University Hospital Mcduffie

UNIVERSITY HOSPITAL –MCDUFFIE

MEDICAL STAFF BYLAWS

TABLE OF CONTENTS

Page

TABLE OF CONTENTS2

ADOPTION5

PREAMBLE6

DEFINITIONS7

ARTICLE I: NAME9

ARTICLE II: PURPOSES AND RESPONSIBILITIES9

ARTICLE III: MEDICAL STAFF MEMBERSHIP10

SECTION 1 - GENERAL10

SECTION 2 - SPECIFIC QUALIFICATIONS11

SECTION 3 - NO ENTITLEMENT TO MEMBERSHIP11

SECTION 4 - NON-DISCRIMINATION POLICY12

SECTION 5 - CONDITIONS & DURATION OF APPOINTMENT12

ARTICLE IV: CATEGORIES OF THE MEDICAL STAFF13

SECTION 1 - THE MEDICAL STAFF13

SECTION 2 - THE ACTIVE MEDICAL STAFF13

SECTION 3 - THE SENIOR ACTIVE MEDICAL STAFF13

SECTION 4 - THE COURTESY MEDICAL STAFF14

SECTION 5 - THE PODIATRIC STAFF14

SECTION 6 - THE CONSULTING MEDICAL STAFF15

SECTION 7 - THE PROVISIONAL MEDICAL STAFF15

SECTION 8 - THE HONORARY MEDICAL STAFF16

SECTION 9 - THE ASSOCIATE MEDICAL STAFF16

ARTICLE V: LEAVE OF ABSENCE17

SECTION 1 - REQUESTS FOR LEAVE OF ABSENCE17

ARTICLE VI: PROCEDURES FOR APPOINTMENT & REAPPOINTMENT18

SECTION 1 - BASIC RESPONSIBILITIES18

SECTION 2 - BURDEN OF PROVIDING INFORMATION20

SECTION 3 - APPLICANT'S AUTHORIZATION20

SECTION 4 - APPLICATION & PROCEDURE FOR INITIAL21

APPOINTMENT

SECTION 5 - APPLICATION & PROCEDURE FOR 27

REAPPOINTMENT

ARTICLE VII: CLINICAL PRIVILEGES32

SECTION 1 - GENERAL32

SECTION 2 - CLINICAL PRIVILEGES FOR DENTISTS34

SECTION 3 - CLINICAL PRIVILEGES FOR PODIATRISTS35

SECTION 4 - TELEMEDICINE PRIVILEGES35

SECTION 5 - INTERNS AND RESIDENTS37

SECTION 6 - PROCEDURE FOR REQUESTING37

ADDITIONAL PRIVILEGES

SECTION 7 - VOLUNTARY RELINQUISHMENT38

CLINICAL PRIVILEGES

SECTION 8 - PROCEDURE FOR TEMPORARY PRIVILEGES39

SECTION 9 - EMERGENCY CLINICAL PRIVILEGES41

SECTION 10 - DISASTER CLINICAL PRIVILEGES41

ARTICLE VIII: STRUCTURE OF THE MEDICAL STAFF43

SECTION 1 - OFFICERS OF THE MEDICAL STAFF43

SECTION 2 - TERM OF OFFICE43

SECTION 3 - ELECTION OF OFFICERS43

SECTION 4 - DUTIES OF OFFICERS44

SECTION 5 - REMOVAL OF OFFICERS45

SECTION 6 - VACANCIES IN OFFICE45

ARTICLE IX: CLINICAL DEPARTMENTS45

SECTION 1 - ORGANIZATION OF DEPARTMENTS45

ARTICLE X: COMMITTEES46

SECTION 1 - STANDING COMMITTEES46

SECTION 2 - DUTIES/RESPONSIBILITIES OF STANDING47

COMMITTEES

SECTION 3 - COMMITTEES FOR SPECIAL SERVICES47

AND/OR FUNCTIONS

SECTION 4 - MANAGERIAL COMMITTEES47

SECTION 5 - EXECUTIVE COMMITTEE47

SECTION 6 – CREDENTIALS COMMITTEE49

SECTION 7 – UTILIZATION REVIEW COMMITTEE49

SECTION 8 – PERFORMANCE IMPROVEMENT COUNCIL 50

ARTICLE XI: MEETINGS51

SECTION 1 - GENERAL MEDICAL STAFF MEETINGS51

SECTION 2 - SPECIAL MEDICAL STAFF MEETINGS51

SECTION 3 – QUORUM51

ARTICLE XII: RULES OF ORDER51

ARTICLE XIII: RULES AND REGULATIONS OF THE MEDICAL STAFF52

SECTION 1 - ADOPTION AND MODIFICATION52

SECTION 2 - FINAL APPROVAL BY GOVERNING BODY52

SECTION 3 - DISAGREEMENT AND CONTROVERSIES52

SECTION 4 – POLICIES & PROCEDURES OF MEDICAL STAFF52

SECTION 5 – FINAL APPROVAL BY THE GOVERNING 53

BODY OF

POLICES AND PROCEDURES

SECTION 6 - HISTORY AND PHYSICAL REQUIREMENTS53

ARTICLE XIV: BYLAWS REVIEW AND AMENDMENTS55

SECTION 1 - REVIEW OF BYLAWS55

SECTION 2- AMENDMENT OF BYLAWS55

ARTICLE XV: NOMINATIONS TO THE GOVERNING BODY55

SECTION 1 – NOMINATIONS55

SECTION 2 – TERM56

ARTICLE XVI: RULES OF CONSTRUCTION56

ARTICLE XVII: CORRECTIVE ACTION56

SECTION 1 - CIRCUMSTANCES REQUIRING PEER REVIEW56

SECTION 2 - PRECAUTIONARY SUSPENSION OF CLINICAL59

PRIVILEGES

SECTION 3 - AUTOMATIC VOLUNTARY RELINQUISHMENT 60

OF PRIVILEGES

ARTICLE XVIII: HEARING AND APPEAL RIGHTS64

SECTION 1 - RIGHT TO HEARING64

SECTION 2 - INITIATION OF APPELLATE REVIEW65

SECTION 3 - FAIR HEARING PLAN66

SECTION 4 - GOVERNING BODY FINAL ACTION66

SECTION 5 - NUMBER OF HEARINGS AND REVIEWS66

SECTION 6 - MEMBER'S PEER REVIEW FILE67

SECTION 7 - IMMUNITY67

UNIVERSITY HOSPITAL-MCDUFFIE

Thomson, Georgia

ADOPTION

1. These Medical Staff Bylaws are adopted and made effective upon approval of the Board of Trustees of University Hospital-McDuffie, superseding and replacing any and all previous Medical Staff Bylaws, and henceforth all activities and actions of the Medical Staff and of each individual exercising clinical privileges at University Hospital-McDuffie shall be taken under and pursuant to the requirements of these Bylaws.

1. The present Rules and Regulations of the Medical Staff are hereby readopted and placed into effect insofar as they are consistent with these Bylaws, until such time as they are amended in accordance with the terms of these Bylaws.

Adopted by the Medical Staff on: August 1, 2016

Approved by the Board of Trustees on:August 22, 2016

Words used in this document shall be read as the masculine or feminine gender, and as the singular or plural, as the content requires. The captions or headings are for convenience only and are not intended to limit or define the scope or effect of any provision of this document.

PREAMBLE

WHEREAS, the Board of Trustees of University Hospital-McDuffie ("the Board") recognizes that each physician, dentist, and podiatrist appointed to the Medical Staff and/or privileged to attend patients at University Hospital-McDuffie has responsibility for the exercise of professional judgment in the care and treatment of patients; and

WHEREAS, the Board, in accordance with legal and accreditation requirements, has delegated to the Medical Staff, through its committees, the duties and responsibilities set forth in these Bylaws for supervising and monitoring the quality of care provided by physicians, dentists, podiatrists and others at the hospital, and for making recommendations concerning appointment, reappointment and clinical privileges; and

WHEREAS, the Medical Staff recognizes and accepts its role and responsibilities in the efforts of University Hospital-McDuffie to foster prevention, amelioration and cure of illness, disease and injury, and to provide or assist in providing medical education and continuing medical education for Medical Staff members, other health care professionals and residents, interns, medical students and nurses; and

WHEREAS, the cooperative efforts of the Medical Staff, the Administration and the Board are necessary to fulfill the hospital's obligation to its patients;

WHEREAS, it is the intention of University Hospital-McDuffie's medical staff to be in compliance with State and Federal laws and regulations as well as those of other regulatory bodies such as the Joint Commission; and

THEREFORE, to discharge those duties and responsibilities, and to provide for an orderly process concerning matters of election, meetings, duties and procedures, the officers, and committees of the Medical Staff as described in these Bylaws assume responsibility for fulfilling those duties and functions delegated to them by the Board, and in conformity with these bylaws organize themselves into a medical staff which is ultimately accountable to the Board of Trustees.

DEFINITIONS

For the purpose of these Bylaws, Rules and Regulations the following definitions shall apply:

1. "Administration" means the non-medical personnel responsible for the operation of the hospital to include Administrator/Chief Operating Nurse, Administrator/Chief Operating Nurse or other designee.

1. “President or Chief of Staff” means the individual elected to the position by the Medical Staff.

1. “Allied Health Professional” (AHPs) shall be interpreted to include non-physicians who work in the hospital under the supervision of the practitioner to whom they are to be assigned. The appointment process and procedure are addressed by a separate Medical Staff policy and not within these Bylaws.

1. "Administrative Officer" means the individual appointed by the Governing Body to act in its behalf in the overall management of the hospital.

1. "Clinical privileges" means the authorization of the Governing Body to provide specified diagnostic and/or therapeutic health care services independently at the hospital. An individual shall be granted clinical privileges in the hospital only in accordance with the process for delineation of such privileges as set forth in these Bylaws.

1. "Executive Committee" means that committee of the Medical Staff with the duties and responsibilities delineated in Article X, Section 5.

1. "Governing Body" means University Hospital-McDuffie or a committee duly appointed by University Hospital-McDuffie

1. "Hospital" means the Board of Trustees of University Hospital-McDuffie and the facilities operated by University Hospital-McDuffie. The hospital also means a "health care entity" as that term is defined under Sections 431(4) and 431(5) of the Health Care Quality Improvement Act.

1. "House Staff" means those interns and residents who are receiving training at the hospital because of an affiliation with the training program of Georgia Regents University, Medical College of Georgia or any other recognized medical education institution.

1. "Medical Staff" or "Practitioner" means all physicians, dentists, and podiatrists, who are privileged to attend patients at University Hospital-McDuffie.Center and the facilities which it operates.

1. "Physicians" shall be interpreted to include both doctors of medicine ("M.D.'s") and doctors of osteopathy ("D.O.'s").

1. "Dentist" shall be interpreted to include a doctor of dental surgery (“D.D.S.’s) and doctor of dental medicine (“D.M.D.’s”).

1. "Podiatrist" shall be interpreted to mean a doctor of podiatric medicine (D.P.M.’s).

1. "Professional review activity" means a peer review activity of the hospital with respect to an individual staff member (a) to determine whether the staff member may have clinical privileges with respect to appointment; (b) to determine the scope and/or conditions of those clinical privileges and/or appointment; or (c) to change or modify such privileges and/or appointment.

1. "Professional review action" means an action or recommendation which is taken or made in the conduct of professional peer review activity, which is based on the competence or professional conduct of a staff member, and which affects or may affect adversely the clinical privileges or appointment of the individual.

1. "Section" refers to those organized subspecialties of the various departments whose administrative quality assurance activities are merged with the department to which that subspecialty belongs.

1. "Suspension" means an adverse action resulting in a temporary loss of staff status or privileges which will end at the expiration of a specified period of time or upon the fulfillment of specified conditions.

1. “Leadership Position” means any Medical Staff officer, Chief of Staff, or Committee Chair position as described in these Bylaws, any position with equivalent duties and responsibilities of any other hospital’s medical staff, and any medical school faculty leadership position, including any position equivalent to that of a dean, assistant or associate dean, faculty department chair, and assistant or associate faculty department chair.

1. "Peer" means a professional health care provider as defined by Georgia law at Official Code of Georgia Section 31-7-131. The term peer includes, but is not limited to, any physician, dentist, podiatrist, psychologist, pharmacist, nurse, physical therapist, occupational therapist, or health care facility administrator licensed by the state of Georgia or any other state.

ARTICLE I: NAME

The name of this organization shall be the Medical Staff of University Hospital-McDuffie.

ATICLE II: PURPOSES AND RESPONSIBILITIES

PURPOSES:

The purposes of the medical staff are:

1. to be the formal organizational structure through which the benefits of membership on the staff may be obtained by individual practitioners and the obligations of staff membership may be fulfilled.

1. to serve as the primary means for accountability to the Board for the appropriateness of the quality of the medical care, treatment, and services provided to patients and appropriateness of the professional performance and ethical conduct of its members as well as of all designated professional personnel; and to strive to assure that a high level of patient care efficiently delivered, achievable by the state of the healing arts.

1. to develop an organizational structure, reflected in Medical Staff Bylaws, Rules and Regulations, Policies and Procedures, and Protocols, that adequately defines the responsibility and when appropriate, the authority and accountability of each organizational component.

1. to provide a means through which the medical staff may participate in the hospital's policy-making and planning procedures.

RESPONSIBILITIES:

The responsibilities of the medical staff are to provide oversight and account for the activities of the organized medical staff including for the quality and appropriateness of patient care, treatment and services rendered by all practitioners and designated professional personnel, authorized to provide patient care services in the hospital through the following measures:

1. a credentials program, including mechanisms for the matching of clinical privileges to be exercised or of specified services to be performed with the certified credentials and current demonstrated performance of the applicant, staff member or affiliate.

1. providing continuing education that is relevant to patient care provided in the hospital as determined, to the degree reasonably possible, from the findings of quality related activities.

1. providing an effective utilization review program for allocation of medical/health services based upon patient-specific determinations of individual medical needs.

1. an organization structure that allows for continuous monitoring of patient care practices.

1. review and evaluation of the quality of patient care through a valid and reliable process.

1. to recommend to the Board of Trustees action with respect to appointments, reappointments, staff category, departmental and service assignments, clinical privileges, specified services for affiliates and corrective action.

1. to initiate and pursue corrective action with respect to practitioners, when warranted.

1. to initiate, develop, and approve bylaws, rules and regulations, and any amendments thereto to be forwarded to the Board for final approval, as well as seek compliance with these bylaws, rules and regulations and policies and procedures.

1. to assist in identifying community health needs and in setting appropriate institutional goals and implementing programs to meet those needs.

1. to provide leadership in performance improvement activities to improve quality of care, treatment, and services.

1. to provide leadership in activities related to patient safety.

1. to provide oversight in the process of analyzing and improving patient satisfaction.

1. to exercise the authority granted by these bylaws as necessary to adequately fulfill the foregoing responsibilities.

ARTICLE III: MEDICAL STAFF MEMBERSHIP

SECTION 1 – GENERAL

1. Membership on the Medical Staff of University Hospital-McDuffie is a privilege that shall be extended only to professionally competent individuals who continuously meet the qualifications, standards and requirements set forth in these Bylaws, Rules and Regulations, and policies of the hospital.

1. All processes described in this Article shall be subject to the confidentiality provisions described in these Bylaws.

SECTON 2 - SPECIFIC QUALIFICATIONS

Only physicians, dentists and podiatrists who satisfy the following threshold conditions as described in these Bylaws, shall be qualified for appointment to the Medical Staff: The specific qualifications that apply to Associate Staff are addressed under Article IV, Section 9.

1. are currently licensed to practice in this state;

1. possess current, valid professional liability insurance coverage in such form and in amounts satisfactory to the hospital as specified in the current medical staff policy;

1. can document the following with sufficient adequacy to assure the medical staff and governing board that any patient treated by the physician in the hospital will be given a high quality of medical care:

1. background, experience, education, training and demonstrated competence,

1. adherence to the ethics of their profession,

1. good reputation and character, including current health status, and ability to work with others sufficiently to convince the hospital that all patients treated by them at the hospital will receive quality care and that the hospital and its Medical Staff will be able to operate in an orderly manner,

1. board certification (see Article XVII, Section 3, (C),willingness to appear for an interview with regard to his/her application, if requested,

1. willingness to undergo a criminal background check,

1. eligible to participate in federal healthcare programs (Medicare/Medicaid), and

1. provision of appropriate call coverage in specialty.

1. commitment to using the electronic medical record system adopted by the organization and to obtaining the required training for its use in the safe effective care of patients

SECTION 3 - NO ENTITLEMENT TO MEMBERSHIP:

No individual shall be entitled to membership to the Medical Staff or to the exercise of particular clinical privileges in the hospital merely by virtue of the fact that such individual:

1. is licensed to practice a profession in this or any other state,

1. is a member of any particular professional organization,
2. has had in the past, or currently has, Medical Staff appointmentor privileges at any hospital or health care facility,

1. or resides in the geographic service area of the hospital

SECTION 4 - NON-DISCRIMINATION POLICY:

No individual shall be denied appointment on the basis of age, sex, race, creed, religion, color or national origin, or on the basis of any criteria unrelated to the delivery of quality patient care at the hospital, to professional qualifications or to the hospital's purposes, needs and capabilities.

SECTION 5 - CONDITIONS AND DURATION OF APPOINTMENT

1. Duties of Appointees and Duration of Appointment:

Appointment to the Medical Staff shall require that each staff member assume such reasonable duties and responsibilities as the Medical Staff or the Governing Body shall require. Every application for staff appointment shall be on a form approved by the Chief Executive Officer and provided by the Medical Staff Office and signed by the applicant and shall contain the applicant's specific acknowledgement of every medical staff members' obligations to provide continuous care and supervision of his/her patients, to abide by the medical staff Bylaws, Rules and Regulations and Policies and Procedures.

Initial appointments and reappointments to the medical staff shall be made by the Governing Body. They shall act on initial appointments, reappointments, or revocation of appointments only after there has been a recommendation from the medical staff as described in these bylaws; provided that in the event of unwarranted delay on the part of the medical staff, the Governing Body may act without such recommendation on the basis of documented evidence of the applicant's or staff member's professional and ethical qualifications obtained from reliable sources.

Initial appointments shall be for a period of one year from date of appointment. At that time, applicants are reappointed for a two year period unless a second provisional year is required.

Appointments to the medical staff shall confer on the appointee only such clinical privileges as have been granted by the governing board, in accordance with these bylaws.

1. Professional Conduct:

Individuals appointed to the Medical Staff shall be expected to relate in a positive and professional manner to other health care professionals, and to cooperate and work collegially with the Medical Staff leadership and hospital management and personnel.

1. Meeting Requirement:

Medical Staff appointees shall be encouraged to attend a minimum of two (2) bi-annual general medical staff meetings each year.

ARTICLE IV: CATEGORIES OF THE MEDICAL STAFF

SECTION 1 - THE MEDICAL STAFF

The Medical Staff shall be divided into the following categories: Active, Senior Active, Courtesy, Podiatric, Consulting, Honorary, and Associate.

SECTION 2 - THE ACTIVE MEDICAL STAFF

1. The Active Medical Staff shall consist of practitioners engaged primarily in the private practice of medicine or dentistry in this community, as further defined by the hospital's rules and regulations. They must be able to provide continuous, timely patient care and a yearly minimum of twelve (12) admissions/discharges and/or hospital procedures to include inpatient, outpatient, emergency room care and consultations. They also assume all the functions and responsibilities of membership on the Active Medical Staff, including acceptance of committee appointments and encouraged attendance at regular meetings of the Medical Staff and when required, emergency service care and consultation assignments. Members of the Active Medical Staff shall be eligible to vote and hold office as determined by these Bylaws and Departmental Rules and Regulations.

1. Practitioners whose practice does not customarily result in hospital admissions/discharges/procedures may, on a selected basis, be assigned to the Active Medical Staff as requested by the practitioner. The practitioner must be willing to provide access to his office records for review by the Chief of the Staff or his designee.

1. Practitioners who have delegated a physician or physician group to admit their patients to the hospital may request active status.

SECTION 3 - THE SENIOR ACTIVE MEDICAL STAFF