaining quality patient care and appropriate professional conduct; and




care audit;

6) Peer review;

7) Utilization reviews;

8) Morbidity and mortality conferences; and

9) Other hospital[, department, section,] or committee activities related to monitoring and improving the quality of patient care and appropriate professional conduct

b. Information

The acts, communications, reports, recommendations, disclosures, and other information referred to in this Bylaws Article 12 may relate to a practitioner’s professional qualifications, clinical ability, judgment, character, physical and mental health, emotional stability, professional ethics or other matter that might directly or indirectly affect patient care.

(f) queries and reports concerning the National Practitioner Data Bank, peer review organization, the Medical Board of California, and similar queries and reports.

12.5 RELEASES

Each practitioner shall, upon request of the hospital, execute general and specific releases in accordance with the tenor and import of this Bylaws Article 12; however, execution of such releases shall not be deemed a prerequisite to the effectiveness of this Bylaws Article 12.

12.6 CUMULATIVE EFFECT

Provisions in these bylaws and in Medical Staff application forms relating to authorizations, confidentiality of information, and immunities from liability shall be in addition to other protections provided by law and not in limitation thereof.

13.5 RELEASES

Each applicant or member shall, upon request of the medical staff or hospital, execute general and specific releases in accordance with the express provisions and general intent of this Article. Execution of such releases shall not be deemed a prerequisite to the effectiveness of this Article.

12.7 INDEMNIFICATION

The hospital shall indemnify, defend, and hold harmless the Medical Staff and its individual members (“Indemnitee(s)”) from and against losses and expenses (including reasonable attorneys’ fees, judgments, settlements, and all other costs, direct or indirect) incurred or suffered by reason of or based upon any threatened, pending or completed action, suit,

13.6 INDEMNIFICATION

The hospital shall indemnify, defend and hold harmless the medical staff and its individual members from and against losses and expenses (including attorneys’ fees, judgments, settlements, and all other costs, direct or indirect) incurred or suffered by reason of or based upon any threatened, pending or completed action, suit, proceeding, investigation, or other

The CHA Bylaws indemnification clause is tailored to meet the standards of California Corporations Code Section 5238 (respecting indemnification limitations under the California nonprofit corporation law). Of particular import, the CHA Bylaws indemnification provision is conditioned upon the Indemnitee’s good faith, and does not include acts or omissions taken in




proceeding, investigation, or other dispute relating or pertaining to any alleged act or failure to act within the scope of peer review or quality assessment activities including, but not limited to:

a. As a member of or witness for a Medical Staff [department, service,] committee, or hearing committee;

b. As a member of or witness for the hospital Governing Body or any hospital task force, group or committee; and

c. As a person providing information to any Medical Staff or hospital group, officer, Governing Body member or employee for the purpose of aiding in the evaluation of the qualifications, fitness or character of a Medical Staff member or applicant.

The hospital shall retain responsibility for the sole management and defense of any such claims, suits, investigations or other disputes against Indemnitees, including but not limited to selection of legal counsel to defend against any such actions. The indemnity set forth herein is expressly conditioned on Indemnitees’ good faith belief that their actions and/or communications are reasonable and warranted and in furtherance of the Medical Staff’s peer review, quality assessment or quality improvement responsibilities, in accordance with the purposes of the Medical Staff as set forth in these bylaws. In no event will the hospital indemnify an Indemnitee for acts or omissions taken in bad faith or in pursuit of the Indemnitee’s private economic interests.

dispute relating or pertaining to any alleged act or failure to act within the scope of peer review or quality assessment activities including, but not limited to, (1) as a member of or witness for a medical staff department, service, committee or hearing panel, (2) as a member of or witness for the hospital board or any hospital task force, group, or committee, and (3) as a person providing information to any medical staff or hospital group, officer, board member or employee for the purpose of aiding in the evaluation of the qualifications, fitness or character of a medical staff member or applicant. The medical staff or member may seek indemnification for such losses and expenses under this bylaws provision, statutory and case law, any available liability insurance or otherwise as the medical staff or member sees fit, and concurrently or in such sequence as the medical staff or member may choose. Payment of any losses or expenses by the medical staff or member is not a condition precedent to the hospital’s indemnification obligations hereunder.

for the Indemnitee’s private economic interests.

The CMA Bylaws indemnification clause is much broader, and does not require that the member act in good faith or in accordance with the Medical Staff Bylaws. Further, the defense obligation, as written, could result in the hospital being required to provide separate legal counsel to each and every committee member, witness, etc. The cost and lack of coordination that could result from such provisions could be extraordinary. These indemnity provisions could well extend beyond insurance coverage conditions, which means that the hospital, alone, would have to provide the defense and the indemnification. Finally, the unconditional nature of these indemnity provisions could serve as an “incentive” for an individual member to act recklessly, carelessly, or in his/her personal self-interest – knowing that he/she will always be made whole by the hospital. Finally these provisions appear to be in excess of those authorized under the Corporations Code for nonprofit corporations, and hence could call into question whether a nonprofit hospital could legally honor such a broad indemnification obligation. In a related vein, not limiting indemnification where the indemnitee is acting for his/her private economic interests may jeopardize a nonprofit hospital’s tax-exempt status, or in the case of a public hospital, result in a gift of public funds.

Article 13

PERFORMANCE IMPROVEMENT AND CORRECTIVE ACTION

13.1 PEER REVIEW PHILOSOPHY

13.1-1 Role of Medical Staff in Organizationwide Quality Improvement Activities

The Medical Staff is responsible to oversee the quality of medical care, treatment and services delivered in the

Article VI

EVALUATION AND CORRECTIVE ACTION

[For comparative purposes, portions of CMA’s Chapter VI have been placed here, and other portions (Ongoing Peer Review and Focused Review) have been aligned with CHA’s Article 7.]

The CHA Bylaws include an important overview of the philosophy of performance improvement and corrective action.




hospital. An important component of that responsibility is the oversight of care rendered by members and AHPs practicing in the hospital. The following provisions are designed to achieve quality improvements through collegial peer review and educative measures whenever possible, but with recognition that, when circumstances warrant, the Medical Staff is responsible to embark on informal corrective measures and/or corrective action as necessary to achieve and assure quality of care, treatment and services. Toward these ends:

a. Members of the Medical Staff are expected to actively and cooperatively participate in a variety of peer review activities to measure, assess and improve performance of their peers in the hospital.

b. The initial goals of the peer review processes are to prevent, detect and resolve problems and potential problems through routine collegial monitoring, education and counseling. However, when necessary, corrective measures, including formal investigation and discipline, must be implemented and monitored for effectiveness.

c. Peers in the [departments and] committees are responsible for carrying out delegated review and quality improvement functions in a manner that is consistent, timely, defensible, balanced, useful and ongoing. The term “peers” generally requires that a majority of the peer reviewers be members holding the same license as the practitioner being reviewed, including, where possible, at least one member practicing the same specialty as the member being reviewed. Notwithstanding the foregoing, D.O.s and M.D.s shall be deemed to hold the “same licensure” for purposes of participating in peer review activities.

[d. The departments and committees may be assisted by the Chief Medical Officer.]

13.1-2 Informal Corrective Activities

The Medical Staff officers, [departments] and committees may counsel, educate, issue letters of warning or censure, or conduct focused professional practice evaluation in

The CHA Bylaws provide for informal corrective actions that attempt to resolve matters collegially, without need for formal action and consequent reports and hearings.




accordance with Section 7.4 in the course of carrying out their duties without initiating formal corrective action. Comments, suggestions and warnings may be issued orally or in writing. The practitioner shall be given an opportunity to respond in writing and may be given an opportunity to meet with the officer[, department] or committee. Any informal actions, monitoring or counseling shall be documented in the member’s file. Medical Executive Committee approval is not required for such actions, although the actions shall be reported to the Medical Executive Committee. The actions shall not constitute a restriction of privileges or grounds for any formal hearing or appeal rights under Article 14, Hearings and Appellate Reviews.

13.1-3 Criteria for Initiation of Formal Corrective Action

Formal corrective action may be initiated whenever reliable information indicates a member may have exhibited acts, demeanor or conduct, either within or outside of the hospital, that is reasonably likely to be:

a. detrimental to patient safety or to the delivery of quality patient care within the hospital;

b. unethical;

c. contrary to the Medical Staff bylaws or rules;

d. below applicable professional standards;

e. disruptive of Medical Staff or hospital operations; or

f. an improper use of hospital resources.

Generally, formal corrective action measures should not be initiated unless reasonable attempts at informal resolution have failed; however, this is not a mandatory condition, and formal corrective action may be initiated whenever circumstances reasonably appear to warrant formal action. Any recommendation of formal corrective action must be based on evaluation of applicant-specific information.

6.3 CORRECTIVE ACTION

6.3-1 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 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.

CHA Bylaws acknowledge that conduct disruptive of hospital operations may also be subject to discipline. (Note, this long-standing CHA Bylaws provision is a DNV-accreditation requirement – see DNV MS.14.)

13.1-4 Initiation 6.3-2 Initiation The CHA Bylaws provisions regarding initiating investigations are more complete and reflective of what




a. Any person who believes that formal corrective action may be warranted may provide information to the Chief of Staff, any other Medical Staff officer, [any department chair], any Medical Staff committee, the chair of any Medical Staff Committee, the Governing Body or the Chief Executive Officer.

b. If the Chief of Staff, any other Medical Staff officer, [any department chair,] any Medical Staff Committee, the chair of any Medical Staff committee, the Governing Body or the Chief Executive Officer determines that formal corrective action may be warranted under Section 13.1-3, that person, entity, or committee may request the initiation of a formal corrective action investigation or may recommend particular corrective action. Such requests may be conveyed to the Medical Executive Committee orally or in writing.

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 recording of the reasons.

generally actually happens with respect to corrective actions.

c. The Chief of Staff shall notify the Chief Executive Officer, or his or her designee in his or her absence, and the Medical Executive Committee and shall continue to keep them fully informed of all action taken. In addition, the Chief of Staff shall immediately forward all necessary information to the committee or person that will conduct any investigation, provided, however, that the Chief of Staff or the Medical Executive Committee may dispense with further investigation of matters deemed to have been adequately investigated by a committee pursuant to Section 13.1-6 or otherwise.

CHA Bylaws provide for notice to the CEO of initiation of corrective action. This is an important communication for a number of reasons – e.g., if the affected practitioner holds a contract with the hospital, the circumstances may involve a breach of that contract. Also, such investigations often require commitment of hospital resources and the CEO should be apprised of such circumstances.

13.1-5 Expedited Initial Review

a. Whenever information suggests that corrective action may be warranted, the Chief of Staff or his or her designee [and/or the Chief Medical Officer] may, on behalf of the Medical Executive Committee, immediately investigate and conduct whatever interviews may be indicated. The information developed during this initial review shall be presented to the Medical Executive Committee, which shall decide whether to initiate a formal corrective action investigation.

b. In cases of complaints of harassment or discrimination involving a patient, etc., an expedited initial

CHA Bylaws’ provision for Expedited Initial Review are especially useful in investigating complaints of harassment or discrimination, which, by law, must be promptly handled, and which may require coordination with hospital investigatory processes.




review shall be conducted on behalf of the Medical Executive Committee by the Chief of Staff, the Chief of Staff’s designee, [or the Chief Medical Officer], together with representatives of administration, or by an attorney for the hospital. In cases of complaints of harassment or discrimination where the alleged harasser is a Medical Staff member and the complainant is not a patient, an expedited initial review shall be conducted by the [Chief Medical Officer and the] hospital’s human resources director or their designee, or by an attorney for the hospital, who shall use best efforts to complete the expedited initial review within the timeframe set out at Section 13.1-8. The Chief of Staff shall be kept apprised of the status of the initial review. The information gathered from an expedited initial review shall be referred to the Medical Executive Committee if it is determined that corrective action may be indicated against a Medical Staff member.

13.1-6 Formal Investigation

a. If the Medical Executive Committee concludes action is indicated but that no further investigation is necessary, it may proceed to take action without further investigation.

b. If the Medical Executive Committee concludes a further investigation is warranted, it shall direct a formal investigation to be undertaken. The Medical Executive Committee may conduct the investigation itself or may assign the task to an appropriate officer or standing or ad hoc committee to be appointed by the Chief of Staff. The investigating body should not include partners, associates or relatives of the individual being investigated. Additionally, the investigating person or body may, but is not required to, engage the services of one or more outside reviewers as deemed appropriate or helpful in light of the circumstances (e.g., to help assure an unbiased review, to firm up an uncertain or controversial review or to engage specialized expertise). If the investigation is delegated to an officer or committee other than the Medical Executive Committee, such officer or committee shall proceed with the investigation in a prompt manner, using best efforts to complete the expedited initial review within the timeframe

6.3-3 Investigation

Subject to the provision of section 2.7-3, Medical Staff Conduct Complaints, 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 clinical privileges under Section 5.6, 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




set out at Section 13.1-8, 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.

c. Prior to any adverse action being approved, the Medical Executive Committee shall assure that the member was given an opportunity to provide information in a manner and upon such terms as the Medical Executive Committee, investigating body, or reviewing committee deems appropriate. The investigating body or reviewing body may, but is not obligated to, interview persons involved; however, such an interview shall not constitute a hearing as that term is used in Article 14, Hearings and Appellate Reviews, nor shall the hearings or appeals rules apply.

d. 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 action.

e. The provisions of this Section 13.1-6 (including a determination to dispense with formal investigation and proceed immediately to further action pursuant to 13.1-6(a)) shall demark the point at which an “impending investigation” is deemed to have commenced within the meaning of Business and Professions Code Section 805(c).

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.

13.1-7 Executive Committee Action

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

6.3-4 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 should be taken and, if the Medical Executive Committee determines there was no credible evidence for the complaint in the first instance, clearly documenting those findings in the member’s file;

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;

referring the member to the Medical Staff Aid Committee for evaluation and follow-up as appropriate;

CHA Bylaws provide for documenting the absence of credible evidence in support of a complaint (but not for removing it altogether).

CMA Bylaws, on the other hand, require removal of the information. While in any isolated occurrence it is possible that information cannot be corroborated and




1) Deferring action for a reasonable time;

2) Issuing letters of admonition, censure, reprimand or warning, although nothing herein shall be deemed to preclude [department or] committee chairs 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;

3) 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-admissions, mandatory consultation or monitoring;

4) Recommending reduction, modification, suspension or revocation of privileges. If suspension is recommended, the terms and duration of the suspension and the conditions that must be met before the suspension is ended shall be stated;

5) Recommending reductions of membership status or limitation of any prerogatives directly related to the member’s delivery of patient care;

6) Recommending suspension, revocation or probation of Medical Staff membership. If suspension or probation is recommended, the terms and duration of the suspension or probation and the conditions that must be met before the suspension or probation is ended shall be stated;

7) Referring the member to the Well-Being Committee for evaluation and follow-up as appropriate; and

8) Taking other actions deemed appropriate under the circumstances.

b. If the Medical Executive Committee takes any action that would give rise to a hearing pursuant to Bylaws, Section 14.2, it shall also make a determination whether the action is a “medical disciplinary” action or an “administrative disciplinary” action. A medical disciplinary action is one taken for cause or reason that involves that aspect of a practitioner’s competence or professional

deferring action for a reasonable time where circumstances warrant;

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;

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

recommending reduction, modification, suspension or revocation of clinical privileges;

recommending reductions of membership status or limitation of any prerogatives directly related to the member’s delivery of patient care;

recommending suspension, revocation or probation of medical staff membership;

determining whether the action is taken for any of the reasons required to be reported pursuant to Business & Professions Code §805.01 [sic 805.1]; and

taking other actions deemed appropriate under the circumstances.

thus lead to removal from the file, recurring reports of a problem can be indicative of an actual problem (e.g., one that is being covered up, or of a system problem). Removal of the information altogether destroys documentation that could, in retrospect, prove important. A more prudent approach would be to document the results of an investigation that found the information not validated, but keep that documentation in the file for later review as may be warranted.

CHA Bylaws now include a provision allowing the MEC to distinguish between medical discipline and administrative discipline, with corresponding changes to the hearing rights associated with each.




conduct that is reasonably likely to be detrimental to patient safety or to the delivery of patient care. All other actions are deemed administrative disciplinary actions. In some cases, the reason may involve both medical disciplinary and administrative disciplinary cause or reason, in which case, the matter shall be deemed medical disciplinary for Bylaws, Article 14 hearing purposes.

c. And, if the Medical Executive Committee makes a determination that the action is medical disciplinary, it shall also determine whether the action is taken for any of the reasons required to be reported to the Medical Board of California pursuant to California Business and Professions Code Section 805.1.

13.1-8 Time Frames

Insofar as feasible under the circumstances, formal and informal investigations should be conducted expeditiously, as follows:

a. Informal investigations should be completed and the results should be reported within 60 days.

b. Expedited initial reviews should be completed and the results should be reported within 30 days.

c. Other formal investigations should be completed and the results should be reported within 90 days

13.1-9 Procedural Rights

a. If, after receipt of a request for formal corrective action pursuant to Section 13.1-4, the Medical Executive Committee determines that no corrective action is required or only a letter of warning, admonition, reprimand or censure should be issued, the decision shall be transmitted to the Governing Body. The Governing Body may affirm, reject or modify the action. The Governing Body shall give great weight to the Medical Executive Committee’s decision and initiate further action only if the failure to act is contrary to the weight of the evidence that is before it, and then only after it has consulted with the Medical Executive Committee and the Medical Executive Committee still has not acted. The decision shall become final if the Governing

6.3-5 Subsequent Action

If corrective action as set forth in Section 7.2(a)-(k) is recommended by the medical executive committee, that recommendation shall be transmitted to the board of [trustees/directors].

So long as the recommendation is supported by substantial evidence the recommendation of the medical executive committee shall be adopted by the board as final action unless the member requests a hearing, in which case the final decision shall be determined as set forth in Article VII.

The CHA Bylaws preserve the Governing Body’s prerogatives to take action contrary to the MEC, but in accordance with the statutory limitations set out at Section 809.05.

The CMA Bylaws constrain the Governing Body’s prerogatives by imposing the “substantial evidence” standard. Substantial evidence is a legal term of art that implies there is at least some credible evidence in support of a decision – but it does not necessarily imply that there is a preponderance of evidence. The CMA Bylaws do not recognize the Business & Professions Section 809.05 prerogatives granted to the Governing




Body affirms it or takes no action on it within 70 days after receiving the notice of decision.

b. If the Medical Executive Committee recommends an action that is a ground for a hearing under Section 14.2, the Chief of Staff shall give the practitioner special notice of the adverse recommendation and of the right to request a hearing. The Governing Body may be informed of the recommendation, but shall take no action until the member has either waived his or her right to a hearing or completed the hearing.

Body by California law in this circumstance. This standard is not particularly problematic when it is used in the context of an appeal – i.e., the appeal body sustains the hearing decision if it is supported by substantial evidence. This is because there will have been a fair hearing involved and ample opportunity to present and explore the evidence. This, however, is not the case here, the Board would be required to sustain a MEC decision where there had been no such hearing. Consider this possible scenario: A member of the staff has a new affiliate in his office. His references and history are sketchy, and there are indications of prior problems. However, for a variety of reasons – peer pressure, loyalty, etc. – the MEC reluctantly agrees to recommend appointment. The Board does not believe this to be an appropriate recommendation – but since there is “substantial evidence” that the physician is qualified, the Board must allow the appointment, even though, in the Board’s view, the preponderance of the evidence would not support the appointment. See additional comments accompanying CHA Section 14.6-18 regarding the substantial evidence standard.

13.1-10 Initiation by Governing Body

a. The Medical Staff acknowledges that the Governing Body must act to protect the quality of medical care provided and the competency of its Medical Staff, and to ensure the responsible governance of the hospital in the event that the Medical Staff fails in any of its substantive duties or responsibilities.

b. Accordingly, if the Medical Executive Committee fails to investigate or take disciplinary action, contrary to the weight of the evidence, the Governing Body may direct the Medical Executive Committee to initiate an investigation or disciplinary action, but only after consulting with the Medical Executive Committee. If the Medical Executive Committee fails to act in response to that Governing Body direction, the Governing Body may, in furtherance of the Governing Body’s ultimate responsibilities and fiduciary duties, initiate corrective action, but must comply with applicable provisions of

6.3-6 Initiation by Board of [Trustees/Directors]

If the medical executive committee fails to investigate or take disciplinary action, contrary to the weight of the evidence, the board of [trustees/directors] may direct the medical executive committee to initiate investigation or disciplinary action, but only after consultation with the medical executive committee. The board’s request for medical staff action shall be in writing and shall set forth the basis for the request. If the medical executive committee fails to take action in response to that board of [trustees/directors] direction, the board of [trustees/directors] may initiate corrective action after written notice to the medical executive committee, but this corrective action must comply with Articles VI and VII of these medical staff bylaws.

The CHA Bylaws include articulation of the Governing Body’s responsibilities and authority, as set out in the legislative findings of SB 1325 (2004).




Article 13, Peer Review and Corrective Action, and Article 14, Hearings and Appellate Reviews, of these bylaws. The Governing Body shall inform the Medical Executive Committee in writing of what it has done.

13.2 SUMMARY RESTRICTION OR SUSPENSION

13.2-1 Criteria for Initiation

a. Whenever a practitioner’s conduct is such that a failure to take action may result in an imminent danger to the health of any individual, the Chief of Staff, the Medical Executive Committee, [the chair of the department in which the member holds privileges,] or the Chief Executive Officer [or any officer of the Board] may summarily restrict or suspend the Medical Staff membership or privileges of such member.

b. Unless otherwise stated, such summary restriction or suspension (summary action) shall become effective immediately upon imposition, and the person or body responsible shall promptly give special notice to the member and written notice to the Governing Body, the Medical Executive Committee, and the Chief Executive Officer. The special notice shall fully comply with the requirements of Section 13.2-1(d), below..

6.4 SUMMARY RESTRICTION OR SUSPENSION

6.4-1 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, 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 clinical 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 [trustees/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 7.3-1 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.

The CHA Bylaws criteria for summary suspension are as stated in California Business & Professions Code Section 809.5.

The CMA Bylaws criteria modify these criteria rather significantly – in particular requiring a “substantial and imminent likelihood of significant impairment” – as compared to the statutory provision for “may result in an imminent danger to the health…”

The CHA Bylaws include an optional provision allowing Board officer-initiated summary actions (per DNV Standard MS.12).

c. The summary action 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 action, 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 and the affected practitioner in the choice of a substitute member.




d. Within one working day of imposition of a summary suspension, the affected Medical Staff member shall be provided with verbal notice of such suspension; followed, within three working days of imposition, by written notice of such suspension. This initial written notice shall include a statement of facts demonstrating that the suspension was reasonable and warranted because failure to suspend or restrict the member’s privileges summarily could reasonably result in an imminent danger to the health of any 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 14.3-1(which applies in all cases where the Medical Executive Committee does not immediately terminate the summary suspension). The notice under Section 14.3-1 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.

e. The notice of the summary action given to the Medical Executive Committee shall constitute a request to initiate corrective action and the procedures set forth in Section 13.1-4 shall be followed.

6.4 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 medical executive committee 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.

13.2-2 Medical Executive Committee Action

Within one week after such summary action 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 13, Hearings and Appellate Reviews, nor shall any procedural rules apply. The Medical Executive Committee may thereafter continue, modify or terminate the terms of the summary action. It shall give the practitioner special notice of its decision within two working days of the meeting, which shall

6.4-3 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.




include the information specified in Section 14.3-1 if the action is adverse.

13.2-3 Procedural Rights

Unless the Medical Executive Committee promptly terminates the summary action, and if the summary action constitutes a suspension or restriction of clinical privileges (required to be reported to the Medical Board of California pursuant to Business and Professions Code Section 805), the member shall be entitled to the procedural rights afforded by Article 14, Hearings and Appellate Reviews [, including but not limited to a right to a preliminary hearing as described at Section 14.5.]

6.4-4 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: 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 medical executive committee’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.

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 medical executive committee within one week of the date of the procedural hearing. 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. If the hearing officer [or hearing panel]

The CHA Bylaws include an option for preliminary hearings – see CHA Section 14.5. The preliminary hearing provisions are designed to achieve the benefits of a bifurcated hearing, but have been designed to address some of the concerns described below with respect to CMA’s bifurcated hearings.

The CMA Bylaws provide for bifurcating these hearings, such that there is an early hearing on the validity of the summary action. While this does provide an avenue for prompt redress of a summary action, in most instances the involved practitioners actually request continuances of these hearings to permit their own and their attorneys’ preparation, such that the result is simply a need for two hearings, but without the prompt resolution that is contemplated by this provision. Two hearings are not only costly, they are labor intensive not only for the involved member, but also for the MEC representative and the hearing committee members. Here are some of the specific pros and cons to this approach:

Pros

Timely rectification of erroneously-imposed summary suspension.

Minimizes exposure to damages that may occur in the event the summary suspension is overturned.

Cons

The Bylaws already provide a safeguard against arbitrary imposition of summary suspension, in the form of prompt MEC review following the summary action.

Bifurcating the hearing could substantially prolong




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.

the hearing process itself, in that the facts supporting the summary suspension are often more than a single incident (i.e., they are often a culmination of incidents that need to be fully explored in the hearing). Thus, the summary suspension hearing is likely to involve more than a single incident.

Two hearings are likely to result, because some or all of the same facts are often involved in both the summary suspension decision and the permanent decision. To bifurcate the decisions is likely to result in duplication of hearing efforts – at substantial expense to both the hospital and the involved practitioner.

• In addition to the expense, the time required of the MEC representative and the hearing panel could be substantial (i.e., often doubled).

• Bifurcation, coupled with immediate stay of the MEC decision in the event the hearing panel disagrees with the MEC places the hearing panel in the position of functioning as a credentialing or executive committee.

o Neither the hearing committee nor the hearing officer is instilled with the same peer review duties and accountability as apply to the MEC. Rather, their purpose and functions are much more restricted.

o The hearing committee may not be comprised of a complement of physicians who are appropriate to make credentialing decisions (i.e., the hearing committee is generally comprised of only one physician of the practitioner's specialty – and often that practitioner is only a member of the courtesy staff, or not even a member of the staff (because it is often necessary to bring in an outsider to avoid conflicts of interest)).




o The purpose of the hearing committee is to determine whether an action of the MEC appears to be supported by the evidence, but it is not to formulate the recommended remedial action with respect to a practitioner's privileges.

o For example, it may appear to a hearing committee that full suspension of privileges is inappropriate, and that something less severe is appropriate – e.g., summary imposition of mandatory consultations. The proposed Bylaws do not (and should not) give the hearing committee the power to impose alternative disciplines – rather, the hearing committee is just empowered to continue the existing restriction or order unrestricted reinstatement.

o Moreover, if following the hearing committee’s reinstatement of a practitioner, the MEC determines that unrestricted reinstatement will not adequately protect patients and that some lesser disciplinary measure must be imposed, that action itself could trigger an additional hearing right.

The provisions do not require any speedier proceedings; rather, they are likely to prolong ultimate resolution because there will need to be duplicate proceedings.

Further, it does not appear that there is any provision for appeal of the outcome of the hearing committee's decision on the summary action. This could usurp the Board of Directors’ ultimate authority.

13.2-4 Initiation by Governing Body

a. If no one authorized under Section 13.2-1(a) to take a summary action is available to summarily restrict or suspend a member’s membership or privileges, the Governing Body (or its designee) may immediately suspend or restrict a member’s privileges if a failure to act

6.4-5 INITIATION BY BOARD OF [TRUSTEES/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




immediately may result in imminent danger to the health of any individual, provided that the Governing Body (or its designee) made reasonable attempts to contact the Chief of Staff [and the chair of the department to which the member is assigned] before acting.

b. Such summary action is subject to ratification by the Medical Executive Committee. If the Medical Executive Committee does not ratify such summary action within two working days, excluding weekends and holidays, the summary action shall terminate automatically.

clinical privileges, the board of [trustees/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 person, provided that the board of [trustees/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.

The bifurcated hearings apply to Board-initiated actions, as well.

13.3 AUTOMATIC SUSPENSION OR LIMITATION

In the following instances, the member’s privileges or membership may be suspended or limited as described:

6.5 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.

CMA Bylaws provide hearing rights (albeit limited) for all automatic actions. The occurrence or nonoccurrence of these actions can be objectively established, such that hearing rights are unnecessary and wasteful of hospital and medical staff resources.

13.3-1 Licensure

a. Revocation, Suspension or Expiration: Whenever a member’s license or other legal credential authorizing practice in this state is revoked, suspended or expired without an application pending for renewal, 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 are within the scope of such 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.

6.5-1 LICENSURE

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

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 clinical 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




c. Probation: Whenever a member is placed on probation by the applicable licensing or certifying authority, his or her membership status and privileges shall automatically become subject to the same terms and conditions of the probation as of the date such action becomes effective and throughout its term.

and throughout its term.

Probation: Whenever a member is placed on probation by the applicable licensing or certifying authority, membership status and clinical privileges shall automatically become subject to the same terms and conditions of the probation as of the date such Action becomes effective and throughout its term.

13.3-2 Drug Enforcement Administration (DEA) Certificate

a. Revocation, Suspension, and Expiration: Whenever a member’s DEA certificate is revoked, limited, suspended or expired, the member shall automatically and correspondingly be divested of the right to prescribe medications covered by the certificate as of the date such action becomes effective and throughout its term.

b. Probation: Whenever a member’s DEA certificate is subject to probation, the member’s right to prescribe such medications shall automatically become subject to the same terms of the probation as of the date such action becomes effective and throughout its term.

6.5-2 CONTROLLED SUBSTANCES

Whenever a member’s DEA certificate is revoked, limited, or suspended, the member shall automatically and correspondingly be divested of the right to prescribe medications covered by the certificate, as of the date such action becomes effective and throughout its term.

Probation: Whenever a member’s DEA certificate is subject to probation, the member’s right to prescribe such medications shall automatically become subject to the same terms of the probation, as of the date such action becomes effective and throughout its term.

13.3-3 Failure to Satisfy Special Appearance Requirement

A member who fails without good cause to appear and satisfy the requirements of Section 11.7-3 shall automatically be suspended from exercising all or such portion of privileges as the Medical Executive Committee specifies.

6.5-6 FAILURE TO SATISFY SPECIAL ATTENDANCE REQUIREMENT

Failure of a member without good cause to provide information or appear when requested by a medical staff committee as described in these bylaws shall result in the referral to the Medical Executive Committee for action, which may include automatic suspension of all privileges. The automatic suspension shall remain in effect until the practitioner has provided requested information and/or satisfied the special attendance requirement which has been made by the medical staff committee.

13.3-4 Medical Records

Medical Staff members are required to complete medical records within the time prescribed by the Medical Executive Committee. Failure to timely complete medical records shall result in an automatic suspension after notice is given as provided in the rules. Such suspension shall apply to the

6.5-3 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




Medical Staff member’s right to admit, treat or provide services to new patients in the hospital, but shall not affect the right to continue to care for a patient the Medical Staff member has already admitted or is treating; provided, however, members whose privileges have been suspended for delinquent records may admit and treat new patients in life-threatening situations. The suspension shall continue until the medical records are completed. If after 30 consecutive days of suspension the member remains suspended, the member shall be considered to have voluntarily resigned from the Medical Staff. Nothing in the foregoing shall preclude the implementation, by the Medical Executive Committee, of a monetary fine for delinquent medical records.

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, assisting in surgery, consulting on hospital cases, and providing professional services within the hospital for future patients. Bona 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 may admit patients only in life-threatening situations. The suspension shall continue until lifted by the chief of staff or the chief of staff’s designee.

Note provision in CHA Model to accommodate imposition of fines to address medical record delinquencies.

13.3-5 Cancellation of Professional Liability Insurance

Failure to maintain professional liability insurance as required by these bylaws shall be grounds for automatic suspension of a member’s privileges. Failure to maintain professional liability insurance for certain procedures shall result in the automatic suspension of privileges to perform those procedures. The suspension shall be effective until appropriate coverage is reinstated, including coverage of any acts or potential liabilities that may have occurred or arisen during the period of any lapse in coverage. A failure to provide evidence of appropriate coverage within six months after the date of automatic suspension shall be deemed a voluntary resignation of the member from the Medical Staff

6.5-5 PROFESSIONAL LIABILITY INSURANCE

Failure to maintain professional liability insurance, if any is required, shall be ground for automatic suspension of a member’s clinical 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.

13.3-6 Failure to Pay Dues or Fines

If the member fails to pay required dues or fines within 30 days after written warning of delinquency, a practitioner’s Medical Staff membership and privileges shall be automatically suspended and shall remain so suspended until the practitioner pays the delinquent dues. If after 60 consecutive days of suspension the member remains suspended, the member will be considered to have voluntarily resigned from the Medical Staff.

6.5-4 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 14.2, shall be ground for automatic suspension of a member’s clinical 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.

13.3-7 FAILURE TO COMPLY WITH GOVERNMENT AND




OTHER THIRD PARTY PAYOR REQUIREMENTS

[If a member’s Medicare or Medi-Cal provider status is revoked or terminated, the member shall be automatically [suspended][removed from all emergency call activities].] Additionally, the Medical Executive Committee shall be empowered to determine that compliance with certain specific third party payor, government agency, and professional review organization rules or policies is essential to hospital and/or Medical Staff operations and that compliance with such requirements can be objectively determined. The rules may authorize the automatic suspension of a practitioner who fails to comply with such requirements. The suspension shall be effective until the practitioner complies with such requirements.

Unless the hospital requires Medicare/Medi-Cal eligibility as a condition of membership (see CHA Bylaws Section 2.2-2d), CHA’s Bylaws are not blanket automatic termination mandates; rather they permit each medical staff, through its MEC, to ascertain what payor requirements must be enforced. (Note, however, that DNV-accredited hospitals must include an automatic suspension provision for loss of Medicare/Medicaid status – see DNV Standard MS.12, SR 7.)

13.3-8 Automatic Termination

If a practitioner is suspended for more than six months, his or her membership (or the affected privileges, if the suspension is a partial suspension) shall be automatically terminated. Thereafter, reinstatement to the Medical Staff shall require application and compliance with the appointment procedures applicable to applicants.

13.3-9 Executive Committee Deliberation and Procedural Rights

a. As soon as practicable after action is taken or warranted as described in Section 13.3-1, Licensure, Section 13.3-2, Drug Enforcement Administration, Certificate, or 13.3-3, Failure to Satisfy Special Appearance, 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 13.1-6, Formal Investigation (or, at Bylaws, Section 13.1-6 where circumstances warrant). The Medical Executive Committee review and any subsequent hearings and reviews shall not address the propriety of the licensure or DEA action, but instead shall address what, if any, additional action should be taken by the hospital. There is no need for the Medical Executive Committee to act on automatic suspensions for

6.5-7 MEDICAL EXECUTIVE COMMITTEE DELIBERATION

As soon as practicable after action is taken or warranted as described in Sections 6.5-1 through 6.5-6, the medical executive committee shall convene to review and consider the facts, and may recommend any further corrective action as it may deem appropriate in accordance with these bylaws.




failures to complete medical records (Section 13.3-4), maintain professional liability insurance (Section 13.3-5), to pay dues (Section 13.3-6) or comply with government and other third party payor rules and policies (Section 13.3-7).

b. Practitioners whose privileges are automatically suspended and/or who have been deemed to have automatically resigned their Medical Staff membership shall be entitled to a hearing only if the suspension is reportable to the Medical Board of California or the federal National Practitioner Data Bank.

CHA Bylaws provide for hearing rights if the action is one that must be reported.

13.3-10 Notice of Automatic Suspension or Action

Special notice of an automatic suspension or action shall be given to the affected individual, and regular notice of the suspension shall be given to the Medical Executive Committee, Chief Executive Officer and Governing Body, but such notice shall not be required for the suspension to become effective. Patients affected by an automatic suspension shall be assigned to another member by the [department chair or] Chief of Staff. The wishes of the patient and affected practitioner shall be considered, where feasible, in choosing a substitute member.

[13.3-11 Automatic Action Based upon Actions Taken by Another Peer Review Body after a Hearing

a. The Medical Executive Committee shall be empowered to automatically impose any adverse action that has been taken by another peer review body (as that term is used in the Medical Staff Hearing Law, Business and Professions Code Section 809 et seq.) after a hearing at that other peer review body that meets the requirement of the Medical Staff Hearing Law. Such an adverse action may be any action taken by the other peer review body, including, but not limited to, denying membership and/or privileges restricting privileges or terminating membership and/or privileges. The action may be taken automatically only if the other peer review body took automatic action based upon standards that were essentially the same as those in effect at this hospital at the time the automatic action will be taken. Also, the action that will be the basis of the automatic

CHA Bylaws include an optional provision permitting automatic action without hearing based on actions of other peer review bodies. This provision should be exercised only in close consultation with the Medical Staff’s attorney.




action must have become final within the past 36 months. The action may be taken only after the practitioner has completed the hearing and any appeal at that other peer review body; however, it is not necessary to await a final disposition in any judicial proceeding that may be brought challenging the action

b. The practitioner shall not be entitled to any hearing or appeal at this hospital unless the Medical Executive Committee takes an action that is more restrictive than the final action taken by the other peer review body. Any hearing and appeal that is requested by the practitioner shall not address the merits of the action taken by the original peer review body, which were already reviewed at the other peer review body’s hearing, and shall be limited to only the question of whether the automatic action is more restrictive than the other peer review body’s action. The practitioner shall not be entitled to challenge the automatic peer review action unless he or she successfully overturns the other peer review action in court.

c. Nothing in this section shall preclude the Medical Staff or Governing Body from taking a more restrictive action than another peer review body based upon the same facts or circumstances.

13.4 INTERVIEW

Interviews shall neither constitute nor be deemed a hearing as described in Article 14, Hearings and Appellate Reviews, shall be preliminary in nature, and shall not be conducted according to the procedural rules applicable with respect to hearings. The Medical Executive Committee shall be required, at the practitioner’s request, to grant an interview only when so specified in this Article 13, Performance Improvement and Corrective Action. In the event an interview is granted, the practitioner shall be informed of the general nature of the reasons for the recommendation and may present information relevant thereto. A record of the matters discussed and the findings resulting from an

CHA Bylaws provide for interview rights.




interview shall be made.

13.5 CONFIDENTIALITY

To maintain confidentiality, participants in the corrective action process shall limit their discussion of the matters involved to the formal avenues provided in these bylaws for peer review and discipline.

CHA Bylaws iterate the confidentiality of these peer review activities.

[13.6 SYSTEMWIDE CORRECTIVE ACTION

13.6-1 NOTICE OF PENDING INVESTIGATIONS/JOINT INVESTIGATIONS

a. The Chief of Staff and the Chief Executive Officer each shall have the discretion to notify their counterpart officers or other system members whenever a request for corrective action has been received.

b. In addition, the Medical Executive Committee may authorize a coordinated investigation and may appoint other system members’ medical staff members to assist in the coordinated investigation.

CHA Bylaws include optional provisions for cooperative peer review actions within a health system.

c. The Chief of Staff and the Chief Executive Officer are authorized to disclose to another system member’s peer review body (or an authorized representative of that body) information from hospital and medical staff records to assist in the other system member’s independent or joint investigation of any practitioner.

d. The results of any joint investigation shall be reported to each system member’s peer review body for its independent determination of what, if any, corrective action should be taken

13.6-2 Notice of Actions

a. In addition to the discretionary reporting and joint investigation provisions set forth at Section 13.6-1, the Chief of Staff and/or the Chief Executive Officer are authorized to inform his or her counterpart officer at any other system member where the practitioner is known to hold privileges whenever any of the following actions has been taken:




1) Summary suspension of clinical privileges should be reported promptly upon imposition (other than automatic suspensions for failure to complete medical records or pay dues).

2) Other corrective actions may be reported at any time the Chief of Staff or Chief Executive Officer determines such a report to be appropriate, and should be reported promptly upon final action by the board.

b. The effect of such action on the involved practitioner’s privileges at another system member shall be determined by the medical staff bylaws or other applicable policies of that other system member; or, if there are no applicable bylaws or policies, the information shall be deemed transmitted for the receiving system member’s independent review and action.

c. The Chief of Staff and Chief Executive Officer are authorized to disclose to another system member’s peer review body (or an authorized representative of that body) information from the hospital and medical staff records regarding such a practitioner or allied health professional.

13.6-3 Effect of Actions Taken by Other Entities

Except as provided in Bylaws, Section 13.3-11, whenever the Chief of Staff or Medical Executive Committee receives information about an action taken at another system member and involving a practitioner or Allied Health Professional holding privileges at the hospital, the Chief of Staff or Medical Executive Committee shall, if time permits, independently assess the facts and circumstances to ascertain whether to take comparable action. However, when the practitioner or Allied Health Professional was summarily suspended or restricted at the other system member, any person authorized under Bylaws, Section 13.2-1, Criteria for Initiation, to impose a summary action is authorized to immediately impose a comparable suspension or restriction at this hospital, subject to review by the Medical Executive Committee in accordance with the provisions of Bylaws, Section 13.2, Summary Restriction or




Suspension.]

Article 14

HEARINGS AND APPELLATE REVIEWS


14.1-1 Review Philosophy

The intent in adopting these hearing and appellate review procedures is to provide for a fair review of decisions that adversely affect practitioners (as defined below), and at the same time to protect the peer review participants from liability. It is further the intent to establish flexible procedures which do not create burdens that will discourage the Medical Staff and Governing Body from carrying out peer review.

Accordingly, discretion is granted to the Medical Staff and Governing Body to create a hearing process which provides for the least burdensome level of formality in the process and yet still provides a fair review and to interpret these bylaws in that light. The Medical Staff, the Governing Body, and their officers, committees and agents hereby constitute themselves as peer review bodies under the federal Health Care Quality Improvement Act of 1986 and the California peer review hearing laws and claim all privileges and immunities afforded by the federal and state laws.


CHA Bylaws articulate a fair hearing philosophy, and clarify that the participating bodies are part of the peer review process for purposes of immunities and other statutory protections.

14.1-2 Exhaustion of Remedies

If an adverse action as described in Section 14.2 is taken or recommended, the practitioner must exhaust the remedies afforded by these bylaws before resorting to legal action.

7.1-1 EXHAUSTION OF REMEDIES

If adverse action described in Section 7.2 is taken or recommended, the applicant or member must exhaust the remedies afforded by these bylaws before resorting to legal action.

14.1-3 Intra-Organizational Remedies

The hearing and appeal rights established in the bylaws are strictly adjudicative rather than legislative in structure and function. The hearing committees have no authority to adopt or modify rules and standards or to decide questions about

The authority of the hearing body vis-à-vis adopting or modifying applicable standards is stated in the CHA Bylaws. There is also provision for Governing Body review of challenges to rules. These provisions are




the merits or substantive validity of bylaws, rules or policies. However, the Governing Body may, in its discretion, entertain challenges to the merits or substantive validity of bylaws, rules or policies and decide those questions. If the only issue in a case is whether a bylaw, rule or policy is lawful or meritorious, the practitioner is not entitled to a hearing or appellate review. In such cases, the practitioner must submit his challenges first to the Governing Body and only thereafter may he or she seek judicial intervention.

important in that they provide an avenue of redress for the affected practitioner, yet do not extend to a hearing committee the effective ability to change the standards.

14.1-4 Joint Hearings and Appeals

The Medical Staff and Governing Body are authorized to participate in joint hearings and appeals in accordance with Bylaws, Section 14.14 .

14.1-5 Definitions

Except as otherwise provided in these bylaws, the following definitions shall apply under this Article:

a. Body whose decision prompted the hearing refers to the Medical Executive Committee in all cases where the Medical Executive Committee or authorized Medical Staff officers, members or committees took the action or rendered the decision which resulted in a hearing being requested. It refers to the Governing Body in all cases where the Governing Body or its authorized officers, directors or committees took the action or rendered the decision which resulted in a hearing being requested.

b. Practitioner, as used in this Article, refers to the practitioner who has requested a hearing pursuant to Bylaws, Section 14.3-2.

