Medical Staff Documents:
By-Laws of the Medical and Dental Staff of Kaleida Health

Table of Contents

ARTICLE 1. DEFINITIONS.

1.1. "Board of Directors" or "Board" shall mean the Board of Directors of KALEIDA Health.

1.2. "By-Laws" shall mean the By-Laws of the Medical and Dental Staff of KALEIDA Health.

1.3. "KALEIDA Health" is the name of a domestic not-for-profit corporation licensed as a hospital under Article 28 of the Public Health Law.

1.4. "Chief Executive Officer" shall mean the Chief Executive Officer of KALEIDA Health.

1.5 "Chief Medical Officer" shall mean the Executive Vice President for Medical Affairs and Chief Medical Officer of KALEIDA Health.

1.6. "Clinical Director" shall mean the leader of a Staff Clinical Service whose responsibilities include the clinical directorship of the Clinical Service and such other duties or responsibilities as are specified in the By-Laws and the Rules and Regulations and Policies of the Staff.

1.7. "Fair Hearing Procedure" shall mean the procedures set forth in Article 12 of the By-Laws.

1.8. "Hospital" shall refer to all hospitals, as defined in the New York State Public Health Law, including for example, general hospitals, long-term care facilities and diagnostic and treatment centers, operated solely by KALEIDA Health.

1.9. "Medical Executive Committee" shall mean the Executive Committee of the Medical and Dental Staff.

1.10. "Member" shall mean a physician, dentist, podiatrist or other individual who has been duly appointed to the Staff.

1.11. "NYCRR" shall mean the Official Compilation of Codes, Rules and Regulations of the State of New York.

1.12. "Physician" shall mean a doctor of medicine or a doctor of osteopathy.

1.13. "Policies" shall mean the Health Professional Affiliate Policy, and such other policies as may be adopted by the Medical Executive Committee and approved by the Board of Directors pursuant to Article 10 of the By-Laws.

1.14. "Rules and Regulations" shall mean the Rules and Regulations of the Medical and Dental Staff of KALEIDA Health which are adopted by the Medical Executive Committee and approved by the Board of Directors pursuant to the provisions of Article 10 of the By-Laws.

1.15. "Staff" shall mean the Medical and Dental Staff of KALEIDA Health.

1.16. "University" shall mean the State University of New York at Buffalo School of Medicine and Biomedical Sciences and School of Dental Medicine.

ARTICLE 2. MEMBERSHIP.

2.1. Nature of Staff Membership. Membership on the Staff is a privilege which will be conferred by the Board after receipt of the Medical Executive Committee’s recommendation, only upon professionally competent physicians, dentists, podiatrists, and other specified individuals, who continuously meet the qualifications, standards, and requirements set forth in the By-Laws, Rules and Regulations, and Policies of the Staff and KALEIDA Health, consistent with the needs of KALEIDA Health and its patients. Appointment to the Staff does not in itself confer clinical privileges. Both Staff Membership and specific clinical privileges are subject to approval by the Board of Directors in accordance with the by-laws. The by-laws, Rules and Regulations and Policies of the Staff do not create any contractual right on the part of a Member of the Staff in relationship to KALEIDA Health.

2.2. Qualifications and Criteria for Membership.

2.2.1. Only physicians, dentists, podiatrists and other specified individuals holding a license to practice in the State of New York who can sufficiently document their background, experience, training, physical and mental ability, present appropriate evidence of good judgment, individual character, clinical competence, adherence to the ethics of their profession, and ability to work with others to assure the Staff and the Board of Directors that any patient treated by them will receive care of a quality acceptable to the Hospital, shall be qualified for membership on the Staff. No individual is entitled to membership on the Staff or to the exercise of particular clinical privileges merely by virtue of licensure to practice in this or any other State or of Staff membership and/or privileges at another health care facility, or of membership in any professional organization.

2.2.2. Satisfactory completion of residency training requirements in a recognized training program approved by the Accreditation Council for Graduate Medical Education (ACGME), the American Osteopathic Association (AOA), the American Podiatric Medical Association (APMA) or the American Dental Association is required for physicians, podiatric surgeons and dental specialists (including oral surgeons).

2.2.3. Applicants for membership on the Staff must agree to accept the responsibilities of membership as set forth in the By-Laws, Rules and Regulations, and Policies of the Staff and KALEIDA Health.

2.3. Responsibilities of Staff Membership. Every Member of the Staff will:

a. Provide his or her patient with continuous and appropriate care; arrange for suitable alternative coverage for his or her patients by a Member of the Staff when necessary; seek consultation when necessary or required by the rules of the Hospital or Clinical Service; and supervise the work of any Health Professional Affiliate under his or her direction.

b. Abide by the By-Laws, Rules and Regulations, Policies, and lawful standards of the Staff and KALEIDA Health.

c. Accept assignments relating to Staff and Hospital activities and functions and conscientiously discharge any and all Staff, Clinical Service, committee, and Hospital functions for which he or she is responsible by virtue of appointment, election, or otherwise.

d. Assist the Hospital in fulfilling its mission and responsibility to provide emergency and uncompensated care.

e. Act in a lawful, ethical and professional manner, including adherence to the ethical standards and principles set forth in the Codes of Ethics and Principles adopted by his or her profession or specialty and the laws of the State of New York and the United States of America.

2.4. Nondiscrimination. Staff membership or particular clinical privileges shall not be denied on the basis of age, sex, sexual orientation, race, color, creed, national origin, a disability unrelated to the ability to fulfill patient care and Staff responsibilities or any other criterion unrelated to the efficient delivery of quality patient care, to professional qualifications or to the needs of the community or to the purposes, needs, and capabilities of KALEIDA Health.

2.5. Exemption from Liability. No Member of the Staff will incur any liability to KALEIDA Health for informing a patient that he or she refuses to give advice with respect to, or participate in, any induced termination of pregnancy.

2.6. Application and Approval Process. The form, content and method of processing applications for appointment and reappointment to the Staff and requests for clinical privileges shall be prescribed in Article 5 of the By-Laws.

2.7. Duration of Appointment. Initial appointment to the Staff shall be to the Associate Staff and shall be provisional and for a period of not more than two years. Reappointment to any category of the Staff shall be for a period of not more than two (2) years.

2.8. Waiver of Qualifications. Any qualification for Staff membership may be waived at the discretion of the Medical Executive Committee upon consultation with the appropriate Clinical Director and with the approval of the Board of Directors upon determination that such waiver shall serve the best interests of the KALEIDA Health and its patients.

2.9. Leave of Absence from Staff Membership.

2.9.1. Procedure. A Staff Member may request a leave of absence for a period not to exceed two (2) years, by written application stating the purpose of the request, accompanied by the written recommendation of the Clinical Director, to the Medical Executive Committee which will promptly notify the Board of Directors of its action on the request. Extension of a leave of absence shall be requested in the same manner. A Staff Member will not be required to pay dues during an approved leave of absence.

2.9.2. Reinstatement. A Staff Member may be reinstated as follows:

a. The Staff Member shall request reinstatement of membership in the following manner: (i) if the period of absence did not exceed the unexpired duration of the Member’s term of appointment, by forwarding a request on the prescribed re-instatement application form approved by the Medical Executive Committee, accompanied by written recommendation of the Clinical Director, to the Medical Executive Committee which will promptly notify the Board of Directors of its action on the request; or (ii) if the period of absence exceeded the unexpired duration of the Member’s term of appointment, by applying for reappointment to the Staff.

b. Provided that the proper request for reinstatement has been made pursuant to the By-Laws, denial of a request for reinstatement will be considered an adverse action and will afford the Member the procedural rights set forth in the Fair Hearing Procedure.

ARTICLE 3. CATEGORIES OF STAFF; HEALTH PROFESSIONAL AFFILIATES; AND OTHERS.

3.1. Categories. The Staff shall consist of an Active Staff, Associate Staff, and Emeritus Staff.

3.1.1. Active Staff.

3.1.1.1. Qualifications. The Active Staff shall consist of Staff Members who have completed at least two (2) years of satisfactory performance as an Associate Staff Member and who actively and regularly participate in patient care at KALEIDA Health (or one of its predecessor hospitals), or other activities of KALEIDA Health.

