Nemours/Alfred I. duPont Hospital for Children
Medical Staff Bylaws
Nemours/Alfred I. duPont Hospital for Children
Medical Staff Bylaws
Adopted by Board of Managers: March 17, 2015
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 10
2. Associate Employed Staff 11
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 24
D. Medical Staff Committees and Functions 26
1. Committees 26
2. Standing Committees 26
3. Medical Executive Committee 27
4. Credentials Committee 29
5. Nominating Committee 30
6. Medical Staff Member Referral Team (MSMRT) 30
7. Graduate Medical Education Committee 30
8. Peer Review Committee 31
9. Special Committees 31
E. Meetings 31
1. Medical Staff Year 31
2. Medical Staff Meetings 31
3. Department, Division and Committee Meetings 32
F. Provisions Common to All Meetings 33
1. Notice of Meetings 33
2. Quorum and voting 33
3. Agenda 33
4. Rules of Order 33
III. APPOINTMENT, REAPPOINTMENT, AND CLINICAL PRIVILEGES 34
A. Qualifications, Conditions, and Responsibilities 34
1. Qualifications for Membership: 34
2. Waiver of Criteria 36
3. No Entitlement to Membership 36
4. Nondiscrimination Policy 36
5. Limitation of Privileges and Membership 36
B. General Conditions of Appointment and Reappointment 37
1. Basic Responsibilities and Requirements for Applicants and Members 37
2. Burden of Providing Information 40
C. Application 41
1. Information 41
D. Grant of Immunity and Authorization to Obtain/Release Information 43
1. Immunity 43
2. Authorization to Obtain Information 44
3. Authorization to Release Information 44
E. Procedure for Initial Appointment to the Medical Staff 45
1. Pre-Credentialing Process. Request for Application 45
2. Submission of Application. 46
3. Division Chief Procedure 46
4. Department Chairperson Procedure 47
5. Hospital Medical Director Procedure 47
6. Credentials Committee Procedure 47
7. Medical Executive Committee Procedure 48
8. Managers Procedure 49
F. Provisional Status 51
1. Nature of Provisional Status 51
2. Focused Professional Practice Evaluation 51
3. Duration of Initial Provisional Membership 52
4. Duties of Provisional Members 52
G. Clinical Privileges 53
1. Exercise of Privileges 53
2. Unavailable Clinical Privileges 54
3. Clinical Privileges for Dentists and Oral Surgeons 54
4. Clinical Privileges for Podiatrists 54
5. Clinical Privileges for New Procedures 55
6. Criteria for Clinical Privileges 55
7. Physicians-in-Training 56
8. Telemedicine Privileges 56
9. Emergency Clinical Privileges 56
10. Temporary Privileges 57
11. Disaster Privileges 57
H. Procedures for reappointment 57
1. Applications for Reappointment 58
2. Factors to Be Considered 58
3. Division Chief Procedures 59
4. Hospital Medical Director Procedure 60
5. Credentials Committee Procedure 60
6. Medical Executive Committee Procedure 61
7. Managers Procedure 62
IV. PEER REVIEW AND FAIR HEARING PROCEDURES 62
A. Questions Involving Medical Staff Members 62
1. Collegial Intervention/Informal Proceedings 62
2. Deemed Resignations: 64
3. Application for Medical Staff Membership After Resignation: 64
4. Ongoing and Focused Professional Practice Evaluations 65
5. Investigations 65
6. Precautionary Suspension of Clinical Privileges 68
7. Medical Executive Committee Procedure. 69
8. Automatic Relinquishment 70
9. Leaves of Absence 72
B. Hearings and Appeal Procedures 72
1. Initiation of Hearing 72
2. The Hearing 73
3. Pre-Hearing and Hearing Procedure 76
4. Hearing Conclusions, Deliberations, and Recommendations 79
5. Appeal Procedure 80
V. AMENDMENTS, ADOPTION, AND MEDICAL STAFF RULES AND REGULATIONS AND POLICIES AND PROCEDURES 82
A. Amendments/Adoption 82
B. Medical Staff Policies and Procedures 83
C. Conflict Management Process 83
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Nemours/Alfred I. duPont Hospital for Children
Medical Staff Bylaws
I. GENERAL PROVISIONS
A. PURPOSE
The purposes of these Bylaws are to:
- Establish the formal structure of the Medical Staff of the Nemours/Alfred I. duPont Hospital for Children;
- Establish the requirements and processes for application for initial appointment and periodic reappointment to membership on the Medical Staff, for Clinical Privileges and for changes in status of membership on the Medical Staff;
- Establish the prerogatives and responsibilities of membership on the Medical Staff;
- Achieve a high level of professional performance by the Practitioners and Affiliate Professionals authorized to practice in the Hospital and affiliate sites through the appropriate delineation of the Clinical Privileges that each Practitioner and Affiliate Professional may exercise in the Hospital, and through an ongoing review and evaluation of each Practitioner’s and Affiliate Professional’s performance in the Hospital;
- Provide a means whereby issues concerning the Medical Staff and the Hospital may be discussed by the Medical Staff with the Managers and the Chief Executive Officer; and
- Serve as a means for accountability to the Managers for the professional performance and ethical conduct of the Members and to strive towards assuring that patients treated at Nemours/Alfred I. duPont Hospital for Children, including without limitation inpatients, outpatients, ambulatory surgery patients (including patients seen at Nemours duPont Pediatrics, Ambulatory Surgery Center at Bryn Maw and any such other ambulatory surgical facility as Nemours/Alfred I. duPont Hospital for Children may open in the future) will receive high quality medical care. The Medical Staff will strive toward the continual upgrading of the quality and efficiency of patient care delivered, consistent with the state of the healing art and the resources locally available.
