Nemours/Alfred I. duPont Hospital for Children Medical Staff Bylaws Adopted by Board of Managers

87 Pages·2013·0.4 MB·English

Nemours/Alfred I. duPont Hospital for Children
Medical Staff Bylaws

Adopted by Board of Managers: June 18, 2013
Nemours/Alfred I. duPont Hospital for Children
Medical Staff Bylaws

I. GENERAL PROVISIONS ............................................................................................... 5
A. Purpose .......................................................................................................................... 5
B. Definitions..................................................................................................................... 5
C. Confidentiality and Peer Review Protections ............................................................... 7
D. Conflict of Interest Principles ....................................................................................... 8
E. Indemnification When Performing Credentialing and Peer Review Functions ............ 8
F. Delegation of Functions ................................................................................................ 9
II. GOVERNANCE AND STRUCTURE ............................................................................. 9
A. Categories of the Medical Staff .................................................................................... 9
1. Active Employed Staff .............................................................................................. 9
2. Associate Employed Staff ....................................................................................... 10
3. Affiliate Employed Staff ......................................................................................... 12
4. Regional Medical Staff ........................................................................................... 13
5. Loss of Status …………………………………………………………………......12
6. Active Community Staff ......................................................................................... 14
7. Courtesy Community Staff ..................................................................................... 15
8. Consulting Community Staff .................................................................................. 16
10. Associate Community Staff .................................................................................... 17
B. Officers of the Medical Staff ...................................................................................... 18
1. Qualifications .......................................................................................................... 18
2. Term of Office ........................................................................................................ 19
3. Election of Officers ................................................................................................. 19
4. Vacancies in Office: ................................................................................................ 19
5. Duties of Officers .................................................................................................... 19
6. Removal of Elected Officers ................................................................................... 20
C. Departments ................................................................................................................ 21
1. Organization ............................................................................................................ 21
2. Department Chairpersons........................................................................................ 21
3. Divisions and Division Chiefs ................................................................................ 23
D. Medical Staff Committees and Functions ................................................................... 25
1. Committees ............................................................................................................. 25
2. Standing Committees .............................................................................................. 25
3. Medical Executive Committee ................................................................................ 26
4. Credentials Committee............................................................................................ 28
5. Nominating Committee ........................................................................................... 29
6. Medical Staff Member Referral Team (MSMRT) .................................................. 29
7. Graduate Medical Education Committee ................................................................ 29
8. Peer Review Committee ......................................................................................... 30
9. Special Committees ................................................................................................ 30
E. Meetings ...................................................................................................................... 30
1. Medical Staff Year .................................................................................................. 30
2. Medical Staff Meetings ........................................................................................... 31
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3. Department, Division and Committee Meetings .................................................... 31
F. Provisions Common to All Meetings .......................................................................... 32
1. Notice of Meetings .................................................................................................. 32
2. Quorum and voting ................................................................................................. 32
3. Agenda .................................................................................................................... 32
4. Rules of Order ......................................................................................................... 32
III. APPOINTMENT, REAPPOINTMENT, AND CLINICAL PRIVILEGES ............... 33
A. Qualifications, Conditions, and Responsibilities ........................................................ 33
1. Qualifications for Membership: .............................................................................. 33
2. Waiver of Criteria ................................................................................................... 35
3. No Entitlement to Membership ............................................................................... 35
4. Nondiscrimination Policy ....................................................................................... 35
5. Limitation of Privileges and Membership .............................................................. 35
B. General Conditions of Appointment and Reappointment ........................................... 36
1. Basic Responsibilities and Requirements for Applicants and Members ................ 36
2. Burden of Providing Information............................................................................ 39
C. Application .................................................................................................................. 40
1. Information ............................................................................................................. 40
D. Grant of Immunity and Authorization to Obtain/Release Information ....................... 42
1. Immunity ................................................................................................................. 42
2. Authorization to Obtain Information ...................................................................... 43
3. Authorization to Release Information ..................................................................... 43
E. Procedure for Initial Appointment to the Medical Staff ............................................. 44
1. Pre-Credentialing Process. Request for Application ............................................. 44
2. Submission of Application. ..................................................................................... 45