3.1.1.2. Prerogatives. An Active Staff Member may admit patients to the Hospital and exercise such privileges as are granted pursuant to the By-Laws. Active Staff are eligible to vote on all matters presented at general and special meetings of the Staff and of the Clinical Services and committees to which they are appointed. Except as otherwise provided in the By-Laws, an Active Staff Member is eligible to hold Staff office.

3.1.1.3. Responsibilities. Each Member of the Active Staff shall actively participate, if requested, in patient care reviews, monitoring new appointees to the Staff, and other quality management activities, and in discharging other Staff functions as may be required from time to time. Active Staff shall pay any dues assessed by the Staff, serve, if asked, as a member of a Staff committee, and attend Clinical Service meetings as required by the By-Laws, Rules and Regulations, and Policies of the Staff.

3.1.2. Associate Staff.

3.1.2.1. Qualifications. Associate Staff shall consist of Staff Members who do not possess the eligibility requirements for the Active Staff. An Associate Staff Member who is otherwise qualified to be an Active Staff member and who is involved in more than twenty (20) patient contacts, defined as admissions, patient evaluations, or procedures at the Hospital per year, must apply for membership on the Active Staff at the end of the Member’s current term of appointment.

3.1.2.2. Prerogatives. An Associate Staff Member may exercise such privileges as are requested and granted pursuant to the By-Laws. Associate Staff may attend Staff and Clinical Service meetings, but are not eligible to vote or to hold Staff office.

3.1.2.3. Responsibilities. Each Member of the Associate Staff shall discharge the basic responsibilities of membership on the Staff, pay any dues assessed by the Staff, participate, if asked, as a member of a Staff committee, and, if required, attend Clinical Service meetings.

3.1.3. Emeritus Staff.

3.1.3.1. Qualifications. Emeritus Staff membership shall be conferred by the Board upon individuals who are recognized and recommended by the Medical Executive Committee for their outstanding reputations, their distinguished contributions to the health and medical sciences and/or their previous long-standing exemplary service to the Staff.

3.1.3.2. Prerogatives. Unless otherwise determined by the Medical Executive Committee, an Emeritus Staff Member is not eligible to admit patients to the Hospital or to exercise clinical privileges in the Hospital. Emeritus Staff may attend Staff and Clinical Service meetings, but are not eligible to vote or to hold a Staff office and are not required to attend meetings or to pay dues or assessments.

3.2. Health Professional Affiliates. A Health Professional Affiliate is an individual, not a Member of the Staff, who is trained in some aspect of health care and who may be allowed pursuant to contract, employment, or otherwise, to perform specified services to patients. Recognizing the responsibility of the Staff to monitor and account to the Board for the quality of patient care services at the Hospital, the Medical Executive Committee shall recommend to the Board, for its approval, a Health Professional Affiliate Policy which will identify: (i) categories of Health Professional Affiliates who may perform patient care services; (ii) the criteria and procedures to be utilized in authorizing Health Professional Affiliates to perform patient care services; (iii) the responsibilities and prerogatives of Health Professional Affiliates; (iv) the criteria and procedures for taking disciplinary action against Health Professional Affiliates; and (v) the procedural rights of Health Professional Affiliates restricted against whom disciplinary action has been taken. No Health Professional Affiliate shall be permitted to independently perform patient care services in the Hospital except as authorized by the Health Professional Affiliate Policy.

3.3. Medical Administrative Positions. The Board of Directors may appoint a physician, dentist, or podiatrist to an administrative position at a Hospital. Clinical privileges may be exercised by such an administrative appointee only if such privileges are granted upon application for Staff Membership and privileges in accordance with the By-Laws. Removal from such medical administrative position shall not result in rights to hearing or appeal under the Fair Hearing Procedure unless so stated in a written agreement governing the relationship.

3.4. Residents and Fellows. Residents and fellows who have not been appointed to the Staff pursuant to the provisions of the By-Laws shall not be considered Members of the Staff and their rights and obligations shall be governed by the statutes and regulations of New York State and, as appropriate, the Graduate Medical and Dental Education Consortium Agreement.

3.5. Organ Procurement Practitioner. Practitioners from outside organ procurement organizations designated by the Administrator of the Health Care Financing Administration, U.S. Department of Health and Human Services, engaged solely in the harvesting of tissues and/or other body parts for transplantation, therapy, research or educational purposes pursuant to the Federal Anatomical Gift Act and the requirements of Section 405.25 of Title 10 of NYCRR, shall be exempt from the requirement to obtain Staff privileges.

ARTICLE 4. Rights of Members.

4.1. Each Staff Member has the right to request a meeting with the Medical Executive Committee by sending a written notice to the Medical Executive Committee requesting the meeting and stating the reason for the request. The Medical Executive Committee shall respond to such a request within ten (10) days following the next regularly scheduled meeting of the Medical Executive Committee. Prior to making such a request, the Member shall meet with his/her Clinical Director in an attempt to resolve the pertinent issues.

4.2. Any Member with voting rights has the right to initiate a recall election of a Medical Staff officer by submitting a petition to the Medical Executive Committee signed by at least 20% of the Members of the Active Staff. Upon presentation of such a petition, the Medical Executive Committee will schedule a special Staff meeting for purposes of discussing the issue and (if appropriate) entertain a motion to recall the officer, which shall be effective only upon the affirmative vote of two-thirds of the voting Members present or participating by teleconference.

4.3. Any Member with voting rights may initiate the scheduling of a special Staff meeting. Upon presentation of a petition signed by at least 5% of the Members of the Active Staff, the Medical Executive Committee will schedule a special Staff meeting for the specific purpose addressed by the petition. No business other than as stated in the petition may be transacted.

4.4. An applicant or Staff Member, as appropriate, has the right to a hearing/appeal pursuant to the Fair Hearing Procedure, subject to the provisions, limitations and exceptions set forth in the By-Laws, Rules and Regulations and Policies of the Staff, in the event any of the following actions are taken or recommended:

a. Denial of initial Staff appointment;
b. Denial of reappointment to the Staff;
c. Denial, upon application for reappointment, of requested appointment to Active Staff status;
d. Denial of reinstatement as a Staff Member;
e. Revocation of Staff appointment;
f. Denial or restriction of requested privileges;
g. Involuntary reduction or limitation of privileges;
h. Revocation of privileges;
i. Suspension of Staff appointment or privileges.

ARTICLE 5. APPOINTMENT AND REAPPOINTMENT PROCEDURE

5.1. General Procedure. This procedure shall apply to all: (a) applications for appointment and reappointment to the Staff; (b) requests for reinstatement after a leave of absence from the Staff; and (c) requests for privileges.

5.2. Application for Initial Appointment and Reappointment. Each application for appointment or reappointment to the Staff shall be in writing and submitted on the prescribed form as established by the Medical Executive Committee and approved by the Board of Directors. Each application shall include at least the following information:

a. Nature of request
b. Qualifications, including licensure, education and training
c. Experience, including present and prior affiliations
d. Requested delineation of privileges and supporting documentation
e. Documentation of current health status and any additional training as required by New York State and other regulatory agencies
f. Professional Liability coverage and detailed professional liability history
g. Professional sanctions, misconduct proceedings, and criminal actions
h. Peer references (as applicable)
i. Acknowledgment, agreement, authorization and verification statements
j. Application process fee (initial appointment only)

5.3. Processing the Application.

5.3.1. Applicant’s Burden. Each applicant will have the burden of producing adequate information for complete evaluation of his or her application.

5.3.2. Verification of Information. The applicant will deliver a completed application to the Staff Office. Staff administrators will, in timely fashion, seek to verify information from the primary source, whenever feasible and required, and will request information from the National Practitioner Data Bank. The Staff Office will promptly notify an applicant of any problems in obtaining required information. When the collection and verification process is complete, the Staff Office shall submit the application and supporting materials to the Clinical Director for review and recommendation.

5.3.3. Clinical Director Action. The appropriate Clinical Director shall submit his or her written recommendation and the reasons for that recommendation to the Credentials Committee.