B. DEFINITIONS
The following definitions shall apply to terms used in these Bylaws:
A. “Administration” means those persons to whom the Chief Executive Officer and/or the Managers have delegated authority to carry our administrative responsibilities.
B. “Administrator” means the Chief Executive Officer or other individual appointed to act in the overall administration of the Hospital.
C. “Ambulatory Surgical facility” means a facility or portion thereof not located upon the premises of a hospital which provides specialty or multispecialty outpatient surgical treatment.
D. “Ambulatory Surgery” means surgery which is performed on an outpatient basis in a facility which is not located in a hospital; on patients who do not require hospitalization but who do require constant medical supervision following the surgical procedure performed and whose total length of stay does not exceed a total of 8 hours (4 hours surgical time; 4 hour recovery time).
E. Affiliate Professional” means any licensed, independent health care provider who is not a physician, dentist, or podiatrist, but who practices independently within the scope of his or her license to provide patient care services at the Hospital and who must be credentialed and granted Clinical Privileges through existing Medical Staff mechanisms. Such individuals include, but are not limited to, clinical psychologists, advanced practice nurses and physician assistants.
F. Affiliate Sites- includes Ambulatory Care, Impatient Sites, Surgical centers covered by a Nemours Physicians within their scope of Practice
G. “Bylaws” means these Medical Staff Bylaws of the Hospital.
H. “Clinical Fellow” means a physician in training who has completed residency program and is receiving sub-specialty level training.
I. “Clinical Privileges” means the permission granted to a Practitioner or Affiliate Professional to render specific diagnostic, therapeutic, medical, dental, or surgical services at the Hospital to inpatients and outpatients.
J. “Credentials Committee” means the Credentials Committee of the Medical Staff.
K. “Credentialing Department” means the Credentialing Department of Nemours.
L. “Dentist” means a person who holds a doctor of dental surgery or doctor of dental medicine degree.
M. “Ex Officio” means a role or function being performed by a person due to the person’s office or position held and, unless otherwise expressly provided, does not limit voting rights.
N. “Hospital” means the Nemours/Alfred I. duPont Hospital for Children.
O. “Hospital Medical Director” means the physician appointed by the Chief Medical Officer and the Administrator who has certain delegated responsibilities related to the Hospital and the Medical Staff and whose complete duties are contained in the job description for that position.
P. “Managers” means the Board of Managers.
Q. “Medical Executive Committee” means the Executive Committee of the Medical Staff.
R. “Medical Staff” or “Staff” means the Medical Staff of the Hospital.
S. “Medical Staff Year” means the twelve-month period commencing on the first day of January in each year.
T. “Member” or “Members” means a member or members of the Medical Staff.
U. “Nemours” means The Nemours Foundation, a Florida non-profit corporation.
V. “Medical Staff Member Referral Team” means the team consisting of the Hospital Medical Director, the President of the Medical Staff and the Chief Medical Officer that addresses concerns relating to impaired Members.
W. “Physician Health Committee” means the Physician Health Committee of the Medical Society of Delaware or other Committee designated by the Delaware State Board of Licensure and Discipline.