7.1-2 APPLICATION OF ARTICLE

For purposes of this Article, the term “member” may include “applicant,” and those with temporary privileges, as it may be applicable under the circumstances, unless otherwise stated. [In addition to medical staff members and applicants, clinical psychologists who are providing or applying to provide professional services in the hospital, but are not members of the medical staff, as well as marriage and family therapists and clinical social workers, are entitled to the hearing rights specified in this article.]

14.1-6 Substantial Compliance

Technical, insignificant or nonprejudicial deviations from




the procedures set forth in these bylaws shall not be grounds for invalidating the action taken.

7.1-3 TIMELY COMPLETION OF PROCESS

The hearing and appeal process shall be completed within a reasonable time.

7.1-4 FINAL ACTION

Recommended adverse actions described in Section 7.2 shall become final only after the hearing and appellate rights set forth in these bylaws have either been exhausted or waived, and only upon being adopted as final actions by the board of [trustees/directors].

14.2 GROUNDS FOR HEARING

Except as otherwise specified in these bylaws (including those Exceptions to Hearing Rights specified in Section 14.11), any one or more of the following actions or recommended actions shall be deemed actual or potential adverse action and constitute grounds for a hearing:

14.2-1 Denial of Medical Staff initial applications for membership and/or privileges.

14.2-2 Denial of Medical Staff reappointment and/or renewal of privileges.

14.2-3 Revocation, suspension, restriction, involuntary reduction of Medical Staff membership and/or privileges.

14.2-4 Involuntary imposition of significant consultation or Level III proctoring requirements as described at Section 7.4-4(a)(3) that cannot be completed prior to the time frame required for reporting the restriction to the Medical Board of California (i.e., Level I and Level II proctoring requirements, as well as transitory restrictions that do not require reporting to the Medical Board of the Data Bank do not entitle the practitioner to a hearing).

14.2-5 Summary suspension of Medical Staff membership and/or privileges during the pendency of corrective action and hearings and appeals procedures.

7.2 GROUNDS FOR HEARING

Except as otherwise specified in these bylaws, any one or more of the following actions or recommended actions shall be deemed actual or potential adverse action and constitute grounds for a hearing:

(a) denial of medical staff membership;

(b) denial of requested advancement in staff membership status, or category;

(c) denial of renewal of medical staff membership;

(d) demotion to lower medical staff category or membership status;

(e) suspension of staff membership;

(f) revocation of medical staff membership;

(g) denial of requested clinical privileges;

(h) involuntary reduction of current clinical privileges;

(i) suspension of clinical privileges;

(j) termination of all clinical privileges;

(k) involuntary imposition of significant consultation or monitoring requirements (excluding monitoring incidental to




14.2-6 Any other “medical disciplinary” action or recommendation that must be reported to the Medical Board of California under the provisions of Section 805 of the California Business and Professions Code or to the National Practitioner Data Bank.

provisional status and Section 5.3); or

(l) any other disciplinary action or recommendation that must be reported to the Medical Board pursuant to 805.01.

14.3 NOTICES OF ACTIONS AND REQUESTS FOR HEARING OR MEDIATION

14.3-1 Notice of Action or Proposed Action, Right to Hearing, Option for Mediation

a. In all cases in which action has been taken or a recommendation made as set forth in Section 14.2, the practitioner shall be given special notice of the recommendation or action and of the right to request a hearing pursuant to Section 14.3-2, Request for Hearing. The notice must state:

1) What action has been proposed against the practitioner;

2) Whether the action, if adopted, must be reported under Business and Professions Code Section 805;

3) A brief indication of the reasons for the action or proposed action;

4) That the practitioner may request a hearing;

5) That a hearing must be requested within 30 days; and

6) That the practitioner has the hearing rights described in the Medical Staff bylaws, including those specified in Section 14.6, Hearing Procedure.

b. The notice shall also advise the practitioner that he or she may request mediation of the dispute pursuant to Section 14.4, and that mediation must be requested, in writing, within 10 days.

7.3 REQUESTS FOR HEARING

7.3-1 NOTICE OF ACTION OR PROPOSED ACTION

In all cases in which action has been taken or a recommendation made as set forth in Section 7.2, the chief of staff or designee on behalf of the medical executive committee shall give the member prompt written notice of (1) the recommendation or final proposed action and that, except with respect to actions reported to Business and Professions Code §805.1, such action, if adopted, shall be taken and reported to the Medical Board of California and/or to the National Practitioner Data Bank if required; (2) the reasons for the proposed action including the acts or omissions with which the member is charged; (3) the right to request a hearing pursuant to Section 7.3-2, and that such hearing must be requested within [30] days; and (4) a summary of the rights granted in the hearing pursuant to the medical staff bylaws. If the recommendation or final proposed action is reportable to the Medical Board of California and/or to the National Practitioner Data Bank, the written notice shall state the proposed text of the report(s).

The CMA Bylaws establish a system for creating and challenging the contents of Medical Board (“805”) and National Practitioner Data Bank reports. These special procedures are not required by law and create unnecessary burdens for the Medical Staff.

The first step in the proposed system requires the notice of any adverse action to include the text of the proposed 805 or Data Bank report, if reporting may be require (CMA Section 7.3-1). This is premature in that the rationale for an action may not be established until after a hearing is concluded and the hearing committee and appeal board have issued their findings. The next step requires the hearing committee to state in its decision the text for the report (CMA Section 7.4-10) even though under the law, the person designated to report is responsible for preparing the report. The third and fourth steps allow the practitioner to appeal the decision to the Board of Directors to challenge the text of the report (CMA Section 7.5-2), and require the appellate review body to issue its version of the text of the report (CMA Section 7.5-6(c)). Another section allows only text approved by the Board of Directors to be used in the reports, which conflicts with the earlier sections giving the MEC (when it prepares the notice of hearing) or the hearing committee (if a decision is reached that is not appealed) authority to draft the text. These provisions open up the possibility that a practitioner could demand yet another hearing if a final report differs materially from the initially proposed report (which could happen if the hearing committee or Board of Directors had modified the recommended action or the reasons for the action). Finally, the proposed Bylaws anticipate some cases in which there will have been no hearing, but the member will want to challenge the proposed text. This is covered by a special




procedure for the Chief of Staff, the Chair of the subject’s department, and the hospital’s authorized representative or their respective designee to hear the practitioner’s claims (CMA Section 7.9).

The CHA Bylaws do not include these extra formal review steps (a practitioner has the statutory right to submit his/her version of events to the Medical Board/Data Bank) – believing they have the significant effect of altering the appropriate focus of a disciplinary hearing (inevitably the focus shifts away from what the practitioner did or did not do and what should be done about it, to what that 805/Data Bank report will say). Moreover, such a provision does not afford deference or discretion to the individuals who are legally bound (and subject to personal legal penalties) to make the reports they deem necessary in light of their personal legal responsibilities.

14.3-2 Request for Hearing or Mediation

a. The practitioner shall have 30 days following receipt of special notice of such action to request a hearing (and, if applicable, a preliminary hearing, as further described at Section 14.5)] The request shall be in writing addressed to the Chief of Staff with a copy to the Chief Executive Officer. If the practitioner does not request a hearing within the time and in the manner described, the practitioner shall be deemed to have waived any right to a hearing and accepted the recommendation or action involved. Such final recommendation shall be considered by the Governing Body within [70] days and shall be given great weight by the Governing Body, although it is not binding on the Governing Body.

b. The practitioner shall state, in writing, his or her intentions with respect to attorney representation at the time he or she files the request for a hearing. Additionally, the practitioner shall provide the names of any attorneys the practitioner wishes to proffer as a possible hearing officer, as further described at Bylaws, Section 14.6-5.

7.3-2 REQUEST FOR HEARING

The member shall have [30] days following receipt of notice of such action to request a hearing. The request shall be in writing addressed to the medical executive committee with a copy to the board of [trustees/directors]. In the event the member does not request a hearing within the time and in the manner described, the member shall be deemed to have waived any right to a hearing and accepted the recommendation or action involved.

The CHA Bylaws preserve the Governing Body’s authority to render a different decision, so long as they do so in a manner consistent with statutory standards (i.e., the Business & Professions Section 809.05 provision requiring the Governing Body to afford “great weight” to the MEC’s actions.

The CHA Bylaws provisions regarding timely notice of intent to be represented is important to facilitating timely involvement of Medical Staff legal counsel, as well as early communications between the Medical Staff’s and practitioner’s attorney. (Some practitioners (or their counsel) prefer to keep this a secret, thereby impeding preparation and prehearing resolution of procedural matters.)




c. . Any request for mediation must be received within 10 days of the date of receipt of the notice sent pursuant to Bylaws, Section 14.3-1(b). Timely request for mediation should also be required.

14.4 Mediation of Peer Review Disputes

14.4-1 Mediation is a confidential process in which a neutral person facilitates communication between the Medical Executive Committee and a practitioner to assist them in reaching a mutually acceptable resolution of a peer review controversy in a manner that is consistent with the best interests of patient care.

14.4-2 The parties are encouraged to consider mediation whenever it could be productive in resolving the dispute.

14.4-3 In order to obtain consideration of mediation, the practitioner must request mediation in writing, as defined herein, within 10 days of his/her receipt of a notice of action or proposed action that would give rise to a hearing pursuant to Section 14.2.

14.4-4 If the practitioner and the Medical Executive Committee agree to mediation, all deadlines and time frames relating to the fair hearing process shall be tolled while the mediation is in process, and the practitioner agrees that no damages may accrue as the result of any delays attributable to the mediation.

14.4-5 Mediation cannot be used by either the medical staff or the practitioner as a way of unduly delaying the corrective action/fair hearing process. Accordingly, unless both the medical staff and the practitioner agree otherwise, mediation must commence within 30 days of the practitioner’s request and must conclude within 30 days of its commencement. If the mediation does not resolve the dispute, the fair hearing process will promptly resume upon completion of the mediation.

14.4-6 The parties shall cooperate in the selection of a mediator (or mediators). Mediators should be both familiar with the mediation process and knowledgeable regarding the issues in dispute. The mediator may also serve as the

The CHA Bylaws include provision for optional mediation of disputes.

Mediation should be conditioned upon an agreed tolling of other deadlines.




hearing officer at any subsequent hearing, subject to the agreement of the parties which may be given prior to the mediation or after, with the parties to decide when they will agree on this issue. The costs of mediation shall be shared two-thirds by the medical staff and one third by the practitioner. The inability of the medical staff and the practitioner to agree upon a mediator within the required time limits shall result in the termination of the mediation process and the resumption of the fair hearing process.

14.4-7 Once selected, the mediator and the parties, working together, shall determine the procedures to be followed during the mediation. Either party has the right to be represented by legal counsel in the mediation process.

14.4-8 All mediation proceedings shall be confidential and the provisions of California Evidence Code Section 1119 shall apply except that communications that confirm that mediation was mutually accepted and pursued may be disclosed as proof that otherwise applicable time frames were tolled or waived. Any such disclosure shall be limited to that which is necessary to confirm mediation was pursued, and shall not include any points that are substantive in nature or address the issues presented. Except as otherwise permitted in this section, no other evidence of anything said at, or any writing prepared for or as the result of, the mediation shall be used in any subsequent fair hearing process that takes place if the mediation is not successful.

14.5 Preliminary Hearing

14.5-1 Any affected practitioner shall have the right to challenge imposition of a summary action, particularly on the issue of whether or not, based on the information presented to the Medical Executive Committee at the time the summary action was imposed and/or continued in effect (as described at Section 13.2-2), the Medical Executive Committee reasonably determined that failure to summarily restrict or suspend could reasonably result in an imminent danger to the health of an individual. Initially, the

[for purposes of comparison, these provisions of CMA Model § 6.4-4 have been duplicated here]

(a) . . . . If the medical executive committee’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

See comments accompanying Section 13.2-3 regarding some of the pros and cons of bifurcated hearings provided for in the CMA Model.

CHA’s Preliminary Hearing provisions are designed to achieve the benefits of prompt review, while addressing many of the other issues that bifurcated hearings could otherwise entail.




practitioner may present this challenge to the Medical Executive Committee at the meeting held within seven calendar days of imposition of the suspension action. If the Medical Executive Committee's decision is to continue the summary action, then any practitioner who has properly requested a hearing under the Medical Staff bylaws may, within the timeframe and as described at Bylaws, Section 14.3-2, also request a preliminary hearing devoted exclusively to whether there is sufficient evidence based on the information presented to the Medical Executive Committee at the time the summary action was imposed and/or continued in effect, that failure to summarily restrict or suspend could reasonably result in an imminent danger to the health of an individual.

14.5-2 This preliminary hearing shall be conducted by the hearing officer appointed pursuant to Section 14.6-5, and, unless waived by the practitioner, the Hearing Committee appointed for the full hearing, comprised pursuant to Section 14.6-4. Except as otherwise agreed by the parties, the preliminary hearing shall be convened within 15 days of the date all members of the Hearing Committee have been appointed. The hearing officer and Hearing Committee members shall be subject to reasonable questions and challenges to qualifications and potential conflicts, as provided at Section 14.6-14), and the evidentiary portion of the preliminary hearing shall be commenced, diligently pursued, and completed as promptly as reasonably possible. Except as modified by this Section 14.5, the provisions of Sections 14.6-14 [right of the parties] shall apply; however the hearing officer shall be empowered to adjust timeframes and modify procedures otherwise described in Article 14-6, as necessary to achieve a timely preliminary hearing. If the hearing officer determines that the member is not proceeding diligently in furtherance of a timely preliminary hearing, the hearing officer, in consultation with the Chair of the Hearing Committee if one has been appointed, may terminate the preliminary hearing, and order that the matter be heard as part of the full hearing, as described at Section 14.6.

14.5-3 At the conclusion of the preliminary hearing, the

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 medical executive committee 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.




hearing officer, or Hearing Committee, as applicable, shall issue a written decision as to whether, based on the information presented to the Medical Executive Committee at the time the summary action was imposed and/or continued in effect (as described at Section 13.2-2) reasonably determined that failure to summarily restrict or suspend could reasonably result in "imminent danger" to the health of an individual. The decision may affirm or reject, but may not modify, the action imposed by the Medical Executive Committee (although it may recommend that the Medical Executive Committee consider modification). The written decision shall include documented findings of fact and a conclusion articulating the connection between the evidence produced at the hearing and the decision reached, and shall be transmitted to both the affected practitioner and the Medical Executive Committee within 15 calendar days from the conclusion of the preliminary hearing.

14.5-4 If the hearing officer's, or Hearing Committee's (as applicable) determination is that the information presented to the Medical Executive Committee at the time the summary action was imposed and/or continued in effect does not reasonably support a determination that failure to summarily restrict or suspend the practitioner's Privileges could reasonably result in imminent danger to the health of an individual, the determination shall be immediately transmitted to the Medical Executive Committee for reconsideration of its imposition of summary action. If the Medical Executive Committee does not rescind the summary action within ten 10 days of receipt of the hearing officer's or Hearing Committee's determination, the matter shall be immediately transmitted to the Governing Body, which shall process the matter as an appeal from a favorable hearing recommendation, as further described at Section 14.7; provided, however, the appeal shall be heard within 45 calendar days of the date of the hearing officer's or Hearing Committee's initial determination in the matter; and further provided that the full hearing on the merits is not stayed and may proceed as usual during the pendency of the appeal.

14.5-5 Nothing in the foregoing precludes the Medical




Executive Committee from imposing other remedial action in lieu of the initial summary action; and if such other action is itself a summarily imposed restriction of privileges that is reportable to the Medical Board of California, then the affected member shall be entitled to challenge such alternative summary actions in the same manner as described above for the initial summary action.

14.5-6 If the hearing officer, or Hearing Committee, determines that the information presented to the Medical Executive Committee at the time the summary action was imposed and/or continued in effect reasonably supports a determination that failure to summarily restrict or suspend could reasonably result in imminent danger to the health of an individual, the summary action shall remain in effect pending conclusion of the full hearing and any appellate review.

14.5-7 A full hearing on the merits of the summary action and any additional restrictions or discipline shall be conducted as soon as reasonably possible, in accordance with the provisions of Business and Professions Code Section 8.09 et seq. Subject to the following limitations, the findings of fact from the preliminary hearing shall be deemed established in the full hearing; provided, however, the Hearing Committee shall be permitted to hear additional evidence and to reconsider the conclusions previously reached in light of the evidence produced at the full hearing. Notwithstanding the foregoing, a preliminary hearing determination that a summary action was not warranted shall, if upheld by the Governing Body pursuant to the appeal provisions set forth above, be binding on the hearing committee with respect to that particular decision.

14.6 HEARING PROCEDURE

14.6-1 Hearings Prompted by Governing Body Action

If the hearing is based upon an adverse action by the Governing Body, the chair of the Governing Body shall fulfill the functions assigned in this Section to the Chief of Staff, and the Governing Body shall assume the role of the Medical Executive Committee. The Governing Body may,

CHA Bylaws now clarify that there is no need to conduct a Governing Body appeal if the decision prompting the hearing was initiated by the Governing Body. However, There may be circumstances where appellate review is advisable, so the provision allows the Governing Body, in its discretion, to permit an




but need not grant appellate review of decisions resulting from such hearings.

appellate review.

14.6-2 Time and Place for Hearing

Upon receipt of a request for hearing, the Chief of Staff shall schedule a hearing and, within 30 days from the date he or she received the request for a hearing, give special notice to the practitioner of the time, place and date of the hearing. The date of the commencement of the hearing shall be not less than 30 days nor more than 60 days from the date the Chief of Staff received the request for a hearing; [provided, however, that when the request is received from a member who is under summary action and has timely requested a preliminary hearing as described in Bylaws, Section 14.5-1, the timely commencement of a preliminary hearing shall be deemed to satisfy the provisions of these bylaws for timely commencement of the hearing.]

7.3-3 TIME AND PLACE FOR HEARING

Upon receipt of a request for hearing, the medical executive committee shall schedule a hearing and, within [15] days give notice to the member of the time, place and date of the hearing. Unless extended by the judicial review committee, the date of the commencement of the hearing shall be not less than [30] days from the date of notice, nor more than [60] days from the date of receipt of the request by the medical executive committee for a hearing; provided, however, that when the request is received from a member who is under summary suspension the hearing shall be held as soon as the arrangements may reasonably be made, so long as the member has at least 30 days from the date of notice to prepare for the hearing or waives this right.

14.6-3 Notice of Charges

Together with the special notice stating the place, time and date of the hearing, the Chief of Staff shall state clearly and concisely in writing the reasons for the adverse proposed action taken or recommended, including the acts or omissions with which the practitioner is charged and a list of the charts in question, where applicable. A supplemental notice may be issued at any time, provided the practitioner is given sufficient time to prepare to respond.

7.3-4 NOTICE OF HEARING

Together with the notice stating the place, time and date of the hearing, which date shall not be less than 30 days after the date of the notice unless waived by a member under summary suspension, the chief of staff or designee on behalf of the medical executive committee shall provide the reasons for the recommended action, including the acts or omissions with which the member is charged, a list of the charts in question, where applicable, and a list of the witnesses (if any) expected to testify at the hearing on behalf of the medical executive committee. The content of this list is subject to update pursuant to Section 7.4-1.

14.6-4 Hearing Committee

a. When a hearing is requested, the Chief of Staff shall appoint a Hearing Committee which shall be composed of not less than three members who shall gain no direct financial benefit from the outcome and who have not acted as accuser, investigator, fact finder, initial decision maker or otherwise have not actively participated in the consideration of the matter leading up to the recommendation or action. Knowledge of the matter involved shall not preclude a member of the Medical Staff

7.3-5 JUDICIAL REVIEW COMMITTEE

When a hearing is requested, the medical executive committee shall appoint a judicial review committee. The judicial review committee shall be composed of not less than [5] members of the medical staff. The judicial review committee members shall be impartial, shall gain no direct financial benefit from the outcome, and shall not have acted as accusers, investigators, fact finders, initial decision makers or otherwise have not actively participated in the consideration of the matter leading up to the recommendation

The CMA Bylaws provision for a five-member hearing committee significantly increases scheduling difficulties (and for those Medical Staffs who compensate hearing committee members for their time, can significantly increase the cost as well).




from serving as a member of the Hearing Committee. In the event that it is not feasible to appoint a Hearing Committee from the active Medical Staff, the Chief of Staff may appoint members from other Medical Staff categories or practitioners who are not Medical Staff members. Such appointment shall include designation of the chair. When feasible, the Hearing Committee shall include at least one member who has the same healing arts licensure as the practitioner and who practices the same specialty as the practitioner. The Chief of Staff may appoint alternates who meet the standards described above and who can serve if a Hearing Committee member becomes unavailable.

b. Alternatively, an arbitrator may be used who is selected using a process mutually accepted by the body whose decision prompted the hearing and the practitioner. The arbitrator need not be either a health professional or an attorney. The arbitrator shall carry out all of the duties assigned to the Hearing Officer and to the Hearing Committee.

c. The Hearing Committee, or the arbitrator, if one is used, shall have such powers as are necessary to discharge its or his or her responsibilities.

or action. In accordance with Section 14.6, all members of the judicial review committee shall disclose in writing to the parties to the hearing those current or impending personal, professional, or financial affiliations or relationships of which they are reasonably aware, including contractual, employment or other relationships with the hospital which could foreseeably result in a conflict of interest with their activities or responsibilities on behalf of the Judicial Review Committee. Any potential conflicts so disclosed shall be resolved as set forth in Section 14.6. Knowledge of the matter involved shall not preclude a member of the medical staff from serving as a member of the judicial review committee. In the event that it is not feasible to appoint a judicial review committee from the active medical staff, the medical executive committee may appoint members from other staff categories or practitioners who are not members of the medical staff. Such appointment shall include designation of the chair. of the [ ] members of the medical staff that serve on the judicial review committee at least one shall be a member who shall have the same healing arts licensure as the accused, and where feasible, the committee shall also include an individual practicing the same specialty as the member. All other members shall have MD or DO degrees or their equivalent as defined in Section 2.2-2(a).

CMA Bylaws rigorous conflict of interest disclosures go well beyond what is required by California law for hearing panel members, and could further complicate the ability to appoint a hearing committee.

Query: Does resolution per 14.6 conflict with Business & Professions Code Section 809.2(c) which provides that the hearing officer shall rule on challenges?

The CMA Bylaws omit the provision of California law permitting use of an arbitrator (Business & Professions Section 809.2(a)).

CMA limits participation of non-physicians, unless the hearing involves such other licensee. Query: does this unnecessarily limit the available pool of potential committee members (e.g., if the issues are non-clinical, is it necessary to so limit the hearing committee)?

14.6-5 The Hearing Officer

Option 1

a. The use of a Hearing Officer to preside at a hearing is mandatory. The appointment of a Hearing Officer shall be by the Chief Executive Officer, as a representative of the Medical Executive Committee as follows:

1) Together with the notice of a hearing, the practitioner shall be provided a list of at least three but no more than five potential Hearing Officers meeting the criteria set forth in Bylaws, Section 14.6-5(b).

2) The practitioner shall have five work days to

7.4-3 THE HEARING OFFICER

The medical executive committee shall appoint a hearing officer to preside at the hearing. The hearing officer shall be an attorney at law qualified to preside over a quasi-judicial hearing, but attorneys from a firm regularly utilized by the hospital, the medical staff or the involved medical staff member or applicant for membership, for legal advice regarding their affairs and activities shall not be eligible to serve as hearing officer.

[The following language has been duplicated from CMA Section 7.4-1(e), for comparison purposes]

…. If the member challenges the impartiality of the hearing officer, the member and the peer review body shall agree to a mutually acceptable hearing officer. If the licentiate and peer

Both the CHA and CMA Bylaws been modified to address concerns raised by the California courts in Yacub v. Salinas Valley Memorial Hospital (2004) 122 Cal.App.4th 474.

The CHA provisions are based on discussions of a group of hospital, medical staff, and physicians’ attorneys who voluntarily convened over a two-year period to address ways to improve peer review and peer review hearing processes. The CHA Bylaws provide alternative means of selecting hearing officers – involving a mutual selection process, if possible, plus (under Option 2) a third party resource for identifying potential hearing officers and a process for choosing the




accept any of the listed potential Hearing Officers, or to propose at least three but no more than five other names of potential Hearing Officers meeting the criteria set forth in Bylaws, Section 14.6-5(b).

3) If the practitioner is represented by counsel, the parties' counsel may meet and confer in an attempt to reach accord in the selection of a Hearing Officer from the two parties' lists.

4) If the parties are not able to reach agreement on the selection of a Hearing Officer within five working days of receipt of the practitioner's proposed list, the hospital’s Chief Executive Officer shall select an individual from the composite list.

5) Unless a Hearing Officer is selected pursuant to stipulation of the parties, he/she shall be subject to reasonable voir dire.

Option 2

a. The use of a hearing officer to preside at a hearing is mandatory. Unless otherwise agreed upon by the practitioner and the Medical Staff, the following procedure shall be used to select the hearing officer:

1) As part of his/her request for a hearing pursuant to Section 14.3-2, the practitioner must list 5 attorneys who the practitioner would accept as a hearing officer, three of whose names must be obtained from the list maintained by the hearing officer listing service operated by the California Society for Healthcare Attorneys, or such other Hearing Officer listing service as may be endorsed for that purpose by both the California Medical Association (CMA) and the California Hospital Association (CHA). The Medical Staff may then select the hearing officer from the practitioner’s list. Failure of the practitioner to submit the requisite list shall constitute a waiver of any right to participate in the hearing officer selection process and the Medical Staff may then select a duly qualified hearing officer.

review body are unable to agree, they shall utilize the services of a third party selection service. In the event the parties are unable to agree to such a service within 10 working days of the request for a hearing, each party shall provide a list of five names. Each party may strike up to two names to which the party objects and shall rank the remaining names in order of preference with “1” being the strongest preference. No name shall be left blank. The person with the lowest combined rank whose name has not been stricken by either party shall be invited to serve as the hearing officer. In the event this process does not result in the selection of a hearing officer, the matter shall be resolved by lot.

The hearing officer shall gain no direct financial benefit from the outcome and must not act as a prosecuting officer or as an advocate. The hearing officer shall preside over the voir dire process and may question panel members directly, and shall make all rulings regarding service by the proposed hearing panel members or the hearing officer. The hearing officer shall endeavor to assure that all participants in the hearing have a reasonable opportunity to be heard and to present relevant oral and documentary evidence in an efficient and expeditious manner, and that proper decorum is maintained. The hearing officer shall be entitled to determine the order of or procedure for presenting evidence and argument during the hearing and shall have the authority and discretion to make all rulings on questions which pertain to matters of law, procedure or the admissibility of evidence.

The Hearing Officer’s authority shall include, but not be limited to, making rulings with respect to requests and objections pertaining to the production of documents, requests for continuances, designation and exchange of proposed evidence, evidentiary disputes, witness issues including disputes regarding expert witnesses, and setting reasonable schedules for timing and/or completion of all matters related

hearing officer in the event the parties cannot reach agreement on a mutually selected hearing officer.

Option 1 of the CHA Model incorporates some mutual selection procedures that could be implemented in lieu of using the selection service described in Option 2.

Option 2 makes use of a third-party selection service that is now available in California.

The CMA Bylaws now include provisions relating to the third party selection service, which are also based on the discussions of the above-referenced group. While the specifics of the processes differ somewhat, the intent is the same – to provide a relatively expeditious means to participatorily select a hearing officer.




2) If the Medical Staff is not willing to accept any of the five proposed hearing officers identified by the practitioner, the Medical Staff, within 5 working days of receipt of the practitioner’s list, must provide the practitioner an alternative written list of 5 potential hearing officers (three of whom must be obtained from the hearing officer listing service. Failure to provide an alternative list within the 5 working days shall constitute a waiver of the right to reject the practitioner’s list and the Medical Staff would then be required to select one of the persons previously identified by the practitioner from the hearing officer selection service list as the hearing officer.

3) If the Medical Staff provides an alternative list, the practitioner has 5 working days to select the hearing officer from that list. The failure of the practitioner to respond to the proposed candidates within the 5 working days shall constitute a waiver of the right to reject the Medical Staff’s alternative list and the Medical Staff may then select anyone from that list as the hearing officer.

4) If the practitioner timely rejects all of the hearing officer candidates from the Medical Staff’s alternative list, the Medical Staff, within five working days, shall contact the hearing officer listing service for a final list of five additional hearing officer candidates. In submitting its request, the Medical Staff may ask the hearing officer selection service to (1) screen potential candidates for obvious conflicts and availability, and (2) provide information regarding potential candidates’ fees and travel

charge policy. Once the list has been supplied, if the Medical Staff and the practitioner cannot agree upon a candidate, the Medical Staff and the practitioner shall, in turn, each strike two candidates and the remaining candidate shall be the hearing officer. The side that strikes first shall be determined by lot. Unless a hearing officer is selected pursuant to stipulation of the parties, as opposed to striking candidate names, he/she shall be subject to reasonable voir dire.

5) Unless waived by the parties, the hearing officer so selected must meet the qualifications set forth at Section

to the hearing.

At the commencement of the hearing, the hearing officer may also apprise the judicial review committee of its right to terminate the hearing due to the member's failure to cooperate with the hearing process, but shall not independently make that determination or otherwise recommend such a termination at any other time. Except as provided above, if the hearing officer determines that either side in a hearing is not proceeding in an efficient and expeditious manner, the hearing officer may take such discretionary action as seems warranted by the circumstances, including, but not limited to, limiting the scope of examination and cross-examination and setting fair and reasonable time limits on either side’s presentation of its case.

If requested by the judicial review committee, the hearing officer may participate in the deliberations of such committee and be a legal advisor to it, but the hearing officer shall not be entitled to vote.

In all matters, the hearing officer shall act reasonably under the circumstances and in compliance with applicable legal principles. In making rulings, the hearing officer shall endeavor to promote a less formal, rather than more formal, hearing process and also to promote the swiftest possible resolution of the matter, consistent with the standards of fairness set forth in these Bylaws. When no attorney is accompanying any party to the proceedings, the hearing officer shall have authority to interpose any objections and to initiate rulings necessary to ensure a fair and efficient process.

As drafted, the CMA Bylaws appear to preclude he hearing officer from even apprising the hearing committee with respect to its termination rights at any time after the hearing has commenced.




14.6-5(b).

b. The hearing officer shall be an attorney at law qualified to preside over a quasi-judicial hearing, but attorneys from a firm regularly utilized by the hospital, the Medical Staff or the involved Medical Staff member or applicant for membership, for legal advice regarding their affairs and activities shall not be eligible to serve as hearing officer. The hearing officer shall gain no direct financial benefit from the outcome and must not act as a prosecuting officer or as an advocate.

c. The hearing officer shall preside over the voir dire process and may question panel members directly, and shall make all rulings regarding service by the proposed hearing committee members or the hearing officer. The hearing officer shall endeavor to assure that all participants in the hearing have a reasonable opportunity to be heard and to present relevant oral and documentary evidence in an efficient and expeditious manner, and that proper decorum is maintained. The hearing officer shall be entitled to determine the order of or procedure for presenting evidence and argument during the hearing and shall have the authority and discretion to make all rulings on questions which pertain to matters of law, procedure or the admissibility of evidence.

d. The hearing officer’s authority shall include, but not be limited to, making rulings with respect to requests and objections pertaining to the production of documents, requests for continuances, designation and exchange of proposed evidence, evidentiary disputes, witness issues including disputes regarding expert witnesses, and setting

reasonable schedules for timing and/or completion of all matters related to the hearing.

e. If the hearing officer determines that either side in a hearing is not proceeding in an efficient and expeditious manner, the hearing officer may take such discretionary action as seems warranted by the circumstances, including, but not limited to, limiting the scope of examination and cross-examination and setting fair and reasonable time

CHA Bylaws also address how a hearing may be terminated in the event either side refuses to proceed in accordance with the Bylaws. CHA Bylaws permit




limits one either side's presentation of its case. [Under extraordinary circumstances, the hearing officer may recommend termination of the hearing; however, the Hearing Officer may not unilaterally terminate the hearing and may only issue an order that would have the effect of terminating the hearing (a “terminating order”) at the direction of the Hearing Committee. The terminating order shall be in writing and shall include documentation of the reasons therefor. If a terminating order is against the Medical Executive Committee, the charges against the practitioner will be deemed to have been dropped. If, instead, the terminating order is against the practitioner, the practitioner will be deemed to have waived his/her right to a hearing. The party against whom termination sanctions have been ordered may appeal the terminating order to the hospital Governing Body.. The appeal must be requested within 10 days of the terminating order, and the scope of the appeal shall be limited to reviewing the appropriateness of the terminating order. The appeal shall be conducted in general accordance with the provisions of Bylaws, Section 14.7. If the order is found to be unwarranted, the Hearing Committee shall reconvene and resume the hearing. If the Governing Body determines that the terminating order should not have been issued, the matter will be remanded to the Hearing Committee for completion of the hearing.]

f. Upon adjournment of the evidentiary portion of the hearing, the hearing officer shall meet with the members of the hearing committee to assist them with the process for their review of the evidence and preparation of the report of their decision. Upon request from the hearing committee members, the hearing officer may remain during the hearing committee's full deliberations. During the deliberative process, the hearing officer shall act as legal advisor to the hearing committee, but shall not be entitled to vote.

g. In all matters, the hearing officer shall act reasonably under the circumstances and in compliance with applicable legal principles. In making rulings, the hearing officer shall endeavor to promote a less formal, rather than more formal, hearing process and also to promote the swiftest possible resolution of the matter, consistent with the

hearing officer recommendations, as well as permitting this to occur at any time in the process (not just at the commencement of the hearing).




standards of fairness set forth in these bylaws. When no attorney is accompanying any party to the proceedings, the hearing officer shall have authority to interpose any objections and to initiate rulings necessary to ensure a fair and efficient process.

h. [[Further Optional Provision:] To the extent that any provision in this section of these bylaws may conflict with any other provision of the bylaws (e.g. granting certain duties and authority to the Chair of the JRC), this provision shall preempt and control.]

14.6-6 Representation

a. The practitioner shall have the right, at his or her expense, to attorney representation at the hearing. If the practitioner elects to have attorney representation, the body whose decision prompted the hearing may also have attorney representation. Conversely, if the practitioner elects not to be represented by an attorney in the hearing, then the body whose decision prompted the hearing shall not be represented by an attorney in the hearing. When attorneys are not allowed, the practitioner and the body whose decision prompted the hearing may be represented at the hearing only by a practitioner licensed to practice in the State of California who is not also an attorney.

b. Notwithstanding the foregoing and regardless of whether the practitioner elects to have attorney representation at the hearing, the parties shall have the right to consult with legal counsel to prepare for a hearing or an appellate review.

c. Any time attorneys will be allowed to represent the parties at a hearing, the Hearing Officer shall have the discretion to limit the attorneys’ role to advising their clients rather than presenting the case.

7.4-2 REPRESENTATION

The hearings provided for in these bylaws are for the purpose of intraprofessional resolution of matters bearing on professional conduct, professional competency, or character.

The member shall be entitled to representation by legal counsel in any phase of the hearing, if the member so chooses, and shall receive notice of the right to obtain representation by an attorney at law. In the absence of legal counsel, the member shall be entitled to be accompanied by and represented at the hearing by an individual of the member’s choosing who is not also an attorney at law, and the medical executive committee shall appoint a representative who is not an attorney to present its action or recommendation, the materials in support thereof, examine witnesses, and respond to appropriate questions. The medical executive committee shall not be represented by an attorney at law if the member is not so represented.

CHA Bylaws clarify that representation by an attorney is at the member’s expense.

CMA Bylaws do not clarify that attorney representation is at the member’s expense.

CHA’s clarification (deleting the “at-law”) phrase helps assure that unlicensed attorneys will not be able to serve as the practitioner’s representative.

In some circumstances, legal counsel for either side can be obstreperous and interfere with the peer review aspects of these hearings. Discretion to limit the role of the attorney can be important in these circumstances.

14.6-7 Failure to Appear or Proceed

Failure without good cause of the practitioner to personally attend and proceed at a hearing in an efficient and orderly

7.3-6 FAILURE TO APPEAR OR PROCEED

Failure without good cause of the member to personally attend and proceed at such a hearing in an efficient and




manner shall be deemed to constitute voluntary acceptance of the recommendations or actions involved.

orderly manner shall be deemed to constitute voluntary acceptance of the recommendations or actions involved.

14.6-8 Postponements and Extensions

Once a request for hearing is initiated, postponements and extensions of time beyond the times permitted in these bylaws may be permitted upon a showing of good cause, as follows:

7.3-7 POSTPONEMENTS AND EXTENSIONS

Once a request for hearing is initiated, postponements and extensions of time beyond the times permitted in these bylaws may be permitted by the hearing officer on a showing of good cause, or upon agreement of the parties. The Medical Executive Committee shall exercise ongoing oversight over the hearing to ensure the timely resolution of issues.

a. Until such time as a Hearing Officer has been appointed, by the Hearing Committee or its chair acting upon its behalf; or

b. Once appointed by the Hearing Officer.

14.6-9 Discovery

a. Rights of Inspection and Copying:

The practitioner may inspect and copy (at his or her expense) any documentary information relevant to the charges that the Medical Staff has in its possession or under its control. The body whose decision prompted the hearing may inspect and copy (at its expense) any documentary information relevant to the charges that the practitioner has in his or her possession or under his or her control. The requests for discovery shall be fulfilled as soon as practicable. Failures to comply with reasonable discovery requests at least 30 days prior to the hearing shall be good cause for a continuance of the hearing.

b. Limits on Discovery:

The hearing officer shall rule on discovery disputes the parties cannot resolve. Discovery may be denied when justified to protect peer review or in the interest of fairness and equity. Further, the right to inspect and copy by either party does not extend to confidential information referring to individually identifiable practitioners other than the practitioner under review nor does it create or imply any obligation to modify or create documents in order to satisfy a request for information.

7.4 HEARING PROCEDURE

7.4-1 PREHEARING PROCEDURE

(a) If either side to the hearing requests in writing a list of witnesses, within [15] days of such request, and in no event less than 10 days before commencement of the hearing, each party shall furnish to the other a written list of the names and addresses of the individuals, so far as is reasonably known or anticipated, who are anticipated to give testimony or evidence in support of that party at the hearing. The member shall have the right to inspect and copy documents or other evidence upon which the charges are based, as well as all other evidence relevant to the charges. The member shall also have the right to receive at least [30] days prior to the hearing a copy of the evidence forming the basis of the charges which is reasonably necessary to enable the member to prepare a defense, including all evidence which was considered by the medical executive committee in determining whether to proceed with the adverse action, and any exculpatory evidence in the possession of the hospital or medical staff. The member and the medical executive committee shall have the right to receive all evidence which will be made available to the Judicial Review Committee. Failure to disclose the identity of a witness or produce copies of all documents expected to be produced at least ten days before the

CHA Bylaws reflect the practitioner’s statutory rights (i.e., to copy at his/her expense).

The CMA “discovery” provisions have been very problematic for medical staffs, and significantly exceed those provided by California law. The provision for “any exculpatory evidence in possession of the hospital or the medical staff” is overbroad. This provision often leads to practitioners seeking information from other practitioner’s files and/or production of massive peer review or other hospital records that are of marginal relevance and/or that may impair ongoing peer review




commencement of the hearing shall constitute good cause for a continuance.

activities.

Also note, under the CMA Bylaws, the production is not at the members’ expense (as provided by California law), which further contributes to sweeping requests for records.

c. Ruling on Discovery Disputes:

In ruling on discovery disputes, the factors that may be considered include:

1) Whether the information sought may be introduced to support or defend the charges;

2) Whether the information is exculpatory in that it would dispute or cast doubt upon the charges or inculpatory in that it would prove or help support the charges and/or recommendation;

3) The burden on the party of producing the requested information; and

4) What other discovery requests the party has previously made.

d. Objections to Introduction of Evidence Previously Not Produced for the Medical Staff:

The body whose decision prompted the hearing may object to the introduction of the evidence that was not provided during an appointment, reappointment or privilege application review or during corrective action despite the requests of the peer review body for such information. The information will be barred from the hearing by the hearing officer unless the practitioner can prove he or she previously acted diligently and could not have submitted the information.

14.6-10 Pre-Hearing Document Exchange

At the request of either party, the parties must exchange all documents that will be introduced at the hearing. The documents must be exchanged at least ten days prior to the hearing. A failure to comply with this rule is good cause for

(b) The medical executive committee shall have the right to inspect and copy at its expense any documents or other evidence relevant to the charges which the member possesses or controls as soon as practicable after receiving the request.

(c) The failure by either party to provide access to this information at least 30 days before the hearing shall constitute good cause for a continuance. The right to inspect and copy by either party does not extend to confidential information referring solely to individually identifiable members, other than the member under review.

(d) The hearing officer shall consider and rule upon any request for access to information and may impose any safeguards the protection of the peer review process and justice requires. In so doing, the hearing officer shall consider:

(1) whether the information sought may be introduced to support or defend the charges;

(2) the exculpatory or inculpatory nature of the information sought, if any;

(3) the burden imposed on the party in possession of the information sought, if access is granted; and

(4) any previous requests for access to information submitted or resisted by the parties to the same proceeding.

(e) The member shall be entitled to a reasonable opportunity to question and challenge the impartiality of judicial review committee members and the hearing officer. Challenges to the impartiality of any judicial review committee member shall be ruled on by the hearing officer. If the member challenges the impartiality of the hearing officer, the member and the peer review body shall agree to a

The CMA Bylaws do, however, require the MEC to pay for any information provided by the member.

See comments at CHA Section 14.6-5,




the hearing officer to grant a continuance. Repeated failures to comply shall be good cause for the hearing officer to limit the introduction of any documents not provided to the other side in a timely manner.

14.6-11 Witness Lists

Not less than 15 days prior to the hearing, each party shall furnish to the other a written list of the names and addresses of the individuals, so far as is then reasonably known or anticipated, who are expected to give testimony or evidence in support of that party at the hearing. Nothing in the foregoing shall preclude the testimony of additional witnesses whose possible participation was not reasonably anticipated. The parties shall notify each other as soon as they become aware of the possible participation of such additional witnesses. The failure to have provided the name of any witness at least ten days prior to the hearing date at which the witness is to appear shall constitute good cause for a continuance.

mutually acceptable hearing officer. If the licentiate and peer review body are unable to agree, they shall utilize the services of a third party selection service. In the event the parties are unable to agree to such a service within 10 working days of the request for a hearing, each party shall provide a list of five names. Each party may strike up to two names to which the party objects and shall rank the remaining names in order of preference with “1” being the strongest preference. No name shall be left blank. The person with the lowest combined rank whose name has not been stricken by either party shall be invited to serve as the hearing officer. In the event this process does not result in the selection of a hearing officer, the matter shall be resolved by lot.

14.6-12 Procedural Disputes

a. It shall be the duty of the parties to exercise reasonable diligence in notifying the hearing officer of any pending or anticipated procedural disputes as far in advance of the scheduled hearing as possible in order that decisions concerning such matters may be made in advance of the hearing. Objections to any pre-hearing decisions may be succinctly made at the hearing.

b. The parties shall be entitled to file motions as deemed necessary to give full effect to rights established by the bylaws and to resolve such procedural matters as the hearing officer determines may properly be resolved outside the presence of the full Hearing Committee. Such motions shall be in writing and shall specifically state the motion, all relevant factual information, and any supporting authority for the motion. The moving party shall deliver a copy of the motion to the opposing party, who shall have five working days to submit a written response to the hearing officer, with a copy to the moving party. The hearing officer shall determine whether to allow oral argument on any such motions. The hearing officer’s ruling shall be in writing and shall be provided to the parties promptly upon its rendering.

(f) It shall be the duty of the member and the medical executive committee or its designee to exercise reasonable diligence in notifying the chair of the judicial review committee of any pending or anticipated procedural disputes as far in advance of the scheduled hearing as possible, in order that decisions concerning such matters may be made in advance of the hearing. Objections to any prehearing decisions may be succinctly made at the hearing.




All motions, responses and rulings thereon shall be entered into the hearing record by the hearing officer.

14.6-13 Record of the Hearing

A court reporter shall be present to make a record of the hearing proceedings and the pre-hearing proceedings if deemed appropriate by the hearing officer. The cost of attendance of the court reporter shall be borne by the hospital, but the cost of the transcript, if any, shall be borne by the party requesting it. The practitioner is entitled to receive a copy of the transcript upon paying the reasonable cost for preparing the record. The hearing officer may, but shall not be required to, order that oral evidence shall be taken only on oath administered by any person lawfully authorized to administer such oath.

7.4-4 RECORD OF THE HEARING

A shorthand reporter shall be present to make a record of the hearing proceedings, and the pre-hearing proceedings if deemed appropriate by the hearing officer. The cost of attendance of the shorthand reporter shall be borne by the hospital, but the cost of the transcript, if any, shall be borne by the party requesting it. The judicial review committee may, but shall not be required to, order that oral evidence shall be taken only on oath administered by any person lawfully authorized to administer such oath.

14.6-14 Rights of the Parties

Within reasonable limitations, both sides at the hearing may ask the Hearing Committee members and hearing officer questions which are directly related to evaluating their qualifications to serve and for challenging such members or the hearing officer, call and examine witnesses for relevant testimony, introduce relevant exhibits or other documents, cross-examine or impeach witnesses who shall have testified orally on any matter relevant to the issues, and otherwise rebut evidence, receive all information made available to the Hearing Committee, and to submit a written statement at the close of the hearing, as long as these rights are exercised in an efficient and expeditious manner. The practitioner may be called by the body whose decision prompted the hearing or the Hearing Committee and examined as if under cross-examination. The Hearing Committee may interrogate the witnesses or call additional witnesses if it deems such action appropriate.

7.4-5 RIGHTS OF THE PARTIES

Within reasonable limitations, both sides at the hearing may call and examine witnesses for relevant testimony , introduce relevant exhibits or other documents , cross-examine or impeach witnesses who shall have testified orally on any matter relevant to the issues, and otherwise rebut evidence , as long as these rights are exercised in an efficient and expeditious manner. The member may be called by the medical executive committee and examined as if under cross-examination.

14.6-15 Rules of Evidence

Judicial rules of evidence and procedure relating to the conduct of the hearing, examination of witnesses, and presentation of evidence shall not apply to a hearing conducted under this Article. Any relevant evidence, including hearsay, shall be admitted if it is the sort of

7.4-6 MISCELLANEOUS RULES

Judicial rules of evidence and procedure relating to the conduct of the hearing, examination of witnesses, and presentation of evidence shall not apply to a hearing conducted under this Article. Any relevant evidence, including hearsay, shall be admitted if it is the sort of




evidence on which responsible persons are accustomed to rely in the conduct of serious affairs, regardless of the admissibility of such evidence in a court of law.

evidence on which responsible persons are accustomed to rely in the conduct of serious affairs, regardless of the admissibility of such evidence in a court of law. The judicial review committee may interrogate the witnesses or call additional witnesses if it deems such action appropriate. At its discretion, the judicial review committee may request or permit both sides to file written arguments. The hearing process shall be completed within a reasonable time after the notice of the action is received, unless the hearing officer issues a written decision that the member or the medical executive committee failed to provide information in a reasonable time or consented to the delay.

14.6-16 Burdens of Presenting Evidence and Proof

a. At the hearing, the body whose decision prompted the hearing shall have the initial duty to present evidence for each case or issue in support of its action or recommendation. The practitioner shall be obligated to present evidence in response.

b. An applicant for membership and/or privileges shall bear the burden of persuading the Hearing Committee, by a preponderance of the evidence, that he or she is qualified for membership and/or the denied privileges. The practitioner must produce information which allows for adequate evaluation and resolution of reasonable doubts concerning his or her current qualifications for membership and privileges.

c. Except as provided above for applicants for membership and/or privileges, throughout the hearing, the body whose decision prompted the hearing shall bear the burden of persuading the Hearing Committee by a preponderance of the evidence, that its action or recommendation was reasonable and warranted.

7.4-7 BURDENS OF PRESENTING EVIDENCE AND PROOF

(a) At the hearing the medical executive committee shall have the initial duty to present evidence for each case or issue in support of its action or recommendation. The member shall be obligated to present evidence in response.

(b) An applicant shall bear the burden of persuading the judicial review committee, by a preponderance of the evidence, of the applicant’s qualifications by producing information which allows for adequate evaluation and resolution of reasonable doubts concerning the applicant’s current qualifications for membership and privileges. An applicant shall not be permitted to introduce information requested by the medical staff but not produced during the application process unless the applicant establishes that the information could not have been produced previously in the exercise of reasonable diligence.

(c) Except as provided above for applicants, throughout the hearing, the medical executive committee shall bear the burden of persuading the judicial review committee, by a preponderance of the evidence, that its action or recommendation is reasonable and warranted.

14.6-17 Adjournment and Conclusion

The hearing officer may adjourn the hearing and reconvene the same without special notice at such times and intervals as may be reasonable and warranted with due consideration

7.4-8 ADJOURNMENT AND CONCLUSION

After consultation with the chair of the judicial review committee, the hearing officer may adjourn the hearing and reconvene the same without special notice at such times and




for reaching an expeditious conclusion to the hearing. intervals as may be reasonable and warranted, with due consideration for reaching an expeditious conclusion to the hearing. Both the medical executive committee and the member may submit a written statement at the close of the hearing. Upon conclusion of the presentation of oral and written evidence, or the receipt of closing written arguments, if submitted, the hearing shall be closed.

14.6-18 Basis for Decision

The decision of the Hearing Committee shall be based on the evidence and written statements introduced at the hearing, including all logical and reasonable inferences from the evidence and the testimony.

7.4-9 BASIS FOR DECISION

The decision of the judicial review committee shall be based on the evidence introduced at the hearing, including all logical and reasonable inferences from the evidence and the testimony. The decision of the judicial review committee shall be subject to such rights of appeal as described in these bylaws, but shall otherwise be affirmed by the board of [trustees/directors] as the final action if it is supported by substantial evidence, following a fair procedure.

See additional comments at pages 112-113 regarding substantial evidence – while not as problematic in the context of a hearing (as here), it does limit the Governing Body’s prerogatives.

14.6-19 Presence of Hearing Committee Members and Vote

A majority of the Hearing Committee must be present throughout the hearing and deliberations. In unusual circumstances when a Hearing Committee member must be absent from any part of the proceedings, he or she shall not be permitted to participate in the deliberations or the decision unless and until he or she has read the entire transcript of the portion of the hearing from which he or she was absent. The final decision of the Hearing Committee must be sustained by a majority vote of the number of members appointed.

CHA Bylaws include provision that permits the hearing to proceed in the event of unavoidable absences. This can be an important provision in keeping the hearings moving and avoiding the equivalent of a “mistrial,” especially where protracted hearings are involved.

14.6-20 Decision of the Hearing Committee

Within 30 days after final adjournment of the hearing, the Hearing Committee shall render a written decision. Final adjournment shall be when the Hearing Committee has concluded its deliberations. A copy of the decision shall be forwarded to the Chief Executive Officer, the Medical Executive Committee, the Governing Body, and by special notice to the practitioner. The report shall contain the Hearing Committee’s findings of fact and a conclusion articulating the connection between the evidence produced

7.4-10 DECISION OF THE JUDICIAL REVIEW COMMITTEE

Within [30] days after final adjournment of the hearing, the judicial review committee shall render a decision which shall be accompanied by a report in writing and shall be delivered to the medical executive committee. If the member is currently under suspension, however, the time for the decision and report shall be [15] days. A copy of said decision also shall be forwarded to the administrator, the board of




at the hearing and the decision reached. Both the practitioner and the body whose decision prompted the hearing shall be provided a written explanation of the procedure for appealing the decision. The decision of the Hearing Committee shall be considered final, subject only to such rights of appeal or Governing Body review as described in these bylaws.

[trustees/directors], and to the member. The report shall contain a concise statement of the reasons in support of the decision including findings of fact and a conclusion articulating the connection between the evidence produced at the hearing and the conclusion reached. If the final proposed action adversely affects the clinical privileges of a physician or dentist for a period longer than 30 days and is based on competence or professional conduct, the decision shall state that the action if adopted will be reported to the National Practitioner Data Bank, and shall state the text of the report as agreed upon by the committee. The decision shall also state whether the action, if adopted, shall be reported to the Medical Board of California [and shall state the text of the report as agreed by the committee]. Both the member and the medical executive committee shall be provided a written explanation of the procedure for appealing the decision. The decision of the judicial review committee shall be subject to such rights of appeal or review as described in these bylaws, but shall otherwise be affirmed by the board of [trustees/directors] as the final action if it is supported by substantial evidence, following a fair procedure.

CMA FN to 7.4-10 – Including the text of the National Practitioner Data Bank report allows the member to be apprised of any changes recommended by the committee as a result of the hearing, and to seek corrections as necessary through the appeal process.

See comments at pages 128-129.

See comments at pages 112-113, and 146-147.

14.7 APPEAL

[These procedures apply to appeals from the results of a preliminary hearing (as described at Section 14.5), as well as appeals from the full hearing; however, in the context of an appeal from a preliminary hearing, the appeal hearing officer shall be empowered to adjust timeframes and modify procedures as necessary to achieve a timely appeal from a preliminary hearing.]

7.5 APPEAL

7.5-1 TIME FOR APPEAL

Within [10] days after receipt of the decision of the judicial review committee, either the member or the medical executive committee may request an appellate review. A written request for such review shall be delivered to the chief of staff, the administrator, and the other party in the hearing. If a request for appellate review is not requested within such




14.7-1 Time for Appeal

Within 40 days after receiving the decision of the Hearing Committee, either the practitioner or the Medical Executive Committee may request an appellate review. A written request for such review shall be delivered to the Chief of Staff, the Chief Executive Officer and the other side in the hearing. If appellate review is not requested within such period, that action or recommendation shall thereupon become the final action of the Medical Staff. The Governing Body shall consider the decision within 70 days, and shall give it great weight.

period, that action or recommendation shall be affirmed by the board of [trustees/directors] as the final action if it is supported by substantial evidence, following a fair procedure.


7.5-2 GROUNDS FOR APPEAL

A written request for an appeal shall include an identification of the grounds for appeal and a clear and concise statement of the facts in support of the appeal. The grounds for appeal from the hearing shall be: (a) substantial non-compliance with the procedures required by these bylaws or applicable law which has created demonstrable prejudice; (b) the decision was not supported by substantial evidence based upon the hearing record or such additional information as may be permitted pursuant to Section 7.5-5; (c) the text of the report(s) to be filed with the Medical Board of California and/or the National Practitioner Data Bank is not accurate.


14.7-2 Time, Place and Notice

If an appellate review is to be conducted, the Appeal Board shall, within 30 days after receiving a request for appeal, schedule a review date and cause each side to be given notice (with special notice to the practitioner) of the time, place, and date of the appellate review. The appellate review shall commence within 60 days from the date of such notice provided; however, when a request for appellate review concerns a member who is under suspension which is then in effect, the appellate review should commence within 45 days from the date the request for appellate review was received [if the Appeal Board is conducting an appeal of the results of a preliminary hearing]. The time for appellate review may be extended by the Appeal Board for good cause.

7.5-3 TIME, PLACE AND NOTICE

If an appellate review is to be conducted, the appeal board shall, within [15] days after receipt of notice of appeal, schedule a review date and cause each side to be given notice of the time, place and date of the appellate review. The date of appellate review shall not be less than [30] nor more than [60] days from the date of such notice, provided however, that when a request for appellate review concerns a member who is under suspension which is then in effect, the appellate review shall be held as soon as the arrangements may reasonably be made, not to exceed [15] days from the date of the notice. The time for appellate review may be extended by the appeal board for good cause.

The CMA provision for scheduling the appeal within 15 days can be very difficult to comply with, and the requirement to conduct certain appeals within 15 days thereafter is especially difficult.




14.7-3 Appeal Board

The Governing Body may sit as the Appeal Board, or it may appoint an Appeal Board which shall be composed of not less than three members of the Governing Body. Knowledge of the matter involved shall not preclude any person from serving as a member of the Appeal Board, so long as that person did not take part in a prior hearing on the same matter. The Appeal Board may select an attorney to assist it in the proceeding. If an attorney is selected, he or she may act as an appellate hearing officer and shall have all of the authority of and carry out all of the duties assigned to a hearing officer as described in this Article 14. That attorney shall not be entitled to vote with respect to the appeal. The Appeal Board shall have such powers as are necessary to discharge its responsibilities.

7.5-4 APPEAL BOARD

The board of [trustees/directors] may sit as the appeal board, or it may appoint an appeal board which shall be composed of not less than [3] members of the board of [trustees/directors]. Knowledge of the matter involved shall not preclude any person from serving as a member of the appeal board, so long as that person did not take part in a prior hearing on the same matter. The appeal board may select an attorney to assist it in the proceeding, but that attorney shall not be entitled to vote with respect to the appeal. The attorney firm selected by the board of [trustees/directors] shall be neither the attorney firm that represented either party at the hearing before the judicial review committee nor the attorney who assisted the hearing panel or served as hearing officer.

14.7-4 Appeal Procedure

The proceeding by the Appeal Board shall, at the discretion of the Appeal Board, either be a de novo hearing or an appellate hearing based upon the record of the hearing before the Hearing Committee, provided that the Appeal Board may accept additional oral or written evidence, subject to a foundational showing that such evidence could not have been made available in the exercise of reasonable diligence and subject to the same rights of cross-examination or confrontation provided at the hearing; or the Appeal Board may remand the matter to the Hearing Committee for the taking of further evidence and for decision. Each party shall have the right to be represented by legal counsel or any other representative designated by that party in connection with the appeal. The appealing party shall submit a written statement concisely stating the specific grounds for appeal. In addition, each party shall have the right to present a written statement in support of his, her or its position on appeal. The appellate hearing officer may establish reasonable time frames for the appealing party to submit a written statement and for the responding party to respond. Each party has the right to personally appear and make oral argument. The Appeal Board may then, at a time convenient to itself, deliberate outside the presence of the parties.

7.5-5 APPEAL PROCEDURE

The proceeding by the appeal board shall be in the nature of an appellate hearing based upon the record of the hearing before the judicial review committee, provided that the appeal board may accept additional oral or written evidence, subject to a foundational showing that such evidence could not have been made available to the judicial review committee in the exercise of reasonable diligence and subject to the same rights of cross-examination or confrontation provided at the judicial review hearing; or the appeal board may remand the matter to the judicial review committee for the taking of further evidence and for decision. The appeal board shall remand the matter to the judicial review committee where it accepted additional written or oral evidence that could materially impact its decision. Each party shall have the right to be represented by legal counsel, or any other representative designated by that party in connection with the appeal , to present a written statement in support of that party’s position on appeal, and to personally appear and make oral argument. The appeal board may thereupon conduct, at a time convenient to itself, deliberations outside the presence of the appellant and respondent and their representatives. The appeal board shall present to the board of [trustees/directors] its written recommendations as to whether the board of [trustees/directors] should affirm or reverse the judicial

The CHA Bylaws permit the Appeal Board to conduct a de novo hearing, as it deems appropriate. This provision would be important, for example, in cases where a member is challenging a rule (which is beyond the discretion of a hearing committee).

This CMA provision may result in delays; on the other hand, it does help assure that a committee of peers has access to all relevant information that could influence its decision, and it could help assure that the practitioner does not withhold information until the appeal stage. The CHA Bylaws permit, but do not require, such a remand (see CHA 14.7-5(b)).




review committee decision consistent with the standard set forth in Section 7.5-6, or remand the matter to the judicial review committee for further review and decision.

14.7-5 Decision

a. Within 30 days after the adjournment of the Appellate Review proceeding [(10 days if the Appeal Board is conducting an appeal of the results of a preliminary hearing)], the Appeal Board shall render a final decision in writing. Final adjournment shall not occur until the Appeal Board has completed its deliberations.

b. The Appeal Board may affirm, modify, reverse the decision or remand the matter for further review by the Hearing Committee or any other body designated by the Appeal Board.

c. The Appeal Board shall give great weight to the Hearing Committee recommendation, and shall not act arbitrarily or capriciously. Unless the Appeal Board elects to conduct a de novo review, the Appeal Board shall sustain the factual findings of the Hearing Committee if they are supported by substantial evidence. The Appeal Board may, however, exercise its independent judgment in determining whether a practitioner was afforded a fair hearing, whether the decision is reasonable and warranted in light of the supported findings, and whether any bylaw, rule or policy relied upon by the Hearing Committee is unreasonable or unwarranted. The decision shall specify the reasons for the action taken and provide findings of fact and conclusions articulating the connection between the evidence produced at the hearing and the appeal (if any), and the decision reached, if such reasons findings and conclusions differ from those of the Hearing Committee.

d. The Appeal Board shall forward copies of the decision to each side involved in the hearing.

7.5-6 DECISION

(a) Except as provided in Section 7.5-6(b), within [30] days after the conclusion of the appellate review proceedings, the board of [trustees/directors] shall render 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.

(b) Should the board of [trustees/directors] determine that the judicial review committee decision is not supported by substantial evidence, the board may reverse the decision of the judicial review committee and may instead, or shall, where a fair procedure has not been afforded, remand the matter to the judicial review committee for reconsideration, stating the purpose for the referral. If the matter is remanded to the judicial review committee for further review and recommendation, the committee shall promptly conduct its review and make its recommendations to the board of [trustees/directors]. This further review and the time required to report back shall not exceed [30] days in duration except as the parties may otherwise agree or for good cause as jointly determined by the chair of the board of [trustees/directors] and the judicial review committee.

See comments at pages 112-113 and 146-147.

e. The Appeal Board may remand the matter to the Hearing Committee or any other body the Appeal Board designates for reconsideration or may refer the matter to the full Governing Body for review. If the matter is remanded for further review and recommendation, the further review shall be completed within 30 days (15 days if the remand is

(c) The decision shall be in writing, shall specify the reasons for the action taken, shall include the text of the report which shall be made to the National Practitioner Data Bank and the Medical Board of California, if any, and shall be forwarded to the chief of staff, the medical executive and credential committees, the subject of the hearing, and the


The CHA Bylaws contain provision for the Appeal Board to refer the matter to the full Governing Body for final action. This can be an important provision in cases




in the context of an appeal from a preliminary hearing) unless the parties agree otherwise or for good cause as determined by the Appeal Board

administrator, at least (10) days prior to submission to the Medical Board of California.

where key policy decisions are at issue and the Appeal Board is not the appropriate body making the decision.

14.8 Administrative Action Hearings

The following modifications to the hearing process apply when the Medical Executive Committee (or Governing Body) has taken or recommended an action described in Bylaws, Section 14.2 for a non-medical disciplinary cause or reason. Such actions shall be deemed administrative disciplinary actions.

14.8-1 Administrative Action Hearing

The affected practitioner shall be entitled to an administrative action hearing, conducted in accordance with Bylaws, Section 14.6, except as follows:

a. At the election of the body whose decision prompted the hearing, the hearing shall be conducted by an arbitrator, meeting the qualifications of Bylaws, Section 14.6-4b, and selected by mutual agreement of the parties, if agreement can be reached within 10 days, failing which the arbitrator shall be selected by the body whose decision prompted the hearing.

b. The arbitrator shall have all of the rights and responsibilities of a Hearing Officer and a Hearing Committee, as described in Bylaws, Section 14.6.

c. At the election of the body whose decision prompted the hearing, both parties shall have the right to be represented by an attorney, whether or not the other party elects to be represented by an attorney. The parties shall be notified of this election at the time the practitioner is notified of his/her right to a hearing. If attorney representation is permitted, the parties shall promptly notify each other of their elections regarding attorney representation, together with the name and contact information of their attorneys.

14.8-2 Nonreportability of Administrative Actions

CHA Bylaws have added provision for Administrative Action Hearings, for those actions that are not “medical disciplinary.” The procedures for such hearings are essentially the same as for medical disciplinary actions, with these notable changes:

- the hearing may be conducted by an arbitrator, at the peer review body’s election.

- the arbitrator shall have the authority of a hearing officer and a hearing committee.

- at the election of the peer review body, both parties may be represented by an attorney (even if the practitioner elects not to be represented by an attorney).




Administrative disciplinary actions are not reportable to the Medical Board of California or the National Practitioner Data Bank.

14.8-3 Nonwaiver of Protections

Notwithstanding the foregoing, it is understood that circumstances precipitating administrative disciplinary actions may nonetheless involve or affect quality of care in the hospital (e.g., conduct that does or may impair the ability of others to render quality care, or that affects patients’ perceptions of the quality of care rendered in the hospital). Processing a matter as and administrative disciplinary action does not waive any protections that may be available under California or federal law for peer review actions taken in furtherance of quality of care or services provided in the hospital.

14.9 Right to One Hearing

No practitioner shall be entitled to more than one evidentiary hearing and one appellate review on any matter which shall have been the subject of adverse action or recommendation.

7.5-7 RIGHT TO ONE HEARING

Except in circumstances where a new hearing is ordered by the Board of Trustees or a court because of procedural irregularities or otherwise for reasons not the fault of the member, no member shall be entitled to more than one evidentiary hearing and one appellate review on any matter which shall have been the subject of adverse action or recommendation.

14.10 ConfidentialityTo maintain confidentiality in the performance of peer review, disciplinary and credentialing functions, participants in any stage of the hearing or appellate review process shall limit their discussion of the matters involved to the formal avenues provided in the Medical Staff Bylaws.

[All proceedings conducted pursuant to these Bylaws, Article 14, shall be held in private unless otherwise ordered by the Governing Body pursuant to a request of the practitioner. The practitioner may request a public hearing. Prior to exercising its discretion on any request for a public hearing, the Governing Body shall seek and consider the comments of the Medical Executive Committee as to the implications and feasibility of conducting such a hearing in

CHA Model Bylaws address the potential public hearing provisions applicable to District Hospitals.




public.]

14.11 RELEASE

By requesting a hearing or appellate review under these bylaws, a practitioner agrees to be bound by the provisions in the Medical Staff bylaws relating to immunity from liability for the participants in the hearing process.

14.12 GOVERNING BODY COMMITTEES

In the event the Governing Body should delegate some or all of its responsibilities described in this Article 14 to its committees (including a committee serving as an Appeal Board), the Governing Body shall nonetheless retain ultimate authority to accept, reject, modify or return for further action or hearing the recommendations of its committee.

The CHA Bylaws preserve the Governing Body’s ultimate authority to act.

14.13 EXCEPTIONS TO HEARING RIGHTS

14.13-1 Exclusive Use [Departments] [Services], Hospital Contract Practitioners

a. Exclusive Use [Departments] [Services]

The procedural rights of Article 14 do not apply to a practitioner whose application for Medical Staff membership and privileges was denied or whose privileges were terminated on the basis that the privileges he or she seeks are granted only pursuant to an exclusive use policy. Such practitioners shall have the right, however, to request that the Governing Body review the denial, and the Governing Body shall have the discretion to determine whether to review such a request and, if it decides to review the request, to determine whether the practitioner may personally appear before and/or submit a statement in support of his or her position to the Governing Body.

7.6 EXCEPTIONS TO HEARING RIGHTS

7.6-1 APPROPRIATENESS OF EXCLUSIVE CONTRACTS

Privileges can be reduced or terminated as a result of a decision to close or continue closure of a department/service pursuant to an exclusive contract, or to transfer an existing exclusive contract, only following review by the medical staff of the related quality of care issues pursuant to Section 11.8 and a determination of appropriateness of the closure, continued closure or transfer as set forth below. The board of [trustees’/directors’] decision shall uphold the medical staff’s determination unless the board of [trustees/directors] makes specific written findings that the medical staff’s determination is arbitrary, capricious, an abuse of discretion, or otherwise not in accordance with the law.

(a) The medical staff shall determine the need to close or continue closure of a department/service pursuant to an exclusive contract to be appropriate where:

These CMA provisions substantially limit the hospital’s authority vis-à-vis exclusive contracts. Not only do they impose a cumbersome (and potentially very political) process with respect to decisions to enter into exclusive contracts, they also produce, in effect, significant rights for the exclusive contractor to maintain the contract.

This subtle change in CMA Bylaws (changing “mandated” to “compensated”) is actually quite significant – not only withdrawing CMA recognition of the validity of mandated call schedules, but also suggesting that exclusive contracting arrangements

(1) a failure to provide full coverage of a needed service cannot be remedied by less extreme measures, such as compensated call schedules; or

(2) irreconcilable differences within an existing August 2013 Page 166



department/service adversely affecting quality of care have not been resolved by less extreme measures; or

(3) demonstrable efficiencies would result, producing significant improvement in the ability of the medical staff to dispense quality care, which have not been accomplished through less extreme measures.

A determination to close a department/service pursuant to an exclusive contract must be based upon the preponderance of the evidence, viewing the record as a whole, presented by any and all interested parties, following notice and opportunity for comment.

A determination to continue closure of a department/service pursuant to an exclusive contract must be based upon the preponderance of the evidence presented by members of the medical staff, following notice and opportunity for comment.

(b) The medical staff shall determine the transfer of an existing exclusive contract to be appropriate only when:

(1) continued closure of the department/service pursuant to an existing contract is found appropriate pursuant to (a) above, and

(2) quality of care is maintained or improved by the transfer.

might not be permitted as an alternative to having to pay for ER call.

Note: a decision to close a service is subject to input from all interested parties.

…whereas a decision to continue closure is only subject to input from members of the medical staff.

Significantly, to the extent these provisions restrict a hospital’s authority to terminate an exclusive contract without cause, tax-exempt hospitals’ ability to meet IRS bond financing requirements (termination without cause upon reasonable notice) could be jeopardized.

b. Hospital Contract Practitioners

The hearing rights of Article 14 do not apply to practitioners who have contracted with the hospital to provide clinical services. Removal of these practitioners from office and of any exclusive privileges (but not their Medical Staff membership) shall instead be governed by the terms of their individual contracts and agreements with the hospital. The hearing rights of this Article 14 shall apply if an action is

(c) The medical staff member(s) whose privileges may be adversely affected by the medical staff’s determination of appropriateness of the closure or continued closure of a department/service pursuant to an exclusive contract, or transfer of an exclusive contract, may request a hearing before the judicial review committee. Such a hearing will be

The provision for individual physicians to request an Article VII hearing further complicates these decisions, and sets up a situation where a five-member hearing committee can be vested with exclusive contracting decisions.

Additionally, a hearing committee could ultimately




taken which must be reported under Business and Professions Code Section 805 and/or the practitioner’s Medical Staff membership status or privileges which are independent of the practitioner’s contract are removed or suspended.

governed by the provisions of Article VII, except that

(1) the hearing shall be limited to the following issues:

(i) whether the medical staff’s determination of appropriateness is supported by a preponderance of the evidence;

(ii) whether the medical staff followed its requirement for notice and comment on the issue of appropriateness;

(iii) in cases of transfer, whether the medical staff’s determination of effect on quality of care was appropriate.

(2) All requests for such a hearing will be consolidated. Should an affected medical staff member request a hearing under this subsection, the medical staff’s recommendation regarding the exclusive contract will be deferred, pending the outcome of the judicial review committee hearing.

(d) A medical staff member providing professional services under a contract with the hospital shall not have medical staff privileges terminated for reasons pertaining to the quality of care provided by the medical staff member without the same rights of hearing and appeal as are available to all members of the medical staff.

(e) Except as specified in this Section, the termination of privileges following the decision determined to be appropriate by the medical staff to close a department/ service pursuant to an exclusive contract or to transfer an exclusive contract shall not be subject to the procedural rights set forth in Article VII. To the degree termination of certain specific privileges, but not all privileges, of a medical staff member are warranted by an exclusive contract, whether in the same or different specialty within the hospital as covered by the exclusive contract, other privileges of that member that are not affected by the institution of the exclusive contract shall remain granted and unchanged. Those specific privileges of a member that are terminated because of institution of an exclusive contract must be stricken from the list of approved privileges maintained by the medical staff for that member.

render a decision that conflicts with the contract and produces a scenario ripe for litigation.




(f) Except in cases of contemporaneous transfer of an existing exclusive contract determined to be appropriate by the medical staff, a decision to terminate an exclusive contract shall not affect the privileges of medical staff members who were performing services pursuant to that contract, except that their privileges shall no longer be exclusive.

(g) Terms of this Section will take precedence over any inconsistent terms in a contract between a member of the medical staff and the hospital, including, but not necessarily limited to, any contractual provisions purporting to waive all rights of hearing and appeal provided in these bylaws.

7.6-3 DEPARTMENT/SERVICE FORMATION OR ELIMINATION

A medical staff department/service can be formed or eliminated only following a determination by the medical staff of appropriateness of department/service elimination or formation. The board of [trustees’/directors’] decision shall uphold the medical staff’s determination unless the board of [trustees/directors] makes specific written findings that the medical staff’s determination is arbitrary, capricious, an abuse of discretion, or otherwise not in accordance with the law.

(a) The medical staff shall determine the formation or elimination of a department/service to be appropriate based upon consideration of its effects on quality of care in the facility and/or community. A determination of the appropriateness of formation or elimination of a department/service must be based upon the preponderance of the evidence, viewing the record as a whole, presented by any and all interested parties, following notice and opportunity for comment.

(b) The medical staff member(s) whose privileges may be adversely affected by a medical staff’s determination of appropriateness of department/service formation or elimination may request a hearing before the judicial review committee. Such a hearing will be governed by the provisions of Article VII, except that

(1) the hearing shall be limited to the following issues:

CMA also extends these significant procedural requirements to service formation or elimination decisions – including directing the governing body to uphold the decision unless it is arbitrary, an abuse of discretion, or not in accordance with law. This can significantly impact a hospital’s ability to configure its services as deemed appropriate to the current needs and resources of the hospital and the community.

The hearing committee is not expected to consider financial issues or other considerations other than quality of care. The result can be that decisions are imposed on the hospital, regardless of financial impact or feasibility.




(i) whether the medical staff’s determination of appropriateness is supported by the preponderance of the evidence;

(ii) whether the medical staff followed its requirements for notice and comment on the issue of appropriateness.

(2) all requests for such a hearing will be consolidated.

Should an affected medical staff member request a hearing under this subsection, the medical staff’s recommendation regarding the department/service elimination or formation will be deferred, pending the outcome of the judicial review committee hearing.

(c) Except as specified in this Section, the termination of privileges pursuant to formation or elimination of a department/service determined to be appropriate by the medical staff shall not be subject to the procedural rights otherwise set forth in Article VII.

14.13-2 Allied Health Professionals

Option 1 (corresponds to Option 1 at Section 6.6-1)

[Allied health professional applicants (other than AHPs who are the subject of an action that must be reported under Business and Professions Code Section 805) are not entitled to the hearing rights set forth in this Article. However, AHP whose already-granted privileges are subject to an action that would constitute grounds for a hearing under Section 14.2-2 through 14.2-6 shall be entitled to the procedural rights set forth in this Article 14.]

Option 2 (corresponds to Option 2 at Section 6.6-1)

[Allied health professionals (AHPs) are not entitled to the hearing rights set forth in this Article unless the action involves and one that must be reported under Business and Professions Code Section 805. (See Section 6.6-1 for a description of AHP hearing rights where no 805 report is required.)]

14.13-3 Denial of Applications for Failure to Meet the




Minimum Qualifications

Practitioners shall not be entitled to any hearing or appellate review rights if their membership, privileges, applications or requests are denied because of their failure to have a current California license to practice medicine, dentistry, [clinical psychology] or podiatry; to maintain an unrestricted Drug Enforcement Administration certificate (when it is required under these bylaws or the rules); to maintain professional liability insurance as required by the rules; or to meet any of the other basic standards specified in Section 2.2-2 or to file a complete application.

14.13-4 Automatic Suspension or Limitation of Privilegesa. No hearing is required when a member’s license or legal credential to practice has been revoked or suspended as set forth in Section 13.3-1, or automatically terminated as set forth in Bylaws, Section 13.3-8. In other cases described in Sections 13.3-1 and 13.3-2, the issues which may be considered at a hearing, if requested, shall not include evidence designed to show that the determination by the licensing or credentialing authority or the Drug Enforcement Administration was unwarranted, but only whether the member may continue to practice in the hospital with those limitations imposed.

b. Practitioners whose privileges are automatically suspended and/or who have resigned their Medical Staff membership for failing to satisfy a special appearance (Section 13.3-3), failing to complete medical records (Section 13.3-4), failing to maintain malpractice insurance (Section 13.3-5), failing to pay dues (Section 13.3-6), or failing to comply with particular government or other third party payor rules or policies (Section 13.3-7) are not entitled under Section 13.3-9 to any hearing or appellate review rights except when a suspension for failure to complete medical records will exceed 30 days in any 12-month period, and it must be reported to the Medical Board of California.

7.6-2 AUTOMATIC SUSPENSION OR LIMITATION OF PRACTICE PRIVILEGES

No hearing is required when a member’s license or legal credential to practice has been revoked or suspended as set forth in Section 6.5-1(a). In other cases described in Sections 6.5-1 and 6.5-2, the issues which may be considered at a hearing, if requested, shall not include evidence designed to show that the determination by the licensing or credentialing authority or certifying authority was unwarranted, but only whether the member may continue practice in the hospital with those limitations imposed.

14.13-5 Failure to Meet Minimum Activity Requirements




Practitioners shall not be entitled to the hearing and appellate review rights if their membership or privileges are denied, restricted or terminated or their Medical Staff categories are changed or not changed because of a failure to meet the minimum activity requirements set forth in the Medical Staff bylaws or rules. In such cases, the only review shall be provided by the Medical Executive Committee through a subcommittee consisting of at least three Medical Executive Committee members. The subcommittee shall give the practitioner notice of the reasons for the intended denial or change in membership, privileges, and/or category and shall schedule an interview with the subcommittee to occur no less than 30 days and no more than 100 days after the date the notice was given. At this interview, the practitioner may present evidence concerning the reasons for the action, and thereafter the subcommittee shall render a written decision within 45 days after the interview. A copy of the decision shall be sent to the practitioner, Medical Executive Committee and Governing Body. The subcommittee decision shall be final unless it is reversed or modified by the Medical Executive Committee within 45 days after the decision was rendered, or the Governing Body within 90 days after the decision was rendered.

[14.14 JOINT HEARINGS AND APPEALS FOR SYSTEM MEMBERS

14.14-1 Joint Hearings

a. Whenever a practitioner is entitled to a hearing because a coordinated, cooperative or joint credentialing or corrective action has been taken or recommended pursuant to Section 13.6, a single joint hearing may be conducted in accordance with hearing procedures that have been jointly adopted by the involved entities, provided such procedures are substantially comparable to those set forth in Bylaws, Sections 14.5, 14.6 or 14.8 (as applicable) and further provided at least one member of the Hearing Committee is a member of this hospital’s Medical Staff.

CHA Bylaws contain optional provisions permitting joint hearings and appeals for system member hospitals. This can be especially important as a means to assure consistency among hospitals that share governing boards.

b. In the event there is such a joint hearing, the recommendation of the Hearing Committee shall be




reported to this hospital’s Governing Body for final action.

14.14-2 Joint Appeals

The procedures may also call for joint appeal rights, provided such procedures are substantially comparable to those set forth in Section 14.7 and, further, provided that at least one member of the Appeal Board is a representative of this hospital’s Governing Body.

14.14-3 Effect of Joint Hearings/Appeals

A joint hearing and/or appeal in accordance with the foregoing shall be deemed to satisfy procedural rights afforded to the practitioner pursuant to Business and Professions Code Section 809 et seq.

14.14-4 Provision for Separate Hearing

Notwithstanding the foregoing, if a practitioner can demonstrate to the Medical Executive Committee (in the case of a hearing based on a recommendation of the Medical Executive Committee) or the Governing Body (in the case of a hearing based on a recommendation of the Governing Body or in the case of an appeal) prior to the initiation of a joint hearing and/or appeal that the benefits of quasi-judicial economy and efficiency are outweighed by particular burdens or unfairness unique to the individual practitioner’s circumstances, the Medical Executive Committee or Governing Body may, in its sole discretion, order that a separate hearing and/or appeal be conducted solely with respect to privileges at this hospital, in accordance with this hospital’s Hearing and Appellate Review Provisions. (Examples of such unique burdens or unfairness would include unavailability of witnesses or documents to the joint proceeding; but the mere fact that the outcome would affect privileges at more than one facility would not ordinarily be deemed sufficient to preclude a joint hearing.)]

7.7 EXPUNCTION OF DISCIPLINARY ACTION

Upon petition, the medical executive committee, in its sole discretion, may expunge previous disciplinary action upon a showing of good cause or rehabilitation.

Very often problems have a way of repeating themselves. To wipe out a historical record of a problem commits the Medical Staff to starting anew – even in cases where “everyone knows” that there have been similar problems in the past.




Moreover, an expunction can result in the Medical Staff and hospital misrepresenting a member’s history in response to inquiries from other health facilities about a person’s performance at your facility. Such a misrepresentation could result in liability to another hospital’s patients in the event a subsequent mishap occurs.

7.8 NATIONAL PRACTITIONER DATA BANK REPORTING

The authorized representative shall report an adverse action to the National Practitioner Data Bank only upon its adoption as final action and only using the description set forth in the final action as adopted by the board of [trustees/directors]. The authorized representative shall report any and all revisions of an adverse action, including, but not limited to, any expiration of the final action consistent with the terms of that final action.


7.9 DISPUTING REPORT LANGUAGE

If no hearing was requested, a member who is the subject of a proposed adverse action report to the Medical Board of California or the National Practitioner Data Bank may request an informal meeting to dispute the text of the report filed. The report dispute meeting shall not constitute a hearing and shall be limited to the issue of whether the report filed is consistent with the final action issued. The meeting shall be attended by the subject of the report, the chief of staff, the chair of the subject’s department, and the hospital’s authorized representative, or their respective designees.

If a hearing was held, the dispute process shall be deemed to have been completed.

Article 15

GENERAL PROVISIONS

15.1 RULES AND POLICIES

15.1-1 Overview and Relation to Bylaws

These bylaws describe the fundamental principles of




Medical Staff self-governance and accountability to the Governing Body. Accordingly, the key standards for Medical Staff membership, appointment, reappointment and privileging are set out in these bylaws. Additional provisions, including but not limited to procedures for implementing the Medical Staff standards may be set out in Medical Staff [or department] rules, or in policies adopted or approved as described below. Upon proper adoption, as described below, all such rules and policies shall be deemed an integral part of the Medical Staff bylaws.

15.1-2 General Medical Staff Rules

The Medical Staff shall initiate and adopt such rules as it may deem necessary and shall periodically review and revise its rules to comply with current Medical Staff practice. New Rules or changes to the Rules (proposed Rules) may emanate from any responsible committee, department, medical staff officer, or by petition signed by at least [insert minimum number or percent]of the voting members of the Medical Staff. Additionally, hospital administration may develop and recommend proposed Rules, and in any case should be consulted as to the impact of any proposed Rules on hospital operations and feasibility. Proposed Rules shall be submitted to the Medical Executive Committee for review and action, as follows:

a. Except as provided at Section 15.1-2d, below, with respect to circumstances requiring urgent action, the Medical Executive Committee shall not act on the proposed Rule until the Medical Staff has had a reasonable opportunity to review and comment on the proposed Rule. [This review and comment opportunity may be accomplished by posting proposed Rules on the Medical Staff website at least [thirty] days prior to the scheduled Medical Executive Committee meeting, together with instructions how interested members may communicate comments. A comment period of at least [fifteen] days shall be afforded, and all comments shall be summarized and provided to the Medical Executive Committee prior to Medical Executive Committee action on the proposed Rule.]

b. Medical Executive Committee approval is

14.1 RULES AND REGULATIONS

Upon the request of (1) the medical executive committee, or the chief of staff or the bylaws committee after approval by the medical executive committee, or (2) upon timely written petition signed by at least [10%] of the members of the medical staff in good standing who are entitled to vote, consideration shall be given to the adoption, amendment, or repeal of the Medical Staff rules and regulations and policies. Such rules and regulations shall be limited to procedural details and processes implementing these bylaws and shall not affect the organizational structure of the medical staff to be self-governing. Such action shall be taken at a regular or special meeting of the medical staff, provided (1) written notice of the proposed change was sent to all members on or before the last regular or special meeting of the medical staff, and such changes were offered at such prior meeting and (2) notice of the next regular or special meeting at which action is to be taken included notice that a rules or regulations change would be considered. Both notices shall include the exact wording of the existing language of the rule(s) or regulation(s), if any, and the proposed change(s) and that there be a 30-day period for responding to submission of petitions. Following adoption such rules, and regulations and policies shall become effective upon approval of the board of [trustees/directors], which approval shall not be withheld unreasonably, or automatically after [ ] days if no action is taken by the board of [trustees/directors]. In the latter event, the board of [trustees/directors] shall be deemed to have approved the rule(s), and regulation(s) and policy(s) adopted by the medical staff. Rules and regulations and policies shall be reviewed (and may be revised if necessary) every [2]

CHA Bylaws have been amended to comply with changes to TJC Standard MS.01.01.01 that become effective March 31, 2011.

Included in the CHA Bylaws is that changes to the rules can initiate with hospital administration, and that hospital administration should be consulted in the development of new rules.

CMA Bylaws require that amendments to rules only be effected at a Medical Staff meeting. This provision, especially when coupled with the quorum requirements for such a meeting (2/3 of the voting members of the staff) make it very difficult to amend Medical Staff rules. This can result in a minority of the Medical Staff controlling their rule-making authority. This is an especially difficult provision in circumstances where expeditious action may be needed to conform to regulatory or accreditation requirements. CMA Bylaws contain no provision to more expeditiously amend the rules where urgent action is needed to comply with law or regulation.

CHA Bylaws delegate rulemaking (and policy – see CHA Section 15,1-5) authority to the MEC. TJC Standard MS.01.01.01 permit this delegation, but require the MEC to give the medical staff prior notice of proposed changes unless urgent action is required to comply with law or regulation; and requires a process to




required, unless the proposed Rule is one generated by petition of at least [insert minimum number or percent]of the voting members of the Medical Staff. In this latter circumstance, if the Medical Executive Committee fails to approve the proposed Rule, it shall notify the Medical Staff. The Medical Executive Committee and the Medical Staff each has the option of invoking or waiving the conflict management provisions of Section 15.1-5

1) If conflict management is not invoked within [30] days it shall be deemed waived. In this circumstance, the Medical Staff’s proposed Rule shall be submitted for vote, and if approved by the Medical Staff pursuant to Section 15.1-2b 3, the proposed Rule shall be forwarded to the Governing Body for action. The Medical Executive Committee may forward comments to the Governing Body regarding the reasons it declined to approve the proposed Rule.

2) If conflict management is invoked, the proposed Rule shall not be voted upon or forwarded to the Governing Body until the conflict management process has been completed, and the results of the conflict management process shall be communicated to the Governing Body.

3) With respect to the proposed Rules generated by petition of the Medical Staff, approval of the Medical Staff requires the affirmative vote of a majority of the Medical Staff members voting on the matter by mailed secret ballot, provided at least 14 days’ advance written notice, accompanied by the proposed Rule, has been given, and at least [insert minimum # or % of return votes required] votes have been cast.

c. Following approval by the Medical Executive Committee or the favorable vote of the Medical Staff as described above, a proposed Rule shall be forwarded to the Governing Body for approval, which approval shall not be withheld unreasonably. The Rule shall become effective immediately following approval of the Governing Body or automatically within 60 days if no action is taken by the Governing Body. If there is a conflict between the bylaws and the rules, the bylaws shall prevail.

years. Applicants and members of the medical staff shall be governed by such rules and regulations and policies as are properly initiated and adopted. If there is a conflict between the bylaws and the rules and regulations and policies, 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 and policies.

manage conflicts in the event the MEC and the Medical Staff disagree.

CMA requires all rules, regulations and policies to be submitted to Medical Staff vote.

CMA Bylaws do not contain urgent rule-making provisions (nor do they provide for expeditious policy




d. Where urgent action is required to comply with law or regulation, the Medical Executive Committee is authorized to provisionally adopt a Rule and forward it to the Governing Body for approval and immediate implementation, subject to the following. If the Medical Staff did not receive prior notice of the proposed Rule (as described at Section 15.1-2a) the Medical Staff shall be notified of the provisionally-adopted and approved Rule, and may, by petition signed by at least [insert number or percent] of the voting members of the Medical Staff require the Rule to be submitted for possible recall; provided, however, the approved Rule shall remain effective until such time as a superseding Rule meeting the requirements of the law or regulation that precipitated the initial urgency has been approved pursuant to any applicable provision of this Section 15.1-2.

15.1-3 [Departmental Rules

Subject to the approval of the Medical Executive Committee and Governing Body, each department shall formulate its own rules for conducting its affairs and discharging its responsibilities. Such rules shall not be inconsistent with the Medical Staff or hospital bylaws, rules or other policies.]

[15.1-4 Section Rules

Subject to the approval of the committee of the department that oversees the section, the Medical Executive Committee and the Governing Body, each section may formulate its own rules for conducting its affairs and discharging its responsibilities. Additionally, hospital administration may develop and recommend proposed section Rules, and in any case should be consulted as to the impact of any proposed section Rules on hospital operations and feasibility. Such rules shall not be inconsistent with the Medical Staff or hospital bylaws, rules, or policies].

15.1-5 Medical Staff Policies

a. Policies shall be developed as necessary to implement more specifically the general principles found within these bylaws and the Medical Staff rules. New or

changes). Indeed, all require the same formality as adoption or amendment of Medical Staff Bylaws.

CHA Bylaws have been amended to address changes in TJC Standard MS.01.01.01 regarding adoption of policies. The standard specifically permits the MEC to be delegated policymaking authority; allows policies to




revised policies (proposed policies) may emanate from any responsible committee, department, medical staff officer, or by petition signed by at least [insert minimum number or percent]of the voting members of the Medical Staff. Proposed such policies shall not be inconsistent with the Medical Staff or hospital bylaws, rules or other policies, and upon adoption shall have the force and effect of Medical Staff bylaws.

b. Medical Executive Committee approval is required, unless the proposed policy is one generated by petition of at least [insert minimum number or percent] of the voting members of the Medical Staff. In this latter circumstance, if the Medical Executive Committee fails to approve the proposed policy, it shall notify the Medical Staff. The Medical Executive Committee and the Medical Staff each has the option of invoking or waiving the conflict management provisions of Section 15.1-6.

1) If conflict management is not invoked within [30] days it shall be deemed waived. In this circumstance, the Medical Staff’s proposed policy shall be submitted for vote, and if approved by the Medical Staff pursuant to Section 15.1-5b 3, the proposed policy shall be forwarded to the Governing Body for action. The Medical Executive Committee may forward comments to the Governing Body regarding the reasons it declined to approve the proposed policy.

2) If conflict management is invoked, the proposed policy shall not be voted upon or forwarded to the Governing Body until the conflict management process has been completed, and the results of the conflict management process shall be communicated to the Medical Staff and the Governing Body.

3) Approval of the Medical Staff shall require the affirmative vote of a majority of the Medical Staff members voting on the matter by mailed secret ballot, provided at least 14 days’ advance written notice, accompanied by the proposed policy, has been given and at least [insert minimum # or % of return votes required] votes have been cast.

be adopted without prior notice to the Medical Staff; but requires a process for retrospective review and conflict management in the event of disagreement.

As noted above, CMA Bylaws do not differentiate the processes for adoption and amendment of policies from those required for adoption and amendment of rules and regulations.




c. Following approval by the Medical Executive Committee or the voting Medical Staff as described above, a proposed policy shall be forwarded to the Governing Body for approval, which approval shall not be withheld unreasonably. The policy shall become effective immediately following approval of the Governing Body or automatically within 60 days if no action is taken by the Governing Body.

d. The Medical Staff shall be notified of the approved policy, and may, by petition signed by at least [insert number or percent] of the voting members of the Medical Staff require the policy to be submitted for possible recall; provided, however, the approved policy shall remain effective until such time as it is repealed or amended pursuant to any applicable provision of this Section 15.1-5.

15.1-6 Conflict Management

In the event of conflict between the Medical Executive Committee and the Medical Staff (as represented by written petition signed by at least [insert number or percent] of the voting members of the Medical Staff) regarding a proposed or adopted Rule or policy, the President of the Medical Staff shall convene a meeting with the petitioners’ representative(s). The foregoing petition shall include a designation of up to five members of the voting Medical Staff who shall serve as the petitioners’ representative(s). The Medical Executive Committee shall be represented by an equal number of Medical Executive Committee members. The Medical Executive Committee’s and the petitioners’ representative(s) shall exchange information relevant to the conflict and shall work in good faith to resolve differences in a manner that respects the positions of the Medical Staff, the leadership responsibilities of the Medical Executive Committee, and the safety and quality of patient care at the hospital. Resolution at this level requires a majority vote of the Medical Executive Committee’s representatives at the meeting and a majority vote of the petitioner’s representatives. Unresolved differences shall be submitted to the Governing Body for final resolution.

CHA Bylaws include provision for conflict management of disputes between the Medical Staff and the MEC, as required by MS.01.01.01.

CMA’s provisions with respect to dispute management are much more limited, and appear in the MEC Duties section (CMA Section 11,3-2).

15.2 FORMS




Application forms and any other prescribed forms required by these bylaws for use in connection with Medical Staff appointments, reappointments, delineation of privileges, corrective action, notices, recommendations, reports and other matters shall be approved by the Medical Executive Committee and the Governing Body. Upon adoption, they shall be deemed part of the Medical Staff rules. They may be amended by approval of the Medical Executive Committee and the Governing Body.

15.3 DUES

The Medical Executive Committee shall have the power to establish reasonable annual dues, if any, for each category of Medical Staff membership, and to determine the manner of expenditure of such funds received. However, such expenditures must be appropriate to the purposes of the Medical Staff [and shall not jeopardize the nonprofit tax-exempt status of the hospital.]

14.2 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. Such power shall include the ability to assess dues on a sliding scale basis, depending on the level of participation in medical staff activities by the member staff member.

Business and Professions Code Section 2282.5 grants Medical Staff the right to establish dues and to control expenditures; nonetheless, unless the Medical Staff is separately incorporated and does not derive its funding from the hospital, a tax-exempt hospital’s Medical Staff expenditures must be compatible with the hospital’s tax exempt purposes.

15.4 Medical Screening Exams

15.4-1 All patients who present to the hospital, including the Emergency Department and the Labor and Delivery Unit, and who request examination and treatment for an emergency medical condition or active labor, shall be evaluated for the existence of an emergency medical condition or, where applicable, active labor. This screening examination may be performed by the following persons:

a. In the Emergency Department: by a registered nurse who has been determined by the ER nurse manager to be qualified and experienced in emergency nursing and who is required to follow standardized procedures approved by the Medical Staff.

b. In the Labor and Delivery Unit: by a registered nurse who has been determined by the L&D nurse manager to be qualified and experienced in obstetrical nursing and who is required to follow standardized procedures approved by the Medical Staff.

c. In all circumstances: in the event the RN performing the screening examination is uncertain about the

EMTALA (42 CFR 489.24(a)) states that screening exams must be conducted by individuals who are determined qualified by hospital bylaws or rules. CHA addresses this in the Medical Staff Bylaws.




nature of the patient’s condition or the existence of an emergency or active labor, a physician from either the Emergency Department or Labor and Delivery shall be required to examine the patient and make the determination of the existence of an emergency or active labor.

15.4-2 Medical screening examinations and emergency services shall be provided in compliance with all applicable provisions of state and federal law, and hospital policies and procedures respecting Emergency Medical Services.

15.4-3 Informed Consent

a. Based upon input from [the departments], the Medical Staff shall develop a list of procedures requiring informed consent of the patients. This list may be adopted, amended or repealed by majority vote of the Medical Executive Committee and approval by the Governing Body, and upon adoption shall have the force and effect of

Medical Staff bylaws. The list shall include, but is not limited to informed consent requirements with respect to the following procedures:

1) Surgery.

2) Blood transfusions.

3) Physical restraints.

4) Antipsychotic medications.

5) Sterilization.

6) Hysterectomy.

7) Abortion.

8) Reuse of hemodialysis filters.

9) Breast cancer treatment.

10) Silicon implants and collagen injections.

11) Psychosurgery.

12) Convulsive therapy.

13) Implantation of cells, tissue, or organs.

14) Assisted reproduction procedures.

This CHA Section on Informed Consent was developed when CMS required the Bylaws to include a description of those procedures requiring informed consent. That section has been amended, and the Medical Staff could elect to move these provisions out of Bylaws and into policies.




15) Telemedicine.

16) Such other procedures as may be identified in the Informed Consent policy.

b. The informed consent policy shall assure that the patient [or his/her representative] receives information necessary to make informed decisions about his/her care, including but not limited to:

1) Health status, diagnosis, and progress;

2) The nature and purpose of the proposed procedure, anesthesia to be used [if applicable], short and long-term risks and consequences, and the probability that the proposed procedures will be successful;

3) An explanation of alternative methods of treatment [if any] and their associated risks and benefits

4) An explanation of the risks and prognosis if not treatment is rendered; and

5) An explanation of who will actually perform the procedure, who will administer the anesthesia [if applicable], and which other practitioners will perform important parts of the surgical procedures.

c. Informed consents shall be documented in the medical record.

14.2-1 MEDICAL STAFF FUNDS

Medical Staff funds, regardless from what source (i.e., medical staff dues, hospital funds) shall be under the sole control of the Medical Staff. All medical staff members may at all reasonable times copy and inspect all bank statements and the quarterly financial statements prepared pursuant to Section 9.2-4. The medical staff must be notified of and provided with the opportunity to comment upon impending significant expenditures of medical staff funds of amounts which exceed [dollar amount or a stated percentage of the account balance].

14.2-2 HOSPITAL-PROVIDED FUNDS DEPOSITED TO THE MEDICAL STAFF FUND

CMA Bylaws include provisions relating to exclusive control of Medical Staff funds, regardless of source of such funds, and require the hospital to fund functions required under the Bylaws. CMA recently added the inspection and copy rights of the Medical Staff.

Note: This could result in the hospital funding activities that may be inconsistent with its tax-exempt purposes; and/or could even result in the hospital funding Medical Staff litigation against the hospital.




Funds shall be deposited into the Medical Staff account from the hospital to assure the medical staff the financial ability to solely administer those functions required under the bylaws.

15.5 LEGAL COUNSEL

The Medical Staff may, at its expense, retain and be represented by independent legal counsel.

14.10 MEDICAL STAFF REPRESENTATION BY LEGAL COUNSELUpon the authorization of the medical staff, or of the medical executive committee acting on its behalf, the medical staff may retain and be represented by independent legal counsel who, , to the extent practicable, shall not be employed by a law firm representing the hospital. The medical staff shall enter into a written engagement letter with the individual selected to be independent legal counsel affirming that the medical staff, not the hospital, is the counsel’s client, that the counsel represents solely the interests of the medical staff, and that the attorney-client privilege of confidentiality applicable to all communications between the counsel and the medical staff is held solely by the medical staff, regardless of whether the medical staff or a third party pays the counsel’s fees. In the event the counsel is paid for by a third party, the counsel shall also provide a written assurance to the medical staff that there will be no interference by the third party with the counsel’s independence of professional judgment or with the attorney-client relationship, as required by State Bar of California Rules of Professional Conduct, Rule 3-310.

CMA Bylaws include these extensive provisions regarding Medical Staff legal counsel. These provisions appear to contemplate the Medical Staff as an autonomous entity, and not part of the hospital organization.

15.6 AUTHORITY TO ACT

Any member who acts 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.

14.3 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.

14.4 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.

CHA Bylaws address this at Section 2.6-8. See responsibility of membership.

15.7 DISPUTES WITH THE GOVERNING BODY

In the event of a dispute between the Medical Staff and the Governing Body relating to the independent rights of the Medical Staff, as further described in California Business

CHA Bylaws include a specific Dispute Resolution Section. This was originally developed in response to the enactment of Business & Professions Code Section




and Professions Code Section 2282.5, the following procedures shall apply.

a. Invoking the Dispute Resolution Process

1) The Medical Executive Committee may invoke formal dispute resolution, upon its own initiative, or upon written request of 25% of the members of the Active Staff.

2) In the event the Medical Executive Committee declines to invoke formal dispute resolution, such process shall be invoked upon written petition of 50% of the members of the Active Staff.

b. Dispute Resolution Forum

1) Ordinarily, the initial forum for dispute resolution shall be the Joint Conference Committee, which shall meet and confer as further described in Section 9.2-2(b) of the bylaws.

2) However, upon request of at least 2/3 of the members of the Medical Executive Committee, the meet and confer will be conducted by a meeting of the full Medical Executive Committee and the full Governing Body. A neutral mediator acceptable to both the Governing Body and the Medical Executive Committee may be engaged to further assist in dispute resolution upon request of (a) at least a majority of the Medical Executive Committee plus two members of the Governing Body; or (b) at least a majority of the Governing Body plus two members of the Medical Executive Committee.

c. The parties’ representatives shall convene as early as possible, shall gather and share relevant information, and shall work in good faith to manage and, if possible, resolve the conflict. If the parties are unable to resolve the dispute the Governing Body shall make its final determination giving great weight to the actions and recommendations of the Medical Executive Committee. Further, the Governing Body determination shall not be arbitrary or capricious, and shall be in keeping with its legal responsibilities to act to protect the quality of medical care provided and the competency of the Medical Staff, and to ensure the

2282.5. It has been further amended to accommodate recent changes to TJC Standard MS.01.01.01.

Compare CMA Bylaws Section 11.3-1(x) and (y).




responsible governance of the hospital.

14.5 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:

Name and proper title of addressee, if known or applicable

Name of department, division or committee

[c/o medical staff coordinator, chief of staff]

Hospital name

Street address

___________________, California ___________

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.

CHA addresses notice requirements in the definitions section of the Bylaws.

[CMA Section 14.6 moved adjacent to CHA Section 8.1-3 for comparison purposes.]

14.7 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.

[CMA Section 14.8 re Medical Staff Credentials Files has been moved adjacent to CHA Section 12.3 for comparison purposes.]




15.8 RETALIATION

Neither the medical staff, its members, committees or department heads, the governing body, its chief administrative officer, or any other employee or agent of the hospital or medical staff, shall discriminate or retaliate, in any manner, against any patient, hospital employee, member of the medical staff, or any other health care worker of the health facility because that person has done either of the following:a. Presented a grievance, complaint, or report to the facility, to an entity or agency responsible for accrediting or evaluating the facility, or the medical staff of the facility, or to any other governmental entity.b. Has initiated, participated, or cooperated in an investigation or administrative proceeding related to, the quality of care, services, or conditions at the facility that is carried out by an entity or agency responsible for accrediting or evaluating the facility or its medical staff, or governmental entity.

14.9 RETALIATION PROHIBITED

(a) Neither the medical staff, its members, committees or department heads, the governing body, its chief administrative officer, or any other employee or agent of the hospital or medical staff, may engage in any punitive or retaliatory action against any member of the medical staff because that member claims a right or privilege afforded by, or seeks implementation of any provision of, these medical staff bylaws.

(b) The medical staff recognizes and embraces that it is the public policy of the State of California that a physician and surgeon be encouraged to advocate for medically appropriate health care for their [sic] patients. To advocate for medically appropriate health care includes, but is not limited to, the ability of a physician to protest a decision, policy, or practice that the physician, consistent with that degree of learning and skill ordinarily possessed by reputable physicians practicing according to the applicable legal standard of care, reasonably believes impairs the physician’s ability to provide medically appropriate health care to their [sic] patients. No person, including but not limited to the medical staff, the hospital, its employees, agents, directors or owners, shall retaliate against or penalize any member for such advocacy or prohibit, restrict or in any way discourage such advocacy, nor shall any person prohibit, restrict, or in any way discourage a member from communicating to a patient information in furtherance of medically appropriate health care.

(c) This section does not preclude corrective and/or disciplinary action as authorized by these medical staff bylaws

The CHA Model is consistent with California law regarding non-retaliation.

The CMA Model also includes provisions regarding retaliation against members who claim rights or privileges under the bylaws and who advocate for appropriate health care. CMA does not appear to require that the physician advocate in a professional manner and in accordance with reasonable conduct guidelines. (CMA’s conduct standards (CMA Section 2.7.1) classify these as “appropriate conduct” and appear to place them off limits for any redress, regardless of how the advocacy is effected.)

Article 16

ADOPTION AND AMENDMENT OF BYLAWS

16.1 MEDICAL STAFF RESPONSIBILITY AND AUTHORITY

16.1-1 The Medical Staff shall have the initial




responsibility and delegated authority to formulate, adopt and recommend Medical Staff bylaws and amendments which shall be effective when approved by the Governing Body, which approval shall not be unreasonably withheld. Such responsibility and authority shall be exercised in good faith and in a reasonable, timely and responsible manner, reflecting the interests of providing patient care of the generally recognized level of quality and efficiency, and maintaining a harmony of purpose and effort with the Governing Body. Additionally, hospital administration may develop and recommend proposed Bylaws, and in any case should be consulted as to the impact of any proposed Bylaws on hospital operations and feasibility.

The CHA Bylaws articulate a reasonable standard to apply in adoption and approval of bylaws.

16.1-2 Proposed amendments shall be submitted to the Governing Body for comments at least 30 days before they are distributed to the Medical Staff for a vote. The Governing Body has the right to have its comments at least 30 days regarding the proposed amendments circulated with the proposed amendments at the time they are distributed to the Medical Staff for a vote.

Although California law (Business & Professions Section 2282.5) establishes the Medical Staff’s right to adopt bylaws, and sets out a standard for Governing Body approval (shall not be unreasonably withheld), this CHA provision affords an opportunity for the Medical Staff to have prior notice of any problematic provisions at a point where it may be possible to invoke a meet and confer session (pursuant to CHA Section 9.2-2b) to discuss issues of disagreement.

16.1-3 Amendments to these bylaws shall be submitted for vote upon the request of the Medical Executive Committee or upon receipt of a petition signed by at least [insert minimum number or percent] of the voting Medical Staff members. Amendments submitted upon petition of the voting Medical Staff members shall be provided to the Medical Executive Committee at least 30 days before they are submitted to the Governing Body for review and comment as described in Section 16.1-2. The Medical Executive Committee has the right to have its comments regarding the proposed amendments circulated to the Governing Body when the proposed amendments are submitted to the Governing Body for comments; and to have its comments circulated to the Medical Staff with the proposed amendments at the time they are distributed to the Medical Staff for a vote.

These provisions in the CHA Bylaws provide a means to flush out potential problems before a vote is taken.

16.2 METHODOLOGY 15.1 PROCEDURE




16.2-1 Medical Staff bylaws may be adopted, amended or repealed by the following combined actions:

a. The affirmative vote of a majority of the Medical Staff members voting on the matter by mailed secret ballot, provided at least fourteen days’ advance written notice, accompanied by the proposed bylaws and/or alterations, has been given; and

b. The approval of the Governing Body, which shall not be unreasonably withheld. If approval is withheld, the reasons for doing so shall be specified by the Governing Body in writing, and shall be forwarded to the Chief of Staff, the Medical Executive Committee and the bylaws committee.

Upon the request of (1) the medical executive committee, or the chief of staff or the (2) bylaws committee, or (3) upon timely written petition signed by at least [10%] of the members of the medical staff in good standing who are entitled to vote, consideration shall be given to the adoption, amendment, or repeal of these bylaws. Such action shall be taken at a regular or special meeting of the medical staff, provided (1) written notice of the proposed change was sent to all members on or before the last regular or special meeting of the medical staff, and such changes were offered at such prior meeting and (2) notice of the next regular or special meeting at which action is to be taken included notice that a bylaw change would be considered. Both notices shall include the exact wording of the existing bylaw language, if any, and the proposed change(s).

CMA Bylaws require a Medical Staff meeting to amend bylaws. When coupled with the quorum requirements (2/3 of the members eligible to vote), it can be very difficult to effectuate Bylaw amendments. Also, this permits a minority of the staff to prevent Bylaw amendment by simply not attending the meeting.

16.2-2 In recognition of the ultimate legal and fiduciary responsibility of the Governing Body, the organized Medical Staff acknowledges, in the event the Medical Staff has unreasonably failed to exercise its responsibility and after notice from the Governing Body to such effect, including a reasonable period of time for response, the Governing Body may impose conditions on the Medical Staff that are required for continued state licensure, approval by accrediting bodies, or to comply with law or a court order. In such event, Medical Staff recommendations and views shall be carefully considered by the Governing Body in its actions.

15.2 ACTION ON BYLAW CHANGE

If a quorum is present for the purpose of enacting a bylaw change, the change shall require an affirmative vote of [greater than 50%] of the members voting in person or by written ballot.

15.3 APPROVAL

Bylaw changes adopted by the medical staff shall become effective following approval by the board of [trustees/directors], which approval shall not be withheld unreasonably, or automatically within [ ] days if no action is taken by the board of [trustees/directors]. Medical staff members are provided with copies of the revisions in the bylaws, rules and regulations and medical staff policies. If approval is withheld, the reasons for doing so shall be specified by the board of [trustees/directors] in writing, and shall be forwarded to the chief of staff, the medical executive and bylaws committee.

While the foregoing provision is an important feature to protect the hospital in the case of impasse that jeopardizes accreditation, licensure or court order, it may itself be deemed to violate the TJC requirement that neither the Medical Staff nor the Governing Body have unilateral authority to amend the bylaws. Note, however, this provision does not actually provide for amendment of the bylaws, but rather is an acknowledgement that conditions may be imposed as needed to comply with these external authorities. Medical Staffs should consult with their own legal counsel as to the advisability of including this provision.

Nonetheless, SB1325 (2004) arguably increases the necessity for including this provision: “The Governing Body must act to protect the quality of medical care provided and the competency of its Medical Staff and to ensure the responsible governance of the hospital in the event that the Medical Staff fails in any of its substantive duties or responsibilities.”

16.3 TECHNICAL AND EDITORIAL CORRECTIONS

The Medical Executive Committee shall have the power to approve technical corrections such as reorganization or renumbering of the bylaws, or to correct punctuation,

15.4 EXCLUSIVITY

The mechanism described herein shall be the sole method for the initiation, adoption, amendment, or repeal of the medical staff bylaws.




spelling or other errors of grammar or expression or inaccurate cross-references. No substantive amendments are permitted pursuant to this Section. Corrections may be effected by motion and acted upon in the same manner as any other motion before the Medical Executive Committee. After approval, such corrections shall be communicated in writing to the Medical Staff and to the Governing Body. Such corrections are effective upon adoption by the Medical Executive Committee; provided however, they may be rescinded by vote of the Medical Staff or the Governing Body within 120 days of the date of adoption by the MEC. (For purposes of this section, “vote of the Medical Staff” shall mean a majority of the votes cast, provided at least 25% of the voting members of the Medical Staff cast ballots.)

15.5 EFFECT OF THE BYLAWS

(a) Upon adoption and approval as provided in Article XV, in consideration of the mutual promises and agreements contained in these bylaws, the hospital and the medical staff, intending to be legally bound, agree that these bylaws shall constitute part of the contractual relationship existing between the hospital and the medical staff members, both individually and collectively.

(b) These bylaws may not be unilaterally amended or repealed by the medical staff or board of [trustees][directors].

(c) No medical staff governing document and no hospital corporate bylaws or other hospital governing document shall include any provision purporting to allow unilateral amendment of the medical staff bylaws or other medical staff governing document.

(d) Hospital corporate bylaws, policy, rules, or other hospital requirements that conflict with medical staff bylaw provisions, rules, regulations and/or policies and procedures, shall not be given effect and shall not be applied to the medical staff or its individual members.

Treating Bylaws as a contract raises a number of questions and concerns, including:

Treating hospitals and Medical Staffs as contracting parties may increase the likelihood that they will be deemed separate legal entities.

If hospitals and Medical Staffs are separate legal entities, they could be deemed to be co-conspirators for antitrust causes of action, some of which would not be protected by HCQIA (e.g., exclusive contracting decisions).

Medical Staffs are undercapitalized, making it virtually certain the hospital would still bear the financial responsibility for the Medical Staff’s obligations.

Would a tax-exempt hospital be able to fund a separate legal entity? (Would the Medical Staff qualify for tax-exemption?)

Would a public hospital be able to fund a separate legal entity. (Would it be a gift of public funds?)

Will the Medical Staff need to carry separate insurance? Who will pay for that?

Will the hospital’s insurance cover contractual liabilities, and if so at what added cost? [CHAIS has indicated verbally that the CHAIS coverage would probably not apply.]




In the context of credentialing decisions (one of the most likely contexts in which the contract theory will be tested), hospital governing bodies are not free to make independent decisions (i.e., they must act on recommendation of the Medical Staff; they must afford either “substantial evidence” (per CMA Bylaws) or “great weight” (per CHA Bylaws) to the Medical Staff’s recommendation; and if they disagree, they must send the matter back to the Medical Staff for a hearing). Necessarily, this would mean that both the hospital and the Medical Staff would need to be sued in any credentialing action. At the very least, this will likely increase costs of defense.

The contract would lack mutuality of remedy. A hospital could not feasibly terminate its entire Medical Staff for poor performance (e.g., if the hospital’s accreditation or Medicare certifications were jeopardized by failures of the Medical Staff to effectively perform all of its responsibilities).

A hospital could not even terminate ineffective Medical Staff officers or committee members (this could lead to claims that the hospital is violating the precept of “self governance”).

What effective remedy would the hospital have against the Staff as a whole, or against individual physicians? (Unless insufficient performance of Medical Staff responsibilities becomes an independent ground to terminate individual members of the Medical Staff, there is no effective remedy.)

The available immunities clearly run in favor of individual members of the Medical Staff who participate in certain peer review activities. The hospital does not enjoy all of these immunities. Moreover, the immunities do not cover all of the potential actions that would arise if the Medical Staff Bylaws were deemed a contract.

More litigation is certain, at increased cost to the health care system.

This climate will jeopardize smooth hospital – Medical Staff relations.




The standard of review on a contract action is different (i.e., the deference afforded via the “substantial evidence” standard of a mandamus action would not apply).

Would Medical Staffs “water down” obligations imposed via the Bylaws (e.g., emergency call responsibilities), so that contractual enforcement would not be an option?

What is the consideration for the contract? Physicians are required by law to form a self-governing Medical Staff. Obligations imposed by law, regulation, and accreditation standards form the essence of the responsibilities of the Medical Staff.

15.6 SUCCESSOR IN INTEREST/AFFILIATIONS

15.6-1 SUCCESSOR IN INTEREST

These bylaws, and privileges of individual members of the medical staff accorded under these bylaws, will be binding upon the medical staff, and the board of [trustees/directors] of any successor in interest in this hospital, except where hospital medical staffs are being combined. In the event that the staffs are being combined, the medical staffs shall work together to develop new bylaws which will govern the combined medical staffs, subject to the approval of the hospital’s board of [trustees/directors] or its successor in interest. Until such time as the new bylaws are approved, the existing bylaws of each institution will remain in effect.

15.6-2 AFFILIATIONS

Affiliations between the hospital and other hospitals, health care systems or other entities shall not, in and of themselves, affect these bylaws.

These successor provisions are especially problematic when hospitals are sold or they affiliate with health systems. When coupled with the difficult bylaw amendment provisions, it can be extremely difficult to effectuate changes in medical staff operations to align them with the governance structure of the successor or system affiliated entities.

15.7 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 genders




wherever either term is used.


CHA MODEL MEDICAL STAFF RULES 2014

CMA MODEL MEDICAL STAFF RULES 2013

COMMENTS

RULE 1

CATEGORIES OF MEMBERSHIP

Categories

The medical staff shall consist of the following categories [check applicable boxes]. The rules applicable to each staff category are set forth in the corresponding appendix (and the appendix will apply only if the medical staff so elects by checking the appropriate box).

Check below if applicable See Appendix

Active Staff 1A

Affiliate Staff 1B

Consulting Staff 1C

Courtesy Medical Staff 1D

Honorary and Retired Staff 1E

House Officer Staff 1F

Locum Tenens Affiliate Staff 1G

Provisional Staff 1H

Telemedicine Staff 1I

The CHA Rules contain a separate “Appendix” for each staff category (to facilitate selecting just those categories appropriate for each hospital’s medical staff).

1.2 Qualifications Generally

Each practitioner who seeks or enjoys staff appointment must continuously satisfy the basic qualifications for membership set forth in the Bylaws and Rules, except those that are specifically waived for a particular category, and the additional qualifications that attach to the staff category to which he or she is assigned. The Governing Body may, after considering the Medical Executive Committee’s recommendations, waive any qualification in accordance with Section 2.2-4 of the Bylaws.

1.3 Prerogatives and Responsibilities

1.3-1 The prerogatives available to a medical staff

This section generally describes prerogatives and responsibilities, and the Table at 1.3-3 (see attached) displays the specific prerogatives and responsibilities of




COMMENTS

member depending upon staff category enjoyed are:

a. Admit patients: Admit patients consistent with approved privileges.

b. Eligible for Clinical Privileges: Exercise those clinical privileges that have been approved.

c. Vote: Vote on any medical staff matter including Bylaws amendments, officer selection and other matters presented at any general or special staff meetings and on matters presented at department meetings.

d. Hold Office: Hold office in the medical staff and in the department to which he or she is assigned.

e. Serve on Committees: Serve on committees and vote on committee matters.

1.3-2 The responsibilities which medical staff members will be expected to carry out in addition to the basic responsibilities set forth in the Bylaws, Section 2.6, Basic Responsibilities of Medical Staff Membership, are to:

a. Medical Staff Functions: Contribute to and participate equitably in staff functions, at the request of [a department chair] or other staff officer, including: contributing to the organizational and administrative activities of the medical staff, such as quality improvement, risk management and utilization management; serving in medical staff [and department] offices and on hospital and medical staff committees; participating in and assisting with the hospital’s medical education programs; proctoring of other practitioners; and fulfilling such other staff functions as may reasonably be required.

b. Consulting: Consulting with other staff members consistent with his or her delineated privileges.

c. Emergency Room Call: Serving on the on-call roster and accepting responsibility for providing care to any patient requiring on-call coverage in his or her specialty, in accordance with rules established by [the departments and approved by] the Medical Executive Committee and the Governing Body.

each staff category. Substantively, they do not differ significantly from the CMA Bylaws.




COMMENTS

d. Attend Meetings: Attend at least the minimum number of staff [and department] meetings specified in the Medical Staff Bylaws.

e. Pay Fees/Dues: Pay staff application fees, dues and assessments in the amounts specified in the rules.

1.3-3 Prerogatives and Obligations of Staff Categories

The prerogatives and obligations of each staff category are described in the table following:

[See attached Table]

1.4 Qualifications for Staff Category

1.4-1 Assignment and Transfer in Staff Category

a. Medical staff members shall be assigned to the category of staff membership based upon the qualifications identified below. Active staff members who fail to achieve the minimum activity for two consecutive years shall be automatically transferred to the appropriate category. Action shall be initiated to evaluate and possibly terminate the privileges and membership of any staff member who has failed to have any activity. A Courtesy Member who has exceeded the maximum activity permitted for two consecutive years shall be deemed to have requested transfer to the appropriate category. The Medical Executive Committee shall approve these assignments and transfers, which shall then be evaluated in accordance with the bylaws and these rules. The transfers shall be done at the time of reappointment.

3.2-3 TRANSFER OF ACTIVE STAFF MEMBERAfter [two] consecutive years in which a member of the active staff fails to regularly care for patients in this hospital or be regularly involved in medical staff functions as determined by the medical staff, that member shall be automatically transferred to the appropriate category, if any, for which the member is qualified.

b. In assigning practitioners to the proper staff category, the medical staff shall also consider whether the practitioner participated in other aspects of the hospital’s activities by, for example, serving on committees. The Governing Body (on recommendation of the Medical Executive Committee) may rescind an automatic transfer, but only if the practitioner clearly demonstrates that unusual circumstances unlikely to occur again in his or her practice caused the failure to meet the minimum or maximum requirements.


CHAMODEL MEDICAL STAFF RULES 2014


COMMENTS

Appendix 1A

ACTIVE STAFF

The Active Staff shall consist of the members who:

1. Are regularly involved in caring for patients or demonstrate, by way of other substantial involvement in medical staff or hospital activities, a genuine concern and interest in the hospital. Regular involvement in patient care shall mean admitting inpatients or outpatients, referring or consulting on at least [eight] cases each medical staff year (except that allergists, dentists, dermatologists and psychiatrists need only be involved in at least [five] cases in order to maintain Active Staff status).

2. Have been members in good standing of the provisional staff for at least [twelve months].

See Table.

3.2 ACTIVE STAFF


The active staff shall consist of members who:

(a) meet the general qualifications for membership set forth in Section 2.2;

(b) have offices or residences which, in the opinion of the medical executive committee, are located closely enough to the hospital to provide appropriate continuity of quality care;

(c) regularly care for patients in this hospital or are regularly involved in medical staff functions, as determined by the medical staff [regularly admit, or are otherwise regularly involved in the care of in excess of [ ] patients a year in the hospital]; and

CHA Bylaws cover these general requirements at Section 2.2-2 and 2.2-3.

[Optional Provisional Stage Category of Membership:]

d) [except for good cause shown as determined by the medical staff, have satisfactorily completed their designated term in the provisional staff category.]

[Board certification option]*

*CMA policy is that, while board certification is desirable, medical staffs generally should not require board certification as a condition for the granting of clinical privileges. If a medical staff wishes to adopt a board certification requirement, it may consider language such as the following:

[(e) are certified or are progressing towards certification by (1) boards which are duly organized and recognized by an American Board of Medical Specialties member board or (2) a board or association with equivalent requirements approved by the Medical Board of California or (3) a board or association with an Accreditation Council for Graduate Medical Education-approved postgraduate training program that provides complete training in that specialty or subspecialty. Applicants/Re-applicants who are progressing toward board certification must become board certified within




COMMENTS

five years of the initial granting of medical staff membership, unless extended for good cause by the medical executive committee.

Current members of the medical staff who were not, as of date of adoption of this amendment, board certified or progressing toward board certification, and who cannot reasonably be expected to pursue board certification, may be considered for renewal of medical staff membership if they can document sufficient training, experience, and competence, and otherwise meet the requirements of medical staff membership.

Persons not fulfilling the above eligibility criteria including board certification may apply for special consideration and must demonstrate that their education, training, experience, demonstrated ability, judgment and medical skills are equivalent to or greater than the level of proficiency evidenced by the eligibility criteria listed above.]

3.2-2 PREROGATIVES

Except as otherwise provided, the prerogatives of an active medical staff member who is in good standing shall be to:

(a) admit patients and exercise such clinical privileges as are granted pursuant to Article V;

(b) attend and vote on medical staff bylaws and amendments and all other matters presented at general and special meetings of the medical staff and of the department and committees to which the member is duly appointed; and

(c) hold staff, division, or department office and serve as a voting member of committees to which the member is duly appointed or elected by the medical staff or duly authorized representative thereof, so long as the activities required by the position fall within the member’s scope of practice as authorized by law.

Note CMA’s new definition of “good standing” (see CMA Section 1.2-7a).

3.2-3 TRANSFER OF ACTIVE STAFF MEMBER

After [two] consecutive years in which a member of the active staff fails to regularly care for patients in this hospital or be regularly involved in medical staff functions as determined by the medical staff, that member shall be automatically transferred to the appropriate category, if any, for which the




COMMENTS

member is qualified.

Appendix 1B

AFFILIATE STAFF

The Affiliate Staff shall consist of members who have not completed full training in their specialty and/or do not meet board certification or eligibility for board examination requirements or who have not met all minimum experience requirements to qualify for full privileges, but who nevertheless appear likely to provide a distinct service to the hospital, the medical staff and the patients. Affiliate Staff members may be granted privileges to co-admit patients, assist in surgery and write progress notes, depending upon the member’s training and experience.

See Table.

Appendix 1C

CONSULTING STAFF

The Consulting Staff shall consist of practitioners who possess ability and knowledge that enable them to provide valuable assistance in difficult cases.

See Table.

3.4 THE CONSULTING MEDICAL STAFF


Any member of the medical staff in good standing may consult in that member’s area of expertise; however, the consulting medical staff shall consist of such practitioners who:

(a) are not otherwise members of the medical staff and meet the general qualifications set forth in Section 2.2, except that this requirement shall not preclude an out-of-state practitioner from appointment membership as may be permitted by law if that practitioner is otherwise deemed qualified by the medical executive committee;

(b) possess adequate clinical and professional expertise;


(c) are willing and able to come to the hospital on schedule or promptly respond when called to render clinical services within their area of competence;

(d) are members in good standing of the active or associate medical staff of another hospital licensed by California or another state, although exceptions to this requirement may be made by the medical executive




COMMENTS

committee for good cause; and

(e) have satisfactorily completed membership in the provisional category.

3.4-2 PREROGATIVES

The consulting medical staff member shall be entitled to:

(a) exercise such clinical privileges as are granted pursuant to Article V; and

(b) attend meetings of the medical staff and the department of which that person is a member, including open committee meetings and educational programs, but shall have no right to vote at such meetings, except within committees when the right to vote is specified at the time of appointment.

Consulting staff members shall not be eligible to hold office in the medical staff organization, but may serve on committees.

Appendix 1D

COURTESY MEDICAL STAFF

The Courtesy Medical Staff shall consist of the members who:

1. Admit, refer or otherwise provide services for at least [three] patients a year in the hospital, but no more than [eight] patients during each medical staff year.

2. Prior to reappointment, provide evidence of current clinical performance at the hospital where they practice in such form as [the member’s department,] [the Credentials Committee] or the Medical Executive Committee may require in order to evaluate their current ability to exercise the requested clinical privileges.

3. Have completed at least [twelve months] of satisfactory performance on the provisional staff.

See Table.

3.3 THE COURTESY MEDICAL STAFF


The courtesy medical staff shall consist of members who:

(a) meet the general qualifications set forth in subsections (a)-(b) of Section 3.2 1;

(b) do not regularly care for patients or are not regularly involved in medical staff functions as determined by the medical staff [admit, or regularly care for (or reasonably anticipate admitting or regularly caring for) not more than [ ] patients per year in the hospital];

(c) are members in good standing of the active or associate medical staff of another California licensed hospital, although exceptions to this requirement may be made by the medical executive committee for good cause; and

(d) have satisfactorily completed their designated term in the provisional category.


3.3-2 PREROGATIVES

Except as otherwise provided, the courtesy medical staff August 2013 Page 200



COMMENTS

member shall be entitled to:

(a) admit patients to the hospital with the limitations of Section 3.3-1(b) and exercise such clinical privileges as are granted pursuant to Article V; and

(b) attend and vote [or not vote] on medical staff bylaws and amendments and all other matters presented at general and special meetings of the medical staff and of the department and committees to which the member is duly appointed.

Courtesy staff members shall not be eligible to hold office in the medical staff.

3.3-3 LIMITATION

Courtesy staff members who admit patients or regularly care for patients at the hospital shall, upon review of the medical executive committee, be obligated to seek membership in the appropriate staff category.

Appendix 1E

HONORARY AND RETIRED STAFF

The Honorary and Retired Staff shall consist of practitioners who are deemed deserving of membership by virtue of their outstanding reputations, noteworthy contributions to the health and medical sciences, or their previous longstanding service to the hospital, and members who were in good standing when they retired.

See Table.

3.6 HONORARY, RETIRED, AND AFFILIATE STAFF


(a) The Honorary Staff

The honorary staff shall consist of physicians, [dentists] [podiatrists] [clinical psychologists] who do not actively practice at the hospital but are deemed deserving of membership by virtue of their outstanding reputation, noteworthy contributions to the health and medical sciences, or their previous long-standing service to the hospital, and who continue to exemplify high standards of professional and ethical conduct.


(b) The Retired Staff

The retired staff shall consist of members who have retired from active practice and, at the time of their retirement, were members in good standing of the active medical staff for a period of at least [ ] continuous years, and who continue to adhere to appropriate professional and ethical standards.




COMMENTS

(c) The Affiliate Staff

The Affiliate Staff Shall Consist of Physicians, [Dentists] [Podiatrists][Clinical Psychologists] Who Do Not Actively Practice at the Hospital But Are An Important Resource For Medical Staff Eeducational Activities.

3.6-2 PREROGATIVES

Honorary, retired and affiliate staff members are not eligible to admit patients to the hospital or to exercise clinical privileges in the hospital, or to vote or hold office in this medical staff organization, but they may serve on committees with or without vote at the discretion of the medical executive committee. They may attend staff and department meetings, including open committee meetings and educational programs.

Appendix 1F

HOUSE OFFICER STAFF

The House Officer Staff shall consist of residents and fellows who are actively training in an approved program at another hospital, and who only provide coverage for patients admitted by medical staff members. They function pursuant to a medical staff member’s supervision.

See Table.

3.9 RESIDENT MEDICAL STAFF


Resident medical staff membership shall be held by post-doctoral trainees (residents and fellows) in training programs of teaching institutions who are not eligible for another staff category and who are either licensed or registered with the appropriate State of California licensing board. All resident medical staff members must obtain a license to practice medicine within the State of California when eligible.

3.9-2 APPOINTMENT

(a) Post-doctoral trainees who are enrolled in accredited residency training programs and who meet the above qualifications shall be appointed to the resident medical staff. Members of the resident staff are not eligible to hold office within the medical staff, but may participate in the activities of the medical staff through membership on medical staff committees, with the right to vote within committees if specified at the time of appointment, and non-voting attendance at medical staff meetings.

(b) All medical care provided by resident medical staff is under the supervision of members of the active, courtesy or consulting staff. Such care shall be in accordance with the provision of a program approved by and in conformity with




COMMENTS

the Accreditation Council on Graduate Medical Education of the American Medical Association, the American Osteopathic Association, or the American Dental Association’s Commission Dental Accreditation. Residents must be supervised by teaching staff in such a way that the trainee assumes progressively increasing responsibility for patient care according to their level of training, ability and experience.

(c) Appointment to the resident medical staff shall be for one year and may be renewed annually. Resident medical staff membership may not be considered as the observational period required to be completed by provisional staff. Resident medical staff membership terminates with termination from the training program.

[3.9-3 RESIDENT MEDICAL STAFF COMMITTEE]

(a) The resident medical staff committee shall consist of a resident staff representative from each clinical department which has an accredited residency program. Nominations and appointments for the positions of chair and members of the resident medical staff committee will be solicited from the resident medical staff. Appointment term shall be for one year, [July 1] to [June 30].

(b) The committee provides a formal mechanism for resident staff participation in the development, review and evaluation of resident staff patient care responsibilities and functions at the training hospital to include quality assessment and improvement, utilization review, risk management and patient satisfaction. The resident medical staff committee shall be advisory to the medical staff executive committee. [The chair of the resident medical staff committee shall serve as a member of the medical staff executive committee.]

(c) The proceedings and records of the committee shall be maintained as confidential and a copy of the minutes submitted to the medical staff executive committee.]

Appendix 1G

LOCUM TENENS AFFILIATE STAFF

The Locum Tenens Affiliate Staff shall consist of practitioners who only provide coverage for medical staff August 2013 Page 203



COMMENTS

members. They may be in residency or fellowship training programs or have completed training.

See Table.

3.7 TEMPORARY STAFF


The temporary staff shall consist of physicians, [dentists] [podiatrists] [clinical psychologists] who do not actively practice at the hospital but are important resource individuals for medical staff quality assessment and improvement activities. Such persons shall be qualified to perform the functions for which they are made temporary members of the staff.

3.7-2 PREROGATIVES

Temporary medical staff members shall be entitled to attend all meetings of committees to which they have been appointed for the limited purpose of carrying out quality assessment and improvement functions. They shall have no privileges. They may not admit patients to the hospital, or hold office in the medical staff organization. They may, however, serve on designated committees with or without vote at the discretion of the medical executive committee. Finally, they may attend medical staff meetings outside of their committees, upon invitation.

Appendix 1H

PROVISIONAL STAFF

The Provisional Staff shall consist of the members who:

1. Are initial appointees to the medical staff and plan to qualify for, and seek transfer to, the Active, [Consulting, Affiliate, or Courtesy] Staff in [12 to 36] months.

2. In the ordinary course of events, are transferred to active, [Consulting, Affiliate, or Courtesy] status after serving at least [twelve] but not more than [36] months on the provisional staff. Action shall be initiated by the Medical Executive Committee to terminate the privileges and membership of a provisional member who does not qualify for advancement within [36] months. The member

3.5 PROVISIONAL STAFF


The provisional staff shall consist of members who:

(a) meet the general medical staff membership qualifications set forth in Sections 3.2-1(a) and (b) or 3.4-1(a)-(d); and

(b) immediately prior to their application and grant of membership were not members (or were no longer members) in good standing of this medical staff.

3.5-2 PREROGATIVES

The provisional staff member shall be entitled to:





COMMENTS

shall not be entitled to any hearing and appeal under Article 14, Hearings and Appellate Reviews, if advancement was denied because of a failure to have a sufficient number of cases proctored or because of a failure to maintain a satisfactory level of activity. The member shall be entitled to the hearing and appeal rights under Article 14, Hearings and Appellate Reviews, if advancement was denied because the member’s clinical performance or professional conduct was unsatisfactory.

See Table.

(a) admit patients and exercise such clinical privileges as are granted pursuant to Article V; and

(b) attend meetings of the medical staff and the department of which that person is a member, including open committee meetings and educational programs, but shall have no right to vote at such meetings, except within committees when the right to vote is specified at the time of appointment.

Provisional staff members shall not be eligible to hold office in the medical staff organization, but may serve on committees.

3.5-3 OBSERVATION OF PROVISIONAL STAFF MEMBER

Each provisional staff member shall undergo a period of observation by designated monitors as described in Section 5.3. The purpose of observation shall be to evaluate the member’s (1) proficiency in the exercise of clinical privileges initially granted and (2) overall eligibility for continued staff membership and advancement within staff categories. Observation of provisional staff members shall follow whatever frequency and format each department deems appropriate in order to adequately evaluate the provisional staff member including, but not limited to, concurrent or retrospective chart review, mandatory consultation, and/or direct observation. Appropriate records shall be maintained. The results of the observation shall be communicated by the department chair to the credentials committee.

3.5-4 TERM OF PROVISIONAL STAFF STATUS

A member shall remain in the provisional staff for a period of [ ], unless that status is extended by the medical executive committee for an additional period of up to [ ] upon a determination of good cause, which determination shall not be subject to review pursuant to Articles VI or VII.

3.5-5 ACTION AT CONCLUSION OF PROVISIONAL STAFF STATUS

(a) If the provisional staff member has satisfactorily demonstrated the ability to exercise the clinical privileges initially granted and otherwise appears qualified for continued medical staff membership, the member shall be eligible for

CHA Bylaws describe proctoring requirements at Bylaws Section 7.4.4.




COMMENTS

placement in the active, courtesy or consulting staff as appropriate, upon recommendation of the medical executive committee; and

(b) In all other cases, the appropriate department shall advise the credentials committee which shall make its report to the medical executive committee which, in turn, shall make its recommendation to the board of [trustees/directors] regarding a modification or termination of clinical privileges or termination of medical staff membership.

APPENDIX 1I

TELEMEDICINE STAFF

1. Telemedicine Definitions

a. Distant Site is the site where a Telemedicine Provider who provides health care services is located while providing these services via a telecommunications system.

b. Originating Site is where the patient is located at the time health care services are provided via a telecommunications system or where the asynchronous store and forward service originates.

c. Telemedicine Provider is the individual provider who uses the telemedicine equipment at the Distant Site to render services to patients who are located at the Originating Site. The Telemedicine Provider is generally a physician, but other health professionals may also be involved as Telemedicine Providers. The Telemedicine Provider would generally contract with (or in the case of nonphysicians, be employed by) the entity that serves as the Distant Site.

2. Prerogatives and Responsibilities of the Telemedicine Staff

The Telemedicine Staff shall consist of Telemedicine Providers who provide diagnostic, consulting or treatment services, from the Distant Site to hospital patients at the Originating Site via telecommunication devices. Telecommunication devices include interactive (involving a real time [synchronous] or near real time [asynchronous store and forward] two-way transfer of medical data and

CHA has added a more detailed approach to Telemedicine in light of TJC and CMS definitions and recognition of this service.

CMA addresses these issues at CMA Section 5.5.




COMMENTS

information) telecommunications (but do not include telephone or electronic mail communications) between the Telemedicine Provider at the Distant Site and the patient at the Originating Site.

See Table.

3. Additional Provisions Applicable to Telemedicine Staff

a. Requirement for Contract with Distant Site: This hospital must have a written agreement with each Distant Site from which a Telemedicine Provider delivers telemedicine services that specifies the following:

1) The Distant Site is a contractor of services to the hospital.

2) The Distant Site furnishes services in a manner that permits this hospital to be in compliance with the Medicare Conditions of Participation.

3) This hospital makes certain through the written agreement that all Distant Site Telemedicine Providers' credentialing and privileging processes meet, at a minimum, the Medicare Conditions of Participation at 42 CFR 482.12(a)(1) through (a)(9) and 482.22(a)(1) through (a)(4).

b. Requirement to Communicate Regarding Clinical Services: The medical staffs at both this hospital and the Distant Site shall recommend the clinical services to be provided through a telemedical link at their respective sites. The Medical Staff at this hospital evaluates this hospital’s ability to safely provide services on an ongoing basis. The medical staff at the Distant Site evaluates and communicates with this hospital with respect to performance of those services as part of privileging and as part of the reappraisal conducted at the time of reappointment, renewal, or revision of clinical privileges.

c. Responsibility to Communicate Concerns/Problems:

1) There is a need for clear delineation of reporting responsibilities respecting the Telemedicine providers’




COMMENTS

performance. At the very least, the Medical Staff officials at this hospital must be informed of any practitioner-specific problems that arise in the delivery of services to this hospital’s patients.

2) Additionally, this hospital should communicate to the Medical Staff officials at the Distant Site, through peer review channels, any problems that may arise in the delivery of care by the Telemedicine Provider to patients at this hospital.

3) Similarly, when a member of this hospital’s Medical Staff is providing telemedicine services to patients at another facility, this hospital’s Medical Staff should communicate to the Medical Staff officials at the Originating Site, through peer review channels, any problems that may arise in the delivery of telemedicine services by members of this hospital’s Medical Staff.

4) The Chief of Staff may enter into appropriate information sharing agreements and/or develop and implement appropriate protocols to effectuate these provisions.

d. Responsibility to Review Practitioner-Specific Performance:

1) Special proctoring arrangements may be made for qualified practitioners at the Distant Site to proctor cases performed by new members of the Telemedicine Staff.

2) Primary responsibility to assess what, if any, practitioner-specific performance improvement and/or corrective action may be warranted rests with the Originating Site. If such action gives rise to procedural rights at this hospital, the provisions of Article 14 of the Bylaws will apply.

3) [However, this Medical Staff is authorized to develop integrated peer review policies and procedures with other System members, whereby representatives of both the Originating Site’s and the Distant Site’s Medical Staffs engage in integrated review and recommendation.]

RULE 2




COMMENTS

APPOINTMENT AND REAPPOINTMENT

2.1 Overview of Process

The following charts summarize the appointment, temporary privileges and reappointment processes. Details of each step are described in Rules 2.2 through 2.9.

See Tables.

2.2 Application

2.2-1 Each practitioner who expresses formal interest in a recognized and appropriate category of membership and privileges shall be provided an application form for medical staff membership. Upon completion by the practitioner, the form shall be returned to the medical staff office together with the nonrefundable application fee required by the rules.

2.2-2 The application form shall be approved by the Medical Executive Committee and the Governing Body and, once approved, shall be considered part of these rules. The application shall include an agreement to abide by the medical staff and hospital bylaws, rules and applicable policies. The application shall request information pertinent to the applicant’s qualifications, such as (but not limited to) information regarding the applicant’s education (including participation in continuing medical education), specialty training, experience, abilities and current competencies, professional affiliations, proffered references (including the names and addresses of professional peers [when possible from the same professional discipline as the applicant] who will be able to attest in writing to the applicant’s relevant qualifications, experience, abilities, and current competencies), relevant health status (as further described at Rule 2.3), as well as information regarding possible involvement in professional liability actions (including but not limited to all final judgments or settlements involving the applicant); previously completed or currently pending challenges involving professional licensure, certification or registration (state or district, Drug Enforcement Administration) or the voluntary relinquishment of such licensure, certification or registration; voluntary or involuntary termination, limitation, reduction or loss of medical staff or medical group membership and/or clinical

4.5 APPLICATION FOR INITIAL MEMBERSHIP AND RENEWAL OF MEMBERSHIP

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 of CPR training, and continuing medical education information related to the clinical privileges to be exercised by the applicant;

(b) peer references familiar with the applicant’s professional competence and ethical character;

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

(d) past or pending professional disciplinary action, voluntary or involuntary denial, revocation, suspension, reduction for relinquishment of medical staff membership or privileges or any licensure or registration, and related matters; current physical and mental health status;

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

(f) professional liability coverage, if any is required; and

(g) any past, pending or current exclusion from a federal health care program.




COMMENTS

privileges at any other hospital or health facility or entity; any formal investigation or disciplinary action at another hospital or health facility that was taken or is pending; and information detailing any prior or pending government agency or third party payor investigation, proceeding or litigation challenging or sanctioning the practitioner’s patient admission, treatment, discharge, charging, collection or utilization practices, including but not limited to Medicare or Medi-Cal fraud and abuse proceedings or convictions. The application shall also release all persons and entities from any liability that might arise from their investigating and/or acting on the application. Additionally, the practitioner shall provide the names and addresses of professional peers who are able to attest to the practitioner’s relevant qualifications.

Each application for initial membership on 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 unavailable), 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, as deemed appropriate by the medical executive committee, copies or summaries of any other applicable medical staff policies relating to clinical practice in the hospital.

The CHA Bylaws articulate the expectation that the application form will contain a release.

2.3 Physical and Mental Capabilities

2.3-1 Obtaining Information

a. The application shall require the applicant to submit a statement attesting that no health problems exist that could affect his or her ability to perform the responsibilities of medical staff membership or exercise of requested clinical privileges. If the applicant does have a health condition and/or requires special accommodations with respect to a health condition, he/she shall provide information pertaining to his/her physical and mental health on a separate page of the form, which can be removed from the remaining application and processed separately. Upon receipt of the application, the page addressing physical and mental disabilities or conditions requiring accommodation shall be removed and referred to the [Well-Being Committee].

b. When the medical staff office verifies information and obtains references, it shall ask for any information concerning physical or mental status to be reported on a confidential form, which can be processed separately from the other information obtained regarding the applicant. This information will also be referred to the [Well-Being Committee].

c. The [Well-Being Committee] shall be responsible for investigating any practitioner who has or may have a

CHA Bylaws include specific provisions for obtaining information about physical or mental problems, in a manner that will facilitate compliance with any ADA requirements that may apply.

CMA Bylaws address ADA Bylaws at Footnote 18 to Section 2.2-1 as follows: Caution: Medical Staffs should be aware of the potential applicability of the federal Americans with Disabilities Act (ADA) to the credentialing processes of their facilities. To the extent that the ADA is applicable, a medical staff is prohibited from asking applicants questions soliciting information regarding health conditions that are deemed disabilities under the ADA (e.g., alcoholism, mental illness and past drug abuse) as part of the initial application process. See Note to Rationale for MS.11.01.01, stating “organizations should consider the applicability of the Americans with Disabilities Act (ADA) to their credentialing and privileging activities, and, if applicable, review their medical staff bylaws, policies and procedures.” See also TJC Standard 06.01.05, EP No 6 and the accompanying Note, which provides: “The applicant’s ability to perform privileges requested must be evaluated. This evaluation is documented in the individual’s credentials file. Such documentation may include the applicant’s statement that no health problems exist that could affect his or her




COMMENTS

physical or mental disability or condition that might affect the practitioner’s ability to exercise his or her requested privileges in a manner that meets the hospital and medical staff’s quality of care standards. This may include one or all of the following:

1) Medical Examination: To ascertain whether the practitioner has a physical or mental disability that might interfere with his or her ability to provide care which meets the hospital and medical staff’s quality of care standards.

practice. Documentation regarding an applicant’s health status and his or her ability to practice should be confirmed. Initial applicants may have their health status confirmed by the director of a training program, the chief of services, or the chief of staff at another hospital at which the applicant holds privileges, or by a currently licensed doctor of medicine or osteopathy approved by the organized medical staff. In instances where there is doubt about an applicant’s ability to perform privileges requested, an evaluation by an external and internal source may be required. The request for an evaluation rests with the organized medical staff.”

2) Interview: To ascertain the condition of the practitioner and to assess if and how reasonable accommodations can be made.

d. Any practitioner who feels limited or challenged in any way by a qualified mental or physical disability in exercising his or her clinical privileges and in meeting quality of care standards should make such limitation immediately known to the [Well-Being Committee]. Any such disclosure will be treated with the high degree of confidentiality that attaches to the medical staff’s peer review activities.

2.3-2 Review and Reasonable Accommodations

a. Any practitioner who discloses or manifests a qualified physical or mental disability or condition requiring accommodation will have his or her application processed in the usual manner without reference to the condition.

b. The [Well-Being Committee] shall not disclose any information regarding any practitioner’s qualified physical or mental disability or condition until the Medical Executive Committee (or, in the case of temporary privileges, the medical staff representatives who review temporary privilege requests) have determined that the practitioner is otherwise qualified for membership and/or to exercise the privileges requested. Once the determination is made that the practitioner is otherwise qualified, the [Well-Being Committee] may disclose information it has regarding any physical or mental disabilities or conditions and the effect of those on the practitioner’s application for membership and August 2013 Page 211



COMMENTS

privileges. Any such disclosure shall be limited as necessary to protect the practitioner’s right to confidentiality of health information, while at the same time communicating sufficient information to permit the Medical Executive Committee to evaluate what, if any, accommodations may be necessary and feasible. The [Well-Being Committee] and any other appropriate committees may meet with the practitioner to discuss if and how reasonable accommodations can be made.

c. As required by law, the medical staff and hospital will attempt to provide reasonable accommodations to a practitioner with known physical or mental disabilities or conditions, if the practitioner is otherwise qualified and can perform the essential functions of the staff appointment and privileges in a manner which meets the hospital and medical staff quality of care standards. If reasonable accommodations are not possible under the standards set forth herein, it may be necessary to withdraw or modify a practitioner’s privileges and the practitioner shall have the hearing and appellate review rights described in Article 14, Hearings and Appellate Reviews, of the Bylaws.

2.4 Effect of Application

By applying for or by accepting appointment or reappointment to the medical staff, the applicant:

2.4-1 Signifies his or her willingness to appear for interviews in regard to his or her application for appointment.

2.4-2 Authorizes medical staff and hospital representatives to consult with other hospitals, persons or entities who have been associated with him or her and/or who may have information bearing on his or her competence and qualifications or that is otherwise relevant to the pending review and authorizes such persons to provide all information that is requested orally and in writing.

2.4-3 Consents to the inspection and copying, by hospital representatives, of all records and documents that may be relevant or lead to the discovery of information that is relevant to the pending review, regardless of who possesses

4.5-2 EFFECT OF APPLICATIONIn addition to the matters set forth in Section 4.1, by applying for membership on 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 clinical 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 August 2013 Page 212



COMMENTS

these records, and directs individuals who have custody of such records and documents to permit inspection and/or copying.

2.4-4 Certifies that he or she will report any subsequent changes in the information submitted on the application form to [the Credentials Committee]/[Medical Executive Committee] and the chief executive officer.

2.4-5 Releases from any and all liability the medical staff and the hospital and its representatives for their acts performed in connection with evaluating the applicant.

2.4-6 Releases from any and all liability all individuals and organizations who provide information concerning the applicant, including otherwise privileged or confidential information, to hospital representatives.

2.4-7 Authorizes and consents to hospital representatives providing other hospitals, professional societies, licensing boards and other organizations concerned with provider performance and the quality of patient care with relevant information the hospital may have concerning him or her, and releases the hospital and hospital representatives from liability for so doing.

provided by law, all persons for their acts performed in connection with investigating and evaluating the applicant;

(e) releases from any liability, to the fullest extent provided by law, 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 boards, 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 law;

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

(h) agrees 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 failing to disclose to patients when another surgeon will be performing the surgery, and refraining from delegating patient care responsibility to non-qualified or inadequately supervised practitioners or allied health practitioners; andj) pledges to be bound by the medical staff bylaws, rules and regulations, and policies. CMA Footnote on (j) – In California, medical staff bylaws should not require compliance with hospital documents, such as bylaws, rules, policies, etc., over which the medical staff has no control. Rather, any hospital policy or rule that is desirable may be adopted as a medical staff policy by action of the medical staff. See Section 15.3 APPROVAL. Once duly adopted by the medical staff, such a policy will be deemed to be a medical staff policy that, as such, will be binding upon all medical staff members. See also Section 15.5 EFFECT OF THE BYLAWS, subsection (d), prohibiting any effect to be given to provisions in hospital governing

CMA Bylaws limit the medical staff obligation to compliance with medical staff bylaws, rules, and policies. The CHA Bylaws provide for Medical Staff compliance with appropriate hospital policies as well. Without acknowledgement of medical staff responsibility to comply with hospital policy, the medical staff itself may have difficulty enforcing compliance with important requirements – e.g., the hospital’s sexual harassment policy. Governing Bodies should assess whether the CMA approach usurps governance authority.




COMMENTS

documents that conflict with medical staff governing documents.

(k) agrees that if membership and privileges are granted, and for the duration of medical staff membership, the member has an ongoing and continuous duty to report to the medical staff office within ten days any and all information that would otherwise correct, change, modify or add to any information provided in the application or most recent reapplication when such correction, change, modification or addition may reflect adversely on current qualifications for membership or privileges.

[2.4-8 Agrees that the hospital and medical staff may share information with a representative or agent from any system member, including information obtained from other sources, and releases each person and each entity who received the information and each person and each entity who disclosed the information from any and all liability, including any claims of violations of any federal or state law, including the laws forbidding restraints of trade, that might arise from the sharing of the information and likewise agrees that the system and any and all system members may act upon such information.]

2.4-9 Consents to undergo and to release the results of a physical or mental health examination by a practitioner acceptable to the Medical Executive Committee, at the applicant’s expense, if deemed necessary by the Medical Executive Committee.

2.4-10 Signifies his or her willingness to abide by all the conditions of membership, as stated on the appointment application form, on the reappointment application form, and in the bylaws and these rules.

2.4-11 For purposes of this Rule 2.4, the term “hospital representative” includes the Governing Body, its individual [Directors/Trustees] and committee members; the chief executive officer, the medical staff, all medical staff [,department and section] officers and/or committee members having responsibility for collecting information regarding or evaluating the applicant’s credentials; and any authorized representative or agent of any of the foregoing.




COMMENTS

2.5 Verification of Information

2.5-1 – General: The applicant shall fill out and deliver an application form to the medical staff office, which shall seek to verify the information submitted. Verification shall encompass, but is not limited to, written verification of peer references, licensure status, training and education, current proficiency with respect to the hospital’s general competencies (as applicable to the privileges requested), health status, other evidence submitted in support of the application, and confirmation that the practitioner is the same individual identified in the credentialing documents (by viewing a current, valid picture hospital ID card or a valid state of federal agency picture ID card). The application will be deemed complete when all necessary verifications have been obtained, including but not limited to current license, licensing board disciplinary records, specialty board certification status, National Practitioner Data Bank information, Drug Enforcement Administration certificate, if appropriate, verification of all practice from professional school through the present, current malpractice liability insurance and reference letters, verification of current proficiency in the hospital’s general competencies (Section 5.2 of the Medical Staff bylaws), and other evidence that the applicant submitted in support of this/her application. Additionally, the Medical Staff office may seek information from other relevant sources, such as the American Medical Association’s Physician Masterfile (for verification of a physician’s medical school graduation and residency completion), the American Board of Medical Specialties (for verification of a physician’s board certification), the Educational Commission for Foreign Medical Graduates (for verification of a physician’s graduation from a foreign medical school), the American Osteopathic Association Physician Database (for pre- and post-doctoral education), and the Federation of State Medical Boards Physician Disciplinary Data Bank (for all actions against a physician’s medical license). [The medical staff office shall then transmit the application and all supporting materials to the chair of each department in which the applicant seeks privileges, and to the Credentials Committee]

2.5-2 Primary Source Verification for Disaster

4.5-3 VERIFICATION OF INFORMATION

The applicant shall deliver a completely filled-in, signed, and dated application and supporting documents to the appropriate medical staff officer and an advance payment of medical staff dues [and][or] fees paid to the medical staff, as 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 and to the credentials committee. The credentials committee, and the administrator when requested to assist by the credentials committee, 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 to the credentials committee 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 any reasonably requested information. When collection and verification of information other than the National Practitioner Data Bank is accomplished, the application shall be considered complete, and all such information shall be transmitted to the credentials committee and the appropriate department(s). No final action on an application may be taken until receipt of the Data Bank report.

The CHA Bylaws are more elaborate as to source checks for relevant information.

CHA has augmented its provisions relating to Disaster Privileges in accord with TJC Standards EM.02.02.13 and




COMMENTS

Privileges: With respect to volunteer practitioners who may be permitted to exercise privileges or perform functions when the hospital’s disaster plan has been activated and the organization is unable to handle the immediate patient needs:

a. Primary source verification of licensure must occur as soon as the disaster is under control or within 72 hours from the time the volunteer practitioner presents him- or herself to the hospital, whichever comes first. If primary source verification of a volunteer practitioner’s licensure cannot be completed within 72 hours of the practitioner’s arrival due to extraordinary circumstances, the all of the following must be documented:

1. Reason(s) it could not be performed within 72 hours of the practitioner’s arrival;

2. Evidence of the practitioner’s demonstrated ability to continue to provide adequate care, treatment, and services; and

3. Evidence of the hospital’s attempt to perform primary source verification as soon as possible.

b. If, due to extraordinary circumstances, primary source verification of licensure of the volunteer practitioner cannot be completed within 72 hours of the practitioner’s arrival, it must be performed as soon as possible. (Note: Primary source verification of licensure is not required if the volunteer practitioner has not provided care, treatment, or services under the disaster privileges.)

EM.02.02.15.

CMA addresses Disaster Privileges at CMA Section 5.8.

2.6 Incomplete Application

2.6-1 If the medical staff office is unable to verify the information, or if all necessary references have not been received, or if the application is otherwise significantly incomplete, the medical staff office may delay further processing of the application, or may begin processing the application based only on the available information with a decision that further information may be considered upon receipt.

The CHA Bylaws contain provisions describing how and if to proceed in the face of incomplete information.




COMMENTS

2.6-2 If the processing of the application is delayed for more than 60 days and if the missing information is reasonably deemed significant to a fair determination of the applicant’s qualifications, the affected practitioner shall be so informed. He or she shall then be given the opportunity to withdraw his or her application, or to request the continued processing of his or her application. If the applicant does not respond within 30 days, he or she shall be deemed to have voluntarily withdrawn his or her application. If the applicant requests further processing, but then fails to provide or arrange for the provision within 45 days or any other date mutually agreed to when the extension was granted (whichever is later) of the necessary information that the practitioner could obtain using reasonable diligence, the practitioner shall be deemed to have voluntarily withdrawn his or her application.

2.6-3 Any application deemed incomplete and withdrawn under this rule may, thereafter, be reconsidered only if all requested information is submitted, and all other information has been updated.

5.11 LAPSE OF APPLICATION

If a medical staff member requesting a modification of clinical privileges or department assignments fails to timely furnish the information reasonably 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 VII.

CMA also addresses this, but only in the context of request for modification of clinical privileges or department assignments.

2.7 Action on the Application

2.7-1 Department Action

Upon receipt, the [Department Chair]/[Department Committee] shall review the application and supporting documentation, may personally interview the applicant, and, based upon the criteria for appointment or reappointment (as applicable) described in the Bylaws, shall transmit to the [Credentials Committee]/[Medical Executive Committee] on the prescribed form a written report and recommendations as to staff appointment and clinical privileges

4.5-4 DEPARTMENT ACTION

After receipt of the application, the chair or appropriate committee 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 committee’s discretion. The chair or appropriate committee shall evaluate all matters deemed relevant to a recommendation, including information concerning the applicant’s provision of services within the scope of privileges granted, the applicant’s clinical and technical skills and any relevant data available from hospital performance improvement activities, and the reapplicant’s participation in relevant continuing education and shall transmit to the credentials committee a written report and recommendation as to membership and, if membership is recommended, as to membership category, department affiliation, clinical 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.

2.7-2 Credentials Committee Action 4.5-5 CREDENTIALS COMMITTEE ACTION




COMMENTS

The Credentials Committee shall review the application, the supporting documentation, the department’s report and recommendations, and such other information available to it that may be relevant. The Credentials Committee or a subcommittee thereof may personally interview the applicant. The Credentials Committee shall then transmit to the Medical Executive Committee on the prescribed form a written report and recommendations as to staff appointment, [and] department [and section] affiliations and clinical privileges.]

The credentials committee shall review the application, evaluate and verify the supporting documentation, the department chair’s report and recommendations, and other relevant information. The credentials committee may elect to interview the applicant and seek additional information. As soon as practicable, the credentials committee shall transmit to the medical executive committee a written report and its recommendations as to membership and, if membership is recommended, as to membership category, department affiliation, clinical privileges to be granted, and any special conditions to be attached to the membership. The committee may also recommend that the medical executive committee defer action on the application.


a. Preliminary Recommendation: At its next regular meeting after receipt of the [department] [and Credentials Committee] report and recommendations, the Medical Executive Committee shall consider all relevant information available to it. The Medical Executive Committee shall then formulate a preliminary recommendation. If the preliminary recommendation as to whether the applicant meets the relevant criteria specified at Article 4 (with respect to membership) and Article 5 (with respect to privileges) of the bylaws. Is favorable, the Medical Executive Committee shall then assess the applicant’s health status, and determine whether the applicant is able to perform, with or without reasonable accommodation, the necessary functions of a member of the medical staff.

b. Final Recommendation: Thereafter, a final recommendation shall be formulated, and the Medical Executive Committee shall forward to the Governing Body a written report and recommendations, as follows:

1) Favorable Recommendation: Favorable recommendations shall be promptly forwarded to the Governing Body together with the application form and its accompanying information and the reports and recommendations of the department [and Credentials Committee] as to staff appointment, [and department] [and section] affiliations, clinical privileges to be granted and any special conditions to be attached to the appointment.

4.5-6 MEDICAL EXECUTIVE COMMITTEE ACTION

At its next regular meeting after receipt of the credentials committee 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 credentials committee for further investigation, and/or elect to interview the applicant. The medical executive committee shall immediately forward to the administrator, for prompt transmittal to the board of [trustees/directors], or in cases eligible for expedited processing, the committee duly appointed by the board to handle expedited cases, a written report and recommendation as to medical staff membership and, if membership is recommended, as to membership category, department affiliation, clinical privileges to be granted, and any special conditions to be attached to the membership. 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 immediately forwarded, together with supporting documentation, to the board of [trustees/directors] or, in cases eligible for expedited processing, applicable committee duly appointed by the Board

.




COMMENTS

2) Adverse Recommendation: When the recommendation is adverse in whole or in part, the Chief of Staff shall immediately inform the practitioner by special notice, and he or she shall be entitled to such procedural rights as may be provided in Bylaws Article 14, Hearings and Appellate Reviews. The Governing Body shall be generally informed of, but shall not receive detailed information and shall not take action on, the pending adverse recommendation until the applicant has exhausted or waived his or her procedural rights.

(For the purposes of this section, an adverse recommendation by the Medical Executive Committee is as defined in Bylaws Section 14.2.)

3) Deferral: The [department], [Credentials Committee,] or Medical Executive Committee may defer its recommendation in order to obtain or clarify information, or in other special circumstances. A deferral must be followed up within 60 days of receipt of information with a subsequent recommendation for appointment and privileges, or for rejection for staff membership.

to handle expedited calls.

(b) Adverse Recommendation: When a final recommendation of the medical executive committee is adverse to the applicant, the board of [trustees/directors] and the applicant shall be promptly informed by written notice. The applicant shall then be entitled to procedural rights as provided in Article VII.

2.7-4 Governing Body Action

a. On Favorable Medical Executive Committee Recommendation: The Governing Body shall adopt, reject or modify a favorable recommendation of the Medical Executive Committee, or shall refer the recommendation back to the Medical Executive Committee for further consideration, stating the reasons for the referral and setting a time limit within which the Medical Executive Committee shall respond. If the Governing Body’s action is a ground for a hearing under the Bylaws, Section 14.2, the chief executive officer shall promptly inform the applicant by special notice, and he or she shall be entitled to the procedural rights as provided in the Bylaws Article 14, Hearings and Appellate Reviews.

b. Without Benefit of Medical Executive Committee Recommendation: If the Governing Body does not receive a Medical Executive Committee recommendation within the time specified in Rule 2.7-6 below, it may, after giving the Medical Executive Committee written notice and a reasonable time to act, take action on its own initiative. If

4.5-8 ACTION ON THE APPLICATION

The board of [trustees/directors] or, in cases eligible for expedited processing, the duly appointed committee of the board, 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 [trustees/directors] or its duly appointed committee in cases eligible for expedited processing 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 [trustees/directors] concurs in that recommendation, the decision of the board shall be deemed


The CHA Bylaws acknowledge the Board’s rights, under Business & Professions Section 809.05, to take independent action in the absence of a MEC recommendation.




COMMENTS

such recommendation is favorable, it shall become effective as the final decision of the Governing Body. If the recommendation is a ground for a hearing under the Bylaws, Section 14.2, the chief executive officer shall give the applicant special notice of the tentative adverse recommendation and of the applicant’s right to request a hearing. The applicant shall be entitled to the Bylaws Article 14, Hearings and Appellate Reviews, procedural rights before any final adverse action is taken.

final action.

(2) If the tentative final action of the board of [trustees/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 [trustees/directors] shall be deemed final action.

In cases eligible for expedited processing, if the duly appointed committee and the Board concur in that recommendation, the positive decision shall be ratified by the board of [trustees/directors] at its next regularly scheduled meeting. The ratification by the board shall be deemed final. If the committee’s decision is adverse to the applicant, or the Board fails to ratify the committee’s decision, the matter shall be referred back to the medical executive committee for evaluation.

(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.

c. After Procedural Rights: In the case of an adverse Medical Executive Committee recommendation pursuant to Rule 2.7-3 or an adverse Governing Body decision pursuant to Rule 2.7-4a. or 2.7-4b., the Governing Body shall take final action in the matter only after the applicant has exhausted or has waived his or her Bylaws Article 14, Hearings and Appellate Reviews, procedural rights. Action thus taken shall be the conclusive decision of the Governing Body, except that the Governing Body may defer final determination by referring the matter back for reconsideration. Any such referral shall state the reasons therefore, shall set a reasonable time limit within which reply to the Governing Body shall be made, and may include a directive that additional hearings be conducted to clarify issues which are in doubt. After receiving the new recommendation and any new evidence, the Governing Body shall make a final decision.

(1) If procedural rights are waived by the applicant, the recommendations of the medical executive committee shall be forwarded to the board of [trustees/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 [trustees/directors] tentative final action pursuant to 4.5-8(a) (2), the board of [trustees/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

This CMA provision limits the Board’s discretion to take another action.






COMMENTS

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.

d. Expedited Review: The Governing Body may use an expedited process for appointment, reappointment or when granting Privileges when criteria for that process are met. The Governing Body may delegate this authority to any other committee of at least two voting members of the Governing Body; however, any final decision of the [delegated committee] must be subject to ratification by the full Governing Body at its next regularly scheduled meeting. Expedited processing is generally not available if:

1) The practitioner or Member submits an incomplete application;

2) The Medical Executive Committee’s final recommendation is adverse in any respect or has any limitations;

3) There is a current challenge or a previously successful challenge to the practitioner’s licensure or registration;

4) The practitioner has received an involuntary termination of medical staff membership or some or all privileges at another organization;

5) The practitioner has received involuntary limitation, reduction, denial, or loss of medical privileges;

6) There has been a final judgment adverse to the practitioner in a professional liability action.

(c) Applicants are ineligible for expedited processing if, at the time membership may be granted, any of the following has occurred:

(3) The applicant submits an incomplete application.

(4) The medical executive committee makes a final recommendation that is adverse or with limitation.

(5) There is a current challenge or previously successful challenge to licensure.

(6) The applicant has received an involuntary termination of medical staff membership at another organization.

(7) The applicant has received involuntary limitation, reduction, denial, or loss of medical privileges.

(8) There has been a final judgment adverse to the applicant in a professional liability action.

2.7-5 Notice of Final Decision

A decision and notice to appoint shall include:

a. The staff category to which the applicant is appointed;

b. [The department and section, if any, to which the practitioner is assigned;]

4.5-9 NOTICE OF FINAL DECISION

(a) Notice of the final decision shall be given to the chief of staff, the medical executive and the credentials committees, the chair of each department concerned, the applicant, and the administrator.

(b) A decision and notice to grant or renew membership shall include, if applicable: (1) the staff category to which the




COMMENTS

c. The clinical privileges the practitioner may exercise; and

d. Any special conditions attached to the appointment.

If the decision is adverse, the notice to the applicant shall be by special notice, as further described at Section 14.-3-1 of the bylaws.

applicant becomes a member; (2) the department to which that person is assigned; (3) the clinical privileges granted; and (4) any special conditions attached to the membership.

2.7-6 Guidelines for Time of Processing

All individuals and groups shall act on applications in a timely and good faith manner. Except when additional information must be secured, or for other good cause, each application should be processed within the following time guidelines:

See Table.

These time periods are guidelines and are not directives which create any rights for a practitioner to have an application processed within these precise periods. If action at a particular step in the process is delayed without good cause, the next higher authority may immediately proceed to consider the application upon its own initiative or at the direction of the Chief of Staff or the chief executive officer.

4.5-11 TIMELY PROCESSING OF APPLICATIONS

Applications for staff membership 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: [30] days from receipt of all necessary documentation;

(b) review and recommendation by department(s): [30] days after receipt of all necessary documentation from the medical staff office;

(c) review and recommendation by credentials committee: [30] days after receipt of all necessary documentation from the department(s);

(d) review and recommendation by executive committee: [30] days after receipt of all necessary documentation from the credentials committee; and

(e) final action: [180] days after receipt of all necessary documentation by the medical staff office, [30] days in expedited cases, or [7] days after conclusion of hearings.

2.8 Duration of Appointment

2.8-1 All new staff members shall be appointed to the provisional staff and subjected to a period of formal observation and review [, except for those appointed to the House Officers or Staff]. Provisional appointments are for not more than twelve months.

4.4 DURATION OF MEMBERSHIP AND MEMBERSHIP RENEWAL

Except as otherwise provided in these bylaws, initial membership on the medical staff shall be for a period of [ ]. Membership renewals shall be for a period of up to two medical staff years.




COMMENTS

2.8-2 Reappointments to any staff category other than provisional shall be for a maximum period of two years, and shall be staggered throughout the year so as to enable thorough review of each member. [Changes in staff category may be requested at any time during the reappointment period after requirements of provisional status are met.]

2.9 Reappointment Process

2.9-1 Schedule for Reappointment

2.9-2 Content of Reappointment Form

a. The reappointment form shall be approved by the Medical Executive Committee and the Governing Body and, once approved, shall be considered part of these rules. The form shall seek information concerning the changes in the member’s qualifications since his or her last review. Specifically, the form shall request an update of all of the information and certifications requested in the appointment application form, as described in Rule 2.2-2, with the exception of that information which cannot change over time, such as information regarding the member’s premedical and medical education, date of birth, and so forth. The form shall also require information as to whether the member requests any change in his or her staff status and/or in his or her clinical privileges, including any reduction, deletion or additional privileges. Requests for additional privileges must be supported by the type and nature of evidence which would be necessary for such privileges to be granted in an initial application.

4.6 MEMBERSHIP RENEWALS AND REQUESTS FOR MODIFICATIONS OF STAFF STATUS OR PRIVILEGES

4.6-1 APPLICATIONAt least [__ months] prior to the expiration date of the current staff membership (except for temporary membership), a reapplication form developed by the medical executive committee shall be mailed or delivered to the member. If an application for renewal of membership is not received at least [__days] prior to the expiration date, written notice shall be promptly sent to the applicant advising that the application has not been received. At least [45 days] prior to the expiration date, each medical staff member shall submit to the credentials committee the completed application form for renewal of membership to the staff for the coming year, and for renewal or modification of clinical 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. If the staff member’s level of clinical activity at this hospital is not sufficient to permit the staff and board to evaluate his or her competence to exercise the clinical privileges requested, the staff member shall have the burden of providing evidence of clinical performance at his or her principal institution in whatever form as the staff may require.c. In addition to completing the information requested on the reappointment form, the staff member shall submit his or her biennial dues.

(a) A medical staff member who seeks a change in medical staff status or modification of clinical 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 [ ] of the time a similar request has been denied.

4.6-2 EFFECT OF APPLICATIONThe effect of an application for renewal of membership or modification of staff status or privileges is the same as that set forth in Section 4.5-2.

CHA Bylaws contain a provision to address practitioners whose activities are insufficient to permit evaluation.




COMMENTS

2.9-3 Verification and Collection of Information

The medical staff shall, in timely fashion, seek to verify the additional information made available on each reappointment application and to collect any other materials or information deemed pertinent by the Medical Executive Committee [, the Credentials Committee,] [or department chair]. The information shall address, without limitation:

a. Reasonable evidence of current ability to perform privileges that may be requested, including but not limited to consideration of the member’s professional performance, judgment, clinical or technical skills and patterns of care and utilization as demonstrated in the findings of quality improvement, risk management and utilization management activities.

4.6-3 STANDARDS AND PROCEDURE FOR REVIEW

When a staff member submits the first application for renewal of membership, and every two years thereafter, or when the member submits an application for modification of staff status or clinical 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.

CHA addresses the standards for review at Section 4.3-3 of the Bylaws.

b. Participation in relevant continuing education activities.

c. Level/amount of clinical activity (patient care contacts) at the hospital.

d. Sanctions imposed or pending, including but not limited to 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.

e. Health status including completion of a physical examination or psychiatric evaluation by a physician who is mutually accepted by the affected practitioner and staff, when requested by the [department chair or] Medical Executive Committee and subject to the standards set forth in Rule 2.3 pertaining to physical and mental capabilities.

f. Attendance at required medical staff[, department] and committee meetings.

g. Participation as a staff officer and committee member/chair.

h. Timely and accurate completion and preparation of medical records.




COMMENTS

i. Cooperativeness and general demeanor in relationships with other practitioners, hospital personnel and patients.

j. Professional liability claim experience, including being named as a party in any professional liability claims and the disposition of any pending claims.

k. Compliance with all applicable medical staff and hospital bylaws, rules, and policies.

l. Professional references from at least one practitioner who is familiar with the member’s current qualifications by virtue of having recently worked with the member or having recently reviewed the member’s cases.

m. Any other pertinent information including the staff member’s activities at other hospitals and his or her medical practice outside the hospital.

n. Information concerning the member from the state licensing board and the federal National Practitioner Data Bank.

o. Information from other relevant sources, such as but not limited to the Federation of State Medical Boards Physician Disciplinary Data Bank.

The Medical Staff office shall transmit the completed reappointment application form and supporting materials to the chair of the department to which the staff member belongs and [to the chair of any other department in which the staff member has or requests privileges.]

[2.9-4 Department Action

The department chair shall review the application and all other relevant available information. The chair may confer with the department committee or the whole department, if there is no department committee. He or she shall transmit to the Medical Executive Committee his or her written recommendations, which are prepared in accordance with Rule 2.7-1.]





COMMENTS

a. The Medical Executive Committee shall review [the department chair’s recommendations and all other] [all recommendations and all other] relevant information available to it and shall forward to the Governing Body its favorable recommendations, which are prepared in accordance with Rule 2.7-3.

b. When the Medical Executive Committee recommends adverse action, as defined in the Bylaws, Section 14.2, either with respect to reappointment or clinical privileges, the Chief of Staff shall give the member special notice of the adverse recommendation and of the member’s right to request a hearing in the manner specified in Section 14.3. The member shall be entitled to the Article 14, Hearings and Appellate Reviews, procedural rights. The Governing Body shall be informed of, but not take action on, the pending recommendation until the member has exhausted or waived his or her procedural rights.

c. Thereafter, the procedures specified for members in Rule 2.7-4 (Governing Body action), Rule 2.7-5 (Notice of Final Decision) and in the bylaws, Section 4.6 (Waiting Period After Adverse Action), shall be followed. The committee may also defer action; however, any deferral must be followed up within 70 days with a recommendation.

2.9-4 Department Action

The department chair shall review the application and all other relevant available information. The chair may confer with the department committee or the whole department, if there is no department committee. He or she shall transmit to the Credentials Committee his or her written recommendations, which are prepared in accordance with Rule 2.7-1.

2.9-5 Credentials Committee Action

The Credentials Committee shall review the application, all other relevant available information and the department chair’s recommendations. The committee shall transmit to the Medical Executive Committee its written recommendations, which are prepared in accordance with




COMMENTS

Rule 2.7-2.


The Medical Executive Committee shall review the [department chair and Credentials Committee’s] recommendations and all other relevant information available to it and shall forward to the Governing Body its favorable recommendations, which are prepared in accordance with Rule 2.7-3.

2.9-7 Reappointment Recommendations

Reappointment recommendations shall be written and shall specify whether the member’s appointment should be renewed; renewed with modified membership category[, department affiliation] and/or clinical privileges; or terminated. The reason for any adverse recommendation shall be described. The medical staff may require additional proctoring of any clinical privileges that are used so infrequently as to make it difficult or unreliable to assess current competency without additional proctoring, and such proctoring requirements imposed for lack of activity shall not result in any hearing rights.

CHA Bylaws provide for additional proctoring of infrequently used privileges, without this being deemed a practice restriction necessitating reporting and hearing.

2.9-8 No Extension of Appointment

Except as provided at Section 4.3-4 of the Bylaws, if the reappointment application has not been fully processed before the member’s appointment expires, the staff member shall refrain from exercising his or her current membership status and clinical privileges until the reappointment review is complete.

2.9-9 Failure to File Reappointment Application

Failure to file a complete application for reappointment 90 days prior to the expiration of the appointment shall result in the automatic suspension of a practitioner’s privileges and prerogatives effective on the date the member’s current appointment expires, unless otherwise extended by the Medical Executive Committee with the approval of the Governing Body. Prior to suspension, the practitioner will be sent at least one letter by special notice warning of the impending suspension. If an application for reappointment is not submitted, completed as required, before the

4.6-4 FAILURE TO FILE APPLICATION FOR RENEWAL OF MEMBERSHIP

If the member in good standing fails to submit a completed application for renewal of membership within [ ] days past the date it was due, the member shall be deemed to have resigned membership in the medical staff, unless otherwise extended by the Medical Executive Committee with the approval of the board of [trustees/directors] so long as processing the member’s application is completed prior to the expiration of the privileges. In the event membership terminates for the

See comments accompanying CMA Bylaws Section 1.2-7.




COMMENTS

appointment expires, the member shall be deemed to have resigned his or her membership in the medical staff, effective the date his or her appointment expires. Members who automatically resign under this rule will be processed as new applicants should they wish to reapply.

reasons set forth herein, the procedures set forth in Article VII shall not apply. If the member subsequently submits a new application for medical staff membership within [90] days of resigning membership, the member shall be subject to the procedures set forth in Sections 4.5-3 through 4.5-11, except that the member will not be required to undergo initial proctoring requirements for clinical privileges that were previously granted by the medical staff.

See comments accompanying CHA Section 4.4-5.

2.9-10 Relinquishment of Privileges

A staff member who wishes to relinquish or limit particular privileges (other than privileges necessary to fulfill Emergency Room call responsibilities) shall send written notice to the Chief of Staff [and the appropriate department chair] identifying the particular privileges to be relinquished or limited. A copy of this notice shall be forwarded to the medical staff office for inclusion in the member’s credentials file.

The CHA Bylaws contain protection against “gerrymandering” privileges to avoid ER call responsibilities.

RULE 3

STANDARDS OF CONDUCT

3.1 Purpose

The purpose of this Rule is to clarify the provisions of Section 2.7 of the Medical Staff Bylaws, regarding expectations of all practitioners during any and all interactions with persons at the hospital, whether such persons are colleagues, other health care professionals, hospital employees, patients and/or other individuals. This Rule is intended to address conduct which does not meet the professional standards expected of Medical Staff members. In dealing with incidents of inappropriate conduct, the protection of patients, employees, practitioners and other persons at the hospital is the primary concern. In addition, the well-being of a practitioner whose conduct is in question is also of concern, as is the orderly operation of the hospital.

Note: CMA Bylaws now include more extensive conduct provisions (than in prior editions of the CMA Bylaws). However, they are still not as extensive as CHA’s, and they do not appear to permit any supplemental policies to further clarify conduct expectations. See comments at page 18.

3.2 Examples of Inappropriate Conduct

Examples of common inappropriate conduct include, but are




COMMENTS

not limited to, the following :

3.2-1 Verbal abuse: Verbal abuse is usually in the form of vulgar, profane or demeaning language, screaming, sarcasm or criticism directed at an individual, having the intent or effect of lowering the recipient’s reputation or self-esteem. It is often intimidating to the recipient, and often causes the recipient or others around him or her to become ineffective in performing their responsibilities (e.g., the individuals become afraid or unwilling to question or to communicate concerns, or to notify or involve either the involved practitioner or others when problems occur). This kind of conduct becomes disruptive at the point where it reaches beyond the bounds of fair professional comment or where it seriously impinges on staff morale.

3.2-2 Noncommunication: Refusal to communicate with responsible persons can be extremely disruptive in the patient care setting. This kind of behavior often results from individual fighting or feuding, or lack of trust. It becomes disruptive at the point where important information should be communicated, but is not. Closely related are incomplete or ambiguous communications. This becomes disruptive when it diverts patient care resources into having to devote substantial and unnecessary time obtaining follow-up clarification.

3.2-3 Refusal to return calls: Refusing to return telephone calls from the facility staff can be another form of the problem. Often this type of behavior is a result of what a practitioner feels are repeated, inappropriate phone calls from the facility’s staff. However, unless a phone call is returned, the practitioner cannot know the urgency of the matter. The problem becomes disruptive at the point where patient care is placed in unnecessary jeopardy, or when matters that were not initially urgent, and needn’t have become urgent, become so as a result of a refusal to return calls.

3.2-4 Inappropriate communication: It is inappropriate to criticize the facility, its staff, or professional peers outside of official problem-solving and peer review channels. This includes written or verbal derogatory statements to an inappropriate audience, such as patients and families, or statements placed in the medical records of patients. These




COMMENTS

kinds of communications indiscriminately undermine morale and reputation of the facility and its staff, and contribute to inaccurate perceptions of facility quality.`

3.2-5 Failure to comply: Failure to comply with the bylaws, policies and procedures of the medical staff and the facility can be inadvertent, or it can be willful. Willful failure to comply – i.e., refusal to comply – with rules becomes disruptive at the point that it places the medical staff or the facility in jeopardy with respect to licensing or accreditation requirements, complying with other applicable laws, or meeting other specific obligations to patients, potential patients and facility staff. Specific examples include:

a. Refusing to provide information or otherwise cooperate in the peer review process (e.g., refusing to meet with responsible committee members, refusing to answer reasonable questions relevant to the evaluation of patient care rendered in the facility, especially when coupled with an attitude that the responsible committee has no right to be questioning or examining the matter at hand).

b. Refusing to provide information necessary to process the facility’s or a patient’s paperwork. The facility, its patients and their families have a right to expect timely and thorough compliance with all requirements of the facility, third party payors, regulators, etc., as necessary to assure smooth functioning of the facility and that patients receive the benefits to which they are entitled.

c. Violating confidentiality rules – e.g., disclosing confidential peer review information outside the confines of the formal peer review process. This has the effect of undermining the peer review process, and jeopardizing important protections that often serve as inducements to assuring ongoing willingness to participate in peer review activities.

d. Refusing to comply with established protocols and standards, including but not limited to utilization review standards. Here, it is recognized that from time to time established protocols and standards may not adequately address a particular circumstance, and deviation is necessary in the best interests of patient care. However, in




COMMENTS

such circumstances, the member will be expected to account for the deviation, and in appropriate circumstances, to work cooperatively and constructively toward any necessary refinements of protocol or standards so as to avoid unnecessary problems in the future.

e. Refusing to participate in or meet medical staff obligations can be disruptive when it reaches the point that the individual’s refusal obstructs or significantly impairs the ability of the Medical Staff to perform its delegated responsibilities – all of which, in the final analysis, are aimed at facilitating quality patient care.

f. Repeatedly abusing or ignoring scheduling policies, or reporting late for scheduled appointments, surgeries, and treatments, resulting in unnecessary delays in or hurrying of patient care services being rendered to any patient of the facility.

g. Sexual harassment – unwelcome comments or contacts of a sexual nature or characterized by sexual overtones, whether overt or covert, are both illegal and disruptive.

3.2-6 Physical abuse: Offensive or nonconsensual physical contact would generally be deemed disruptive, as would intentional damage to facility premises or equipment.

3.2-7 Threatening behavior: Threats to another’s employment or position, or otherwise designed to intimidate a person from performing his or her designated responsibilities or interfering with his or her well-being are generally disruptive. Examples include threats of litigation against peer review participants or against persons who report concerns in accordance with established reporting channels, and threats to another’s physical or emotional safety or property.

3.2-8 Combative behavior: Combative behavior refers to that which is constantly challenging, verbally or physically, legitimate and generally recognized authority or generally recognized lines of professional interaction and communication. It becomes disruptive at the point that it results in an inability to acknowledge or to deliver




COMMENTS

constructive comments and criticism.

3.3 Procedures

3.3-1 Reporting: Any person may report potentially disruptive conduct in accordance with the hospital’s usual reporting procedures. The Medical Staff office or other appropriate recipient of a disruptive conduct complaint shall submit each report to the Chief of Staff and Chief Executive Officer for investigation. The Chief of Staff and Chief Executive Officer may agree to delegate the investigation and any action to [an appropriate committee] [the Professional Conduct Committee]. The Chief of Staff and Chief Executive Officer may agree to consult with the hospital’s Human Resources department or other consultant as appropriate.

3.3-2 Investigation

a. The Chief of Staff and Chief Executive Officer, or designated committee, shall ensure that appropriate documentation of each incident of disruptive conduct is acquired in order to facilitate the investigation process. Such documentation should include:

1) Date and time of the reported disruptive behavior.

2) A statement by the reporting individual of whether the behavior involved a patient in any way, and, if so, information identifying the patient involved.

3) The reporter’s account of the circumstances that precipitated the situation.

4) A factual and objective description of the reported disruptive behavior.

5) To the extent known to the reporter, the consequences, if any, of the disruptive behavior as it relates to patient care or hospital operations.

6) A record of any action taken to address the situation, prior to the Medical Staff’s investigation as required by the Code of Conduct, including the date, time, place, action and name(s) of those taking such an action.

b. The Chief of Staff and Chief Executive Officer, or August 2013 Page 232



COMMENTS

designated committee, shall conduct an appropriate investigation for each matter reported.

c. If the report of inappropriate conduct is anonymous, then, the Chief of Staff and Chief Executive Officer, or designated committee, shall exercise discretion as to whether or not to investigate the matter.

d. The investigation shall take place within 14 calendar days from receipt of a report of inappropriate conduct.

3.3-3 Action

a. Unfounded Report: Based on the investigation, the Chief of Staff, Chief Executive Officer, or designee shall dismiss any unfounded report by providing a written explanation of the evidence supporting this conclusion. The report shall be maintained in the Medical Staff member’s file with the original complaint. The individual who initiated the report of the decision shall be notified of the decision.

b. Confirmed Report: A confirmed report will be addressed as follows: The Chief of Staff and Chief Executive Officer, or designee, shall consider a number of variables to determine how best to address each incident of disruptive behavior. These variable shall include, but not be limited to:

1) Degree of disruptiveness

2) Number of incidents (i.e., pattern of disruptive behavior over time)

3) Length of time between incidents of disruptive behavior, if multiple incidents have occurred.

c. Plan for Addressing Disruptive Behavior: Relying on the variables described above as well as the overall intent of Section 2.7 of the Medical Staff Bylaws, the Chief of Staff, and Chief Executive Officer, or the designated committee, shall document a plan for addressing the disruptive behavior. The copy of the plan shall be included in the individual’s file. The plan shall include item (1) below and may include any portion or all of items (2) and




COMMENTS

(3) below:

1) The Chief Executive Officer, or designee, shall send a letter to the offending individual that describes the inappropriate conduct, explains that the behavior is in violation of Section 2.7 of the Medical Staff Bylaws, notes any patient care or hospital operations implications, explains why the behavior in question is inappropriate, encourages the individual to be more thoughtful or careful in the future, invites the individual to respond, and makes clear that attempts to confront, intimidate, or otherwise retaliate against the individuals who reported the behavior in question is a violation of this Rule and grounds for further disciplinary action. A copy of Section 2.7 of the Bylaws and this Rule should be included with the letter. Documentation of both the letter and the individual’s response should be included in the individual’s file.

2) The Chief of Staff, Chief Executive Officer or the designated committee, and any other number of appropriate participants from the Medical Staff and Governing Body, shall initiate a discussion with the offending individual to discuss the inappropriateness of their behavior and require that such behavior cease. A copy of Section 2.7 of the Medical Staff Bylaws and this Rule may be hand delivered to the offending individual and he or she should be advised that the Medical Staff requires compliance with the Bylaws. Each individual or a designated member of a group, (if the group meets with the offending individual), shall send a follow-up letter documenting the content of the discussion and any specific actions the offending individual has agreed to perform. The offending individual should be invited to respond. This letter and any response will be included in the individual’s file.

3) The plan may incorporate additional components, including, but not limited to:

i) Warning the offending individual that failure to abide by the terms of the Standards of Conduct shall be grounds for disciplinary action, including but not limited to suspension and/or actual termination of Medical Staff membership.

ii) Notifying one or all of the following individuals of August 2013 Page 234



COMMENTS

the member’s disruptive behavior and any relevant history relating to the member: Chief of Staff, Medical Executive Committee and Chief Executive Officer.

iii) Requiring the offending individual to agree to specific corrective actions aimed at eliminating that individual’s disruptive behavior. Suggested actions are counseling, leave of absence, written apologies, courses or programs specific to the behavior trait (i.e., anger management), or requiring the offending individual to sign a behavior modification contract. The Chief of Staff, Chief Executive Officer or designated committee shall document any corrective action and require the offending individual to sign his or her acceptance of this plan. The plan may clearly delineate the consequences for the offending individual not successfully completing the agreed upon corrective action.

iv) In appropriate circumstances, the plan may provide for immediate suspension and/or action to terminate Medical Staff membership without need of further warning or counseling.

3.3-4 Final Warning: If the Chief of Staff, Chief Executive Officer, or designated committee determines that the plan has been unsuccessful, the Medical Executive Committee shall be informed in writing of the offending individual’s disruptive behavior, including any relevant history regarding this behavior, and advise the Medical Executive Committee to proceed with a final warning. If the Medical Executive Committee determines that the offending individual deserves a final warning, the Medical Executive Committee Chair/designee (or the Chief of Staff/designee or CEO/designee) shall meet with and advise the offending individual that the disruptive behavior in question is intolerable and must stop. The Chief of Staff/designee or CEO/designee will inform the individual that a single recurrence of disruptive behavior shall be sufficient cause to result in his/her suspension and/or termination of Medical Staff membership. This meeting shall not be a discussion, but rather will constitute the offending individual’s final warning. The offender will also receive a follow-up letter that reiterates the final warning and the consequence of suspension and possible termination of Medical Staff




COMMENTS

membership and privileges.

3.3-5 Suspension: If after the final warning the offending individual engages in disruptive behavior that is deemed to require intervention, the individual’s Medical Staff membership and privileges shall be subject to suspension consistent with the terms of the Medical Staff Bylaws and policies and procedures. Additional action may also be taken at this time. Action may be taken to revoke the individual’s membership and privileges. The individual may also be found ineligible to reapply to the Medical Staff for a period of at least two years.

3.3-6 Consequences of a Member’s Failure to Comply with the Standards of Conduct: Members who do not act in accordance with the Standards of Conduct shall be subject to corrective action and/or disciplinary action, up to and including termination of membership and privileges, pursuant to the Bylaws. Any recommendation to restrict, or restriction of Member’s membership or privileges shall entitle the member to the medical disciplinary or administrative hearing procedures set forth in the Bylaws.

RULE 4

COMMITTEES

4.1 Committees

The medical staff hereby establishes the following committees [check applicable boxes]. The rules applicable to each committee are set forth in the corresponding appendix.

The CHA Bylaws include a separate appendix for each committee, facilitating individual hospitals’ tailoring of committees to the needs of their Medical Staffs.

Check below if applicable See Appendix

Bioethics Committee 4A

Bylaws Committee 4B

Cancer Committee 4C

Credentials Committee 4D

Department Committees 4E

Emergency Services Committee 4F

The CHA Bylaws also include a number of provisions to the Committees to better link committee activities with the educational and quality assessment/improvement activities, in keeping with TJC’s Shared Vision/New Pathways initiatives—especially linking peer review and educative activities.




COMMENTS

Infection Control Committee 4G

Institutional Review Board 4H

Interdisciplinary Practice Committee 4I

Professional Conduct Committee 4J

Quality Improvement Committee 4K

Rehabilitation Committee 4J

Special Care Units Committee 4M

Utilization Review Committee 4N

Well-Being Committee 4O

Appendix 4A

BIOETHICS COMMITTEE

(d) Composition

The Bioethics Committee shall be composed of at least the following voting members: [three practitioners, one of whom should be a psychiatrist, one registered nurse, one clergy, one medical social worker (or a comparable discipline), one member of hospital administration, one non-hospital local community member at large and one ethicist (if one is available)]. Additional members may be appointed by the Chief of Staff.

11.14 BIOETHICS COMMITTEE

11.14-1 COMPOSITION

The bioethics committee shall consist of physicians and such other staff members as the medical executive committee may deem appropriate. It may include nurses, lay representatives, social workers, clergy, ethicists, attorneys, administrators and representatives from the board of [trustees/directors], although a majority shall be physician members of the medical staff.

2. Duties

The Bioethics Committee shall strive to contribute to the quality of health care provided by the hospital by:

a. Providing assistance and resources for decisions which have bioethical implications. The Bioethics Committee shall not, however, be a decision-maker in any case.

b. Educating members within the hospital community concerning bioethical issues and dilemmas.

c. Facilitating communication about ethical issues and dilemmas among members of the hospital community,

11.14-2 DUTIESThe bioethics committee may participate in development of guidelines for consideration of cases having bioethical implications; development and implementation of procedures for the review of such cases; development and/or review of institutional policies regarding care and treatment of such cases; retrospective review of cases for the evaluation of bioethical policies; consultation with concerned parties to facilitate communication and aid conflict resolution; and education of the hospital staff on bioethical matters.




COMMENTS

in general, and among participants involved in bioethical dilemmas and decisions, in particular.

d. Retrospectively reviewing cases to evaluate bioethical implications, and providing policy and education guidance relating to such matters.

3. Meetings

The Bioethics Committee shall meet as often as necessary, but at least quarterly.

11.14-3 MEETINGS

The committee shall meet as often as necessary at the call of its chair. It shall maintain a record of its activities and report to the medical executive committee.

Appendix 4B

BYLAWS COMMITTEE

(d) Composition

The Bylaws Committee shall include [at least five active staff members, including the immediate past Chief of Staff, who serves as an ex-officio member].

2. Duties

The duties of the Bylaws Committee shall include:

a. Conducting an [annual] review of the Medical Staff Bylaws, as well as the Rules and forms promulgated by the Medical Staff [and its departments];

b. Receiving and evaluating suggestions for modification of the Medical Staff Bylaws, as well as the Rules and forms promulgated by the Medical Staff and its departments;

c. Submitting recommendations to the Medical Executive Committee for changes in these documents as necessary to reflect current Medical Staff practices; and

11.11 BYLAWS COMMITTEE

11.11-1 COMPOSITION, QUALIFICATIONS AND NOMINATION

(a) The bylaws committee shall consist of at least five (5) members of the medical staff, including the vice chief of staff and immediate past chief of staff. The remaining members shall be elected at the annual meeting of the medical staff which falls during the election year. The nominating committee appointed pursuant to Section 9.1-3 shall nominate the nominees for the remaining [3] members of the committee. The nominations of the committee shall be reported to the medical executive committee at least [60] days prior to the annual meeting and shall be delivered or mailed to the voting members of the medical staff at least [40] days prior to the election.

(b) Further nominations may be made for membership on the bylaws committee by any voting member of the medical staff, provided that the name of the candidate is submitted in writing to the chair of the nominating committee, is endorsed by the signature of at least [10%] of other members who are eligible to vote, and bears the candidate’s written consent. These nominations shall be delivered to the chair of the nominating committee as soon as reasonably practicable, but at least [20] days prior to the date of the election. If any nominations are made in this manner, the voting members of the medical staff shall be advised by notice delivered or mailed at least [10] days prior to the meeting. Nominations from the floor will be recognized if the

CMA Bylaws provide for election of certain Bylaws committee members.




COMMENTS

nominee is present and consents.

(c) All nominees shall disclose their experience and familiarity with respect to medical staff bylaws. In accordance with Section 14.6, all nominees for election shall disclose in writing to the medical staff those current or impending personal, professional, or financial affiliations or relationships of which they are reasonably aware, including contractual, employment or other relationships with the hospital, which could foreseeably result in a conflict of interest with their activities or responsibilities on behalf of the medical staff. Such disclosure statement shall accompany the ballot.

11.11-2 DUTIES

The duties of the bylaws committee shall include:

(a) conducting an annual review of the medical staff bylaws, as well as the rules and regulations, policies and forms promulgated by the medical staff, its departments and divisions;

(b) receiving and evaluating concerns relating to the ability of the medical staff to be self-governing and reporting back to the medical staff;

(c) developing and submitting recommendations to the medical staff for changes in medical staff documents and operations as necessary to reflect or improve current medical staff practices; and

(d) reviewing the hospital bylaws and policies, which shall be provided by the hospital and made available by the medical staff office to any medical staff member upon request, for inconsistencies and conflicts with medical staff documents and reporting issues and recommendations to the medical executive committee for its review.

In addition, two members of the bylaws committee, as selected by the medical executive committee, shall also serve on the nominating committee appointed pursuant to Section 9.1-3.

CMA includes a policing function to the Bylaws charge.

CMA has removed this as a MEC prerogative; and appears to have deleted any formal role of the MEC in the adoption of Bylaws or Rules.

CMA Bylaws committee also includes a review of hospital Bylaws and policies; and provides for distribution of all hospital policies to any Medical Staff member (whether or not such policy applies to the Medical Staff).

CMA includes a provision for Bylaws committee member representation on the nominating committee.




COMMENTS

d. Assuring that the Bylaws and Rules comply with applicable laws, regulations, and accreditation standards, and that they adequately and accurately describe the current structure of the Medical Staff, including but not limited to:

1) Establishing and enforcing criteria and standards for Medical Staff membership and clinical privileges, as well as the mechanisms for doing so;

2) Establishing and enforcing clinical criteria and standards to oversee and manage quality improvement and assessment, utilization review, and other Medical Staff activities, including procedures for meetings of the Medical Staff and its committees [and departments] and review and analysis of patient medical records; as well as procedures for evaluating and revising such activities;

3) The mechanism for terminating Medical Staff membership;

4) The fair hearing and appeal procedures;

5) Provisions for assessing Medical Staff dues and utilizing the Medical Staff dues as appropriate for the purposes of the Medical Staff [and in a manner that is consistent with the hospital’s nonprofit tax-exempt purposes];

6) Provisions respecting the Medical Staff’s ability to retain and be represented by independent legal counsel at the expense of the Medical Staff; and

The CHA Bylaws specify provisions that need to be addressed in the Bylaws (per Business & Professions Code Section 2282.5). (CMA addresses this as a MEC function, see CMA Section 11.3-2(w).)

7) Provisions requiring a physical examination and medical history to be completed within the time frames established by state hospital licensing regulations and federal Medicare law.

3. Meetings

The committee will meet as requested by the Bylaws Committee chair or Chief of Staff.

11.11-3 MEETINGS

The bylaws committee shall meet as often as necessary at the call of its chair but at least [annually]. It shall maintain a record of its proceedings and shall report its activities and recommendations to the medical executive committee.

Appendix 4C




COMMENTS

CANCER COMMITTEE

1. Composition

The Cancer Committee shall be multi-disciplinary, including [members from the specialties of Surgery, Internal Medicine, Gynecology, Pediatrics, Diagnostic and Therapeutic Radiology, Pathology, and Family Practice. The committee must also include representatives of hospital administration, nursing, social services, rehabilitation and the cancer registry].

2. Duties

The duties of the Cancer Committee are to:

a. Make certain that educational programs address major cancer issues.

b. Evaluate the quality of care given patients with cancer and report as necessary to assure that the results of such evaluations are incorporated into the hospital-wide quality assessment and improvement systems.

c. Supervise the cancer data system.

d. Appoint Cancer Committee members to act as registry physician advisors.

e. Educate hospital and Medical Staff members and patients about cancer prevention, detection and treatment.

3. Meetings and Reporting

The committee shall meet as often as necessary, but no less than quarterly. It shall report to the Quality Improvement Committee.

Appendix 4D

CREDENTIALS COMMITTEE

1. Composition

The Credentials Committee shall be composed of [at least one active staff member from each department].

11.4 CREDENTIALS COMMITTEE

11.4-1 COMPOSITION

The credentials committee shall consist of not less than [ ] members of the active staff selected on a basis that will ensure, insofar as feasible, representation of major clinical specialties and each of the staff departments.




COMMENTS

2. Duties

The Credentials Committee shall evaluate or coordinate the evaluation of the qualifications of all applicants for medical staff appointment, [reappointment] or changes in staff categories. The committee shall develop recommendations based on its [and the responsible departments’] evaluations of each applicant, as well as (with respect to reappointments) the results of any Medical Staff quality assessment and improvement activities, including but not limited to ongoing professional performance evaluations and focused professional performance evaluations.

3. Meetings

The Credentials Committee shall meet as often as necessary, but at least quarterly.

11.4-2 DUTIES

The credentials committee shall:

(a) review and evaluate the qualifications of each practitioner applying for initial membership, renewal of membership, or modification of clinical privileges, and, in connection therewith, obtain and consider the recommendations of the appropriate departments;

(b) submit required reports and information on the qualifications of each practitioner applying for membership or particular clinical privileges including recommendations with respect to membership, membership category, department affiliation, clinical privileges, and special conditions;

(c) investigate, review and report on matters referred by the chief of staff or the medical executive committee regarding the qualifications, conduct, professional character or competence of any applicant or medical staff member; and

(d) submit periodic reports to the medical executive committee on its activities and the status of pending applications.

11.4-3 MEETINGS

The credentials committee shall meet as often as necessary at the call of its chair. The committee shall maintain a record of its proceedings and actions and shall report to the medical executive committee.

Appendix 4E

DEPARTMENT COMMITTEES

Composition

Each department shall have a committee consisting of [at least three active staff members].

2. Duties

The department committees shall assist the department chair to carry out the responsibilities assigned to the department chair, including the duties to recommend professional




COMMENTS

criteria for clinical privileges within the department, review applicants for appointment, reappointment, and clinical privileges, and to fulfill the responsibility for peer review. The department committees shall also fulfill the medical assessment and treatment, use of medications, use of blood and blood components, operative and other procedures, efficiency of clinical practice patterns, monitoring of departures from established clinical patterns, patients’ and families’ education, coordination of care, and medical records and functions otherwise assigned to the Quality Improvement Committee.

3. Meetings

Each department committee shall meet as often as necessary, but at least quarterly.

Appendix 4F

EMERGENCY SERVICES COMMITTEE

1. Composition

The Emergency Services Committee shall be composed of [at least five active staff members, including at least one representative of the emergency physicians’ contract group. In addition, the chief nurse of the emergency room and a representative of the hospital administration shall be voting members].

2. Duties

Consistent with any hospital agreement for emergency medical care services, the Emergency Services Committee shall develop, implement and maintain a plan for emergency care based on community needs and the capabilities of the hospital that strives to assure that adequate appraisal, advice or initial treatment shall be rendered to all ill or injured persons who present themselves at the hospital. This plan shall address not only the provision of services in the emergency service, but also back-up specialty services that may be needed for patients who present to the hospital needing emergency medical care.

3. Meetings




COMMENTS

The Emergency Services Committee shall meet at least twice a year.

Appendix 4G

INFECTION CONTROL COMMITTEE

1. Composition

a. The Infection Control Committee shall be composed of [at least five active staff members, including one representative from each department and one physician whose primary specialty is infectious disease. In addition, a nurse whose responsibilities primarily involve infectious disease and the pharmacy director shall be voting members. The employee health nurse, a representative of nursing administration, the operating room supervisor and director of central supply, and a representative of hospital administration shall be ex officio members.

b. Representatives from housekeeping, laundry, dietetic services and engineering and maintenance shall be available on a consultative and ad hoc basis].

11.9 INFECTION CONTROL COMMITTEE

11.9-1 COMPOSITION

The infection control committee shall consist of at least [ ] members including representatives from the departments of medicine, surgery, obstetrics/gynecology, pediatrics, pathology, nursing service, administration, and an individual employed in a surveillance or epidemiological capacity. It may include non-voting consultants in microbiology and non-voting representatives from relevant hospital services.

2. Duties

The Infection Control Committee shall develop and monitor the hospital’s infection control program and the staff’s treatment of infectious disease, including review of the clinical use of antimicrobials. The committee shall approve action to prevent or control infections and the infection potential among patients and hospital personnel. The committee shall ensure that the hospital’s infection control plan links with external support systems and with communitywide agencies as they relate to reduction of risk from the environment. The committee shall ensure that appropriate resources are available for infection control activities. The committee shall also assure that the results of infection control studies and reviews are incorporated into the hospital’s educational programs and into the hospital’s quality assessment and improvement activities. At least every two years, the committee shall review and approve all policies relating to the infection control program. The chair or his or her designee shall be available for on-the-spot interpretation of applicable rules.

11.9-2 DUTIES

The duties of the infection control committee shall include:

(a) developing a hospital-wide infection control program and maintaining surveillance over the program;

(b) developing a system for reporting, identifying and analyzing the incidence and cause of nosocomial infections, including assignment of responsibility for the ongoing collection and analytic review of such data, and follow-up activities;

(c) developing and implementing a preventive and corrective program designed to minimize infection hazards, including establishing, reviewing and evaluating aseptic, isolation and sanitation techniques;

(d) developing written policies defining special indications for isolation requirements;

(e) coordinating action on findings from the medical




COMMENTS

staff’s review of the clinical use of antibiotics;

(f) acting upon recommendations related to infection control received from the chief of staff, the medical executive committee, departments and other committees; and

(g) reviewing sensitivities of organisms specific to the facility.

3. Meetings

The Infection Control Committee shall meet at least every other month.

11.9-3 MEETINGS

The infection control committee shall meet as often as necessary at the call of its chair but at least [once every two months]. It shall maintain a record of its proceedings and shall submit reports of its activities and recommendations to the medical executive committee.

Appendix 4H

INSTITUTIONAL REVIEW BOARD

1. Composition

a. Each IRB shall have at least five members, with varying backgrounds to promote complete and adequate review of research activities commonly conducted by the entity. The IRB shall be sufficiently qualified through the experience and expertise of its members, and the diversity of the members, including consideration of race, gender, and cultural backgrounds and sensitivity to such issues as community attitudes, to promote respect for its advice and counsel in safeguarding the rights and welfare of human subjects. In addition to possessing the professional competence necessary to review specific research activities, the IRB shall be able to ascertain the acceptability of proposed research in terms of institutional commitments and regulations, applicable law, and standards of professional conduct and practice. The IRB shall therefore include persons knowledgeable in these areas. If an IRB regularly reviews research that involves a vulnerable category of subjects, such as children, prisoners, pregnant women, or handicapped or mentally disabled persons, consideration shall be given to the inclusion of one or more individuals who are knowledgeable about and experienced in working with these subjects.

CHA Bylaws make the IRB a medical staff committee so that important immunities will apply.




COMMENTS

b. Every nondiscriminatory effort will be made to ensure that no IRB consists entirely of men or entirely of women, including the institution’s consideration of qualified persons of both sexes, so long as no selection is made to the IRB on the basis of gender. No IRB may consist entirely of members of one profession.

c. Each IRB shall include at least one member whose primary concerns are in scientific areas and at least one member whose primary concerns are in nonscientific areas.

d. Each IRB shall include at least one member who is not otherwise affiliated with the institution and who is not part of the immediate family of a person who is affiliated with the institution.

e. No IRB may have a member participate in the IRB’s initial or continuing review of any project in which the member has a conflicting interest, except to provide information requested by the IRB.

f. An IRB may, in its discretion, invite individuals with competence in special areas to assist in the review of issues which require expertise beyond or in addition to that available on the IRB. These individuals may not vote with the IRB.

2. Duties

a. The IRB must adopt and follow written procedures for carrying out the duties imposed by the HHS and FDA regulations, including procedures for:

1) Conducting its initial and continuing review of approving research and for reporting its findings and actions to the investigator and to the institution.

2) Determining which projects require review more often than annually and which projects need verification from sources other than the investigators that no material changes have occurred since previous IRB review.

3) Assuring prompt reporting to the IRB of proposed changes in a research activity, and for assuring that changes in approved research, during the period for which IRB approval was already given, may not be initiated without IRB review and approval, except where necessary to




COMMENTS

eliminate apparent immediate hazards to the subject.

4) Assuring prompt reporting to the IRB and institutional officials of unanticipated problems involving risks to subjects or others.

5) For research subject to HHS or FDA regulations, assuring prompt reporting of unanticipated problems involving risks to subjects or others by filing reports with the appropriate federal agency.

6) Assuring timely reporting to the appropriate institutional officials of: (i) any serious or continuing noncompliance by investigators with the requirements and determinations of the IRB and (ii) any suspension or termination of IRB approval. For research subject to the HHS and FDA regulations, these reports must also be made to HHS, or to the FDA, as appropriate.

7) Except when an expedited review procedure is used, the IRB shall review proposed research at convened meetings at which a majority of the members of the IRB are present, including at least one member whose primary concern is in nonscientific areas. This review must be conducted in accordance with the provisions set forth in Paragraph 2.b. below. In order for the research to be approved, it must meet the criteria set forth in federal regulations and it must receive the approval of a majority of those members present at the meeting. Research which is approved by the IRB may be subject to further appropriate review and approval or disapproval by officials of the institution, but such review is not required. However, those officials may not approve any research subject to the federal regulations if it has not been approved by an IRB.

b. The Institutional Review Board shall:

1) Review and have authority to approve, require modifications in (to secure approval) or disapprove all research activities covered by HHS, FDA or state law and regulations.

2) Require that information given to subjects as part of the informed consent process complies with the provisions of the applicable law or regulations. The IRB may require that information, in addition to that specifically mentioned in the law or regulations, be given to the subjects August 2013 Page 247



COMMENTS

when, in the IRB’s judgment, the information would meaningfully add to the protection of the rights and welfare of subjects.

3) Require documentation of informed consent or waive documentation in accordance with the provisions of applicable law or regulations.

4) Notify the investigator and the institution in writing of its decision to approve or disapprove a proposed research activity, or of modifications required to secure IRB approval of the research activity. If the IRB decides to disapprove a research activity, it shall include in its written notification a statement of the reasons for its decision and give the investigator an opportunity to respond in person or in writing.

5) Conduct continuing review of research covered by these regulations at intervals appropriate to the degree of risk, but not less than once per year, and have authority to observe or have a third party observe the consent process and the research.

6) Have authority to suspend or terminate approval of research that is not being conducted in accordance with the IRB’s requirements or that has been associated with unexpected serious harm to subjects. Any suspension or termination of approval shall include a statement of all the reasons for the IRB’s action and shall be reported promptly to the investigator, appropriate institutional officials and appropriate regulatory authorities.

3. Meetings

The IRB shall meet as often as needed, but at least quarterly.

Appendix 4I

INTERDISCIPLINARY PRACTICE COMMITTEE

1. Composition

The Interdisciplinary Practice Committee (IPC) shall have an equal number of medical staff members and nursing staff

11.15 COMMITTEE ON INTERDISCIPLINARY PRACTICE ,

11.15-1 COMPOSITION

The committee on interdisciplinary practice (CIDP) shall consist of, at a minimum, the director of nursing, the

CMA limits the role of the Interdisciplinary Practices Committee.




COMMENTS

members. It shall include a representative from the nursing administration. In addition, representatives of the categories of allied health professionals (AHPs) granted privileges in the hospital should serve as consultants on an as-needed basis and shall participate, when available, in the committee proceedings when a member of the same specialty is applying for privileges.

2. Duties

a. Standardized Procedures

1) The IPC shall develop and review standardized procedures that apply to nurses or AHPs; identify functions that are appropriate for standardized procedures and initiate such procedures; and review and approve standardized procedures.

2) Standardized procedures can be approved only after consultation with the medical staff [department involved] and by affirmative vote of the administrative representatives, a majority of physician members, and a majority of nurse members.

b. Credentialing Allied Health Professionals

administrator or designee, and an equal number of physicians appointed by the medical executive committee and registered nurses appointed by the director of nursing. [In addition, one or more clinical psychologists shall be appointed by the medical executive committee.] Licensed or certified health professionals other than registered nurses who perform functions requiring standardized procedures shall be included in the committee. The chair of the committee shall be a physician member of the active medical staff appointed by the medical executive committee.

11.15-2 DUTIES

The CIDP shall perform functions consistent with the requirements of law and regulation. The CIDP shall routinely report to the board of [trustees/directors] through the medical executive committee and, in addition, shall submit an annual report directly to the board of [trustees/directors] and the medical executive committee.

11.15-3 MEETINGS

The CIDP shall meet at the call of the chair at such intervals as the chair or the medical executive committee may deem appropriate.]

1) The IPC shall recommend policies and procedures for expanded role privileges for assessing, planning and directing the patients’ diagnostic and therapeutic care.

2) The IPC shall review AHPs’ applications and requests for privileges and forward its recommendations and the applications on to [the appropriate clinical department.]

3) The IPC shall participate in AHP peer review and quality improvement. It may initiate corrective action when indicated against AHPs in accordance with the Medical Staff Bylaws, these Rules or guidelines governing AHPs.

4) The IPC shall serve as liaison between AHPs and the medical staff.

c. Education - The IPC shall assure that appropriate ongoing educational programs are developed and implemented addressing issues of interest to the AHP staff.

11.16 COMMITTEE ON ALLIED HEALTH PRACTITIONERS

11.16-1 COMPOSITION

The committee on allied health practitioners (CAHP) shall consist of at least [ ] members of the medical staff, a majority of whom shall be physicians, including the chair.

11.16-2 DUTIES

The duties of the CAHP shall include the following:

(a) evaluating and making recommendations regarding the need for and appropriateness of the performance of in-hospital services by allied health practitioners (AHPs).

(b) evaluating and making recommendations regarding:

(1) the mechanism for evaluating the qualifications and

This CMA Committee is in addition to the Interdisciplinary Practices Committee.




COMMENTS

3. Meetings

The IPC shall meet as often as needed, but at least quarterly

credentials of AHPs who are eligible to apply for and provide in-hospital services;

(2) the minimum standards of training, education, character, competence, and overall fitness of AHPs eligible to apply for the opportunity to perform in-hospital services;

(3) identification of in-hospital services which may be performed by an AHP, or category of AHPs, as well as any applicable terms and conditions thereon; and

(4) the professional responsibilities of AHPs who have been determined eligible to perform in-hospital services.

(c) making recommendations regarding appropriate monitoring, supervision, and evaluation of AHPs who may be eligible to perform in-hospital services.

(d) evaluating and reporting whether in-hospital services proposed to be performed or actually performed by AHPs are inconsistent with the rendering of quality medical care and with the responsibilities of members of the medical staff.

(e) evaluating and reporting on the effectiveness of supervision requirements imposed upon AHPs who are rendering in-hospital services.

(f) periodically evaluating and reporting on the efficiency and effectiveness of in-hospital services performed by AHPs.

(g) coordinating insofar as necessary with the committee on interdisciplinary practice.

11.16-3 MEETINGS

The CAHP shall meet as often as necessary at the call of its chair but at least [ ]. It shall maintain a record of its proceedings and it shall submit reports of its activities and recommendations to the medical executive committee.

Appendix 4J

PROFESSIONAL CONDUCT COMMITTEE

1. Composition

The Professional Conduct Committee shall consist of [the

CHA has added a new Professional Conduct Committee to assist in managing practitioner conduct issues.




COMMENTS

Chief Medical Officer and at least three Medical Staff (at least one whom should be a psychiatrist), and at least one representative of hospital administration who shall be appointed by the Chief Executive Officer].

2. Duties

The Professional Conduct Committee is charged with monitoring practitioners compliance with the Medical Staff Standards of Conduct, reviewing incident reports involving practitioner conduct, meeting with individuals who have been referred to the committee by self-referral, by referral of any Medical Staff [or department] officer or committee, developing and monitoring compliance with corrective action plans developed in accordance with Bylaws, Section 2.7, and Rule 3, and making recommendations to the Medical Executive Committee for administrative or disciplinary action whenever informal measures are insufficient or ineffective in addressing reported problems.

3. Meetings

The committee shall meet at least [quarterly].

Appendix 4K

QUALITY IMPROVEMENT COMMITTEE

1. Composition

The Quality Improvement Committee shall consist of [the general medical staff officers, department chairs, (insert other members, usually including chairs of committees such as Infection Control and Utilization Review, plus the director of quality improvement, director of risk management, director of health information, the nursing quality improvement liaison, and the director of pharmacy.) The chair shall be the Vice Chief of Staff].

2. Duties

The Quality Improvement Committee shall be responsible to provide leadership in measuring, assessing and improving medical care rendered in the hospital, including but not limited to oversight of ongoing professional practice evaluation activities and on its own behalf or in concert with

11.12 QUALITY ASSESSMENT AND IMPROVEMENT COMMITTEE

11.12-1 COMPOSITION

The quality assessment and improvement committee shall consist of such members as may be designated by the medical executive committee including, insofar as possible, at least one representative from each clinical department, from the nursing service and from administration.

11.12-2 DUTIES

The quality assessment and improvement committee shall perform the following duties:

(a) recommend for approval of the medical executive committee plans for maintaining quality patient care within the hospital. These may include mechanisms to:

(1) establish systems to identify potential problems in




COMMENTS

other medical staff [or department] committees oversight of focused professional practice evaluations to assess members’ general competencies, medical assessment and treatment, use of medications, use of blood and blood components, operative and other procedures, efficiency of clinical practice patterns, monitoring of significant departures from established clinical patterns, patients’ and families’ education, coordination of care with other practitioners and hospital personnel, and the accurate, timely, and legible completion of patients’ medical records. Subcommittees that report to the Quality Improvement Committee may be appointed, using the procedure described in the Medical Staff Bylaws, when necessary to carry out these functions.

patient care;

(2) set priorities for action on problem correction;

(3) refer priority problems for assessment and corrective action to appropriate departments or committees;

(4) monitor the results of quality assessment and improvement activities throughout the hospital; and

(5) coordinate quality assessment and improvement activities.

(b) submit regular confidential reports to the medical executive committee on the quality of medical care provided and on quality assessment and improvement activities conducted.

11.12-3 MEETINGS

The committee shall meet as often as necessary at the call of its chair, but [at least monthly]. It shall maintain a record of its proceedings and report its activities and recommendations to the medical executive committee and board of [trustees/directors] on a regular basis, except that routine reports to the board shall not include peer evaluations related to individual members.

a. Quality Improvement

1) Develop, review annually and revise as needed, a quality improvement plan that is appropriate for the hospital and Medical Staff and that meets Joint Commission and regulatory requirements, including but not limited to assessing the hospital’s general competencies and all major areas of patient care, including ongoing professional practice evaluations and, on its own behalf or in concert with other medical staff [or department] committees, focused professional practice evaluations. This shall specifically include, but is not limited to, providing leadership in measuring, assessing and improving: medical assessment and treatment, use of medications, use of blood and blood components, operative and use of information about adverse privileging decisions for any practitioner privileged through the Medical Staff process, other procedures, appropriateness of clinical practice patterns,




COMMENTS

significant departures from established clinical pattern, and the use of developed criteria for autopsies. The quality improvement plan may also include mechanisms for:

i) Establishing objective criteria;

ii) Measuring actual practice against the criteria;

iii) Analyzing practice variations from criteria by peers;

iv) Taking appropriate action to correct identified problems;

v) Following up on action taken; and

vi) Reporting the findings and results of the audit activity to the medical staff, the chief executive officer and the Governing Body.

2) Utilize at least sentinel event data and patient safety data in measuring and assessing performance improvement.

3) Review and act upon, on a regular basis, factors affecting the quality, appropriateness and efficiency of patient care provided in the hospital, including review of surgical and other invasive procedures, mortality, use of medications, including antibiotics, blood and blood components usage, admissions and continued hospitalization, and fulfillment of consultation requirements.

4) Coordinate the findings and results of [department] committee, and staff patient care review activities, utilization review activities, continuing education activities, reviews of medical record completeness, timeliness, and clinical pertinence; and other staff activities designed to monitor patient care practices.

5) Submit monthly reports to the Medical Executive Committee on the overall quality, appropriateness and efficiency of medical care provided in the hospital, and on the [department,] committee, and staff patient care review, utilization review and other quality review, evaluation and monitoring activities.




COMMENTS

6) Make recommendations to the committee(s) responsible for continuing medical education for the development of appropriate educational programs.

7) On at least an annual basis, evaluate the coordination of patient care and formulate policy recommendations for dietary services, equipment standardization, home health, physical therapy and social services.

8) At least once a year, evaluate and revise as needed the hospital-wide quality improvement program to assess the effectiveness of the monitoring and evaluation activities and to recommend improvement.

b. Surgical Case Review Duties

Review the monthly [surgery department’s] review of all surgical cases, including those in which a tissue specimen was not removed. All surgical cases must be reviewed except that when surgical case review consistently supports the justification and appropriateness of surgical procedures performed by individual practitioners, an adequate sample of cases may be reviewed. The review should address: (i) selecting appropriate procedures; (ii) preparing the patient for the procedure; (iii) performing the procedure and monitoring the patient; and (iv) providing postprocedure care.

c. Death and Tissue Review

Review all deaths and review all removed tissue when the tissue is found to be normal or not consistent with the clinical diagnosis, and develop and implement measures to correct any problems discovered.

d. Medication Administration and Usage Duties

Develop, implement and monitor professional policies regarding evaluation, selection and procurement and storage of drugs comprising the hospital formulary; preparing and dispensing medications; distribution, administration, safety, and effect (including reactions and interactions) of drug usage; patient education; and other matters pertinent to drug use in the hospital.




COMMENTS

e. Blood and Blood Components Usage Review Duties

1) Provide for at least a quarterly review of blood usage. This includes evaluating all or a sample of cases involving transfusion; all confirmed transfusion reactions; the adequacy of transfusion services in meeting patient needs; ordering practices; distributing, handling and dispensing, and administration of blood and blood components.

2) Provide for review of policies governing blood usage.

f. Medical Records Function

1) Provide for at least quarterly review of medical records for clinical pertinence and timely completion.

2) Provide for the quarterly review by a multidisciplinary team including medical staff members, nursing, health information management service staff and administration, of a sample of records to determine whether they reflect the diagnosis, results of diagnostic tests, therapy rendered, condition and in-hospital progress of the patient and the condition of the patient at discharge.

3) Review summary reports concerning timely completion of medical records.

4) Approve a standardized medical record format, forms used in the record and electronic data processing and storage systems.

5) Recommend solutions for problems identified during review and monitor effectiveness of these interventions.

3. Meetings

The committee shall meet at least ten times each year.

Appendix 4L

REHABILITATION COMMITTEE




COMMENTS

1. Composition

The Rehabilitation Committee shall consist of [the Chief Medical Officer of Rehabilitation and at least two other medical staff members who actively practice in or use the rehabilitation service. An administrative representative, a nursing representative, the director of rehabilitation services, a representative of quality improvement, and the directors of occupational therapy, physical therapy, communications disorders and psychosocial services shall serve as ex officio members].

2. Duties

a. The Rehabilitation Committee shall be responsible for conducting quality improvement studies, peer review and program evaluation as required by the Commission on Accreditation of Rehabilitation Facilities (CARF), the Joint Commission on Accreditation of Healthcare Organizations (Joint Commission) and any other applicable regulatory and/or accrediting bodies.

b. The Rehabilitation Committee shall be responsible for reviewing quality and services provided for rehabilitation patients, including physical therapy, occupational therapy, communication disorders, audiology and psychosocial services.

c. The Rehabilitation Committee shall review and advise on the credentials and clinical privileges of any practitioner applying for staff privileges in the area of rehabilitation.

d. The Rehabilitation Committee shall assure that appropriate educational programs are developed and delivered to members of the hospital and Medical Staff.

3. Meetings

The committee shall meet at least quarterly.

Appendix 4M

SPECIAL CARE UNITS COMMITTEE




COMMENTS

1. Composition

The Special Care Units Committee shall include the director(s) of the hospital’s special care units [and at least two other members of the staff who regularly use one or more of the hospital’s special care units]. In addition, a registered nurse having managerial responsibilities for one or more of the special care units [and a representative of hospital administration shall be voting ex officio members].

2. Duties

The Special Care Units Committee shall develop, implement and maintain a plan for continuous delivery of quality care in the special care units of the hospital. This plan shall provide for development, implementation and oversight of unit-specific policies and procedures, shall address the admission and discharge of patients to the special care units, shall address communications systems as they relate to the special care units, shall assure 24-hour in-hospital or on-call coverage of the units by the directors or their designees, and shall provide for ongoing quality improvement. The committee shall assure that appropriate educational programs are developed and delivered to address issues involving the special care units. The committee shall maintain a list of those Medical Staff members who have special care units privileges.

3. Meetings

The Special Care Units Committee shall meet at least quarterly, and shall report matters pertaining to quality improvement to the Quality Improvement Committee as well as the Medical Executive Committee.

Appendix 4N

UTILIZATION REVIEW COMMITTEE

1. Composition

[The committee shall consist of sufficient members to afford, insofar as feasible, representation from major departments or sections. Subcommittees may be established by the committee as it deems appropriate. The Director of Quality Improvement and the Utilization Review Coordinator shall

11.7 UTILIZATION REVIEW COMMITTEE

11.7-1 COMPOSITION

The utilization review committee shall consist of sufficient members to afford fair representation. Subcommittees may be appointed by the committee for departments or divisions as the committee may deem appropriate.

11.7-2 DUTIES




COMMENTS

serve as ex officio nonvoting members. Other committee members may be appointed and subcommittees formed as needed to carry out the Utilization Review Plan.]

2. Duties

The Utilization Review Committee shall perform the following functions:

a. General Duties: Oversees the review of the medical necessity for admissions, extended stays and services rendered. The committee addresses over-utilization, under-utilization, and inefficient scheduling and use of resources. Patterns of care will be followed, and focused review may be undertaken as deemed necessary. They shall also work toward maintaining proper continuity of care upon discharge. The committee shall communicate pertinent data and results of review to the Medical Executive Committee and shall make recommendations for the utilization of resources and facilities commensurate with quality patient care and safety.

b. Utilization Review Plan: The committees shall establish and follow a Utilization Review Plan which shall be approved by the Medical Executive Committee and Governing Body, and shall comply with applicable federal and state regulations.

The duties of the utilization review committee shall include:

(a) conducting utilization review studies designed to evaluate the appropriateness of admissions to the hospital, lengths of stay, discharge practices, use of medical and hospital services and related factors which may contribute to the effective utilization of services. The committee shall communicate the results of its studies and other pertinent data to the medical executive committee and shall make recommendations for the utilization of resources and facilities commensurate with quality patient care and safety;

(b) establishing a utilization review plan which shall be approved by the medical executive committee; and

(c) obtaining, reviewing, and evaluating information and raw statistical data obtained or generated by the hospital’s case management system.

11.7-3 MEETINGS

The utilization review committee shall meet as often as necessary at the call of its chair, but [at least monthly]. It shall maintain a record of its findings, proceedings and actions, and shall make a monthly report of its activities and recommendations to the medical executive committee.

c. Evaluation: The committees shall evaluate the medical necessity of continued hospital services for particular patients, where appropriate. In making such evaluations, the committees shall be guided by the following criteria:

1) No practitioner shall have review responsibility for any extended stay cases in which he or she was professionally involved.

2) Each decision that further inpatient stay is not medically necessary shall be made by the medical staff members of the committee and only after opportunity for consultation has been given the attending practitioner by the committee and full consideration has been given to the availability of hospital facilities and services.




COMMENTS

3) All decisions that further inpatient care is not medically necessary shall be given by written notice, in accordance with the written utilization review plan.

d. Liaison: The committee will act only upon the direct instruction of the Medical Executive Committee as the Liaison Committee for the government agencies and third-party providers.

e. Continuity of Care: The committee shall promote continuity of care upon discharge and supervise the accumulation of data on the availability of health care resources outside the hospital.

f. Education: The committee shall assure that the overall results of quality improvement activities are used to guide educational programs throughout the hospital.

3. Meetings

The committees shall meet regularly, at least ten times per year. The committee shall report matters pertaining to quality improvement to the Quality Improvement Committee as well as the Medical Executive Committee.

Appendix 4O

WELL-BEING COMMITTEE

1. Composition

a. The Well-Being Committee shall be composed of no fewer than three active medical staff members, a majority of whom, including the chair, shall be physicians and one of whom should be a psychiatrist whenever possible.

b. Except for initial appointments, each member shall serve a term of three years, and the terms shall be staggered to achieve continuity. Insofar as possible, members of this committee shall not actively participate on other peer review or quality improvement committees while serving on this committee.

2. Duties

a. The Well-Being Committee is charged to develop a

11.13 MEDICAL STAFF AID COMMITTEE

11.13-1 COMPOSITION

The medical staff aid committee shall be comprised of no less than [ ] active members of the medical staff, a majority of which, including the chair, shall be physicians. Except for initial appointments, each member shall serve a term of [ ] years, and the terms shall be staggered as deemed appropriate by the executive committee to achieve continuity. Insofar as possible, members of this committee shall not serve as active participants on other peer review or quality assessment and improvement committees while serving on this committee.

11.13-2 DUTIES

The medical staff aid committee may receive reports related to the health, well-being, or impairment of medical staff members and, as it deems appropriate, may investigate such reports. With respect to matters involving individual medical staff members, the committee may, on a voluntary basis,




COMMENTS

process that provides education about physician health, addresses prevention of physical, psychiatric or emotional illness, and facilitates confidential diagnosis, treatment and rehabilitation of practitioners who suffer from a potentially impairing condition. These processes should include mechanisms for the following:

1) Educating the medical staff and hospital staff about illness and impairment recognition issues specific to practitioners.

2) Self-referral by a practitioner, and referral by other medical staff and hospital staff.

3) Upon its own initiative, upon request of the involved practitioner, or upon request of a medical staff [or department] committee or officer, providing such advice, counseling or referrals to appropriate professional internal or external resources for diagnosis and treatment of the condition or concern.

4) Evaluating the credibility of a complaint, allegation or concern, including such investigation as reasonably deemed necessary.

5) Monitoring the affected practitioner and the safety of patients until the rehabilitation or any corrective action process is complete; and in the event the member fails to complete a required rehabilitation program, informing the Medical Executive Committee so that need for other appropriate actions may be assessed.

6) Confidentiality with respect to the affected member; however, if the committee receives information that demonstrates that the health or impairment of a medical staff member may pose a risk of harm to hospital patients (or prospective patients), that information shall be referred to the Chief of Staff, who will determine whether corrective action is necessary to protect patients.

7) Informant confidentiality.

b. In accordance with the Rule 2.3 (Physical and Mental Capabilities), the Well-Being Committee shall review the responses from applicants concerning physical or mental disabilities and recommend what, if any, reasonable

provide such advice, counseling, or referrals as may seem appropriate. Such activities shall be confidential; however, in the event information received by the committee clearly demonstrates that the health or known impairment of a medical staff member poses an unreasonable risk of harm to hospitalized patients, that information may be referred for corrective action. The committee shall also consider general matters related to the health and well-being of the medical staff and, with the approval of the executive committee, develop educational programs or related activities.

11.13-3 MEETINGS

The committee shall meet as often as necessary, but [at least quarterly]. It shall maintain only such record of its proceedings as it deems advisable, but shall report on its activities on a routine basis, but at least quarterly, to the medical executive committee.




COMMENTS

accommodations may be indicated in order to assure that the practitioner will provide care in accordance with the hospital and medical staff’s standard of care.

3. Meetings, Reporting and Minutes

The committee shall meet as often as necessary, but at least quarterly. It shall maintain only such records of its proceedings as it deems advisable, and shall routinely report on its activities to the Medical Executive Committee.

11.18 MEDICAL STAFF CONTRACTS REVIEW COMMITTEE

11.18-1 Composition

The medical staff contract committee shall be composed of no less than [ ] active members of the medical staff who do not hold exclusive contracts, including at least one officer.

11.18-2 Duties

(a) The medical staff contracts committee shall review and make recommendations to the board of [trustees/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:

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

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

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

(b) The medical staff contracts committee shall also review and make recommendations to the board of [trustees/directors] regarding quality of care issues related to the selection, performance evaluation, and any change in retention or replacement of physicians with whom the hospital has a contract. Prior to any decision being made, the board of [trustees/directors] shall be required to review and approve the recommendations of the medical staff contracts committee regarding these contracts, which approval shall not be

CMA has added provision for a Contracts Review Committee. Note: These provisions are in addition to the extensive hearing rights that apply with respect to entering into, extending, terminating, or transferring an exclusive contract (per Section 7.6 of the CMA Bylaws). See additional comments at pages 154-157.

This committee recommends directly to the Board (i.e., bypassing the MEC).




COMMENTS

unreasonably withheld.

(c) When reviewing contracts within the purview of the medical staff contracts committee, the committee shall request the hospital to present to it evidence of the need for a contract by:

(i) identifying in writing the patient care needs to be met by the contract;

(ii) discussing with the affected medical staff department, section or committee potential alternatives to a contract that may be equally effective in meeting patient care needs, and if none are acceptable to the administration;

(iii) inviting the chairs of the affected medical staff departments, divisions or committees to the committee meeting to discuss the need for a contract.

(d) No contract between a physician and hospital shall require the surrender of the physician's medical staff privileges, status or membership, solely on the basis of the termination of the contract.

(e) The medical staff contracts committee shall report on the status of its work at each regular medical staff meeting.

11.18-3 Meetings

The committee shall hold meetings at such intervals as the chair or the MEC may deem appropriate.

11.19 RESOURCE ALLOCATION COMMITTEE

The resource allocation committee (RAC) shall be composed of two members of the medical executive committee, two members from hospital administration, and three members from the medical staff at large.

11.19-2 Duties

The RAC shall serve as a financial liaison between the medical staff and the hospital administration. The four principal goals of the RAC are to (1) ensure that the medical staff has input into the capital budgeting process; (2) the medical staff is involved in the annual hospital budget and planning process; (3) the medical staff is provided with

Compare CHA Bylaws Section 14.13-1.

CMA has also added a Resource Allocation Committee that is extensively involved in hospital resource allocation processes.

On the one hand, the RAC is to report to the medical staff August 2013 Page 262



COMMENTS

accurate, adequate and timely information regarding the financial operations and financial condition of the hospital; and (4) assist the hospital, as necessary, with maintaining solvency, consistent with quality care. The RAC shall report to the members at each medical staff regular meeting on the status of its duties.

11.19-3 Confidentiality

All information provided and discussed at the RAC meeting is confidential and cannot be copied, disseminated or discussed with non-committee members without the express written consent of the hospital's chief financial officer.

11.19-4 Meetings

The RAC shall meet at least four times each year. Each meeting shall be scheduled within a reasonable time after the quarterly financial statements are prepared to ensure that relevant financial information is available to the committee. At least one meeting each year will include the hospital's business planning and annual budgeting process.

11.19-5 Capital Budgeting Process

The RAC will review capital requests that come to it through the medical staff departments and from the hospital administration team. The hospital chief financial officer (CFO) will be responsible for the coordination and support of the capital budgeting process and will provide all medical staff department chairs and all hospital department directors with the opportunity to provide input into that process. Department information will be given great weight by the RAC. The hospital CFO will prepare a summary of each department’s request list which will include supporting documentation that will be of use to the RAC when they review such requests. The members of the RAC will work to prioritize all requests with the goal of agreeing to a hospital wide capital equipment request list that will be submitted to hospital Governing Board. All final decisions regarding capital allocation and prioritization will be made by the hospital governing board. The RAC may revise or supplement its recommendation based upon the availability and timing of capital.

at each regular meeting; and on the other…

… all information discussed at the RAC is confidential and cannot be disseminated or discussed with non-committee members unless authorized by the CFO.




COMMENTS

11.19-6 Hospital Budget and Business Planning Process

At least one time each year, the RAC shall review the hospital business plan and the overall hospital budget process. The hospital CFO shall be responsible for preparing a presentation to the RAC that includes assumptions, data and business trends that become part of both the business plan and the budget. Input from the RAC will be incorporated into the business plan and budget that is eventually presented to the hospital Governing Board.

11.19-7 Hospital Financial Operations

The RAC shall meet at least four times each year to review hospital financial operating results. Every effort will be made by hospital CFO to provide timely, complete and accurate hospital financial information so that RAC members will understand hospital operating results. RAC input, concerns and/or questions will be communicated by hospital CFO to the hospital governing board.

11.6 MEDICAL RECORDS COMMITTEE

11.6-1 COMPOSITION

The medical records committee shall consist of, insofar as possible, at least one representative from each clinical department, the nursing service, the medical records department, and hospital administration.

11.6-2 DUTIES

The duties of the medical records committee shall include:

(a) review and evaluation of medical records, or a representative sample, to determine whether they: (1) properly describe the condition and diagnosis, the progress of the patient during hospitalization and at the time of discharge, the treatment and tests provided, the results thereof, and adequate identification of individuals responsible for orders given and treatment rendered; and (2) are sufficiently complete at all times to facilitate continuity of care and communications between individuals providing patient care services in the hospital; and

(b) review and make recommendations for medical staff

The CHA Rules include the medical records function as part of the Quality Improvement Committee’s responsibilities (see Appendix 4J).




COMMENTS

and hospital policies, rules and regulations relating to medical records, including completion, forms and formats, filing, indexing, storage, destruction, availability and methods of enforcement; and

(c) provide liaison with hospital administration and medical records personnel in the employ of the hospital on matters relating to medical records practices.

11.6-3 MEETINGS

The medical records committee shall meet as often as necessary at the call of its chair, but at least quarterly. It shall maintain a permanent record of its proceedings and activities, and shall report to the medical executive committee as necessary but at least quarterly.

11.8 PHARMACY AND THERAPEUTICS COMMITTEE

11.8-1 COMPOSITION

The pharmacy and therapeutics committee shall consist of at least [ ] representatives from the medical staff, a representative from the pharmaceutical service, as well as from the nursing service and hospital administration.

11.8-2 DUTIES

The duties of the pharmacy and therapeutics committee shall include:

(a) assisting in the formulation of professional practices and policies regarding the continuing evaluation, appraisal, selection, procurement, storage, distribution, use, safety procedures, and all other matters relating to drugs in the hospital, including antibiotic usage;

(b) advising the medical staff and the pharmaceutical service on matters pertaining to the choice of available drugs;

(c) making recommendations concerning drugs to be stocked on the nursing unit floors and by other services;

(d) periodically developing and reviewing a formulary or drug list for use in the hospital;

The CHA Rules include the P&T function as part of the Quality Improvement Committee’s responsibilities (see Appendix 4K).




COMMENTS

(e) evaluating clinical data concerning new drugs or preparations requested for use in the hospital;

(f) establishing standards concerning the use and control of investigational drugs and of research in the use of recognized drugs;

(g) maintaining a record of all activities relating to pharmacy and therapeutics functions and submitting periodic reports and recommendations to the medical executive committee concerning those activities;

(h) developing proposed policies and procedures for, and continuously evaluating the appropriateness of blood and blood products usage, including the screening, distribution, handling and administration, and monitoring of blood and blood components’ effects on patients; and

(i) reviewing untoward drug reactions.

11.8-3 MEETINGS

The committee shall meet as often as necessary at the call of its chair but at least quarterly. It shall maintain a record of its proceedings and shall report its activities and recommendations to the medical executive committee as needed but at least quarterly.

11.10 TISSUE COMMITTEE

11.10-1 COMPOSITION

The tissue committee shall consist of at least [ ] members of the medical staff, one of who shall be the chair of the department of pathology, or the chair’s designee.

11.10-2 DUTIES

The duties of the tissue committee shall include review of surgical cases in which a specimen (tissue or non-tissue) is removed, as well as from those cases in which no specimen is removed. In the latter case, however, a screening mechanism based upon pre-established criteria may be established. The review shall include the indications for surgery and all cases in which there is a major discrepancy between the pre-operative and post-operative (including pathologic) diagnosis. Following the recommendation of the surgical departments,

The CHA Rules include the tissue function as part of the Quality Improvement Committee’s responsibilities (see Appendix 4K).




COMMENTS

the medical executive committee may describe a system by which the function of the tissue committee shall be coordinated with departmental surgical case review.

11.10-3 MEETINGS

The committee shall meet as often as necessary at the call of its chair but at least [monthly]. It shall maintain a record of its activities and shall report to the medical executive committee as needed but at least quarterly.

11.17 CONTINUING MEDICAL EDUCATION COMMITTEE

11.17-1 COMPOSITION

The continuing medical education committee shall be composed of physician members and other health professionals of the medical staff whose number shall be appropriate to the size of the hospital and amount of program activities produced annually. The composition shall be a chairperson, who shall serve for at least two years, and committee members who shall serve staggered terms in order to assure continuity. If the hospital has a Director of Medical Education, that individual should be at least an ex-officio member of the committee.

11.17-2 DUTIES

The continuing medical education committee shall perform the following duties:

(a) plan, implement, coordinate and promote ongoing special clinical and scientific programs for the medical staff. This includes:

(1) identifying the educational needs of the medical staff;

(2) formulating clear statements of objectives for each program;

(3) assessing the effectiveness of each program;

(4) choosing appropriate teaching methods and knowledgeable faculty for each program; and

The CHA Rules assign these functions to the Quality Improvement Committee (see Appendix 4K).




COMMENTS

(5) documenting staff attendance at each program.

(b) assist in developing processes to assure optimal patient care and contribute to the continuing education of each practitioner.

(c) establish liaison with the quality assessment and improvement program of the hospital in order to be apprised of problem areas in patient care, which may be addressed by a specific continuing medical education activity.

(d) maintain close liaison with other hospital medical staff and department committees concerned with patient care.

(e) make recommendations to the medical executive committee regarding library needs of the medical staff.

(f) advise administration of the financial needs of the continuing medical education program.

11.17-3 MEETINGS

The continuing medical education committee shall meet as often as necessary, but at least quarterly. It shall maintain minutes of the program planning discussions and report to the medical executive committee.

RULE 5

DEPARTMENTS

5.1 Department Functions

Each department, through its officers and established committees, is responsible for the quality of care within the department, and for the effective performance of the following as it relates to the members and AHPs practicing within the department:

5.1-1 Performance evaluations and monitoring of all members and AHPs exercising privileges in the department and continuous assessment and improvement of the quality of care, treatment and services (including periodic demonstrations of ability), consistent with Article 7 of the Bylaws, and with guidelines developed by the committees responsible for quality improvement, utilization review, education and medical records, and by the Medical

10.4 FUNCTIONS OF DEPARTMENTS

The general functions of each department shall include:

(a) Conducting patient care reviews for the purpose of analyzing and evaluating the quality and appropriateness of care and treatment provided to patients within the department. The number of such reviews to be conducted during the year shall be as determined by the medical executive committee in consultation with other appropriate committees. The department shall routinely collect information about important aspects of patient care provided in the department, periodically assess this information, and develop objective criteria for use in evaluating patient care. Patient care reviews shall include all clinical work performed under the jurisdiction of the department, regardless of whether the member whose work is subject to such review is a member of that department.

(b) Recommending to the medical executive committee




COMMENTS

Executive Committee.

5.1-2 Credentials review, consistent with guidelines developed by the [Credentials Committee and the] Medical Executive Committee.

5.1-3 Recommendation to the Medical Executive Committee criteria for the granting of Clinical Privileges, including but not limited to any privileges that may be appropriately performed by AHPs or via telemedicine, and the performance of specified services within the department.

5.1-4 Initiating and assisting in the conduct of performance improvements and corrective action, when indicated, in accordance with Bylaws Article 13, Performance Improvement and Corrective Action.

5.1-5 Orientations and continuing education consistent with guidelines developed by the committee responsible for continuing medical education and the Medical Executive Committee.

5.1-6 Planning and budget review consistent with guidelines developed by the Medical Executive Committee. This includes making recommendations regarding space and other resources needed by the department.

guidelines for the granting of clinical privileges and the performance of specified services within the department.

(c) Evaluating and making appropriate recommendations regarding the qualifications of applicants seeking appointment or reappointment and clinical privileges within that department.

(d) Conducting, participating and making recommendations regarding continuing education programs pertinent to departmental clinical practice.

(e) Reviewing and evaluating departmental adherence to: (1) medical staff policies and procedures and (2) sound principles of clinical practice.

(f) Coordinating patient care provided by the department’s members with nursing and ancillary patient care services.

(g) Submitting written reports to the medical executive committee concerning: (1) the department’s review and evaluation activities, actions taken thereon, and the results of such action; and (2) recommendations for maintaining and improving the quality of care provided in the department and the hospital.

(h) Meeting at least monthly for the purpose of considering patient care review findings and the results of the department’s other review and evaluation activities, as well as reports on other department and staff functions.

(i) Establishing such committees or other mechanisms as are necessary and desirable to perform properly the functions assigned to it, including proctoring protocols.

(j) Taking appropriate action when important problems in patient care and clinical performance or opportunities to improve care are identified.

(k) Accounting to the medical executive committee for all professional and medical staff administrative activities within the department.

(l) Appointing such committees as may be necessary or appropriate to conduct department functions.




COMMENTS

(m) Formulating recommendations for departmental rules and regulations reasonably necessary for the proper discharge of its responsibilities subject to the approval by the medical executive committee and the medical staff.

5.2 Department Officer Qualifications

Each chair and vice chair shall:

5.2-1 If required by California hospital licensure regulations, be board certified or board admissible in his or her appropriate specialty. Where certification/admissibility is not required by law, a person with comparable training and experience shall be eligible to serve.

5.2-2 Have demonstrated clinical competence in his or her field of practice sufficient to maintain the respect of the members of his or her department.

5.2-3 Have an understanding of the purposes and functions of the staff organization and a demonstrated willingness to promote patient safety over all other concerns.

5.2-4 Have an understanding of and willingness to work with the hospital toward attaining its lawful and reasonable goals.

5.2-5 Have an ability to work with and motivate others to achieve the objectives of the medical staff organization in the context of the hospital’s lawful and reasonable objectives.

5.2-6 Be (and remain during tenure in office) an active staff member in good standing.

5.2-7 Not have any significant conflict of interest.

10.6 DEPARTMENT CHAIRS


Each department shall have a chair and vice-chair who shall be members of the active staff and shall be qualified by licensure, training, experience and demonstrated ability in at least one of the clinical areas covered by the department. Department chairs must be certified by an appropriate specialty board or must demonstrate comparable competence. In addition to exercising their responsibilities pursuant to Section 14.6, all department chairs and vice chairs shall verbally disclose all actual or potential conflicts of interest in the course of each department meeting or other event where such a disclosure may be relevant. Any potential conflicts so disclosed shall be resolved as set forth in Section 14.6.

10.6-2 SELECTION

Department chairs and vice-chairs shall be elected every [2] years by those members of the department who are eligible to vote for general officers of the medical staff. For the purpose of this election, each department chair shall appoint a nominating committee of [3] members at least [60] days prior to the meeting at which election is to take place. The recommendations of the nominating committee of one or more nominees for chair and vice-chair positions shall be circulated to the voting members of each department at least [20] days prior to the election. Nominations also may be made from the floor when the election meeting is held, as long as the nominee is present and consents to the nomination. [Election of department chairs and vice-chairs shall be subject to ratification by the medical executive committee.] In accordance with Section 14.6, all nominees for election for department chair or vice-chair shall disclose in writing to each voting member of the department those current or impending personal, professional, or financial affiliations or relationships of which they are reasonably aware, including contractual, employment or other relationships with the hospital, which could foreseeably result in a conflict of interest with their activities or responsibilities on behalf of the medical staff.

CMA has added provision for disclosure of conflict of interest.

In light of the importance of this position, the CHA Bylaws do not provide for nominations from the floor.

.

.




COMMENTS

Such disclosure statement shall accompany the ballot. Vacancies due to any reason shall be filled for the unexpired term through special election by the respective department with such mechanisms as that department may adopt.

5.3 Procedures for Selecting Department Officers

5.3-1 Each department [through its [Department Committee]/[Nominating Committee] that includes at least three active staff members from the department appointed by the department chair] shall nominate at least one person meeting the qualifications in Rule 5.2 for each of the offices of chair and vice chair.

5.3-2 In addition, the department members may select candidates for office by a petition signed by at least ten active staff members from the department. Such nominations must be received by the department [chair]/[Nominating Committee] at least 30 days prior to the scheduled elections.


Each department chair and vice-chair shall serve a [2] year term which coincides with the medical staff year or until their successors are chosen, unless they shall sooner resign, be removed from office, or lose their medical staff membership or clinical privileges in that department. Department officers shall be eligible to succeed themselves.

5.3-3 All nominees for election or appointment to department offices (including those nominated by petition of the department members, pursuant to Rule 5.3-2, above) shall, at least 20 days prior to the date of election or appointment, disclose in writing to the department [chair]/[Nominating Committee] those personal, professional or financial affiliations or relationships of which they are reasonably aware that could foreseeably result in a conflict of interest with their activities or responsibilities on behalf of the department. The department [chair]/[Nominating Committee] shall evaluate the significance of such disclosures and discuss any significant conflicts with the nominee. If a nominee with a significant conflict remains on the ballot, the nature of his or her conflict shall be disclosed, in writing, and circulated with the ballot.

5.4 Procedures for Removing Department Officers

Removal of a department chair or vice chair may be initiated by one-third of the Medical Executive Committee members or by a petition signed by at least one-third of the department’s voting members. Removal will take effect upon the approval of two-thirds of the hospital’s Medical

10.6-4 REMOVAL

After election [and ratification], removal of department chairs and vice-chairs from office may occur for cause by a [two-thirds] vote of the medical executive committee and a [two-thirds] vote of the department members eligible to vote on




COMMENTS

Executive Committee members or of two-thirds of the department’s voting members. All voting shall be conducted by written secret mail ballot, which shall be sent to those eligible to vote within 45 days after the initiation of removal pursuant to this Rule. The ballots must be received no later than 21 days after they are mailed and shall be counted by the Chief of Staff, secretary-treasurer, and director of medical staff services. No removal shall be effective unless and until it is ratified by the Medical Executive Committee.

departmental matters who cast votes.

5.5 Responsibilities of Department Officers

5.5-1 Each department chair shall be responsible for:

a. All department clinical activities.

b. All administrative activities of the department (unless otherwise provided for by the hospital).

c. Integrating the department into the primary functions of the organization.

d. Coordinating and integrating interdepartmental and intradepartmental services.

e. Developing and implementing policies and procedures that guide and support the provision of services in the department.

f. Recommending qualified and competent persons to provide care/service in the department.

g. Continuing surveillance of the professional performance of all individuals who have delineated clinical privileges in the department.

h. Recommending the criteria for clinical privileges in the department.

i. Evaluating the qualifications and competence of practitioners and allied health professionals (AHPs) who provide patient care services within the purview of the department.

j. Recommending clinical privileges for each practitioner and AHP desiring to exercise privileges in the

10.6-5 DUTIES

Each chair shall have the following authority, duties and responsibilities, and the vice-chair, in the absence of the chair, shall assume all of them and shall otherwise perform such duties as may be assigned:

(a) act as presiding officer at departmental meetings;

(b) report to the medical executive committee and to the chief of staff regarding all professional and administrative activities within the department;

(c) generally and continuously monitor the quality of patient care and professional performance rendered by members with clinical privileges in the department through a planned and systematic process; oversee and maintain the effective conduct of the patient care, evaluation, and monitoring functions delegated to the department by the medical executive committee in coordination and integration with organization-wide quality assessment and improvement activities;

(d) develop and implement departmental programs for retrospective patient care review, ongoing monitoring of practice, credentials review and privilege delineation, medical education, utilization review, and quality assessment and improvement; and all other clinically related activities of the department;

(e) be a member of the medical executive committee, be responsible for all clinically related activities of the department, give guidance on the overall medical policies of the medical staff and hospital and make specific recommendations and suggestions regarding the department;

CHA addresses several of these duties as Departmental responsibilities (see CHA Rule 5),




COMMENTS

department.

k. Maintaining quality control programs, as appropriate and in coordination with the Medical Staff Quality Improvement Committee.

l. Continuously assessing and improving the quality of care and services provided in the department.

m. Overseeing the orientation and continuing education of all persons in the department, in coordination with the medical staff committee(s) responsible for continuing medical education.

n. Making recommendations regarding space and other resources needed by the department.

o. Making recommendations to the relevant hospital authority with respect to off-site sources needed for patient care services not provided by the department or the [hospital]/[system].

p. Chairing all department meetings.

q. Serving as an ex officio member of all committees of his or her department and attending such committee meetings as deemed necessary for adequate information flow.

r. Assuring that records of performance are maintained and updated for all members of his or her department.

s. Reporting on activities of the medical staff to the Governing Body when called upon to do so by the Chief of Staff or the chief executive officer.

[t. Serving as a member of the Medical Executive Committee.]

u. Performing such additional responsibilities as may be delegated to him or her by the Medical Executive Committee or the Chief of Staff

(f) transmit to the medical executive committee the department’s recommendations concerning practitioner appointment and classification, renewal of membership, criteria for clinical privileges, monitoring of specified services, and corrective action with respect to persons with clinical privileges in the department;

(g) endeavor to enforce the medical staff bylaws, rules, policies and regulations within the department;

(h) implement within the department appropriate actions taken by the medical executive committee;

(i) participate in every phase of administration of the department, including maintaining a quality control program, as appropriate, recommending a sufficient number of qualified and competent persons to provide care, treatment, and services, and space and other resources needed by the department; cooperation with the nursing service and the hospital administration in matters such as personnel (including assisting in determining the qualifications and competence of department/service personnel who are not licensed independent practitioners and who provide patient care services), supplies, special regulations, standing orders and techniques;

(j) assist in the preparation of such annual reports, including budgetary planning, pertaining to the department as may be required by the medical executive committee;

(k) assess and recommend to the board of [trustees/directors] off-site sources for needed patient care, treatment, and services not provided by the department or the hospital;

(l) integrate the department or service into the primary functions of the hospital, and coordinate and integrate interdepartmental and intradepartmental services;

(m) develop and implement departmental policies and procedures that guide and support the provision of care, treatment, and services in the department;

(n) provide orientation and continuing education of all persons in the department or service;




COMMENTS

(o) recommend delineated clinical privileges for each member of the department;

(p) recommend space and other resources needed by department; and

(q) perform such other duties commensurate with the office as may from time to time be reasonably requested by the chief of staff or the medical executive committee.

10.6-6. COMPENSATION OF DEPARTMENT CHAIRS

Department Chairs should be compensated for their work spent representing and leading the medical staff. Such compensation shall come from the medical staff bank account, for which the medical staff has sole responsibility. The payment to individual physicians should be in the amount determined by the MEC. If the hospital provides any funds specifically earmarked for such compensation, those funds should be requested and accounted for in the medical staff budget for hospital approval. Payment to each physician shall be contingent upon each physician’s proper performance of those duties, and the evaluation and determination of the quality of that performance is in the sole determination of the MEC.

CMA Bylaws include provision for payment of department chairs, MEC determination of payment, and MEC evaluation of performance.

5.5-2 Each vice chair shall:

a. Assist the department chair to perform his or her duties; and, in the absence or disability of the department chair, be responsible for performing the duties of the department chair (including but not limited to assuming the chair’s voting rights on all medical staff or department committees).

b. [Chair] /[Be a member of] the Quality Improvement Committee.

RULE 6

ALLIED HEALTH PROFESSIONALS

6.1 Overview

6.1-1 The credentialing process for allied health professionals (AHPs) is similar to that for credentialing

The CHA Rules contain extensive provisions relating to AHP practice in the hospital.




COMMENTS

medical staff members. However, the Interdisciplinary Practices Committee (IPC), rather than the [Credentials Committee,] is responsible for overseeing the credentialing of AHPs. The credentialing process for AHPs is summarized at Rule 6.3, below.

6.1-2 Rule 6.4 reflects the basic requirements that all AHPs must meet, and Appendices 6A through 6R set forth requirements that specific types of AHPs must meet in addition to the basic requirements.

6.1-3 Also, the clinical department in which the AHP will exercise privileges has a role in establishing criteria for the exercise of specific privileges in that department, and in evaluating whether the particular applicant meets the established criteria. The departments also have the responsibility for generally supervising AHPs in their department, through their proctoring and peer review mechanisms.

6.1-4 Until the AHP has been granted privileges [and assigned to a department], an AHP should not be practicing within the hospital.

6.1-5 This Rule 6 applies to AHPs who practice independently, as well as AHPs who are employees or independent contractors of a medical staff member. It does not apply to hospital-employed AHPs.

6.2 Categories of AHPs Eligible to Apply for Practice Privileges

6.2-1 The types of AHPs allowed to practice in the hospital will be ultimately determined by the Governing Body, based upon the comments of the Medical Executive Committee and such other information as may be available to the Governing Body.

[6.2-2 The types of AHPs currently eligible to apply for practice privileges are:

Option 1

Check if applicable:

acupuncturist

8.3 CATEGORIES OF AHPS ELIGIBLE TO APPLY FOR SERVICE AUTHORIZATIONS

The categories of AHPs, based on occupation or profession, which shall be eligible to apply for Allied Health Staff membership and for service authorization in the hospital and the corresponding service authorization prerogatives, terms, and conditions for each such AHP category shall be designated by the Board of [Trustees/Directors], upon the recommendation of the Executive Committee, and when approved by the Board of [Trustees/Directors], shall be set forth in the medical staff rules and regulations. Such actions by the Executive Committee and the Board of [Trustees/Directors] shall be based upon the recommendations of the relevant departments for the designation of categories of AHPs eligible to apply for service authorization and the delineation of corresponding service authorization




COMMENTS

audiologist

licensed clinical psychologists

licensed clinical social workers

licensed marriage, family and child counselors

nurse anesthetists

nurse midwives

nurse practitioners

occupational therapists

perfusionists

physical therapists

physician’s assistants

psychiatric technicians

registered nurse first assistants

respiratory care practitioners

speech pathologists

surgical assistants

surgical nurses]

prerogatives, terms, and conditions for each such AHP category. The Board of [Trustees/Directors] shall review the designation of categories of AHPs eligible to apply for service authorizations at least annually and at other times, within its discretion or upon the recommendation of the Executive Committee.

Option 2

[a. The following categories may practice independently or as employees or independent contractors of medical staff members:


acupuncturist

audiologist







COMMENTS

nurse anesthetists

nurse midwives

nurse practitioners


perfusionists

physical therapists





speech pathologists

surgical assistants

surgical nurses]

b. The following categories may practice in the hospital only pursuant to an employment or independent contractor agreement with the hospital:


acupuncturists

audiologists




nurse anesthetists

nurse midwives

nurse practitioners





COMMENTS

perfusionists

physical therapists





speech pathologists

surgical assistants

surgical nurses]

6.2-3 When an AHP in a category that has not been approved as eligible to apply for clinical privileges under Article 6 of the Bylaws requests privileges, the IPC may begin to process an application at the same time the request for recognition of the profession is processed; however, no right to practice in the hospital is thereby created or implied.

6.3 Processing the Application

6.3-1 Applications shall be submitted and processed in a manner parallel to that specified for medical staff applicants in Rule 2, Appointment and Reappointment, except that the applications shall be submitted to the IPC rather than the Credentials Committee.

6.3-2 Once the application is determined to be complete, it will be forwarded to the IPC for consideration. The IPC may meet with the applicant and the sponsoring or supervising practitioner (if applicable). The IPC shall evaluate the AHP based upon the standards set forth in Rules 2 and 6.4. The IPC will also ascertain that appropriate monitoring mechanisms are in place ([in the department or] through the Quality Improvement Committee). Whenever possible, the IPC shall include practitioners in the same AHP category when conducting its evaluation. The IPC shall forward its recommendations to [the department to which the AHP would be assigned.]

6.3-3 Upon receipt of an AHP application from the IPC,




COMMENTS

[the department chair [or Department Committee (in the discretion of the department)] shall evaluate the AHP based upon the standards set forth in Rules 2 and 6.4. The [department chair or his or her designee] [or Department Committee] may meet with the AHP as well as the sponsoring or supervising practitioner (if applicable) to further investigate the AHP’s request for privileges. The department chair [Department Committee] will make a recommendation to the Medical Executive Committee regarding the applicant’s qualifications to exercise the requested privileges.

6.3-4 Thereafter, the application shall be processed by the Medical Executive Committee and Governing Body in accordance with the procedures set forth in Rule 2.7-3 through 2.7-6.

6.4 Credentialing Criteria

6.4-1 Basic Requirements

a. The applicant must belong to an AHP category approved for practice in the hospital by the Governing Body.

b. If required by law, the applicant must hold a current, unrestricted state license or certificate.

c. In addition, hospital independent contractors shall meet all conditions of their contract with the hospital.

d. The applicant must document his or her experience, education, background, training, demonstrated ability, judgment and physical and mental health status with sufficient adequacy to demonstrate that any patient he or she treats will receive care of the generally recognized professional level of quality and efficiency in the community and as established by the hospital, and that he or she is qualified to exercise clinical privileges within the hospital.

e. The applicant must maintain in force professional liability insurance or its equivalent for the privileges exercised in the amounts of at least [$1,000,000/occurrence and $3,000,000/aggregate].

8.2 QUALIFICATIONS [repeated at CHA Article 6]

An Allied Health Practitioner who is neither an employee of the hospital nor eligible for medical staff membership is eligible for a service authorization in this hospital if the practitioner:

(a) Holds a license, certificate, or other legal credential in a category of AHPs which the Board of [Trustees/Directors] has identified as eligible to apply for service authorizations (see Section 8.3, below); and

(b) Documents the practitioner’s experience, background, training, current competence, judgment, and ability with sufficient adequacy to demonstrate that any patient treated by the practitioner will receive care of the generally recognized professional level of quality established by the medical staff; and

(c) Is determined, on the basis of documented references: to adhere strictly to the lawful ethics of the practitioner’s profession, to work cooperatively with others in the hospital setting so as not to affect adversely patient care, and to be willing to commit to and regularly assist the medical staff in fulfilling its obligations related to patient care, within the areas of the practitioner’s professional competence and credentials; and




COMMENTS

f. The applicant must submit a minimum of two references from either licensed physicians or adequately trained professionals in the appropriate field and who are familiar with his or her professional work and have demonstrated competency.

(d) Agrees to comply with all medical staff and Department and Division bylaws, rules and regulations, and protocols to the extent applicable to the AHP; and

(e) Maintains professional liability insurance with a suitable insurer, with minimum limits as determined by the Executive Committee.

[g. The applicant must have actively practiced for an average of at least 20 hours per week in his or her field for eighteen of the previous 24 months. If applicant is working in an independent setting, he or she must have completed one year of clinical practice outside of his or her training program.]

h. The applicant must be determined, on the basis of documented references, to adhere strictly to the lawful ethics of his or her profession, to work cooperatively with others in the hospital setting so as not to adversely affect patient care, to be willing to participate in and properly discharge responsibilities as determined by the medical staff.

6.4-2 Specific Requirements

In addition to meeting the general requirements outlined above, applicants must meet any specific requirements established for his or her category of AHP, as set forth in the applicable appendix:

Check if applicable: See Appendix

acupuncturists 6A

audiologists 6B

licensed clinical psychologists 6C

licensed clinical social workers 6D

licensed marriage, family and child counselors6E

nurse anesthetist 6F

nurse midwives 6G




COMMENTS

nurse practitioners 6H

occupational therapists 6I

perfusionists 6J

physical therapists 6K

physician’s assistants 6L

psychiatric technicians 6M

registered nurse first assistants 6N

respiratory care practitioners 6O

speech pathologists 6P

surgical assistants 6Q

surgical nurses 6R

6.4-3 Supervising Practitioner Responsibilities

a. Any supervising practitioner or group which employs or contracts with the AHP agrees that the AHP is solely his, her or its employee or agent and not the hospital’s employee or agent. The supervising practitioner or group has full and sole responsibility for paying the AHP, and for complying with all relevant laws, including federal and state income tax withholding laws, overtime laws and workers’ compensation insurance coverage laws.

b. A supervising practitioner or group which employs or contracts with the AHP agrees to indemnify the hospital against any expense, loss or adverse judgment it may incur as a result of allowing an AHP to practice at the hospital or as a result of denying or terminating the AHP’s privileges.

6.5 Provisional Status

All AHPs initially shall be appointed to a provisional status for at least twelve months. Advancement from the provisional status will be based upon whether the professional’s performance is satisfactory, as determined by [the department in which the AHP is assigned], IPC (when its review is necessary for the privileges), the Medical Executive Committee and the Governing Body.

6.6 Duration of Appointment and Reappointment




COMMENTS

6.6-1 AHPs shall be granted practice privileges for no more than 24 months. Reappointments to the AHP staff shall be processed every other year, in a parallel manner to that specified in the Rule 2 for medical staff members.

6.6-2 Applications for renewal of the AHP’s privilege and the supervising practitioner’s approval must be completed by the AHP and supervising practitioner and submitted for processing in a parallel manner to the reappointment procedures set forth in the Medical Staff Rules.

[6.7 Exception to Credentialing Process - Contract Allied Health Professionals

6.7-1 On occasion, the hospital may determine that the interests of patient care are best served by entering into a contract with an entity that provides AHPs to work within the hospital. These AHPs are neither employees nor independent contractors of the hospital, nor are they independent professionals working in their own private practice. Rather, they are employees or independent contractors of an entity that has agreed to provide certain health services to the hospital’s patients. For purposes of these rules, these persons shall be referred to as Contract AHPs and the entity employed or contracting with them shall be referred to as the Contracting Entity.

6.7-2 Ordinarily, Contract AHPs must complete the full AHP credentialing process prior to being permitted to render patient care within the hospital. However, the Contracting Entity may be responsible for credentialing the Contract AHPs pursuant to the terms of the contract with the hospital. Formal credentialing as described in these guidelines may be waived for Contract AHPs whom the Contracting Entity warrants to be adequately qualified to perform the patient care activities described in the contract.

6.7-3 Whether the Contracting Entity is responsible for credentialing, the Contract AHPs will be determined by hospital administration and shall be made a part of the written contract between the hospital and the Contracting Entity. If the Contracting Entity will credential the Contract AHPs, the following shall apply:

a. The Contracting Entity shall provide a written




COMMENTS

description of the activities to be performed by the Contract AHPs. This description may be contained in the contract itself or in a separate job description.

b. The hospital chief executive officer may ask the appropriate medical staff department and the IPC to review the job descriptions or contract provisions describing the activities of the Contract AHPs for completeness, accuracy and appropriateness.]

Option 1

[c. The Contracting Entity shall review each AHP using standards comparable to those set forth in Appendices 6A through 6R (as applicable for each AHP category) at the time the Contract AHP is first associated with the Contracting Entity and then periodically (at least every two years) thereafter, based on actual performance. The Contracting Entity shall certify, in writing, that this condition is met for all of its Contract AHPs. Upon receipt of this certification, individual Contract AHPs will not be required to submit applications for AHP privileges.]

Option 2

[c. The Contracting Entity shall review each AHP using standards comparable to those set by Appendices 6A through 6R (as applicable for each AHP category) at the time the Contract AHP is first associated with the Contracting Entity and then periodically (at least every two years) thereafter, based on actual performance. For each Contract AHP assigned to the hospital, the Contracting Entity shall certify, in writing, that this condition has been met for that individual. Upon receipt of this certification, individual Contract AHPs will not be required to submit applications for AHP privileges.]

[d. Contract AHPs shall be limited in their scope of practice to those activities described in the contract or in the job description provided by the Contracting Entity.

e. Contract AHPs shall be subject to such observation requirements as may be recommended by the appropriate department to which the AHP will be assigned, the IPC, and the Medical Executive Committee and approved by the Governing Body.




COMMENTS

f. Quality improvement evaluations of the performance of Contract AHPs shall be conducted by the appropriate hospital department director or chief executive officer, or his or her designee. A report will be made to the Quality Improvement Committee on an annual basis unless that committee requests a report more frequently.

g. Contract AHPs are expected to be competent and cooperative in the hospital setting. The Contracting Entity shall immediately remove or reassign out of the hospital any Contract AHP reasonably determined by the hospital administration not to meet these conditions.

h. As a condition for the exception to the credentialing process provided in this rule, all Contract AHPs shall agree in writing to waive all procedural rights provided by these rules and the medical staff bylaws and to release the hospital, its employees, agents, and medical staff members from any and all liability for any decisions affecting the AHPs’ practice at the hospital.

i. Upon expiration or termination of the contract between the hospital and the Contracting Entity, the Contract AHP’s right to provide patient care services to hospital patients will automatically terminate as well. No procedural rights will be afforded to Contract AHPs in the event the contract is terminated.

6.7-4 Where the contract does not provide for the Contracting Entity to perform the evaluation, each Contract AHP shall be subject to all of the credentialing procedures of these rules.]

6.8 Observation

6.8-1 All new AHPs shall be subject to performance evaluation and monitoring, consistent with the provisions of Article 7 of the bylaws, as adapted to the scope of practice and privileges of the AHP.

6.8-2 [Each department] shall be responsible to establish performance evaluation and monitoring programs appropriate to each category of AHP granted privileges [within that department]. [The department] shall determine the appropriate frequency and methods of initial focused professional practice evaluation, which may include August 2013 Page 284



COMMENTS

proctoring concurrent or retrospective chart review or consultations. AHPs exercising surgery or anesthesia practice privileges shall be observed during surgery.

6.8-3 The proctor or evaluator should be a member in good standing of the medical staff who exercises appropriate clinical privileges; however, in appropriate circumstances, [the department chair] may assign an appropriately credentialed AHP to serve as the proctor/evaluator. Whenever possible, the proctor/evaluator should not be the sponsoring or supervising practitioner of the AHP being observed.

6.8-4 The Governing Body may approve alternative observation procedures for employee or Contract AHPs.

6.9 General

6.9-1 Duties

Upon appointment, each AHP shall be expected to:

a. Consistent with the privileges granted to him or her, exercise independent judgment within his or her areas of competence and, if applicable, within the limits of an approved standardized procedure, provided that a medical staff member who has appropriate privileges shall retain the ultimate responsibility for each patient’s care.

b. Participate directly in the management of patients to the extent authorized by his or her license, certificate, other legal credentials, any applicable standardized procedures, and by the privileges granted by the Governing Body.

c. Write orders to the extent established by any applicable medical staff or department policies, rules or standardized procedures and consistent with privileges granted to him or her.

d. Record reports and progress notes on patient charts to the extent determined by the appropriate department, and in accordance with any applicable standardized procedures.

e. Assure that records are countersigned as follows:

(i) the supervising practitioner, if any, shall countersign all




COMMENTS

entries except routine progress notes; (ii) unless otherwise specified in the rules or specific supervision protocols, all chart entries that require countersignatures must be countersigned within fourteen days after the entry is made.

f. Consistent with the privileges granted to him or her, perform consultations as requested by a medical staff member.

g. Comply with all medical staff and hospital bylaws, rules and policies.

6.9-2 Prerogatives and Status

AHPs are not members of the medical staff, and hence shall not be entitled to vote on medical staff or department matters. [AHPs shall not be required to pay dues.] They are expected to attend and actively participate in the clinical meetings [of their respective departments], to the extent consistent with applicable [department] rules.

6.10 Standardized Procedures

6.10-1 Definition

Standardized procedures means the written policies and protocols for the performance of standardized procedure functions, and which have been developed in accordance with the requirements of state law.

6.10-2 Functions Requiring Standardized Procedures

Standardized procedures are required whenever any registered nurse (including, but not by way of limitation, nurse anesthetists, Nurse Practitioners and nurse midwives) practices beyond the scope of practice taught in the basic curriculum for registered nurses as contemplated by the California Nurse Practice Act (i.e., whenever special training and/or experience are necessary in order for the nurse to perform the procedure or practice in question).

6.10-3 Development of Standardized Proceduresa. Standardized procedures may be initiated by [the appropriate department], the affected AHPs, or sponsoring or supervising practitioners.

b. The IPC is responsible for assuring that August 2013 Page 286



COMMENTS

standardized procedures are a collaborative effort among administrators and health professionals, including physicians and nurses. Representatives of the category of AHPs that will be practicing pursuant to the standardized procedures shall be involved in developing the standardized procedures.

c. Each standardized procedure shall:

1) Be in writing and show the date or dates of approval by the IPC.

2) Specify which standardized procedure functions registered nurses may perform and under what circumstances.

3) State any specific requirements which are to be followed by registered nurses in performing particular standardized procedure functions.

4) Specify any experience, training and/or education requirements for performance of standardized procedure functions.

5) Establish a method for initial and continuing evaluation of the competence of those registered nurses authorized to perform standardized procedure functions.

6) Provide for a method of maintaining a written record of those persons authorized to perform standardized procedure functions.

7) Specify the nature and scope of review and/or supervision required for performance of standardized procedure functions; for example, whether the functions must be performed under the immediate supervision of a physician.

8) Set forth any specialized circumstances under which the registered nurse is to immediately communicate with a patient’s physician concerning the patient’s condition.

9) State the limitations on settings [or departments], if any, in which standardized procedure functions may be




COMMENTS

performed.

10) Specify patient recordkeeping requirements.

11) Provide for a method of periodic review of the standardized procedures.

d. Standardized procedures [shall be reviewed by the department, and then] must be approved by the IPC, the Medical Executive Committee and the Governing Body

Appendix 6

EXAMPLE PROVISIONS

Appendix 6A

ACUPUNCTURISTS

1. Licensure

Acupuncturists shall be currently licensed by the Acupuncture Board.

2. Scope of Practice

a. Acupuncturists may receive privileges to perform the following professional services at the hospital when expressly ordered by the attending physician:

1) Insert needles into the skin to stimulate certain points on the body in order to prevent or modify the perception of pain or in order to control pain for the purposes of assisting in the treatment of diseases or dysfunctions;

2) Administer electroacupuncture, cupping and moxibustion to stimulate a certain point or points on or near the surface of the body in order to prevent or modify the perception of pain or in order to control pain for purposes of assisting in the treatment of diseases or dysfunctions; and

3) As an adjunct to the treatment described above in 1) and 2), prescribe or perform Asian massage, acupressure, breathing techniques, exercise, heat, cold, magnets (without the application of an electric current), nutrition , diet, herbs, plant, animal, and mineral products (not including synthetic compounds, controlled substances, or dangerous drugs), and August 2013 Page 288



COMMENTS

dietary supplements (not including controlled substances or dangerous drugs) to promote, maintain, and restore health.

b. Acupuncturists shall not perform any procedure at the hospital beyond the scope of acupuncture licensure, including:

1) Making incisions in the skin and manipulating nerve tissue with forceps;

2) Inserting sutures in order to stimulate a certain point or points on or near the surface of the body;

3) Using ultrasound or diathermy in order to generate deep heat within body tissues;

4) Using lasers in order to stimulate a certain point or points on or near the surface of the body; or

5) Using heat therapy or hydrotherapy in order to stimulate a certain point or points on or near the surface of the body. (However, an acupuncturist may use heat therapy and hydrotherapy in order to prepare the patient for acupuncture treatment.)

c. Acupuncturists shall not:

1) Sever or penetrate tissues in order to excise a needle that has broken subcutaneously; or

2) Treat complications, such as pneumothorax, hematoma or peritonitis, arising from acupuncture.

d. Acupuncturists shall refer any of the above complications to the attending physician.

e. Acupuncturists shall be responsible to know and adhere to all applicable infection control requirements of the hospital and of the Acupuncture Board

Appendix 6B

AUDIOLOGISTS

1. Licensure

Audiologists shall be currently licensed by the Speech-




COMMENTS

Language Pathology and Audiology Board.


a. Audiologists may receive privileges to perform the following professional services at the hospital:

1) Determine the range, nature and degree of hearing function related to the patient’s communication needs, using instruments such as pure-tone and speech audiometers, and acoustic impedance equipment;

2) Coordinate audiometric results with other diagnostic data, such as educational, medical, social and behavioral information;

3) Differentiate between organic and nonorganic hearing disabilities through evaluation of total response pattern and use of acoustic tests, such as Stenger and electrodermal audiometry; and

4) Plan, direct, conduct or participate in conservation, habilitative and rehabilitative programs, including hearing aid selection and orientation, counseling, guidance, auditory training, speech reading, language habilitation and speech conservation.

b. Audiologists shall not:

1) Perform invasive procedures;

2) Conduct physical examinations;

3) Prescribe medication; or

4) Dispense hearing aids.

Appendix 6C

LICENSED CLINICAL PSYCHOLOGISTS

1. Licensure

Licensed Clinical Psychologists shall be currently licensed by the Board of Psychology of the Department of Consumer Affairs.


a. Licensed Clinical Psychologists may receive August 2013 Page 290



COMMENTS

privileges to perform the following professional services at the hospital pursuant to a medical staff member’s order:

1) Conduct psychological testing and diagnostic procedures;

2) Render a psychological diagnosis;

3) Provide appropriate psychotherapy;

4) Write orders regarding patient activity within the hospital and nursing management of a patient’s behavior problems;

5) Document, in a patient’s medical record, information detailing the patient’s response to psychological treatment; and

6) Participate in decisions regarding discharge and psychological follow-up treatment.

7) Perform hypnosis, if the Licensed Clinical Psychologist:

i) Can demonstrate experience in the clinical use of hypnosis; and

ii) Has had course work in hypnosis from qualified instructors and has experience in a clinical setting using hypnosis under supervision.

b. Licensed Clinical Psychologists shall not:

1) Prescribe drugs, perform surgery, administer electroconvulsive therapy or otherwise practice medicine;

2) Use biofeedback instruments that pierce or cut the skin;

3) Knowingly undertake any therapy or other professional activity in which the characteristics of his or her own personality may likely interfere with the professional services rendered or which may result in harm to the patient or client; or

4) Perform services that are outside his or her education, training and experience.

c. Every patient being treated by a Licensed Clinical




COMMENTS

Psychologist at the hospital shall at all times be under the general care of a physician on the medical staff, who shall have responsibility for the patient’s overall medical condition. Such physician shall perform the admitting history and physical on any patient treated by the Clinical Psychologist at the hospital.

d. Licensed Clinical Psychologists shall at all times identify himself or herself as a psychologist when engaged in any therapy or other professional activity.

Appendix 6D

LICENSED CLINICAL SOCIAL WORKERS

1. Licensure

Licensed Clinical Social Workers shall be currently licensed by the California Board of Behavioral Sciences.


Licensed Clinical Social Workers may receive privileges to perform the following professional services at the hospital pursuant to a medical staff member’s order:

a. Counsel and provide psychotherapy of a nonmedical nature to individuals, families or groups;

b. Provide information and referral services and arrange for the provision of social services;

c. Explain or interpret the psychosocial aspects of individual, family or group situations;

d. Use psychosocial methods to assist persons to achieve better psychosocial adaptation; and

e. Provide marriage, family and child counseling, provided that the clinical social worker does not advertise that he or she is licensed as a Marriage and Family Therapist.

Appendix 6E

LICENSED MARRIAGE AND FAMILY THERAPIST




COMMENTS

1. Licensure

Licensed Marriage and Family Therapists shall be currently licensed by the California Board of Behavioral Sciences.


a. Licensed Marriage and Family Therapists may receive privileges to perform the following professional services at the hospital (but only within the context of marital and/or family relationships, including interpersonal and premarital relationships) pursuant to a medical staff member’s order:

1) Administer and interpret psychological tests;

2) Explain and interpret psychosexual and psychosocial aspects of relationships;

3) Apply psychotherapeutic techniques to assess premarital, couple, family and child relationships to diagnose and treat problems, and to promote healthy functioning; and

4) Counsel patients regarding alcoholism and other chemical substance dependency.

Appendix 6F

NURSE ANESTHETISTS

1. Licensure and Certification

Nurse Anesthetists shall be currently licensed as a registered nurse in California and currently certified as a Nurse Anesthetist by the California Board of Registered Nursing and the American Association of Nurse Anesthetists.


a. Nurse Anesthetists may administer anesthesia only upon the direct order of a qualified physician, dentist or podiatrist who:

1) Is a current member in good standing of the medical staff of the hospital;

2) Is acting within the scope of his or her licensure




COMMENTS

and privileges; and

3) Has personally evaluated the patient in question.

b. Nurse Anesthetists may receive privileges to perform the following professional services at the hospital:

1) Perform a preanesthesia evaluation of the patient, which may involve:

i) Review of the patient’s medical records, x rays, previous experience with anesthesia, and history and physical examination conducted by a physician;

ii) Performance of a physical examination;

iii) Assessment of the patient’s emotional status; and

iv) Choice of anesthetic agent;

2) Record the preanesthetic evaluation in the patient’s record;

3) Administer regional, local or general anesthesia upon appropriate order and under the supervision of the operating or supervising practitioner;

4) Initiate orders to registered nurses and other hospital staff as required for care of the patient;

5) Provide pain management services and emergency procedures including:

i) Endotracheal intubation;

ii) Injection of anesthetic or narcotic substances into epidural, subdural or subarachnoid spaces; and

iii) Injection of somatic or sympathetic nerves with anesthetic agents;

6) Perform postanesthetic evaluation of the patient;

7) Authorize release of an inpatient from the recovery area to a nursing unit pursuant to either the order of a qualified licensed independent practitioner or rigorously-applied criteria approved by the medical staff; and

8) Perform other functions according to standardized August 2013 Page 294



COMMENTS

procedures adopted by the hospital.

c. Nurse Anesthetists shall consult with the physician, dentist or podiatrist responsible for the anesthesia, the chief of [the Department of Anesthesiology] or other qualified physician, when necessary or appropriate.

Appendix 6G

NURSE MIDWIVES


Nurse Midwives shall be currently licensed as Registered Nurses in California and currently certified as Nurse Midwives by the California Board of Registered Nursing.


a. Nurse Midwives may receive privileges to perform the following professional services at the hospital, under the supervision of a physician who is a member of the medical staff:

1) Provide routine gynecological and family planning care, including fitting vaginal diaphragms, insertion of intrauterine devices, and selection of contraceptive agents from an approved formulary;

2) Provide care to women during pregnancy, as long as the medical situation meets criteria accepted as normal, and refer any complications to a physician immediately;

3) Manage labor and deliveries on his or her own responsibility, including the following specific procedures, as long as the medical situation meets criteria accepted as normal:

i) Administering intravenous fluids, analgesics and postpartum oxytocics and Rhogam;

ii) Performing amniotomies during labor;

iii) Applying external or internal monitoring devices;

iv) Administering local anesthesia (paracervical blocks, pudendal blocks and local infiltration);




COMMENTS

v) Performing episiotomies in accordance with this Appendix 6G; and

vi) Repairing episiotomies and lacerations in accordance with this Appendix 6G.

4) Refer any complications during delivery to a physician immediately;

5) Care for the mother and infant immediately after delivery, as long as the medical situation meets criteria accepted as normal (including administering preventive measures [such as vitamin K and eye prophylaxis], detecting abnormal conditions in the mother and newborn, and resuscitating the newborn) and refer any complications to a physician immediately;

6) Provide emergency care for complications, including resuscitation of the newborn, until the assistance of a physician can be obtained; and

7) Furnish drugs or devices (including Schedule IV and V controlled substances) to patients under the following conditions:

i) The drug or device is furnished incidentally to the provision of family planning services or of routine health care or perinatal care or care rendered, consistent with the certified nurse-midwife’s educational preparation or for which clinical competency has been established and maintained, to persons within the hospital;

ii) The drug or device is furnished pursuant to a standardized procedure which is promulgated by the hospital in accordance with legal requirements;

iii) The drug or device is furnished under the supervision of the attending physician, who: (1) collaborated in the development of the standardized procedure, (2) approved the standardized procedure, (3) is available by telephone at the time of patient examination by the Nurse Midwife, and (4) supervises no more than four Nurse Midwives at one time;

iv) The drug or device is furnished pursuant to certification from the Board of Registered Nursing that the




COMMENTS

nurse midwife has completed (1) at least six months physician supervised experience in the furnishing of drugs or devices and (2) a course in pharmacology covering the drugs and devices to be furnished; and

v) The drug or device is furnished under a number issued by the Board of Registered Nursing to the Nurse Midwife, to be included on all transmittals of orders for drugs or devices;

8) Furnish or order Schedule III controlled substances if, in addition to the conditions above at (7) being met, the controlled substances are furnished or ordered in accordance with a patient-specific protocol approved by the treating or supervising physician.

9) Furnish or order Schedule II controlled substances if, in addition to the conditions above at (7) and (8) being met, the provisions in the Schedule II controlled substances protocols address the diagnosis of the illness, injury, or condition for which the Schedule II controlled substance is to be furnished.

10) Perform and repair episiotomies, and repair first degree and second degree lacerations of the perineum, but only if the following additional conditions are met:

i) The supervising physician holds privileges to perform these procedures;

ii) The procedures are performed pursuant to protocols developed and approved by the supervising physician, the Nurse Midwife, the director of [the department or service] in which the supervising physician holds his or her episiotomy privileges, the Interdisciplinary Practice Committee and the hospital administrator (or his or her designee).

iii) These protocols shall require that all complications are referred to a physician immediately, shall provide for immediate care of patients who are in need of care beyond the scope of practice of the nurse midwife, or emergency care when the supervising physician is not on the premises, and shall establish the number of Nurse Midwives that a supervising physician may supervise.




COMMENTS

11) Provide other services set forth in standardized procedures which are promulgated by the hospital in accordance with Rule 6.10.

b. “Criteria accepted as normal” include situations where the patient’s history reveals no condition that would adversely affect, or be adversely affected by, pregnancy; where there is no indication of current pathology present in the mother or fetus; and where there are no obstetric findings indicating the likelihood of an operative delivery.

c. Nurse Midwives shall not:

1) Assist in childbirth by any artificial, forcible or mechanical means, such as forceps, vacuum extractors or Cesarean section; or

2) Perform any turning of the fetus;

3) Practice medicine or surgery.

d. The supervising physician need not be physically present when the Nurse Midwife performs services at the hospital.

Appendix 6H

NURSE PRACTITIONERS


Nurse Practitioners shall be currently licensed as a Registered Nurse in California and currently certified as a Nurse Practitioner by the California Board of Registered Nursing.


Nurse Practitioners may receive privileges to perform the following professional services at the hospital:

a. Perform tasks or functions which fall within the customary scope of nursing practice; and

b. Furnish or order drugs or devices (other than controlled substances) to patients under the following conditions:




COMMENTS

1) The drug or device is furnished or ordered pursuant to a standardized procedure or protocol which is promulgated by the hospital in accordance with legal requirements;

2) The drug or device furnished or ordered is consistent with the Nurse Practitioner’s educational preparation or established (and maintained) clinical competency.

3) The drug or device is furnished or ordered under the supervision of the attending physician, who:

i) Collaborated in the development of the standardized procedure;

ii) Approved the standardized procedure;

iii) Is available by telephone at the time of patient examination by the Nurse Practitioner; and

iv) Supervises no more than four Nurse Practitioners at one time.

4) The drug or device is furnished or ordered pursuant to certification from the Board of Registered Nursing that the Nurse Practitioner has completed:

i) At least six months’ physician supervised experience in the furnishing of drugs or devices; and

ii) A course in pharmacology covering the drugs and devices to be furnished

5) The drug or device is furnished or ordered under a number issued by the Board of Registered Nursing to the Nurse Practitioner, to be included on all transmittals of orders for drugs or devices.

6) The Nurse Practitioner is registered with the United States Drug Enforcement Administration.

c. Furnish or order Schedule IV or Schedule V controlled substances if, in addition to the conditions above at (b) being met, the drugs or services are further limited to those drugs agreed upon by the Nurse Practitioner and the supervising physician and specified in the standardized




COMMENTS

procedure.

d. Furnish or order Schedule III controlled substances if, in addition to the conditions above at (b) and (c) being met, the drugs or devices are furnished in accordance with a patient-specific protocol approved by the treating or supervising physician.

e. Furnish or order Schedule II controlled substances if, in addition to the conditions above at (b), (c), and (d) being met, the following conditions are met:

7) The provision in the protocol for furnishing Schedule II controlled substances addresses the diagnosis of the illness, injury, or condition for which the Schedule II controlled substance is to be furnished; and

8) The nurse practitioner completes, as part of his or her continuing education requirements, a course including Schedule II controlled substances that meets the standards of the Board of Registered Nursing.

9) The term “furnish” shall include

i) Ordering a drug or device in accordance with the standardized procedure; and

ii) Transmitting an order of a supervising physician

f. Perform tasks or functions within the expanded scope of nursing practice as developed in collaboration with physicians and defined in standardized procedures, promulgated by the hospital in accordance with Rule 6.9.

Appendix 6I

OCCUPATIONAL THERAPISTS

1. Registration

Occupational Therapists shall be currently licensed as an occupational therapist by the California Board of Occupational Therapy and registered by the American Occupational Therapy Association.


Occupational Therapists may receive privileges to perform August 2013 Page 300



COMMENTS

the following professional services at the hospital for the purpose of restoring functional capacity to patients, in accordance with the prescription of a medical staff member:

a. Provide the responsible medical staff member with an initial evaluation of the patient’s level of function by diagnostic and prognostic testing;

b. Intervene in acute stages of illness or injury to minimize or prevent dysfunction;

c. Use professionally selected self-care skills, daily living tasks and tests, and therapeutic exercise to improve function;

d. Train patients in the performance of tasks modified to the patient’s level of physical and emotional tolerance;

e. Provide preventive and protective equipment to promote function and to prevent deformity;

f. Reevaluate the patient as changes occur and modify treatment goals consistent with those changes;

g. Provide psychological conditioning to prepare the patient for reentry and integration into the community;

h. Use tests to determine the patient’s ability in the areas of concentration, attention, thought organization, perception and problem-solving; and

i. Provide prevocational evaluation through the use of specific tasks to determine the patient’s potential for vocational performance.

Appendix 6J

PERFUSIONISTS

1. Certification

Clinical Perfusionists shall be currently certified by the American Board of Cardiovascular Perfusion or its successor agency, or the equivalent thereof as determined by the Medical Board of California, Division of Licensure. These requirements will be deemed to have been met if the Perfusionist is currently certified by the American Board of




COMMENTS

Cardiovascular Perfusion or the person has practiced as a Perfusionist and has annually performed a minimum of 40 cases of cardiopulmonary bypass during cardiac surgery in a licensed health facility in the United States and has done so for at least five years between January 1, 1987, and January 1, 1993.


a. Clinical Perfusionists may receive privileges to perform the following professional services at the hospital upon the order and under the supervision of a physician on the medical staff:

1) Extracorporeal circulation, cardiopulmonary support techniques and other ancillary therapeutic and diagnostic technologies;

2) Counterpulsation;

3) Ventricular assistance;

4) Autotransfusion, including blood conservation techniques;

5) Myocardial and organ preservation;

6) Extracorporeal life support;

7) Isolated limb perfusion; and

8) Techniques involving blood management, advanced life support and other related functions.

b. While performing the services in 2.a. above, a Perfusionist may receive privileges also to perform the following services:

1) Administer medications, blood products or anesthetic agents through the extracorporeal circuit or an intravenous line as ordered by a physician;

2) Use anticoagulation analysis, physiologic monitoring, blood gas and chemistry analysis, and hematocrit analysis;

3) Induce hypothermia and hyperthermia;

4) Use hemoconcentration and hemodilution; and




COMMENTS

5) Observe signs and symptoms related to perfusion services and determine whether the signs and symptoms exhibit abnormal characteristics.

c. Perfusionists may, based on perceived abnormalities, make appropriate reports, implement emergency procedures or (upon a physician’s order) make changes in the treatment regimen in accordance with perfusion protocols developed by the hospital and its medical staff.

d. Perfusionists may receive privileges to perform such other services as are determined to be within the legal scope of practice for Perfusionists.

Appendix 6K

PHYSICAL THERAPISTS

1. Licensure

Physical Therapists shall be currently licensed by the Physical Therapy Board of California.


a. Physical Therapists may receive privileges to perform the following professional services at the hospital, for the purpose of physical or corrective rehabilitation or physical or corrective treatment of any bodily or mental condition of a patient, and pursuant to a medical staff member’s order:

1) Provide physical therapy evaluation, treatment planning, instruction and consultation;

2) Use physical, chemical, and other properties of heat, light, water, electricity, sound and massage;

3) Provide active, passive and resistive exercise;

4) Apply (through direct application, iontophoresis or phonophoresis) topical medications (consisting of bacteriological agents, debriding agents, topical anesthetic agents, anti-inflammatory agents, antispasmodic agents and adrenocortico steroids), pursuant to the attending physician’s order and written protocol. This includes a




COMMENTS

description of the medication, its actions, its indications and contraindications, and the proper procedure and technique for its administration;

5) Perform electroneuromyography for the purpose of evaluating neuromuscular performance, provided the Physical Therapist is both given a specific medical staff member’s order to do so and is certified to do so by the Physical Therapy Board of California; and

6) Perform kinesiological electromyography, provided the Physical Therapist both is specifically authorized to do so by the attending physician, and is certified to do so by the Physical Therapy Board of California.

b. Physical Therapists shall not:

1) Diagnose disease;

2) Use roentgen rays or radioactive materials for diagnostic and therapeutic purposes;

3) Use electricity for surgical purposes, including cauterization;

4) Prescribe topical or other medications; or

5) Develop or make diagnostic or prognostic interpretations of data obtained by electroneuromyography or by kinesiological electromyography.

Appendix 6L

PHYSICIAN ASSISTANTS

1. Requirements

Physician’s Assistants shall be currently licensed by the Physician Assistant Committee of the Medical Board of California.

Physician’s Assistants shall perform all services at the hospital under the direction of a qualified supervising physician.





COMMENTS

a. Physician’s Assistants may receive privileges to perform the following professional services at the hospital pursuant to a delegation and protocols where present:

1) Take a history, perform a physical examination, assess the patient, make a diagnosis, and record the pertinent data in a manner meaningful to the supervising physician;

2) Order, transmit an order for and perform or assist in performing laboratory screening and therapeutic procedures, provided that the procedures are consistent with the supervising physician’s practice and with the patient’s condition;

3) Order or transmit an order for x-ray, other studies, therapeutic diets, physical therapy, occupational therapy, respiratory therapy and nursing services;

4) Recognize and evaluate situations which call for the immediate attention of a physician and institute, when necessary, treatment procedures essential for the life of the patient;

5) Administer or provide medication to patient or transmit orally or in writing on a patient’s record or in a drug order, an order to a person who may lawfully furnish the medication to the patient, subject to the following conditions:

i) Any prescription transmitted by the physician assistant shall be based either on a patient-specific order by the supervising physician or on a written practice-specific formulary and protocol approved by the supervising physician which specifies all criteria for the use of a specific drug or device and any contraindications for the selection. Protocols for Schedule II controlled substances shall address the diagnosis of illness, injury, or condition for which the Schedule II controlled substance is being administered, provided, or issued.;

ii) The supervising physician must countersign and date within seven days the medical record of any patient cared for by the physician assistant for whom the Physician Assistant’s Schedule II drug order has been issued,




COMMENTS

transmitted or carried out;

iii) Physician Assistants may not administer, provide or issue a prescription for controlled substances listed in Schedules II through V inclusive without a patient-specific order by the supervising physician unless the Physician Assistant has completed an education course that covers controlled substances and meets all legal requirements set forth in California Business and Professions Code Section 3502.1.

iv) Any drug order issued by a Physician Assistant shall be subject to a reasonable quantitative limitation consistent with customary medical practice in the supervising physician’s practice.

v) All Physician Assistants who are authorized by their supervising physicians to issue drug orders for controlled substances shall register with the United States Drug Enforcement Administration.

6) Instruct and counsel patients regarding matters pertaining to their physical and mental health, such as medications, diets, social habits, family planning, normal growth and development, aging and understanding and managing their diseases;

7) Assist the supervising physician by arranging admissions, making appropriate entries in the patient’s medical record, reviewing and revising treatment and therapy plans, ordering, transmitting orders for, performing, or assisting the performance of radiology services, therapeutic diets, physical therapy treatment, ordering occupational therapy treatment, ordering respiratory care services, and providing continuing care to patients following discharge;

8) Facilitate the supervising physician’s referral of patients to the appropriate health facilities, agencies and resources of the community; and

9) Perform, outside the personal presence of the supervising physician, surgical procedures which are customarily performed under local anesthesia, which the supervising physician has determined the physician assistant




COMMENTS

has training to perform, and for which the physician assistant has privileges to perform;

10) Act as a first or second assistant in surgery under the supervision of the supervising physician.

b. Physician Assistants shall not:

1) Perform any task or function that requires the particular skill, training, or experience of a physician, dentist or dental hygienist;

2) Determine eye refractions or fit glasses or contact lenses; or

3) Prescribe or use any optical device for eye exercises, visual training or orthoptics (this does not, however, preclude administering routine visual screening tests).

3. Supervision

a. Physician Assistants shall perform all services at the hospital under the direction of a supervising physician who:

1) Is currently licensed by the State of California;

2) Is not subject to a disciplinary condition imposed by the Medical Board of California prohibiting supervision or employment of a Physician Assistant;

3) Is a current member in good standing of the medical staff and practices actively at the hospital; and

4) Meets the requirements set forth in this Appendix 6L.

b. Before the Physician Assistant is permitted to perform services at the hospital, the supervising physician shall submit a signed, written request which describes the tasks and functions that the physician assistant would be performing. Those tasks and functions shall be consistent with the supervising physician’s specialty, with the supervising physician’s usual and customary practice, and with the patient’s health and condition.

c. The supervising physician shall establish the following in writing, together with any necessary documentation:




COMMENTS

1) That the supervising physician accepts full legal and ethical responsibility for the performance of all professional activities of the Physician Assistant;

2) Those specific duties and acts, including histories and physical examinations, that the Physician Assistant would be permitted to perform outside of the supervising physician’s immediate supervision and control;

3) That the supervising physician is covered by professional liability insurance with limits as determined by the governing board, for acts or omissions arising from supervision of the Physician Assistant (the supervising physician shall verify such coverage in a form acceptable to the Medical Staff Executive Committee); and

4) That the supervising physician is not subject to a disciplinary condition imposed by the Medical Board of California prohibiting that supervision or the employment of a physician assistant.d. The supervising physician shall agree in writing in a form acceptable to the hospital that:

1) He or she shall notify the hospital and its medical staff immediately in the event that he or she becomes subject to any disciplinary condition, or an action to impose a disciplinary condition, by the Medical Board of California; and

2) He or she shall comply with all Medical Board of California regulations regarding supervision of the Physician Assistant.

e. No supervising physician shall have a supervisory relationship with more than four Physician Assistants at any one time. (Notwithstanding the foregoing, an emergency physician may have a supervisory relationship with more than four emergency care Physician Assistants at any one time, provided that the emergency physician does not oversee the work of more than four such Physician Assistants while on duty at any one time.)

f. The supervision of the Physician Assistant by the supervising physician shall include all of the following:




COMMENTS

1) Availability of the supervising physician in person or by electronic communication when the Physician Assistant is caring for patients;

2) Observation or review of the Physician Assistant’s performance of all tasks and procedures that the supervising physician will delegate to the Physician Assistant until the supervising physician is assured of competency;

3) Establishment of written transport and back-up procedures for the immediate care of patients who are in need of emergency care beyond the Physician Assistant’s scope of practice for such times when the supervising physician is not on the premises;

4) Establishment of written guidelines for the adequate supervision of the Physician Assistant.

i) This requirement may be satisfied by the supervising physician adopting protocols for some or all of the tasks performed by the physician assistant. These protocols, shall comply with all of the following:

(a) The minimum content for any such protocol governing diagnosis and management shall include the presence or absence of symptoms, signs and other data necessary to establish a diagnosis or assessment, any appropriate tests or studies to order, drugs to recommend to the patient and education to be given the patient.

(b) For protocols governing procedures, the protocol shall state the information to be given the patient, the nature of the consent to be obtained from the patient, the preparation and technique of the procedure, and the follow-up care.

(c) Protocols shall be developed by the supervising physician, adopted from, or referred to, texts or other sources.

(d) Protocols shall be signed and dated by the supervising physician and the Physician Assistant.

iii) Alternatively, the requirement of adequate supervision of the Physician Assistant may be satisfied by alternative mechanisms established by the Medical Board of




COMMENTS

California.

5) The supervising physician shall review, countersign, and date a minimum sample of ten percent of medical records of patients treated by the Physician Assistant functioning under these protocols within 24 hours. The supervising physician shall select for review those cases which by diagnosis, problem, treatment or procedure represent, in his or her judgment, the most significant risk to the patient.

6) On-site supervision by the supervising physician of any surgery requiring anesthesia other than local anesthesia; and

7) Responsibility on the part of the supervising physician to follow the progress of the patient and to make certain that the Physician Assistant does not function autonomously.

Appendix 6M

PSYCHIATRIC TECHNICIANS

1. Licensure

Psychiatric Technicians shall be currently licensed by the California Board of Vocational Nursing and Psychiatric Technicians.


a. Psychiatric Technicians may receive privileges to perform the following professional services at the hospital:

1) Perform basic assessment (data collection), participate in planning, execute interventions in accordance with the care plan or treatment plan, and contribute to evaluation of individualized interventions related to the care plan or treatment plan.

2) Provide direct patient care as follows:

i) Perform basic nursing services as described in (1) above

ii) Administer medications;




COMMENTS

iii) Apply communication skills for the purpose of patient care and education; and

iv) Contribute to the development and implementation of a teaching plan related to self-care for the patient.

3) Once certified as competent, Psychiatric Technicians may perform the following medical procedures when prescribed by a physician member of the medical staff:i) Withdraw blood;

ii) Administer medications by hypodermic injection;

iii) Tuberculin, coccidiodin and histoplasmin skin tests;

iv) Immunization techniques;

4) In performing activities under subdivision 3) above, Psychiatric Technicians shall satisfactorily demonstrate competence in all of the following:

i) Administering the testing or immunization agents, including knowledge of all indications and contraindications for the administration of the agents;

ii) Recognizing any emergency reactions;

iii) Treating those emergency reactions by using procedures, medication and equipment within the scope of practice of a Psychiatric Technician.

b. Psychiatric Technicians are responsible to the Director of the Psychiatric [Department] [Service].

Appendix 6N

REGISTERED NURSE FIRST ASSISTANTS

1. Qualifications

An applicant for Registered Nurse First Assistant privileges shall:

a. Be currently licensed as a Registered Nurse in California; and




COMMENTS

b. Either:

1) Be currently certified as a “Registered Nurse First Assistant” by the National Certification Board: Perioperative Nursing; or

2) Be a graduate of a Registered Nurse First Assistant program accredited by the National Certification Board: Perioperative Nursing, who is obtaining the necessary clinical experience before taking the certification examination of the National Certification Board: Perioperative Nursing to become a “Registered Nurse First Assistant[.”]/[; or

3) [Demonstrate sufficient training and experience to ensure the ability to act as a Registered Nurse First Assistant at a level that will ensure that patients receive care of the proper quality.]


a. Registered Nurse First Assistants may receive privileges to perform the following professional services at the hospital under the direct supervision of a physician on the medical staff:

1) Perform the following preoperative services:

i) Conduct patient interviews;

ii) Perform patient assessments;

iii) Perform patient teaching;

iv) Obtain patient histories; and

v) Perform physical examinations.

2) Perform the following intraoperative services:

i) Assist with positioning, preparing and draping the patient;

ii) Provide retraction for adequate exposure;

iii) Use surgical instruments;

iv) Perform dissection;




COMMENTS

v) Apply pressure;

vi) Suction the wound area;

vii) Pack sponges or laparotomy pads into body cavities to hold tissues or organs out of the operating field;

viii) Grasp or fixate tissue with screws, staples or other devices;

ix) Suture tissue;

x) Perform knot tying;

xi) Provide hemostasis by clamping bleeding vessels, suturing or tying clamped vessels or cauterizing vessels;

xii) Cauterize tissues;

xiii) Apply bovie power to instrumentation held by the surgeon when the surgeon is unable to do so;

xiv) Inject medications;

xv) Provide closure of the surgical wound by suturing fascia, subcuticular tissue and skin; and

xvi) Affix and stabilize drains, clean the wound and apply the dressing, and assist in applying casts.

3) Perform the following postoperative services:

i) Remove dressings, sutures, skin staples, drains, chest tubes, and casts;

ii) Perform postoperative assessments;

iii) Perform postoperative teaching; and

iv) Conduct discharge planning.

4) Perform other functions according to standardized procedures adopted by the hospital.

b. Registered Nurse First Assistants shall not function concurrently as a scrub nurse or a circulating nurse.

Appendix 6O




COMMENTS

RESPIRATORY CARE PRACTITIONERS

1. Certification

Respiratory Care Practitioners shall hold a current license issued by the Respiratory Care Examining Committee of the Medical Board of California.

As used herein, the term “Respiratory Care Practitioner” also includes respiratory therapists and inhalation therapists.


a. Respiratory Care Practitioners may receive privileges to perform the following professional services at the hospital:

1) Pursuant to a medical staff member’s order:

i) Administer medical gases (exclusive of general anesthesia), aerosols, environmental control systems and pharmacological agents related to respiratory care procedures;

ii) Use mechanical or physiological ventilatory support, bronchopulmonary hygiene and cardiopulmonary resuscitation;

iii) Maintain natural airways;

iv) Insert and maintain artificial airways without cutting tissues;

v) Apply diagnostic and testing techniques required for implementation of respiratory care protocols;

vi) Collect blood specimens;

vii) Collect respiratory tract specimens; and

viii) Analyze blood gases and respiratory secretions.

2) Observe patients, make determinations and take action, as follows:

i) Observe and monitor signs, symptoms, general behavior and general physical responses to respiratory care treatment or to diagnostic testing;




COMMENTS

ii) Determine whether such signs, symptoms and physical responses are abnormal; and

iii) In response to observed abnormalities, report the abnormalities, refer the patient, implement respiratory care protocols, change the treatment regime (pursuant to a prescription of a physician) or initiate emergency procedures, as appropriate.

3) Transcribe and implement written and verbal orders of a physician pertaining to the practice of respiratory care.

b. Respiratory Care Practitioners shall not administer general anesthesia.

Appendix 6P

SPEECH PATHOLOGISTS

1. Licensure

Speech Pathologists shall be currently licensed by the Speech-Language Pathology and Audiology Board.


a. Speech Pathologists may receive privileges to perform the following professional services at the hospital for the purposes of identifying, preventing, managing, habilitating, rehabilitating, ameliorating or modifying disorders of speech, voice or language:

1) Measure and test as follows:

i) With respect to speech related to articulation, fluency, mastication or swallowing, measure and test the development of patients’ articulation, fluency, mastication or swallowing;

ii) With respect to voice involving vocal quality and vocal production, measure and test the development of patients’ voice quality and voice production;

iii) With respect to language involving auditory processing, auditory memory, verbal language, written language, visual processing, visual memory, cognition and




COMMENTS

communication, and nonverbal/aural language, measure and test the development of patients’ auditory processing, auditory memory, verbal language, visual processing, visual memory, cognition and communication and nonverbal/aural language;

2) Predict disorders;

3) Counsel patients;

4) Conduct binary pure tone screening for the purpose of determining if the screened individuals are in need of further medical or audiological evaluation; and

5) [Perform suctioning in connection with this scope of practice, after compliance with the hospital’s training protocols on suctioning procedures;

6) Perform instrumental procedures, the use of rigid and flexible endoscopes to observe the pharyngeal and laryngeal areas of the throat in order to observe, collect data, and measure the parameters of communication and swallowing assessment and therapy, except that the flexible endoscopic procedures may only be performed by a Speech Pathologist who has received, and has available on file, a written verification from an otolaryngologist that meets all legal requirements and the procedure is directly authorized by a certified otolaryngologist and supervised by a physician and surgeon; and]

7) Plan, direct, conduct, and supervise programs for identification, evaluation, habilitation, and rehabilitation of the disorders of speech voice or language described in subparagraph 2.a.l), above.

b. Speech Pathologists shall not:

1) Perform invasive procedures;

2) Conduct physical examinations; or

3) Prescribe medications.

Appendix 6Q

SURGICAL ASSISTANTS




COMMENTS

1. Qualifications

Surgical Assistants shall hold a certificate from a training program, or be able to demonstrate technical training and competence acquired elsewhere, such as in the military service or in previous employment.

The term “Surgical Assistant” as used in these standards also includes operating room technicians and surgical technicians.


Surgical Assistants may receive privileges to perform the following professional services at the hospital:

a. Under the direct supervision of medical staff member:

1) Assist in patient transfer from gurney to table;

2) Prepare the operating room for surgery, and maintain sterile field and aseptic environment during and after surgery;

3) Scrub for operative procedures and provide the surgeon with instruments necessary for the procedure;

4) Apply pressure;

5) Suction the wound area;

6) Cut sutures;

7) Provide retraction for adequate exposure by hand or with instrumentation;

8) Clamp tissues for nonhemostatic purposes;

9) Apply bovie power to instrumentation held by the surgeon when the surgeon is unable to do so;

10) Keep track of needles, sponges and other instruments during surgery; and

11) Place skin staples and tie skin sutures.

b. Wrap and sterilize instruments;

c. Monitor electrical and other safety hazards in the operating room; and

d. Assist in cleaning up the operating room following surgery.




COMMENTS

Appendix 6R

SURGICAL NURSES

1. Conditions for Granting Practice Privileges to Surgical Nurses

An applicant for Surgical Nurse privileges must have a current, unrestricted California license as either a registered nurse or a licensed vocational nurse.

2. Practice Privileges

A qualified applicant may be granted privileges to assist a medical staff member during surgery by performing the functions normally assumed by surgical nurses. Such functions include, but are not limited to, shaving and preparing the patient, arranging instruments and equipment in preparation for surgery, passing instruments during surgery, starting or discontinuing intravenous fluids, monitoring equipment used during surgery and bandaging patients subsequent to surgery.

3. Supervision

A nurse granted practice privileges as a surgical nurse may not function autonomously and must always act under the direct supervision of a medical staff member when providing direct patient care services