5.3.4. Credentials Committee Action. The Credentials Committee will review the application, supporting documentation, Clinical Director recommendation, and any other relevant information. The Credentials Committee will then submit a written recommendation and the reasons for that recommendation regarding Staff appointment, assignment to an appropriate Clinical Service, privileges, and any special conditions to the Medical Executive Committee.

5.3.5. Medical Executive Committee Action. The Medical Executive Committee will consider the Credentials Committee’s recommendation and such other information available to it and will submit its recommendation, if favorable to the applicant, and reasons for the favorable recommendation in writing to the Board of Directors. If the Medical Executive Committee’s recommendation is an Adverse Action (as defined in Artile 12 of these By-Laws), a Notice of Reasonable Cause shall be sent to the applicant in accordance with the Fair Hearing Procedure.

5.3.6. Action by Board of Directors. The Board of Directors shall consider the Medical Executive Committee’s favorable recommendation and take such action as it deems appropriate. Written notice of the final decision of the Board of Directors regarding assignment to an appropriate Clinical Service, delineation of privileges granted, and any special conditions attached to the appointment shall be forwarded to the applicant. If the Board action is an Adverse Action as defined in Article 12 of these By-Laws, a Notice of Reasonable Cause shall be sent to the applicant in accordance with the Fair Hearing Procedure.

5.4. Expedited Process. Completed applications that meet expedited process criteria as established by the Medical Executive Committee may be processed in an expedited manner. Each applicant retains the burden of producing adequate information as set forth in Section 5.3.1 above, and all information will be verified as set forth in Section 5.3.2 and submitted to the Clinical Service for review and recommendation. After Clinical Service review, applications that continue to meet expedited process criteria may be recommended for appointment, reappointment and/or privileges by the President of the Staff to the Board of Directors. A report will be sent to the Medical Executive Committee regarding all such actions.

5.5. Time Periods for Processing Application. Upon receipt of a completed application, the review and appointment process shall not exceed 180 days, except for good cause. The process is illustrated in a flow chart attached to this Article as Figure 1. (In the case of an inconsistency between the flow chart and the written By-Laws, the written By-Laws shall govern.)

5.6 Length of Appointment/Reappointment. Initial appointment will be provisional and will be for no more than two years. Reappointment will be for no more than two years and will occur during the month of the applicant’s birthdate.

5.7. Emergency Privileges. In the case of an emergency, any practitioner, to the degree permitted by his or her license, and regardless of Clinical Service or Staff status or privileges, will be permitted to do, and will be assisted by Hospital personnel in doing, everything possible to save the life of a patient or to save a patient from serious harm. For the purposes of this section, an emergency is defined as a condition in which serious or permanent harm could result to a patient, or in which the life of a patient is in immediate danger and any delay in administering treatment, could add to that harm or danger.

5.8. Limited Privileges. Limited privileges may be granted upon receipt of a request by an appropriately licensed practitioner for privileges for the care of one or more specific patients. Such privileges will be granted upon the written concurrence of the appropriate Clinical Service, the President of the Staff and the Chief Medical Officer, who shall review and consider the clinical competency of the applicant. The applicant shall also be required to submit satisfactory evidence of licensure and current registration and adequate professional liability insurance coverage. A denial of a request for limited clinical privileges or the revocation or termination of limited privileges shall not give the applicant any procedural or substantive rights to a hearing or review under the Fair Hearing Procedure.

ARTICLE 6. OFFICERS.

6.1. Identification. The Officers of the Staff will be the President, President Elect, Secretary and Treasurer.

6.2. Qualifications of Officers. Officers must be Members of the Active Staff at the time of nomination and election and must remain so in good standing during their terms of office.

6.3. Nomination and Election of Officers.

6.3.1. Nomination Process. At least three (3) months prior to an election, the Medical Executive Committee, upon recommendation of the President of the Staff, shall appoint a Nominating Committee to identify and recommend to the Staff, qualified individuals to nominate for service as Officers and at-large members of the Medical Executive Committee.

6.3.1.1. Nominating Committee. The Nominating Committee shall consist of at least five (5) Members of the Active Staff. Additional qualifications for members of the Nominating Committee may be established by the Medical Executive Committee. The Nominating Committee shall offer one or more nominees for each of the offices of President Elect, Secretary and Treasurer and two or more nominees for each position of at-large member of the Medical Executive Committee to be filled, and shall publish the names of nominees at least twenty (20) days before written ballots are mailed to the Members of the Active Staff. At least forty-five (45) days prior to publishing the names of nominees, the Nominating Committee shall receive the names of the Clinical Directors selected to serve on the Medical Executive Committee pursuant to Section 8.1.1.1. The Nominating Committee shall also provide advice and recommendations to the President of the Staff with respect to his or her appointment of members of the Credentials Committee.

6.3.2. Election. Officers and at-large members of the Medical Executive Committee shall be elected by the Members of the Active Staff. Voting shall be conducted by written ballot by mail pursuant to procedures adopted by the Medical Executive Committee. Write-in nominees shall be permitted. A nominee will be elected to office upon receiving a plurality of the valid votes cast.

6.4. Term of Office. Each Officer will serve a term of two (2) years and no Member may serve more than two (2) consecutive terms in a particular office. Each Officer will serve until the end of his or her term and until a successor is elected. The President Elect will automatically become President.

6.5. Vacancies. Vacancies in office other than the President shall be filled by the Medical Executive Committee from one or more nominees selected by the Nominating Committee. If there is a vacancy in the office of President, the President Elect will serve the remainder of the term.

6.6. Duties.

6.6.1. President. The President shall serve as the chief administrative officer of the Staff and will perform the following duties:

a. Serve as a member of the Board of Directors and represent the Staff through attendance and voice at meetings of the Board.

b. Serve as a voting member of the Medical Executive Committee, preside at all meetings of the Staff and of the Medical Executive Committee and schedule Special Meetings of the Staff and the Medical Executive Committee, as necessary.

c. Appoint the membership of committees of the Staff other than the Medical Executive Committee and serve as ex officio member of all Staff committees.

d. Enforce the By-Laws, Rules and Regulations and Policies of the Staff.

e. Receive and communicate the policies of the Board of Directors to the Staff.

f. Report to the Staff at the annual meeting of the Staff and as necessary on the status of Staff activities and issues.

g. Communicate and present the opinions, policies, concerns and needs of the Staff to the Board.

6.6.2. President Elect. The President Elect will be a voting member of the Medical Executive Committee and in the absence of the President, will assume the duties and have the authority of the President. The President Elect shall perform such additional duties as the Medical Executive Committee or President shall assign.

6.6.3. Secretary. The Secretary will be a voting member of the Medical Executive Committee and will perform the following duties:

a. Prepare accurate and complete minutes of meetings of the Staff and the Medical Executive Committee.

b. Attend to all correspondence of the Staff and the Medical Executive Committee and maintain adequate records, correspondence, reports, minutes and related documents of the Staff and its committees.

c. Give proper notice of all Staff meetings.

d. Maintain a correct list of all Staff Members.

6.6.4 Treasurer. The Treasurer will be a voting member of the Medical Executive Committee and will perform the following duties:

a. Collect annual dues and special assessments as authorized by the Staff.

b. Pay all bills and invoices properly incurred by the Staff and maintain adequate books and records of all financial transactions of the Staff.

c. Present an audit of the funds of the Staff at the annual meeting of the Staff.

6.7. Removal from Office.

6.7.1. Grounds. Removal of an Officer shall be for any one (1) or more of the following reasons, without limitation:

a. Failure to perform the duties or fulfill the responsibilities assigned to the office in a timely and appropriate manner;

b. Failure to continuously satisfy the qualifications of the office;

c. Incapacity by reason of physical or mental infirmity;

d. Conducting oneself in a manner which is damaging to the best interests of the Staff or KALEIDA Health or their respective goals, programs or public image.

6.7.2. Procedure. A Staff Officer may be removed by:

a. The Staff through a two-thirds (2/3) majority vote by secret ballot of those present, or participating by teleconference, at a meeting of the Staff called for that purpose; or

b. The Board, but only after the Board has referred the matter to a special committee and received that committee’s report recommending removal of the Staff Officer. The special committee shall be composed of the Medical Director and three (3) representatives each of the Board and the Staff. The representatives of the Board shall be chosen by the Chair of the Board and the representatives of the Staff shall be chosen by the Medical Executive Committee.