X. “Physician-in-Chief (Chief Medical Officer)” means a physician appointed to perform the duties described in these Bylaws.
Y. “Physician” means a person who holds a doctor of medicine (M.D.) or doctor of osteopathy (D.O.) degree.
Z. “Podiatrist” means a person who holds a doctor of podiatric medicine (D.P.M.) degree.
AA. “Policies and Procedures,” unless otherwise specified, means the Policies and Procedures of the Medical Staff.
BB. “Practitioner,” unless otherwise expressly limited, means any Physician, Podiatrist, Dentist or Oral Surgeon applying for or holding privileges in the Hospital.
CC. “Special Notice” means written notification sent by certified or registered mail, return receipt requested.
DD. Service line – Administrative structure of related services to facilitate patient care.
EE. “Peer Review Committee” means the group of Medical Staff Members formally convened by the Medical Executive Committee to review and evaluate the work of the Medical Staff.
FF. “Resident” means a physician in training receiving post-graduate level training through an ACGME accredited residency program.
Words used in these Bylaws shall be read as the masculine or feminine gender, and as the singular or plural, as the context requires. The captions and headings are for convenience only and are not intended to limit or define the scope or effect of any provision of these Bylaws.
C. CONDIFENTIALITY AND PEER REVIEW PROTECTIONS
Confidentiality: Actions taken and recommendations made pursuant to Article III and Article IV shall be treated as confidential in accordance with applicable legal requirements and such policies regarding confidentiality as may be adopted by the Hospital and the Medical Staff.
Reporting: Reports of actions taken pursuant to Article III and Article IV shall be made by the Chief Executive Officer or designee to such governmental agencies as may be required by law. The Nemours/Alfred I. duPont Hospital for Children shall disclose reports of actions taken pursuant to that reporting requirement to other health care organizations upon receipt of a formal request and authorization form to release the information signed by the affected physician.
Records: All records and other information generated in connection with and/or as a result of professional review activities shall be confidential, and each individual or Committee member participating in such review activities shall make no disclosures of any such information except as authorized, in writing, by the Chief Executive Officer or designee or by legal counsel for the Hospital or as required by applicable law.
Breach of Confidentiality: Any breach of confidentiality by an individual or Committee member may result in a professional review action by the Medical Staff, and/or may result in appropriate legal action to ensure that confidentiality is preserved, including application to a court of law for injunctive or other relief.
Peer Review Protection: All minutes, reports, recommendations, communications, and actions made or taken pursuant to Article III and Article IV are deemed to be covered by the provisions of Title 24, Chapter 17 of the Delaware Code, or the corresponding provisions of any subsequent federal or state statute providing protection to peer review or related activities. Furthermore, the committees and/or panels charged with making reports, findings, recommendations, or investigations pursuant to Article IV shall be considered to be acting on behalf of the Hospital when engaged in such professional review activities and thus shall be deemed to be “professional review bodies” as that term is defined in the Health Care Quality Improvement Act of 1986. All Members agree to execute such documentation to confirm the confidential nature of the matters referred to in this section as may be developed from time to time by the Medical Executive Committee and approved by the Managers.
D. CONFLICT OF INTEREST PRINCIPLES
Members of the Medical Staff shall conduct themselves with integrity, honesty and fairness to avoid any conflict between personal interests and the interests of Nemours/Alfred I. duPont Hospital for Children. Members shall not use their position with Nemours and/or the Alfred I. duPont Hospital for Children to influence decisions in which they know, or have reason to believe, that they have a financial interest.
E. INDEMNIFICATION WHEN PERFORMING CREDENTIALING AND PEER REVIEW FUNCTIONS
Members of the Medical Executive Committee, Medical Staff Credentials Committee, and Medical Staff Peer Review Committee will be immune under Title 24, Chapter 17, Section 1768 of the Delaware Code from any claim, suit, liability, damages, or any other recourse, civil or criminal, arising from any Peer Review Committee act, omission, proceeding, decision, or determination undertaken or performed, or from any recommendation made, so long as the member and/or Committee acted in good faith and without gross or wanton negligence in carrying out the responsibility, authority, duties, powers, and privileges of the officers conferred by law upon them. They and all Medical Staff members functioning as their designees shall be indemnified by Nemours to the fullest extent permitted by law.
F. DELEGATION OF FUNCTIONS
The Medical Staff of the Nemours/Alfred I. duPont Hospital for Children authorizes the Medical Executive Committee to act on its behalf in the day-to-day matters relating to: