Bylaws of the Medical Staff

Bylaws of the Medical Staff

Medical Staff Approval:

Board of Managers Approval:

Version 4-September 2014

1

Version 3 – November 2011

Table of Contents

Table of Contents- UPDATES TO TOC IN PROGRESS

PREAMBLE

DEFINITIONS

MEDICAL STAFF:

ARTICLE III: MEDICAL STAFF MEMBERSHIP

ARTICLE VI: CLINICAL PRIVILEGES

article VII: CORRECTIVE ACTION

article VII: CORRECTIVE action

Article VIII: hearing and appellate review procedure

ARTICLE VIII: HEARING AND APPELLATE REVIEW PROCEDURE

article ix: oFFICERS

article IX: officers

ARTICLE X: organization of the medical staff

ARTICLE X: ORGANIZATION of the medical staff

ARTICLE XI: committees

arTICLE XI: Committees

B.ADDITIONAL FUNCTIONS OF THE MEDICAL EXEXUTIVE COMMITTEE

ARTICLE XIi: IMMUNITY FROM LIABILITY

ARTICLE XIi: IMMUNITY FROM LIABILITY

article XIV: AMENDMENTS

ARTICLE XIV: AMENDMENTS

PURPOSE

SCOPE AND APPLICABILITY

This policy applies to all licensed independent practitioners (LIP) who are members of the medical staff.

ARTICLE XV: ADOPTION

ARTICLE XV: ADOPTION

Page 1

PREAMBLE / 1
DEFINITIONS / 3
ARTICLE I: NAME / 5
ARTICLE II: PURPOSES / 7
ARTICLE III: MEDICAL STAFF MEMBERSHIP / 9
A. Nature of Medical Staff Appointment & Reappointment / 10
B. Conditions & Duration of Appointment / 11
ARTICLE IV: CATEGORIES OF THE MEDICAL STAFF / 12
A. The Active Medical Staff / 13
B. The Courtesy Medical Staff / 13
C. The Affiliate Medical Staff / 14
D. The Limited Medical Staff / 14
E. The Honorary Medical Staff / 15
ARTICLE V: PROCEDURE FOR APPOINTMENT & REAPPOINTMENT / 16
A. Application for Appointment / 17
B. Appointment Process / 19
C. Reappointment Process / 21
D. Evaluation of Practitioner Professional Performance / 21
ARTICLE VI: CLINICAL PRIVILEGES / 22
A. Clinical Privileges / 23
B. Clinical Privileges Restricted / 23
C. Temporary Privileges / 25
D. Emergency Privileges / 26
E. Credentialing in the Event of a Disaster / 26
F. History & Physical Privileges / 27
ARTICLE VII: CORRECTIVE ACTION / 28
A. Procedure / 29
B. Summary Suspension / 29
C. Automatic Suspension / 30
ARTICLE VIII: HEARING & APPELLATE REVIEW PROCEDURE / 31
A. Right to Hearing & to Appellate Review / 32
B. Request for Hearing / 32
C. Notice of Hearing / 33
D. Composition of Hearing Committee / 33
E. Conduct of Hearing / 33
F. Appeal to the Board of Managers / 35
G. Final Decision by Board of Managers / 365
ARTICLE IX: OFFICERS / 37
A. Officers of the Medical Staff / 38
B. Qualifications of Officers / 38
C. Election of Officers / 38
D. Duties of Officers / 38
E. Removal of Officers / 39
ARTICLE X: MEDICAL STAFF COMMITTEES & MEETINGS / 40
A. Executive Committee / 41
B. Functions of the Medical Executive Committee / 42
C. Ethics Committee / 4746
D. Annual Members Meeting / 47
E. Special Meetings / 47
F. Conflict of Interest & Confidentiality / 47
ARTICLE XI: IMMUNITY FROM LIABILITY; CONFLICTS / 48
ARTICLE XII: RULES AND REGULATIONS: POLICIES / 51
ARTICLE XIII: AMENDMENTS / 53
ARTICLE XIV: PERFORMANCE EXCELLENCE CHART / 55
ARTICLE XV: RULES AND REGULATIONS / 57
A. Admission & Discharge of Patients / 58
B. Use of Restraints / 60
C. Code of Conduct for Physicians / 61
D. Consultation / 62
E. Call Responsibilities / 63
F. Medical Records / 63
G. Impaired Physician Management / 67
H. Verbal & Telephone Orders / 67
I. Drugs & Medications / 68
J. Autopsy / 68
K. Orders, Treatments & Consents / 69
L. Emergency Services / 70
M. Peer Review / 70
ARTICLE XVI: ADOPTION / 72