ARTICLE 7. CLINICAL SERVICES

7.1. Organization of Staff. The Staff shall be organized into Clinical Services which will each be directed by a Clinical Director who shall be responsible to the Medical Executive Committee and Board of Directors for the general supervision of clinical practice and teaching activities within the Clinical Service. Each Member of the Staff will be assigned membership in at least one Clinical Service, but may be granted membership and clinical privileges in more than one Clinical Service. The exercise of clinical privileges within the Clinical Service shall be subject to the rules and regulations of that Clinical Service and to the authority of the Clinical Director, as provided in the By-Laws.

7.2. Delineation of Clinical Services. The Staff shall be divided into the following Clinical Services:

Anesthesiology
Dentistry
Dermatology
Emergency Medicine
Family Medicine
Gynecology and Obstetrics
Internal Medicine
Neurology
Neurosurgery
Nuclear Medicine
Ophthalmology
Oral and Maxillofacial Surgery
Orthopedics
Otolaryngology
Pathology
Pediatric Dentistry
Pediatric Surgical Services (Cardiovascular, General, Neurosurgery,
   Ophthalmology, Orthopedics, Otolaryngology, Plastic and Urology)
Pediatrics
Psychiatry and Behavioral Medicine
Radiation Oncology
Radiology
Rehabilitation Medicine
Surgery
Thoracic/Cardiovascular Surgery
Urology

7.3. Responsibilities of the Clinical Services.

The primary responsibility delegated to each Clinical Service is to review and evaluate the provision of patient care in order to preserve and continuously improve the quality and efficiency of patient care provided in the Clinical Service. To carry out this responsibility, each Clinical Service will: (a) account to the Medical Executive Committee for all professional and administrative activities of the Clinical Service; (b) formulate and recommend guidelines and criteria for the granting of clinical privileges within the Clinical Service to the Credentials Committee; (c) submit recommendations pursuant to the By-Laws, regarding the specific privileges each Staff Member or applicant may exercise; (d) conduct continuing review of the clinical care and professional performance of all Members of the Clinical Service and Health Professional Affiliates having privileges in the Clinical Service; (e) formulate rules, regulations, policies and procedures regarding the operations and membership of the Clinical Service, subject to approval by the Medical Executive Committee and the Board of Directors; (f) encourage and supervise teaching and research programs; (g) meet, as often as necessary, to provide a forum for discussion of the needs and concerns of the Members of the Clinical Service.

7.4. Clinical Directors.

7.4.1. Qualifications. Each Clinical Director shall be a Member of the Active Staff, willing and able to discharge the functions of the office, and shall either be certified by an appropriate specialty board or possess equivalent qualifications as determined by the Medical Executive Committee.

7.4.2. Selection and Appointment. A Clinical Director shall be selected and appointed for each Clinical Service by the Board of Directors with advice from the Medical Executive Committee pursuant to the procedures set forth in this Section and shall serve until such time as a successor Clinical Director is appointed.

7.4.2.1. Selection Committee. A Selection Committee composed of the Chief Medical Officer, the President of the Staff and the Chief Executive Officer shall supervise and facilitate the nomination for appointment of Clinical Directors, and the evaluation of Clinical Directors for reappointment. The Selection Committee shall appoint a search committee to nominate candidates for appointment to the position of Clinical Director. Each search committee shall include Members of the respective Clinical Service, Members of other Clinical Services, the Dean of the School of Medicine and Biomedical Sciences or the School of Dental Medicine, or his or her designee, as applicable, and other University representatives, as appropriate.

7.4.2.2. Selection Committee Action. The Selection Committee shall review the qualifications of the candidates, the recommendations of any search committee, and any other recommendations solicited by the Selection Committee, including input from the Clinical Service pursuant to Section 7.4.2.3., and shall transmit the name of its nominee for appointment to the Medical Executive Committee with such comments and/or recommendations as the Selection Committee deems appropriate.

7.4.2.3. Clinical Service Action. The Clinical Service shall receive and review the nomination for Clinical Director from the Selection Committee and shall transmit its comments and confirmation of its concurrence and, if it does not concur, its reasons and recommendations to the Selection Committee before the Selection Committee transmits its recommendation for appointment to the Medical Executive Committee.

7.4.2.4. Medical Executive Committee Action. The Medical Executive Committee shall receive and review the nomination for Clinical Director from the Selection Committee and shall transmit its comments and confirmation of its concurrence and, if it does not concur, its reasons and recommendations to the Selection Committee, prior to the final recommendation for appointment by the Chief Executive Officer to the Board of Directors.

7.4.2.5. Board Action. The Board of Directors shall appoint the Clinical Director upon consideration of the recommendation of the Chief Executive Officer.

7.4.3. Duties and Responsibilities. The Clinical Director is responsible for the following duties and responsibilities to be performed in accordance with the By-Laws, Rules and Regulations and Policies of the Staff:

a. all clinical and administrative activities of the Clinical Service;
b. the integration and coordination of programs with the other Clinical Services and with KALEIDA Health.
c. the development and implementation of policies and procedures that guide and support the provision of care;
d. continuing surveillance of the professional performance of all individuals who have delineated clinical privileges in the Clinical Service;
e. recommending to the Credentials Committee the criteria for granting clinical privileges in the Clinical Service;
f. submitting recommendations concerning clinical privileges for each Member or applicant;
g. determining the qualifications and competence of personnel who are not licensed independent practitioners and who provide patient care services;
h. continuously assessing and improving the quality of care and services provided and maintaining quality control programs, as appropriate;
i. providing for the orientation and continuing education of all persons in the Clinical Service; and
j. making recommendations for space and other resources, including personnel, needed by the Clinical Service and assessing and recommending off-site sources for necessary patient care services, and
k. encouraging and facilitating the establishment of educational and research programs and the participation of Members of the Clinical Service in such programs.

7.4.4. Review of Clinical Director. Each Clinical Director shall be subject to reappointment based upon an evaluation of his or her performance in carrying out the duties and responsibilities of the position. The Selection Committee described in Section 7.4.2.1. shall organize and conduct a review of the performance of an incumbent Clinical Director prior to the conclusion of his or her term. In formulating its recommendation concerning reappointment of the Clinical Director, the Selection Committee shall request advice from the Dean, School of Medicine and Biomedical Sciences or School of Dental Medicine, and the Chair of the relevant Clinical Department at the State University of New York at Buffalo and shall consult with Members of the Clinical Service. The Selection Committee shall act in accordance with Section 7.4.2.2. and shall transmit its recommendation on reappointment of a Clinical Director to the Medical Executive Committee, which shall act in accordance with Section 7.4.2.4. and a Clinical Director shall be reappointed by the Board of Directors pursuant to the procedure set forth in Section 7.4.2.5. for a three year term.

7.4.4.1. Special Review. The President of the Staff, the Chief Executive Officer, the Chief Medical Officer, a majority of the Medical Executive Committee, or a majority of the Members of the Active Staff in the relevant Clinical Service may, for good cause, request that the Board of Directors review a Clinical Director prior to the expiration of his or her term of appointment. Any such request must be in writing and supported by reference to the specific activities or conduct which constitutes the grounds for the request. A copy of the request shall be sent to the Clinical Director and to the President of the Staff or the Chief Executive Officer, who shall request a special review for administrative reasons by the Selection Committee. The Selection Committee shall formulate a recommendation which will be reviewed with the Medical Executive Committee which, in turn, will confirm its concurrence and, if it does not concur, its reasons and recommendations concerning the Clinical Director under review. After consideration of the Medical Executive Committee’s reasons and recommendations, the Selection Committee shall make a final recommendation to the Chief Executive Officer who shall, in turn, make a recommendation to the Board of Directors which shall take such action as it deems appropriate.

7.4.5 Vacancies. In the event of a vacancy in the position of Clinical Director for a Clinical Service, an Interim Director shall be designated by the Chief Medical Officer with advice from the President of the Staff and the Chief Executive Officer to perform the duties and responsibilities of the Clinical Director until such time as a Clinical Director is selected and appointed pursuant to Section 7.4.2

ARTICLE 8. COMMITTEES.

8.1. Medical Executive Committee.

8.1.1. Composition and Selection.

8.1.1.1. Voting Members. The Medical Executive Committee shall have twenty-one (21) voting members consisting of the following:

a. each of the Officers of the Staff;
b. eight (8) Clinical Directors elected by the Clinical Directors' Committee composed of the Clinical Directors of all of the Clinical Services; and
c. nine (9) at-large members elected by the Staff.

8.1.1.2. Non-voting Members. The Chief Executive Officer, the Chief Medical Officer, the Vice President-Corporate Nursing, the immediate past President of the Staff, the Dean of the School of Medicine and Biomedical Sciences, the Dean of the School of Dental Medicine and the Vice President for Health Sciences for the State University of New York at Buffalo shall be non-voting ex officio members of the Medical Executive Committee. In addition, until such time as the Medical Executive Committee shall determine otherwise, the Chair or his designee, of each Medical Executive Committee Advisory Committee shall be a non-voting member of the Medical Executive Committee.

8.1.2 Term. Each voting member of the Medical Executive Committee shall serve a term of two (2) years, except that in the first election of at-large members by the Staff, the terms of four (4) of the initial nine (9) at-large members shall be three (3) years and the terms of the remaining five (5) at-large members shall be two (2) years. Each at-large member shall serve until the end of his or her term and until a successor is chosen and shall serve no more than two (2) consecutive terms.

8.1.3. Vacancies. A vacancy in the position of an at-large member of the Medical Executive Committee shall be filled by the Medical Executive Committee from one or more nominees selected by the Nominating Committee. A vacancy in the position of a member of the Medical Executive Committee elected by the Clinical Directors Committee shall be filled by the Clinical Directors Committee.

8.1.4. Duties. The duties of the Medical Executive Committee shall be to:

a. Act for the Staff in the intervals between Staff meetings and represent the Staff in all matters except as otherwise provided in the By-Laws.

b. Receive and act on reports and recommendations from Staff committees, Clinical Services and special committees.

c. Develop, review, approve and enforce Staff Rules and Regulations, Policies and procedures.

d. Develop, review and recommend to the Staff and to the Board proposals for changes in the By-Laws, Rules and Regulations and Policies of the Staff.

e. Participate with the Board and management in leading ongoing efforts to improve the overall quality and efficiency of patient care in KALEIDA Health and carry out specific regulatory and accreditation requirements pertaining to Staff activities.

f. Take reasonable steps to encourage professionally ethical conduct and competent clinical performance on the part of Staff appointees including initiating investigations and initiating and pursuing corrective action when warranted.

g. Submit recommendations to the Board concerning all matters relating to appointments, re-appointments, privileges and corrective action.

h. Inform the Staff of the results of reviews by accrediting and regulatory agencies.

i. Make recommendations to the Board of Directors on any issue which in the judgment of the Medical Executive Committee impacts on patient care.

j. Make recommendations to the Chief Executive Officer on medical/dental, administrative and planning matters.

k. Act as liaison between the Staff and the CEO and Board of Directors of KALEIDA Health.

l. Conduct such other functions as are necessary for the effective operation of the Staff and to fulfill the Staff’s responsibility to the Board for the medical care of patients in the Hospital.

8.1.5. Issue Resolution. The Medical Executive Committee shall have the right to make recommendations to the Board of Directors on any issue which, in the judgment of the Medical Executive Committee, impacts on patient care. If the Board determines not to follow a recommendation submitted to it by the Medical Executive Committee, the Medical Executive Committee may request a Joint Conference between the officers of the Board and the officers of the Staff to discuss the issue. The Joint Conference shall be scheduled by the Chief Executive Officer within two weeks after receipt of a request for such a conference from the President of the Staff.

8.1.6. Meetings. The Medical Executive Committee shall meet monthly and at such others times as necessary to perform its functions and shall maintain a permanent record of its proceedings and actions. Special Meetings of the Medical Executive Committee may be called at any time by the President of the Staff. Written notice of a Special Meeting shall not be necessary but the President shall endeavor to give reasonable notice under the circumstances to each Member of the Committee. The presence of a majority of the voting members of the Medical Executive Committee at any regular or special meeting will constitute a quorum for the transaction of business. All members are required to attend at least seventy-five (75%) percent of the Medical Executive Committee meetings during the year. Failure to meet mandatory attendance requirements may be the basis for removal from the Committee.

8.1.7. MEC Advisory Committees. MEC Advisory Committees shall serve to facilitate communication and the exchange of information between the Medical Executive Committee and Staff at the Hospital sites. The number of MEC Advisory Committees, the size of each Committee, and the specific charge and responsibilities of the MEC Advisory Committees shall be determined by the Medical Executive Committee. The members of the MEC Advisory Committees shall be selected by the Staff Members who are active at the respective Hospital sites pursuant to procedures determined by the Medical Executive Committee. The Medical Executive Committee shall invite representatives of the administrative staff of each Hospital to participate as members of the appropriate MEC Advisory Committee.

8.2. Credentials Committee.

8.2.1 Composition and Selection.

8.2.1.1. Voting Members. The Credentials Committee shall consist of fourteen (14) voting members who shall be Members of the Staff but not Clinical Directors. The President of the Staff shall appoint the voting members of the Committee with input from the Nominating Committee and shall designate the voting member who shall act as Chair of the Committee. A voting member shall not participate in any discussion by the Committee and shall not vote on any matter before the Credentials Committee which involves a Staff Member or applicant with whom the voting member, (i) is in direct economic competition, or, (ii) has a direct economic interest .

8.2.1.2. Non-voting Members. The President of the Staff or his or her designee, the Chief Executive Officer, or his or her designee, the Chief Medical Officer and two (2) members of the Board of Directors shall be non-voting ex officio members of the Credentials Committee. The Chair of the Board shall appoint the Board members of the Committee.

8.2.2. Term. Each member of the Credentials Committee shall be appointed for a term of two (2) years.

8.2.3. Duties. The duties of the Credentials Committee shall include the following duties:

a. To evaluate the qualifications of individuals applying for appointment or re-appointment to the Staff and privileges;

b. To integrate quality review, risk management, and utilization review, findings and information into the process used to evaluate appointment and re-appointment applications and grant privileges;

c. To make recommendations to the Medical Executive Committee as to the granting or denial of applications for appointment, re-appointment and privileges pursuant to the provisions of the Appointment and Reappointment Procedure;

d. To periodically review the Appointment and Reappointment Procedure and make recommendations about the credentialing process, including but not limited to the criteria, procedures and forms used in the application and credentialing process;

e. To recommend standards for maintenance of a credentials file for each Staff Member;

f. To recommend, review and implement, as appropriate, the Health Professional Affiliate Policy; and

g. To perform such other duties as may be assigned to it by the Medical Executive Committee.

8.2.4 Meetings. The Credentials Committee shall meet monthly and a copy of the minutes of each meeting shall be submitted to the Medical Executive Committee.

8.3 Other Committees. In addition to any committees specifically described in the By-Laws, the Medical Executive Committee may create and appoint standing committees and/or special committees or task forces. The size of each committee shall be determined by the Medical Executive Committee, provided that each committee shall have at least three (3) members.

8.3.1. Standing Committees. Standing committees shall be appointed by the Medical Executive Committee to fulfill continuous or regularly recurring functions of the Staff and the Medical Executive Committee. Members of standing committees shall serve for a term of two (2) years and until their successors are appointed.

8.3.2. Special Committees. Special committees shall be appointed by the Medical Executive Committee to fulfill special tasks as circumstances warrant. A special committee shall limit its activities to the accomplishment of the task for which it was formed, and it shall stand discharged upon the completion of such task.

8.3.3 Meetings. Each standing and special committee shall meet with such frequency as may be prescribed by the Medical Executive Committee, and at such additional times as the particular Committee Chair may determine. Unless otherwise specified, a majority of the Committee Members shall be considered a quorum, and a vote by a majority of the Members present at a duly-organized Committee meeting shall be the act of the Committee. Each Committee shall submit minutes of its proceedings to the Medical Executive Committee.

ARTICLE 9. STAFF MEETINGS AND PROCEDURES.

9.1. Meetings.

9.1.1. Regular Meetings. Regular meetings of the Staff shall be held no less than two times per year at a time and place specified by the President with written notice to all Members at least ten (10) days prior to the date of the meeting. The first meeting of the year will be the annual meeting of the Staff.

9.1.1.1. Order of Business. The agenda at a regular meeting will be determined by the President and shall include, without limitation, the following:

a. Acceptance of the minutes of the last regular and of all special meetings of the Staff and Medical Executive Committee held since the last regular meeting;

b. Administrative reports from the Chief Executive Officer, the President and any communication from the Board of Directors;

c. Unfinished business;

d. New business.

9.1.2. Special Meetings. Special meetings of the Staff may be called at any time by the Chair of the Board of Directors, the President of the Staff, the Medical Executive Committee or as otherwise provided in the By-Laws, and will be held at the time and place designated in the meeting notice. No business will be transacted at any special meeting except that stated in the meeting notice. Notice of a Special Meeting shall be in writing, mailed by regular mail at least five (5) days prior to the date of the meeting.

9.2. Quorum and Attendance Requirement. There shall be no minimum quorum requirement. The business of the Staff may be conducted by vote of the Active Staff. Members of the Staff are encouraged but not required to attend meetings of the Staff.

9.3. Manner of Action. The Staff shall conduct its affairs in accordance with the By-Laws and such Rules and Regulations, Policies and procedures as are adopted in accordance with the By-Laws and the By-Laws of KALEIDA Health. Except as otherwise provided in the By-Laws, the action of a majority of the voting Members present at a meeting of the Staff, shall be the action of the Staff, unless the Medical Executive Committee determines, with respect to a specific matter, that the Staff may act by written ballot and/or may participate in a meeting by teleconference.

9.4. Rules of Procedures. The latest edition of Robert’s Rules of Order shall govern parliamentary procedure in all meetings of the Staff.

9.5. Dues. A schedule of dues and assessments to be collected from each Member as provided in the By-Laws shall be developed by the Medical Executive Committee.


ARTICLE 10. ADOPTION AND AMENDMENT OF BY-LAWS, RULES AND REGULATIONS AND POLICIES.

10.1. Staff Responsibility. The Staff has the responsibility and delegated authority to formulate, review, adopt, and recommend to the Board of Directors, By-Laws and amendments thereof which shall be effective when approved by the Board of Directors. In addition, the Staff will adopt and recommend to the Board of Directors such Rules and Regulations and Policies relating to the proper conduct of its activities and the level of practice required of its Members and other practitioners in the Hospital as may be necessary to implement more specifically the general principles found in the By-Laws. The By-Laws, Rules and Regulations and Policies of the Staff may be amended at any time and will be reviewed by the Staff no less than every two (2) years.

10.2. Adoption and Amendment Procedure. Proposed By-Laws, Rules and Regulations, and Policies or amendments thereof shall be submitted to the Medical Executive Committee for review and discussion. At the discretion of the Medical Executive Committee, the proposed By-Law, Rule and Regulation, Policy or amendment thereof, shall be considered for approval in accordance with the provisions of this Section. The adoption, amendment or repeal of Staff By-Laws, Rules and Regulations and Policies will be accomplished as follows:

a.. Approval of a proposed By-Law or amendment of any Article of the By-Laws shall require the affirmative vote of two-thirds (2/3) of the voting Staff members: (i) present at a meeting of the Staff, provided that a copy of the proposed By-Law or amendment shall be mailed by regular mail to each Member of the Active Staff at least fifteen days prior to the date of the Staff meeting at which the vote is to be taken; or in the alternative, (ii) voting by written ballot in accordance with procedures established by the Medical Executive Committee. Upon adoption by the Staff, a proposed By-Law or amendment thereof, shall be effective upon approval by the Board of Directors

b. Approval of a proposed Rule and Regulation or Policy or amendment thereof, shall require the affirmative vote of two-thirds (2/3) of the voting members of the Medical Executive Committee. Upon adoption by the Medical Executive Committee, a proposed amendment or Rule and Regulation or Policy shall be effective upon approval by the Board of Directors.

ARTICLE 11. CORRECTIVE ACTION.

11.1. Corrective Action. Corrective Action may be taken against a Member of the Staff to maintain the Hospital’s standards of character, competence, and professional conduct. Corrective action shall be defined as:

a. A reprimand or admonition by the Medical Executive Committee; or
b. Adverse action as defined in the Fair Hearing Procedure.

11.2. Procedure.

11.2.1. Informal Resolution. A request for a determination whether corrective action should be taken shall be made to the President or other Officer of the Staff, the Chief Medical Officer, a Clinical Director, the Chief Executive Officer, or the Chair of the Board. Any such person who receives a request for a determination whether corrective action should be taken shall notify the Chief Medical Officer or the Clinical Director of the appropriate Clinical Service with a copy to the Chief Medical Officer, in order to facilitate an informal resolution of the matter without adverse action. The Clinical Director (or the Chief Medical Officer if the Clinical Director is otherwise involved in the matter) shall review the matter and attempt to informally resolve the matter.

11.2.1.1. Upon informal resolution of any matter, a statement concerning the resolution or a copy of the letter resolving the matter shall be promptly sent by the Clinical Director to the Chief Medical Officer and President of the Staff.

11.2.1.2. Neither the pendency of informal discussions nor the agreement on an informal resolution precludes further corrective action.

11.2.1.3. If the matter is not resolved informally within thirty (30) days, the request for a determination whether corrective action should be taken shall be submitted, in writing, to the Medical Executive Committee by the Clinical Director, Chief Medical Officer, President of the Staff or the party making the request.

11.2.2. Action by Medical Executive Committee on Request for Determination. Except as otherwise set forth in Section 11.4.1, within ten (10) days of receipt by the Medical Executive Committee of a request for a determination whether corrective action should be taken against a Member, the President of the Staff shall appoint an ad hoc committee to make such informal inquiry as it deems appropriate, and, within twenty (20) days of appointment, to determine and report to the Medical Executive Committee whether there appears to be reasonable cause for corrective action. The ad hoc committee may interview the Member or any other person with relevant information or expertise. Within thirty (30) days of receipt of the ad hoc committee’s report and recommendation, the Medical Executive Committee shall take one of the following actions:

a. The Medical Executive Committee may determine that there is no reasonable basis for corrective action against the Member and so report to the Board. The Board may accept and approve the determination or reject the determination and decide that there is reasonable cause for adverse action. In such a case, the Chair of the Board shall inform the President of the Staff.

b. The Medical Executive Committee may reprimand or admonish a Member, without adverse action against Membership status or privileges after such informal inquiry as it deems appropriate and provided that the Member has had a reasonable opportunity to be heard.

c. The Medical Executive Committee may determine that there is reasonable cause for adverse action against a Member, that is, that if not explained or rebutted, the facts appear sufficient to form a reasonable basis for adverse action. An adverse action proceeding shall be initiated immediately pursuant to Section 12.4 of the Fair Hearing Procedure.

11.3. Summary Suspension. Whenever immediate action appears advisable in the best interests of patient care in the Hospital, or if a Member is convicted of a felony, any one of the following may summarily suspend a Member or may suspend all or any portion of the clinical privileges of a Member, effective immediately upon imposition:

a. the President of the Staff;
b. the Clinical Director of the Member’s Clinical Service;
c. the Chief Executive Officer of the Hospital (after discussion with an Officer of the Staff);
d. the Chief Medical Officer;
e. the Chair of the Board of Directors.

11.3.1. Notice of Suspension. The person who suspends the Member must promptly notify the Chief Executive Officer, the President of the Staff, the Clinical Director and the Chief Medical Officer. The Chief Executive Officer shall promptly give the suspended Member written notification of the suspension, and the President of the Staff shall promptly convene a meeting of the Medical Executive Committee to review the matter and commence an adverse action proceeding, if appropriate, pursuant to Article 12 of the By-Laws. Pending the adverse action proceeding, the Medical Executive Committee may:

a. recommend the continuation, modification or termination of a summary suspension imposed by the Chair of the Board;
b. continue, modify or terminate a summary suspension imposed by any other person.

11.4. Governmental Action on Credentials.

11.4.1. Upon receipt of notice by the Chief Executive Officer that a Staff Member’s license, certificate, or other legal credential authorizing him or her to practice in this State is suspended with stay, or that he or she has been put on probation, the Chief Executive Officer shall immediately file with the Medical Executive Committee, a request for determination whether corrective action should be taken against the Member. The informal resolution procedure described in Section 11.2.1 shall not be applicable to such a request. Within four weeks of such filing, the Medical Executive Committee shall take action on the request for determination in accordance with the procedures set forth in this Article 11.

11.4.2. Upon receipt of notice by the Chief Executive Officer that a Staff Member’s license, certificate or other legal credential, authorizing him or her to practice in this State, is revoked, or suspended or that the Member is suspended or expelled from participation in the Medicare or Medicaid programs, the Member’s membership on the Staff shall be immediately and automatically revoked and the Member is not entitled to the hearing and appeal procedures set out in the Fair Hearing Procedure.

11.4.3. Revocation or suspension of Drug Enforcement Agency number or other limitation by a State or Federal agency restricting the Member’s legal authority to prescribe controlled substances automatically divests the Member of his right to prescribe medications covered by that number, and may lead to additional restrictions.

11.5. Medical Malpractice Insurance. A Member’s membership on the Staff shall be automatically suspended if the Member fails to maintain professional liability insurance covering the full scope of the Member’s privileges as required by the Board. The suspension may be terminated at such time as the Member is able to present satisfactory proof of such professional liability insurance, pursuant to procedures established by the Medical Executive Committee.

ARTICLE 12. FAIR HEARING PROCEDURE.

12.1. Adverse Action. Adverse action shall be defined as the following:

a. Denial of initial Staff appointment;
b. Denial of reappointment to the Staff;
c. Denial, upon application for reappointment, of requested appointment to Active Staff status;
d. Denial of reinstatement as a Staff Member;
e. Denial or restriction of requested privileges, except as provided in Section 5.8;
f. Involuntary reduction or limitation of privileges;
g. Revocation of privileges;
h. Imposition of conditions on membership or privileges;
i. Revocation of Staff appointment except as provided in Section 11.4.2; and
j. Suspension of Staff appointment or privileges (except as otherwise provided in the By-Laws).

12.2. Adverse Action Only in Accordance with this Article. Adverse action as defined in Section 12.1 will not be recommended by the Medical Executive Committee or taken by the Board of Directors against an Applicant for Staff membership or a Staff Member (both to be hereinafter referred to as "Respondent") except in accordance with this Article.

12.3. Grounds for Adverse Action. Adverse action may be taken only on one or more of the grounds listed below. Adverse action based upon the grounds listed in subsections (b) and (c) below will not be deemed "a professional review action" under the Health Care Quality Improvement Act of 1986, and adverse action based upon grounds listed in subsections (a) and (d) below is not necessarily "a professional review action" under that statute.

a. The Respondent has failed to affirmatively establish that he or she meets the qualifications of character and competence or other criteria set forth in the By-Laws, Rules and Regulations and Policies of the Staff.

b. The Hospital is unable to accommodate the Respondent for reasons based on the Hospital’s documented inability to provide adequate facilities or services to the Respondent and his or her patients or on the basis of inconsistency with the Hospital’s written plan of development, current policies or agreements.

c. In the case of denial of reappointment or reinstatement or denial, reduction or limitation of privileges, the Respondent has failed to perform a sufficient number of procedures, to admit a sufficient number of patients or otherwise to conduct sufficient practice in the Hospital to provide, in view of other available information, a reasonable basis for evaluation of character and competence.

d. The Respondent has failed to comply with the By-Laws, Rules and Regulations and Policies of the Staff including failure to perform quality assurance activities.

e. The Respondent has engaged in conduct or practice inconsistent with the Hospital’s standards of character, competence or professional conduct as set forth in the By-Laws, Rules and Regulations and Policies of the Staff.

f. The Respondent has engaged in activities or professional conduct, which may be detrimental to patient care or welfare or disruptive of Hospital operations.

12.4. Initiation of Proceeding.

12.4.1. Notice of Reasonable Cause. Within twenty (20) days of a finding of reasonable cause for adverse action against a Member by the Medical Executive Committee or the Board of Directors, which is not based on a prior finding of reasonable cause for adverse action by the Medical Executive Committee, the President of the Staff will send a Notice of Reasonable Cause to the Respondent. The Notice will be sent by personal delivery or by certified or registered mail, state concisely the grounds for the finding and advise the Respondent of his or her right to request a hearing in accordance with the Fair Hearing Procedure. A copy of the Fair Hearing Procedure will be transmitted with the Notice, together with a summary of the Respondent’s rights in the hearing and the consequences of failure to request a hearing.

12.4.2. Request for a Hearing or Waiver. Within thirty-five (35) days after delivery or mailing of the Notice of Reasonable Cause, the Respondent may request a hearing by sending a written request to the President of the Staff by personal delivery or by certified or registered mail to his or her office. Failure to make a timely request in such manner will waive the Respondent’s right to a hearing and appellate review under this procedure, and the Medical Executive Committee will conduct such further investigation as it considers appropriate, if any, and will within sixty (60) days of the Respondent’s waiver, submit its report and recommendations to the Board of Directors.

12.5. Appointment of Hearing Committee and Notice of Hearing. Upon receipt of a request for a hearing, the President of the Staff will appoint an ad hoc Hearing Committee composed of at least three (3) impartial Members of the Staff, one (1) of whom the President of the Staff will appoint as Chair. A Staff Member will be considered impartial if he does not have a direct economic interest in common with the Respondent, if he is not in direct economic competition with the Respondent, and if he has not been previously involved in consideration of the matter. Within thirty (30) days of receipt of a request for a hearing, the President will schedule a hearing and send a Notice of Hearing by personal delivery or registered or certified mail to the Respondent with copies by regular mail to the Chair and Members of the Hearing Committee. The Notice of Hearing, shall designate the date (which shall not be less than thirty-five (35) days nor more than sixty (60) days after the date of delivery or mailing of the Notice of Hearing), time and place of the hearing, shall identify the Chair and Members of the Hearing Committee and shall concisely state the grounds for the finding of reasonable cause, including a statement of any alleged acts or omissions upon which the finding is based, a list of any specific or representative patient records involved (identified by number) and a list of witnesses expected to testify.

12.6. Hearing Officers and Representatives.

12.6.1. Appointment of Hearing Officer. Upon request of the President of the Staff, the Chief Executive Officer will appoint a Hearing Officer. The Hearing Officer shall not be Hospital counsel or an employee of the Hospital.

12.6.2. Respondent’s Representation, Witnesses and Duty to Cooperate. The Respondent will be entitled to be represented by an attorney or another representative of his or her choosing, and at the Respondent’s expense, at the hearing and all subsequent stages of the proceedings provided for by the Fair Hearing Procedure. The Respondent shall forward the names and addresses of his representative and any witness he or she expects to testify to the President of the Staff at least two (2) days prior to the date of the hearing. Throughout the proceedings the Respondent will, consistent with law, cooperate with those responsible for conducting the proceeding.

12.6.3. Hearing Advocate. The Chief Executive Officer will on request of the President of the Staff, or otherwise may, appoint an attorney or another representative to serve as Hearing Advocate, whose responsibility will be to present relevant evidence and arguments in support of adverse action.

12.7. Adjournment. The Chairperson of the Hearing Committee may, for good cause shown by either party (that is, the Respondent and the Hearing Advocate) or any Member of the Hearing Committee, postpone, reschedule and adjourn the hearing from time to time (even if the effect is to postpone the hearing beyond the period allowed by the Fair Hearing Procedure).

12.8. Presiding Officer. The Hearing Officer, or if there is none, the Chairperson of the Hearing Committee, will preside at the hearing and will rule on the admissibility of evidence and questions of hearing procedure, set reasonable guidelines for the conduct of the hearing, administer oaths and affirmations, maintain decorum and regulate the course of the hearings; provide for the taking of testimony by written or electronic deposition when appropriate, direct the parties to appear and confer to consider simplification of the issues by consent, and may fix times for the exchange and filing by the parties of documentary evidence and of written statements before and after the hearing.

12.9. Procedure, Evidence, Record of Hearing. The hearing may be conducted with reasonable informality. The rules of evidence in a court of law need not be applied, and the Hearing Committee may receive and consider any evidence that is reasonably probative and relevant to the issues. Committee Members must be present for the entire Hearing and may not vote by proxy on any of the issues before the Hearing Committee.

12.9.1. Witnesses. Each party will be given the opportunity to call and cross-examine witnesses and rebut evidence presented by the other party. Each witness may be examined successively by the party presenting the witness, the opposing party and the Committee. Members of the Hearing Committee may question any witness. The Committee may arrange for the admission of evidence and testimony of witnesses not presented by either party.

12.9.2. Record. A record will be made of the hearing and the Respondent will be entitled to a written or electronic copy of the record.

12.9.3. Order of Proceedings. Subject to such variations as the Presiding Officer may allow, the order of the hearing will be as follows:

a. Opening statement by the Hearing Advocate (if a Hearing Advocate has been appointed);
b. Opening statement by or on behalf of the Respondent or his or her representative:
c. Presentation of evidence by Hearing Advocate;
d. Presentation of evidence by or on behalf of the Respondent;
e. Questioning or presentation of evidence by Committee;
f. Closing statement by Hearing Advocate;
g. Closing statement by or on behalf of the Respondent.

12.9.4. Written Submissions. Each party will have the opportunity to submit written statements prior to and at the close of the hearing or within such time as is allowed by the Presiding Officer.

12.9.5. New Issues. If new issues or evidence, not within the grounds for the finding of reasonable cause as stated in the Notice of Hearing, should emerge before or during the course of the hearing, the Presiding Officer will allow the parties reasonable opportunity to present evidence and arguments as to such issues.

12.9.6. Burden of Proof. If the adverse action being contemplated or proposed is denial of application for initial Staff appointment, denial of application for reinstatement, denial of application for reappointment and/or denial or limitation of privileges requested in connection with such applications, the Respondent shall have the burden of resolving the dispositive issues of fact in his or her favor by a preponderance of the evidence. In all other cases, the Hospital shall have the burden of proving grounds for adverse action by a preponderance of the evidence.

12.10. Deliberations of the Hearing Committee. After the conclusion of the hearing, the Hearing Committee will meet to deliberate and decide upon its findings and recommendations. It may request the assistance of the Hearing Officer. If the Committee determines that further arguments or evidence would contribute to resolution of the matter, it may re-open the hearing.

12.11. Report and Recommendations of Hearing Committee. Within twenty (20) days after the final conclusion of the hearing, the Committee will submit its report, with copies to the Respondent, the Respondent’s representative and the Hearing Advocate. The report will set forth the Hearing Committee’s findings, the general basis for the findings, and its recommendations. The Committee may recommend that the application be granted, that no adverse action be taken with or without a reprimand, or what adverse action it deems appropriate. The Committee’s report will become part of the record of the proceeding. The record shall also consist of the notice of reasonable cause, the request for hearing, the notice of hearing, a written or electronic transcript of the hearing, and all exhibits and all written statements submitted by the parties.

12.12. Medical Executive Committee Proceedings. Within five (5) days after receipt of the report of the Hearing Committee, the President of the Staff will schedule a meeting of the Medical Executive Committee and send notice thereof to the Respondent, the Respondent’s representative, and the Hearing Advocate. The meeting will be scheduled no less than fifteen and no more than twenty-five days after receipt of the report. The notice of meeting will be part of the record.

12.12.1. Written Submissions. The parties may submit written statements to the Medical Executive Committee at least five (5) days prior to the meeting. Any such statements shall be part of the record of the proceeding.

12.12.2. Oral Argument. The President of the Staff may, in his or her discretion, allow the parties to appear to present oral arguments to the Committee at the meeting.

12.12.3. Deliberations. The Medical Executive Committee will deliberate outside of the presence of the parties and shall reach a decision within thirty (30) days after the meeting, basing its decision on the record of the proceedings.

12.12.4. Report and Recommendations. Within ten (10) days after reaching its decision, the Medical Executive Committee will submit its report and recommendations to the Board of Directors, with copies to the Chief Executive Officer, the Respondent and the Respondent’s representative and the Hearing Advocate. If the Medical Executive Committee disagrees with any part of the recommendations of the Hearing Committee, it will concisely set forth the reasons therefor. This report will be part of the record.

12.13. Consideration by Board of Directors. Within fifteen (15) days after receipt of the report of the Medical Executive Committee, the Chair of the Board of Directors will submit it to the Board or, to an ad hoc Review Committee of the Board appointed by the Chair and composed of a Chair and four (4) other members. The Board or Review Committee will meet within thirty (30) days of receiving the report. The parties will be given at least twenty (20) days notice of the meeting of the Board or Review Committee.

12.13.1. Written Submissions and Oral Argument. The parties may submit written statements in accordance with deadlines set by the Chair of the Board or the Chair of the Review Committee, and if requested by the Chair of the Board or the Chair of the Review Committee the parties may present oral arguments.

12.13.2. Deliberations and Decision. If the matter was submitted to a Review Committee, the Chairperson of the Review Committee will present its recommendation to the Board of Directors within ten (10) days of the meeting of the Committee. The Board of Directors will deliberate outside the presence of the parties and shall make its decision based on the record and the statements and argument it has received within ten (10) days after the meeting of the Board referred to in Section
12.13, or, if the matter was submitted to a Review Committee, within ten (10) days of receipt of the Committee’s recommendation. The Board will briefly state the reasons for its decision, and may decide to grant the application or to take adverse action in such form as it considers appropriate, or to refer the matter back to the Medical Executive Committee or Hearing Committee for specified further consideration and further proceedings.

12.13.3. Notice of Decision. The Chief Executive Officer will promptly send a notice of the Board’s decision and the reasons therefor to the Respondent by registered or certified mail. The decision of the Board will be final, subject only to the Respondent’s right to review by the Public Health Council.

12.14. Time Limitations. The time limitations set forth in the Fair Hearing Procedure will be adhered to except that they may be extended by the Medical Executive Committee for good and reasonable cause. The Fair Hearing Procedure is illustrated in Figure 2 attached to this Article. (In the case of an inconsistency between Figure 2 and the written provisions of the By-Laws, the written provisions of the By-Laws shall govern.)


Rev. 10/8/01

Amendments

Approved by Board of Directors July 25, 1998
    Article 8 (8.2.1.1) – Committees

Approved by Board of Directors December, 1999
    Article I (Add 1.5) Definitions
    Article 6 – Officers (6.3.1), (6.3.2)
    Article 7 – Clinical Services (7.4.2), (7.4.2.1), (7.4.2.1.1), (7.4.2.2), (7.4.2.3),
       (7.4.2.4), (7.4.2.5), (7.4.3), (7.4.4), (7.4.4.1)
    Article 11 (11.4.1) – Corrective Action
    Article 12 – Fair Hearing Procedure (12.4.1), (12.4.2), (12.6.2), (12.6.3), (12.11),
       (12.12.1), (12.12.4), (12.13.2)

Aproved by Board of Directors January, 2000
    Article 8 – Committees (8.1.1.1), (8.1.1.2), (8.1.2), (8.1.3), (8.1.7), (8.2.1.1)

Approved by Board of Directors October 1, 2001
    Article 3 (3.2) – Health Care Affiliates
    Article 5 (5.3.5) – Medical Executive Committee Action
    Article 5(5.3.6) – Action by Board of Directors
    Article 7(7.4.4) – Review of Clinical Director
    Article 7(NEW 7.4.5) – Vacancies
    Article 10(10.2) – Adoption and Amendment Procedure
    Article 12(12.4) – Initiation of Proceeding

10/01
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