The University of Kansas Hospital Bylaws of the Medical Staff (“Bylaws”)

Bylaws Amendment Ballot

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SUMMARY OF PROPOSED BYLAWS REVISIONS:

Complete Redline version of these proposed Bylaws revisions may be viewed at Governing Documents: KU Bylaws – CumulativeRedline

  1. 1)Clinical Integration Amendments: Several amendments are proposed to align the Bylaws with the clinical integration that has been accomplished for the Hospital, University of Kansas, Kansas University Physicians, Inc. (“KUPI”), The University of Kansas Physicians (“UKP”) and The University of Kansas Health System (“Health System”) pursuant to the Affiliation Agreement among the Hospital, University of Kansas, KUPI and UKP.
  2. a.Clarification Regarding Clinical Service Chiefs and Department Chairs:
  3. i.Role of Clinical Service Chief (Article IV, Part B, Section 1): Language is included to clarify that a Clinical Service Chief’s role does not encompass non-Hospital activities such as those performed with respect to KUPI, UKP and the Health System. Language is also included to specify that a Clinical Service Chief is required to regularly communicate with and advise the Medical School Dean regarding material clinical issues that could affect the Medical School’s academic and research missions and with the UKP President regarding material clinical issues that could affect UKP’s operations.
  4. ii.Role of Department Chair (Article IV, Part B, Section 2): Language is included to clarify that a Department Chair’s role does not encompass non-Hospital activities such as those performed with respect to KUPI, UKP or the Health System. Department Chairs report to the Medical School Dean as a matter of Medical School governance. Department Chairs are appointed by the Dean after consultation with the Health System Senior Vice President of Clinical Affairs (“SVP”) and the CEO, and may be required to sign a “Leadership Non-Compete” if required by the Affiliation Agreement.
  5. iii.Appointment of Clinical Service Chief (Article IV, Part B, Section 3): The Bylaws currently provide that except in limited circumstances, the Department Chair also serves as Clinical Service Chief. The amendments create additional circumstances where a Department Chair will not serve as Clinical Service Chief – 1) these positions will not be held by the same person if the Clinical Service Chief steps down but remains Department Chair; 2) for periods prior to June 30, 2018, the Health System CEO is responsible for selecting a Hospital-employed cardiologist or cardiothoracic surgeon to serve as Clinical Service Chief for the Cardiovascular Disease Clinical Service; and 3) the Department Chair cannot be Clinical Service Chief if he/she fails to sign the Leadership Non-Compete, if required. In such circumstances, the Health System CEO consults with the Department Chair and SVP and then appoints a UKP physician from the applicable clinical department (or, for the Cardiovascular Diseases Clinical Service, a Hospital-employed cardiologist or cardiothoracic surgeon), subject to approval by the Dean. For the Department of Pediatrics, the Vice Chair serves as Clinical Service Chief of the Pediatric Clinical Service if the Department Chair does not serve as Clinical Service Chief, as long as the Vice Chair is otherwise qualified.
  6. iv.Impact of Termination of Affiliation Agreement (Article IV, Part B, Section 3.E): If the Affiliation Agreement expires or is terminated, the Hospital CEO appoints Clinical Service Chiefs without approval from the Dean or receipt of Leadership Non-Competes.
  7. v.Removal of Clinical Service Chiefs (Article IV, Part B, Section 5): Provisions regarding removal of Clinical Service Chiefs are simplified. Language is included to provide that the Health System CEO may only remove a Clinical Service Chief if agreed to by the Dean.
  8. vi.Appointment of Replacement Clinical Service Chiefs (Article IV, Part B, Section 6): The provisions regarding appointment of a replacement Clinical Service Chief are revised and address instances where (1) there is a replacement Clinical Service Chief but no Department Chair replacement (in which case the Clinical Service Chief appointment is subject to approval by the Dean unless the Affiliation Agreement terminates); (2) there is a change to Department Chair who also serves as Clinical Service Chief (in which case the replacement Department Chair will serve as Clinical Service Chief and is appointed by the Dean after consultation with the SVP and Health System CEO, and approval from the Health System CEO); and (3) if there is a change to Clinical Service Chief and a subsequent change to Department Chair (in which case the new Department Chair will also serve as Clinical Service Chief), all subject to applicable qualifications for Clinical Service Chiefs and Department Chairs.
  9. vii.Executive Committee Meeting Attendance (Article V, Part A, Section 2.B): Executive Committee attendance requirements do not apply to the Dean, however, the Hospital CEO or designee must attend each meeting.
  10. viii.Medical Staff Qualifications (Article VI, Part A, Sections 1, 11): To qualify for Medical Staff appointment, physicains must have an employment or other agreement in effect with UKP or, if permitted by the Affiliation Agreement, with the Hospital or an affiliate. If the Affiliation Agreement is terminated or expires, this requirement and the requirement for Medical School faculty appointment do not apply.
  11. ix.Automatic Suspensions (Article VII, Part E, Section 1.H, Article VIII, Part A, Section 2.E): A member is automatically suspended if he/she fails to maintain the required Medical School faculty appointment or, as applicable, employment or contract with UKP, the Hospital or an affiliate. No fair hearing rights apply.
  12. 2)Additional Amendments:
  13. a.Removal of “Provisional” Medical Staff Category (Article II and Article VI, Part B, Section 1): A “Provisional” Medical Staff category for newly-appointed members was formerly required for accreditation purposes but has been replaced by a period of focused professional practice evaluation or “FPPE.” Accordingly, newly-appointed members will be immediately appointed to their respective categories (Active, Courtesy, or Volunteer), but will be subject to an FPPE period. Active and Courtesy members can admit patients and Active, Courtesy and Volunteer members can serve on committees during the FPPE period. After the FPPE period is completed, members will no longer need to apply for reappointment.
  14. b.Inclusion of Reference to Allied Health Professionals Policy (Article II): A reference to the Allied Health Professionals Policy is included for clarity as to the relationship between Allied Health Professionals and the Medical Staff. No changes to this relationship are proposed.
  15. c.Inclusion of Chief of Staff as Voting Member of the Executive Committee (Article III, Part B, Section 2.A): The Chief of Staff will serve as a voting member of the Executive Committee. Currently, the Chief of Staff serves on an ex-officio, non-voting basis on the Executive Committee.
  16. d.Inclusion of Language Distinguishing Inquiries from Investigations (Article VII, Part C, Sections 3.A.3, 4B): Language is included to indicate that an investigation for potential corrective action is distinct from an initial inquiry into the need for an investigation. The initial inquiry is not an investigation, and an investigation does not begin until formally declared by the Executive Committee.
  17. Inclusion of Alternative to Summary Suspension (Article VII, Part D, Section 1.C): Where a member is subject to summary suspension, he/she will have the option to voluntarily refrain from exercising his or her privileges in lieu of the summary suspension but would still be subject to a corrective action investigation and potential NPDB reporting.

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