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Bylaws of the Medical Staff

Page II

PREAMBLE

PREAMBLE

WHEREAS, the Rehabilitation Hospital of Wisconsin, LLC (Hospital) is operated and organized as a Delawarelimited Liability Company; liability company (“LLC”); and

WHEREAS, its purpose is to serve as an acute rehabilitationRehabilitationHospital providing patient care, education and research; and

WHEREAS, it is recognized that the Medical Staff is responsible for the quality of care in the Hospital and must accept and discharge this responsibility, subject to the ultimate authority of the Hospital Board of Managers, and that the cooperative efforts of the Medical Staff, the CEO and the Board of Managers are necessary to fulfill the Hospital’s obligation to its patients;

THEREFORE, the practitioners practicing in this Hospital hereby organize themselves into a Medical Staff in conformity with these Bylawsbylaws and adopt these Bylawsbylaws, subject to approval by the Board of Managers, and recognizes that the adoption or amendment cannot be delegated by the organized Medical Staff or Board of Managers to another entity. .[1]

Bylaws of the Medical Staff

Page 1

DEFINITIONS

DEFINITIONS

MEDICAL STAFF:

The term “Medical Staff” means all individuals who are currentlymedical or osteopathic physicians, duly licensed to practice medicine, podiatric medicine or dentistry who have been appointed to Medical Staff membershipdentists, and granted clinical privilegespractitioners of psychology and podiatry who are privileged to attend patients in this Hospital.

PHYSICIAN:

The term “physician” shall mean any person holding a license to practice medicine and/or surgery under state statutes, as amended from time to time, and/or any person holding a license to practice osteopathic medicine and/or surgery under state statutes as amended from time to time. The term “dentist” shall mean any person holding a license to practice dentistry under state statutes as amended from time to time.

BOARD OF MANAGERS:

The term “Board” and/or “Board of Managers” means the Board of Managers, or governing body of the Hospital.

PERFORMANCE EXCELLENCE:

The terms “Continuous Quality & term “Performance Improvement” and “CQPI Committee” meanExcellence ” means the Medical Staff membership participating with Hospital leaders and staff inand overseeing the quality and performance improvement functions of the Hospital.

MEDICAL EXECUTIVE COMMITTEE:

The terms “Medical term “Executive Committee and “MEC” ” mean those persons serving from time to time as the Medical Executive Committee” means the officers of the Medical Staff pursuant to Article XIand Physician Liaisons functioning as the executive committee of the Medical Staff.

CEO:

The term “CEO” means the individual appointed by the Board of Managers to act in its behalf in the overall management of the Hospital.

PRESIDENT:

The term “President” means the President of the Medical Staff, elected as provided in these Bylaws.

PRACTITIONER:

The term “practitioner” means aan appropriately licensed medical, osteopathic physician, or dentist, podiatrist or other person permitted by Wisconsin law to distribute, dispense and administer medications in the course of professional practice. .

MEDICAL DIRECTOR:

The term “Medical Director” means the Medical Director of the Hospital, as appointed by the Board of Managers.

ALLIED HEALTH PROFESSIONAL:

The term “Allied Health Professional” (AHP) meansis an individual with license or certificate appropriate to his/her specialty, other than a licensed physician, or a dentist,dentists, podiatrists, psychologists and osteopathic physicians who isare not an employee employees of the Hospital, who exercises independent judgment in areas of his/her professional competence, and who is qualified to render medical or surgical care. Allied Health Professionals assigned to the AHP category shall have a member, in good standing of the Medical/Dental Staff who is in the active or courtesy staff category in the same medical discipline, act as sponsor, accepting responsibility for the patient care rendered by the Allied Health Professional. The following, may be deemed AHPs for the purposes of this section, (or as otherwise allowed by State statutes): audiologists, clinical psychologists, audiologists, dental auxiliariesdentists, nurse anesthetists, nurse cliniciansclinician/practitioners, orthopedic and other surgical technicians, physician assistants, qualified therapists (i.e., occupationoccupational, physical, speech, respiratory), and other AHPs as shall be deemed appropriate by the Board of Managers.

PHYSICIAN EXTENDER: The term “physician extender” means persons who may provide specified health care within the Hospital as the employees of physicians and who do not qualify for independent privileges.

PHYSICIAN LIAISONS:

The term “physician liaisons” means physicians who maintain communication and cooperative working relationships between the Medical Staff and the Hospital and Board of Managers. Physician Liaisons function as committee members and/or leaders and contribute to the planning and development of improving the quality of patient care.

MEMBER:

The term “Member” means any practitioner who has been admitted to membership on the Medical Staff and granted clinical privileges at the Hospital.

ARTICLE I:

NAME

ARTICLE I: NAME

The name of this organization shall be the Medical Staff of theRehabilitationHospital of Wisconsin.

ARTICLE II:

PURPOSES

ARTICLE II: PURPOSES

The purposes of this organization are:

1.To promote high-qualitythe best possible acute rehabilitative care for all patients admitted to or treated in any of the facilities or services of the Hospital.

2.To promote a high level of professional performance of all practitioners authorized to practice in the Hospital through the appropriate delineation of the clinical privileges that each practitioner may exercise in the Hospital and through an ongoing review and evaluation of each practitioner’s performance in the Hospital.

3.To develop, adopt and maintain bylaws, rules, regulations and policies for self-government of the Medical Staff in accordance with the policies of the Board of Managers, subject to the ultimate authority of the Board of Managers to approve the adoption of such Bylawsbylaws and policies, and to propose such Bylawsbylaws and policies (and amendments thereto) directly to the Board of Managers. [2]

4.To provide an appropriate education setting that will maintain scientific standards and that will lead to continuous advancement in professional knowledge and skill.

5.To provide a means whereby issues concerning the Medical Staff and the Hospital may be discussed by the Medical Staff with the Board of Managers and the CEO.

6.To provide information to any in-Hospital committee for the purpose of reducing morbidity and mortality in a manner considered privileged and inaccessible in legal proceedings by taking measures of confidentiality.

7.To provide that all patients admitted to, or treated in the Hospital shall receive quality medical care regardless of agesex, race, creed, color, religion or national origin, ancestry, ethnicity, religion, culture, language, physical or mental disability, handicap, socioeconomic status, sex, sexual orientation, gender identity or expressions, marital status, source of payment, or as otherwise prohibited by lawon the basis of disability or age.

8.To ensure compliance with these Bylawsbylaws and policies adopted hereunder and to enforce such Bylawsbylaws and policies, subject to any required approval by the Board of Managers. [3]

9.To function as part of an Organized Health Care Arrangement.

ARTICLE III:

MEDICAL STAFF MEMBERSHIP

ARTICLE III: MEDICAL STAFF MEMBERSHIP

A. NATURE OF MEDICAL STAFF APPOINTMENT AND REAPPOINTMENT

1.Appointment and reappointment to the Medical Staff is a privilege thatwhich may be extended only to professionallyprofessional competent physiciansdoctors of medicine, doctors of osteopathic medicine, dentists, psychologists, and podiatrists who continuously meet the qualifications, standards and requirements set forth in these Bylaws, Medical Staff Rules and Regulationsbylaws and in such policies as are adopted by the Board of Managers from time to time. Privileges shall not be restricted on grounds of national origin, race, ethnicity, religion, disability unrelated to the provision of patient care or required Medical Staff responsibilities, gender, or any other basis prohibited by applicable laws, to the extent that the applicant is otherwise qualified. age, physical disability, sex, sexual orientation, race, color, creed or national origin.

2. Only physicians, dentists, psychologists, and podiatrists who can document their background, experience, training and demonstrated current competence, their adherence to the ethics of their profession, their good reputation and character, and their ability to work harmoniously with others sufficiently to assure the Medical Staff and the Board of Managers that all patient(s) treated by them in the Hospital will receive quality care and that the Hospital and its Medical Staff will be able to operate in an orderly manner, may be qualified for appointment and reappointment to the medical staff. The applicant has the burden of documenting to the satisfaction of the Board of Managers that they will contribute to meeting the mission of the Hospital. No individual shall be appointedMedical Staff. No physician or dentist shall be entitled to membership on the Medical Staff or to the exercise of particular clinical privileges in the Hospital merely by virtue of the fact that such individual isthey are duly licensed to practice medicine or dentistry in this or in any other state, or that such individual isthey are a member of any professional organization, or that such individualthey had in the past, or presently hashave, such privileges at another hospital.

3. Without limiting the generality of the foregoing, each Membermember of the Medical Staff shall meet, at the time of initial appointment and continuously throughout his or her membership, at least the following minimum criteria:

1. Current licensure to practice in the state of Wisconsin.
2. Current DEA registration to prescribe controlled substances, unless prescribing is not part of such member’s practice.
3. A degree from a school of medicine, osteopathic medicine, dentistry or podiatry or a graduate program in psychology and, in the case of doctors of medicine or osteopathy and dentists,successful completion of an appropriate residency program accredited by the American Board of Medical Specialties, the Commission on Dental Accreditation of the American Dental Association, or another nationally recognized accrediting body.
4. An appropriate level of clinical experience measured by national care criteria.
5. Under no current exclusion from participation in federal healthcare programs.

Additional minimum criteria may be imposed with respect to clinical privileges in particular specialties or subspecialties. The Board may make exceptions or additions to any of the above qualifications and requirements after consulting with and obtaining a recommendation from the MEC.[4]

4. On an annual basis, each Membermember of the Medical Staff shall provide to the Hospital a certificate of insurance evidencing current professional liability coverage. The minimum amount of liability insurance shall be the limit provided for by the state, or such greater amount as may be established by the Board of Managers from time to time.

5. A physician, dentist, or podiatrist who does not meet the basic qualifications is ineligible to apply for Medical Staff membership, and any application from such a physician or dentist shall not be processed. The qualifications for membership must be documented with sufficient adequacy to satisfy the Medical Staff and Board of Managers that each has enough information to make a fully informed decision regarding appointment and assignment of privileges. No person shall be appointed to the Medical Staff if the Board of Managers, in its sole discretion, is unable to provide adequate facilities and support services for the applicant or his/her patients.

6. 5.Acceptance of membership on the Medical Staff shall constitute the staff member’s agreement that he or she will strictly abide in the Principles of Medical Ethics of the American Medical Association, the Code of Ethics of the American Dental Association, and other applicable ethics codes. applicable ethics codes of the American Osteopathic Association, the American Podiatric Medical Association, or the American Psychological Association, whichever is applicable, as the same are in effect from time to time.[5]

B. CONDITIONS AND DURATION OF APPOINTMENT[6]

1.1.Initial appointments and reappointments to the Medical Staff shall be made by the Board of Managers in accordance with the processes specified in these Bylawsbylaws. The Board of Managers shall act on appointments, reappointments, or revocation of appointments after there has been a recommendation from the Medical Staff as provided in these Bylawsbylaws; however, subject to the exhaustion of application processing time frames as noted in Article V, the Board of Managers may act without such Medical Staff recommendation on the basis of documented evidence of the applicant’s or staff member’s professional and ethical qualifications obtained from reliable sources other than the Medical Staff.

2.2.Initial appointments shall be for a period of not less than one year nor more than two years.and if longer until the applicant’s first scheduled reappointment based on odd/even birth year. Reappointments shall be for a period of not more than two years. If during initial appointment or reappointment, the practitioner moves out of state, does not continue malpractice insurance as required by the Bylawsbylaws, or fails to apply for reappointment after notification, such practitioner’stheir staff membership will be administratively discontinued. This will be considered a voluntary relinquishment and a non-reportable event in relation to the National Practitioner Data Bank.

3.3.Appointments to the Medical Staff shall confer on the appointee only such clinical privileges as have been granted by the Board of Managers, in accordance with these Bylawsbylaws.

4.4.Every application for staff appointment shall be signed by the applicant and shall contain the applicant’s specific acknowledgment of every Medical Staff member’s obligations to provide continuous care and supervision of their patients, to abide by the Medical StaffBylaws, rules and regulations,bylaws to accept physician liaison and performance improvement assignments and to accept consultation assignments.

ARTICLE IV:

CATEGORIES OF

THE MEDICAL STAFF

ARTICLE IV: CATEGORIES OF THE MEDICAL STAFF[7]

The Medical Staff shall be divided into “Active” and”, “Courtesy”.”, “Affiliate”, “Limited Staff, and “Honorary”. A one-year provisional period is required in the Activeactive and Courtesycourtesy categories prior to being eligible for full staff membership. The provisional status will be waived during the first twelve (12) months of Hospital operation and practitioners will automatically be placed in active or courtesy categories. The provisional status is for a minimum of one year and may be extended for one additional year by action of the Board of Managers.

Failure of the applicant to fulfill all of the requirements of appointment relating to meeting attendance, completion of medical records or participation in quality improvement activities may result in the extension of the initial provisional period, or relinquishment of staff membership and clinical privileges. By applying for staff membership, the applicant expressly agrees to be bound by these terms, and that any extension of the initial provisional period or relinquishment with causesuch failure does not afford the applicant any rights under the hearing and appellate review procedures outlined in these Bylawsbylaws.

A. THE ACTIVE MEDICAL STAFF

The Active Medical Staff shall consist of physicians, dentists, psychologists, and podiatrists who regularly admit or, attend, or are regularly involved in the treatment of, a minimum of 24 patients in the Hospital over a 24-month period,and who are located close enough (as may be determined by the Board of Managers) to the Hospital to provide continuous care to their patients, and who fulfillassume all the functions and responsibilities of membership on the ActiveactiveMedical Staff, including participating in the provision of coverage for their patients in their absence, and other assignments. Members of the ActiveactiveMedical Staff shall be eligible to vote, to hold office and to serve as functional liaisons, and shall be encouraged to attend CQPIPerformance Excellence Committee meetings. Any reference in these Bylawsbylaws to votes or elections by the Medical Staff shall refer only to votes by the voting Medical Staffmedical staff, which shall be limited to the Active Medical Staff.