3. Division Chief Procedure ........................................................................................ 45
4. Department Chairperson Procedure ........................................................................ 46
5. Hospital Medical Director Procedure ..................................................................... 46
6. Credentials Committee Procedure .......................................................................... 47
7. Medical Executive Committee Procedure .............................................................. 48
8. Managers Procedure................................................................................................ 48
F. Provisional Status........................................................................................................ 50
1. Nature of Provisional Status ................................................................................... 50
2. Focused Professional Practice Evaluation .............................................................. 50
3. Duration of Initial Provisional Membership ........................................................... 50
4. Duties of Provisional Members .............................................................................. 51
G. Clinical Privileges ....................................................................................................... 52
1. Exercise of Privileges ............................................................................................. 52
2. Unavailable Clinical Privileges ............................................................................... 52
3. Clinical Privileges for Dentists and Oral Surgeons ................................................ 52
4. Clinical Privileges for Podiatrists ........................................................................... 53
5. Clinical Privileges for New Procedures .................................................................. 53
6. Criteria for Clinical Privileges ................................................................................ 53
7. Physicians-in-Training ............................................................................................ 55
8. Telemedicine Privileges .......................................................................................... 55
9. Emergency Clinical Privileges ................................................................................ 55
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10. Temporary Privileges .............................................................................................. 56
11. Disaster Privileges .................................................................................................. 56
H. Procedures for reappointment ..................................................................................... 56
1. Applications for Reappointment ............................................................................. 57
2. Factors to Be Considered ........................................................................................ 57
3. Division Chief Procedures ...................................................................................... 58
4. Hospital Medical Director Procedure ..................................................................... 59
5. Credentials Committee Procedure .......................................................................... 59
6. Medical Executive Committee Procedure .............................................................. 60
7. Managers Procedure................................................................................................ 61
IV. PEER REVIEW AND FAIR HEARING PROCEDURES ........................................ 61
A. Questions Involving Medical Staff Members ............................................................. 61
1. Collegial Intervention/Informal Proceedings .......................................................... 61
2. Deemed Resignations: ............................................................................................ 63
3. Application for Medical Staff Membership After Resignation: ............................. 63
4. Ongoing and Focused Professional Practice Evaluations ....................................... 64
5. Investigations .......................................................................................................... 64
6. Precautionary Suspension of Clinical Privileges .................................................... 67
7. Medical Executive Committee Procedure. ............................................................. 68
8. Automatic Relinquishment ..................................................................................... 69
9. Leaves of Absence .................................................................................................. 71
B. Hearings and Appeal Procedures ................................................................................ 72
1. Initiation of Hearing ................................................................................................ 72
2. The Hearing ............................................................................................................ 73
3. Pre-Hearing and Hearing Procedure ....................................................................... 75
4. Hearing Conclusions, Deliberations, and Recommendations ................................. 78
5. Appeal Procedure .................................................................................................... 79
V. AMENDMENTS, ADOPTION, AND MEDICAL STAFF RULES AND
REGULATIONS AND POLICIES AND PROCEDURES .................................................... 81
A. Amendments/Adoption ............................................................................................... 81
B. Medical Staff Policies and Procedures ....................................................................... 82
C. Conflict Management Process .................................................................................... 83
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1 I. GENERAL PROVISIONS
2
3 A. PURPOSE
4 The purposes of these Bylaws are to:
5 A. Establish the formal structure of the Medical Staff of the Nemours/Alfred I.
6 duPont Hospital for Children;
7 B. Establish the requirements and processes for application for initial
8 appointment and periodic reappointment to membership on the Medical Staff,
9 for Clinical Privileges and for changes in status of membership on the Medical
10 Staff;
11 C. Establish the prerogatives and responsibilities of membership on the Medical
12 Staff;
13 D. Achieve a high level of professional performance by the Practitioners and
14 Affiliate Professionals authorized to practice in the Hospital and affiliate sites
15 through the appropriate delineation of the Clinical Privileges that each
16 Practitioner and Affiliate Professional may exercise in the Hospital, and
17 through an ongoing review and evaluation of each Practitioner’s and Affiliate
18 Professional’s performance in the Hospital;
19 E. Provide a means whereby issues concerning the Medical Staff and the
20 Hospital may be discussed by the Medical Staff with the Managers and the
21 Chief Executive Officer; and
22 F. Serve as a means for accountability to the Managers for the professional
23 performance and ethical conduct of the Members and to strive towards
24 assuring that patients treated at Nemours/Alfred I. duPont Hospital for
25 Children, including without limitation inpatients, outpatients, ambulatory
26 surgery patients (including patients seen at Nemours duPont Pediatrics,
27 Ambulatory Surgery Center at Bryn Maw and any such other ambulatory
28 surgical facility as Nemours/Alfred I. duPont Hospital for Children may open
29 in the future) will receive high quality medical care. The Medical Staff will
30 strive toward the continual upgrading of the quality and efficiency of patient
31 care delivered, consistent with the state of the healing art and the resources
32 locally available.
33 B. DEFINITIONS
34 The following definitions shall apply to terms used in these Bylaws:
35 A. “Administration” means those persons to whom the Chief Executive Officer
36 and/or the Managers have delegated authority to carry our administrative
37 responsibilities.
38 B. “Administrator” means the Chief Executive Officer or other individual
39 appointed to act in the overall administration of the Hospital.
40 C. “Ambulatory Surgical facility” means a facility or portion thereof not located
41 upon the premises of a hospital which provides specialty or multispecialty
42 outpatient surgical treatment.
43 D. “Ambulatory Surgery” means surgery which is performed on an outpatient
44 basis in a facility which is not located in a hospital; on patients who do not
45 require hospitalization but who do require constant medical supervision
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Medical Staff Bylaws

1 following the surgical procedure performed and whose total length of stay
2 does not exceed a total of 8 hours (4 hours surgical time; 4 hour recovery
3 time).
4 E. Affiliate Professional” means any licensed, independent health care provider
5 who is not a physician, dentist, or podiatrist, but who practices independently
6 within the scope of his or her license to provide patient care services at the
7 Hospital and who must be credentialed and granted Clinical Privileges
8 through existing Medical Staff mechanisms. Such individuals include, but are
9 not limited to, clinical psychologists, advanced practice nurses and physician
10 assistants.
11 F. Affiliate Sites- includes Ambulatory Care, Impatient Sites, Surgical centers
12 covered by a Nemours Physicians within their scope of Practice
13 G. “Bylaws” means these Medical Staff Bylaws of the Hospital.
14 H. “Clinical Fellow” means a physician in training who has completed residency
15 program and is receiving sub-specialty level training.
16 I. “Clinical Privileges” means the permission granted to a Practitioner or
17 Affiliate Professional to render specific diagnostic, therapeutic, medical,
18 dental, or surgical services at the Hospital to inpatients and outpatients.
19 J. “Credentials Committee” means the Credentials Committee of the Medical
20 Staff.
21 K. “Credentialing Department” means the Credentialing Department of Nemours.
22 L. “Dentist” means a person who holds a doctor of dental surgery or doctor of
23 dental medicine degree.
24 M. “Ex Officio” means a role or function being performed by a person due to the
25 person’s office or position held and, unless otherwise expressly provided, does
26 not limit voting rights.
27 N. “Hospital” means the Nemours/Alfred I. duPont Hospital for Children.
28 O. “Hospital Medical Director” means the physician appointed by the Chief
29 Medical Officer and the Administrator who has certain delegated
30 responsibilities related to the Hospital and the Medical Staff and whose
31 complete duties are contained in the job description for that position.
32 P. “Managers” means the Board of Managers.
33 Q. “Medical Executive Committee” means the Executive Committee of the
34 Medical Staff.
35 R. “Medical Staff” or “Staff” means the Medical Staff of the Hospital.
36 S. “Medical Staff Year” means the twelve-month period commencing on the first
37 day of January in each year.
38 T. “Member” or “Members” means a member or members of the Medical Staff.
39 U. “Nemours” means The Nemours Foundation, a Florida non-profit corporation.
40 V. “Medical Staff Member Referral Team” means the team consisting of the
41 Hospital Medical Director, the President of the Medical Staff and the Chief
42 Medical Officer that addresses concerns relating to impaired Members.
43 W. “Physician Health Committee” means the Physician Health Committee of the
44 Medical Society of Delaware or other Committee designated by the Delaware
45 State Board of Licensure and Discipline.
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1 X. “Physician-in-Chief (Chief Medical Officer)” means a physician appointed to
2 perform the duties described in these Bylaws.
3 Y. “Physician” means a person who holds a doctor of medicine (M.D.) or doctor
4 of osteopathy (D.O.) degree.
5 Z. “Podiatrist” means a person who holds a doctor of podiatric medicine
6 (D.P.M.) degree.
7 AA. “Policies and Procedures,” unless otherwise specified, means the Policies and
8 Procedures of the Medical Staff.
9 BB. “Practitioner,” unless otherwise expressly limited, means any Physician,
10 Podiatrist, Dentist or Oral Surgeon applying for or holding privileges in the
11 Hospital.
12 CC. “Special Notice” means written notification sent by certified or registered
13 mail, return receipt requested.
14 DD. Service line – Administrative structure of related services to facilitate patient
15 care.
16 EE. “Peer Review Committee” means the group of Medical Staff Members
17 formally convened by the Medical Executive Committee to review and
18 evaluate the work of the Medical Staff.
19 FF. “Resident” means a physician in training receiving post-graduate level
20 training through an ACGME accredited residency program.
21
22 Words used in these Bylaws shall be read as the masculine or feminine gender, and as
23 the singular or plural, as the context requires. The captions and headings are for
24 convenience only and are not intended to limit or define the scope or effect of any
25 provision of these Bylaws.
26
27 C. CONDIFENTIALITY AND PEER REVIEW PROTECTIONS
28 Confidentiality: Actions taken and recommendations made pursuant to Article III
29 and Article IV shall be treated as confidential in accordance with applicable legal
30 requirements and such policies regarding confidentiality as may be adopted by the
31 Hospital and the Medical Staff.
32
33 Reporting: Reports of actions taken pursuant to Article III and Article IV shall be
34 made by the Chief Executive Officer or designee to such governmental agencies as
35 may be required by law. The Nemours/Alfred I. duPont Hospital for Children shall
36 disclose reports of actions taken pursuant to that reporting requirement to other health
37 care organizations upon receipt of a formal request and authorization form to release
38 the information signed by the affected physician.
39
40 Records: All records and other information generated in connection with and/or as a
41 result of professional review activities shall be confidential, and each individual or
42 Committee member participating in such review activities shall make no disclosures
43 of any such information except as authorized, in writing, by the Chief Executive
44 Officer or designee or by legal counsel for the Hospital or as required by applicable
45 law.
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1 Breach of Confidentiality: Any breach of confidentiality by an individual or
2 Committee member may result in a professional review action by the Medical Staff,
3 and/or may result in appropriate legal action to ensure that confidentiality is
4 preserved, including application to a court of law for injunctive or other relief.
5
6 Peer Review Protection: All minutes, reports, recommendations, communications,
7 and actions made or taken pursuant to Article III and Article IV are deemed to be
8 covered by the provisions of Title 24, Chapter 17 of the Delaware Code, or the
9 corresponding provisions of any subsequent federal or state statute providing
10 protection to peer review or related activities. Furthermore, the committees and/or
11 panels charged with making reports, findings, recommendations, or investigations
12 pursuant to Article IV shall be considered to be acting on behalf of the Hospital when
13 engaged in such professional review activities and thus shall be deemed to be
14 “professional review bodies” as that term is defined in the Health Care Quality
15 Improvement Act of 1986. All Members agree to execute such documentation to
16 confirm the confidential nature of the matters referred to in this section as may be
17 developed from time to time by the Medical Executive Committee and approved by
18 the Managers.
19
20 D. CONFLICT OF INTEREST PRINCIPLES
21 Members of the Medical Staff shall conduct themselves with integrity, honesty and
22 fairness to avoid any conflict between personal interests and the interests of
23 Nemours/Alfred I. duPont Hospital for Children. Members shall not use their
24 position with Nemours and/or the Alfred I. duPont Hospital for Children to influence
25 decisions in which they know, or have reason to believe, that they have a financial
26 interest.
27
28
29
30 E. INDEMNIFICATION WHEN PERFORMING CREDENTIALING
31 AND PEER REVIEW FUNCTIONS
32 Members of the Medical Executive Committee, Medical Staff Credentials
33 Committee, and Medical Staff Peer Review Committee will be immune under Title
34 24, Chapter 17, Section 1768 of the Delaware Code from any claim, suit, liability,
35 damages, or any other recourse, civil or criminal, arising from any Peer Review
36 Committee act, omission, proceeding, decision, or determination undertaken or
37 performed, or from any recommendation made, so long as the member and/or
38 Committee acted in good faith and without gross or wanton negligence in carrying
39 out the responsibility, authority, duties, powers, and privileges of the officers
40 conferred by law upon them. They and all Medical Staff members functioning as
41 their designees shall be indemnified by Nemours to the fullest extent permitted by
42 law.
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1 F. DELEGATION OF FUNCTIONS
2 The Medical Staff of the Nemours/Alfred I. duPont Hospital for Children authorizes
3 the Medical Executive Committee to act on its behalf in the day-to-day matters
4 relating to:
5 Self-governance – policies, procedures, rules
6 Credentialing and Privileging
7 Graduate Medical Education
8 Peer Review
9 Strategic Planning
10
11 The Medical Executive Committee will advise the Medical Staff as to the actions
12 taken.
13
14 From time to time the Administrative and Physician Leadership of Nemours/Alfred I.
15 duPont Hospital for Children may create multi-disciplinary Service Lines to facilitate
16 the delivery of efficient patient care. The Physician identified as Program Director
17 has responsibility for the day to day operations of the Service Line; however the
18 responsibility for credentialing, privileging, focused practitioner performance
19 evaluation, on-going practitioner performance evaluation, and peer review decisions
20 related to the physicians and other credentialed practitioners who function within the
21 Service line rest with the Chief of the Medical Staff Division and Chairperson of the
22 Medical Staff Department to which the individual practitioner is assigned.
23
24 (Joint Commission Standard- Medical Staff Bylaws: MS.01.01.01)
25
26 II. GOVERNANCE AND STRUCTURE
27
28 A. CATEGORIES OF THE MEDICAL STAFF
29 The Medical Staff shall be divided into the following categories: Active Employed,
30 Associate Employed, Affiliate Employed, Regional Medical Staff, Active
31 Community, Courtesy Community, Consultant Community, Associate Community,
32 and Affiliate Community.
33 Medical Staff Members who have retired from practice shall have the designation of
34 “Retired.”
35
36 Medical Staff Members who have made outstanding contributions to the field of
37 medicine, the community or the Hospital shall have the designation “Emeritus” after
38 being nominated for and approved for such designation.
39
40 1. Active Employed Staff
41 Qualifications:
42 The Active Employed Staff shall be limited to those qualified Physicians,
43 Podiatrists, Dentists and oral surgeons who desire to practice actively at the
44 Hospital. Active Employed staff members must meet all of the following:
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1 a) Meet the qualifications outlined in Article III.A;
2 b) Be employed by the Nemours Children’s Clinic, Delaware
3 Valley;
4 c) Be appointed to a specific Department;
5 d) Obtain board certification as required in Article III.A.1.e and
6 maintain such certification or recertification; and
7 e) Satisfy the requirement as set forth in Article III.A.1.f.
8
9 Prerogatives:
10 Members appointed to the Active Employed Staff shall be entitled to:
11 a) Admit and treat an unlimited number of patients within the
12 limits of their clinical privileges;
13 b) Hold office on the Medical Staff;
14 c) Be appointed to and serve on Medical Staff Committees and to
15 serve as the Chairperson of a Medical Staff Committee; and
16 d) Vote on matters voted upon by the Medical Staff.
17
18 Responsibilities:
19 By accepting membership to the Active Employed Staff category, each
20 Member agrees to assume all the following functions and responsibilities of
21 membership to the Active Employed Staff:
22 a) Attend Medical Staff meetings and Department meetings when
23 possible. Attendance at Department and Division meetings and
24 participation in teaching activities and committee work shall be
25 considered by the Department Chairperson at the biannual
26 reappointment. Excused absences will be permitted at the
27 discretion of the Chairperson of the Department;
28 b) Serve on Medical Staff Committees, as assigned;
29 c) Faithfully perform the duties of any office or position to which
30 the Member is elected or appointed;
31 d) Participate in quality assessment and monitoring activities as
32 may be assigned by the Department Chairperson, Division
33 Chief, or committee chairperson, including the evaluation of
34 provisional members;
35 e) Complete teaching assignments as directed by the Department
36 Chairperson;
37 f) Provide care for unassigned patients, emergency service care,
38 and consultation according to the requirements of the
39 Member’s Division and/or Department and Medical Staff
40 Policy; and
41 g) Submit bi-annual reappointment applications.
42
43 2. Associate Employed Staff
44 Qualifications:
45 The Associate Employed Staff shall be limited to those practitioners who are
46 employed by the Nemours Children’s Clinic, Delaware Valley and who do not
10