Medical Staff Bylaws, Part D
MEDICAL STAFF APPOINTMENT
I. APPOINTMENT TO THE MEDICAL STAFF
PART A. QUALIFICATIONS FOR APPOINTMENT
1. Appointment to the medical staff is a privilege, which shall be extended only to professionally competent physicians, podiatrists, and dentists who continuously meet the qualifications, standards and requirements set forth herein. All persons practicing medicine and dentistry at Hospital, unless excepted by specific provisions of these bylaws, must first have been appointed to the medical staff.
2. Any Physician or independent/dependent practitioner under sanction by any Medicare/
Medicaid or federally funded healthcare programs are ineligible for staff membership or
reappointment.
3. Only physicians, podiatrists, and dentists currently licensed to practice in the State of West Virginia, who can document their background, experience, training and demonstrated competence, their adherence to the ethics of their professions, their good reputation and character and their ability to work harmoniously with others sufficiently to convince Hospital that all patients treated by them in Hospital will receive a high quality of medical care and that Hospital and medical staff organization will be able to operate in an orderly manner, shall be qualified for appointment to the medical staff. The word "character" is intended to include the applicant's mental and emotional stability.
4. No physician, podiatrist, or dentist shall be entitled to appointment to the medical staff or to the exercise of particular clinical privileges in Hospital merely by virtue of the fact that he is duly licensed to practice medicine or dentistry in West Virginia or any other state, or that he is a member of any particular professional organization, or that he had in the past, or currently has, medical staff appointment or privileges in another hospital.
5. Neither shall any physician, podiatrist, or dentist be denied appointment on the basis of sex, race, creed, color, religious belief or national origin.
6. Acceptance of appointment of the medical staff shall constitute the agreement of the physician, podiatrist, or dentist that he will abide by the Principles of Medical Ethics of the American Medical Association, the Principles of Ethics of the American Osteopathic Association or the Code of Ethics of the American Dental Association, whichever is applicable, as well as the Ethical and Religious Directives for Catholic Health Facilities.
7. Persons holding appointments to the medical staff who have contractual or employment relationships with Hospital will be governed by the provisions of their contracts or terms of employment as well as these and Hospital's bylaws. However, since the parties have entered into a negotiated relationship, in the event of a conflict between the medical staff bylaws and the contractual or employment terms, the contractual or employment terms shall be controlling.
8. There is an approximate 50-mile distance limitation in which a physician can reside and practice in order to be a member of the medical staff. This applies to all categories of the staff with the exception of those physicians whom by contractual arrangement for exempted from this requirement, i.e. Telemedicine.
9. Members of the medical staff should be physicians, podiatrists, or dentists who are certified by a member board of the American Board of Medical Specialties or AOA or the American Dental Association, American Board of Podiatric Surgery, American Board of Podiatric Orthopedics and Primary Podiatric Medicine, who have satisfactorily completed a residence accredited by ACGME (Accreditation Council for Graduate Medical Education) or AOA or who have supplied evidence of training, skills and judgment equal to board eligibility requirements. Those physicians who finished medical school after July 1, 1975 must furnish documentation of residency training in their specialty; or in lieu of residency training, hold and maintain a current Board Certification in the afore mentioned Boards.
10. Physicians appointed to the medical staff after June 1, 2004, must meet Board eligibility requirements and must obtain Board certification in the afore mentioned boards within 5 years of initial staff appointment or prior to expiration of board eligibility. Physicians appointed to the Medical Staff after January 1, 2010 must be board certified at the time of application or meet board eligibility requirements and obtain the afore mentioned board certification within 5 years of residency training. Appointees who do not obtain Board Certification prior to the expiration of their eligibility or grace period as defined above, will forfeit medical staff membership at the end of the current reappointment period and are deemed ineligible for reappointment to the medical staff. Physicians granted Medical Staff membership prior to June 1, 2004 are exempt from this requirement and are granted grandfather status.
11. Physicians appointed under the Board Certification requirements must maintain certification in order to maintain medical staff membership and/or specific clinical privileges. Failure to maintain board certification or any lapse or revocation of Board Certification may result in termination of specific privileges and/or medical staff membership. Physicians with more than 20 years service or within five years of anticipated retirement may request exemption through the Medical Executive Committee for continued Board certification requirement.
12. NPDB shall be queried at the time of initial appointment, granting of initial clinical privileges and every two years thereafter. Licensure will be verified at the time of appointment, reappointment, request for additional privileges and at the time of expiration. This may be done through written process, web-site for via telephone communication with the appropriate state agency.
13. The Medical Staff Clinical privileging processes include medication prescription ordering as a granted privilege, when appropriate to the practitioner’s license and as defined by DEA, state narcotics control bureau and as defined by hospital policies and/or protocols.
PART B. CONDITIONS OF APPOINTMENT
Section 1. Duration of (Initial) Provisional (Active-Courtesy) Appointment:
All initial appointments to the medical staff and all initial clinical privileges, unless otherwise provided by the Board, shall be provisional for a period of one year, not to exceed two years, from the date of the appointment. During the term of this provisional appointment, the person receiving the provisional appointment shall be evaluated by the chief of the clinical department(s) to which he is assigned and by the relevant committees of the medical staff as to his clinical competence and as to his general behavior and conduct in Hospital. Provisional clinical privileges shall be adjusted to reflect clinical competence at the end of the provisional period or sooner as warranted. Appointment after the provisional period shall be conditioned on an evaluation of the factors to be considered for reappointment set forth in Article II, Part A, Section 2 herein to Article II, Part A of the Bylaws.
Section 2. Rights and Duties of Appointees
Appointment to the medical staff shall confer on the appointee only such clinical privileges as have been granted by the Board and shall require that each appointee assume such reasonable duties and responsibilities as the Board or medical staff shall require.
Section 3. Condition to Maintain Membership
(a) Each medical staff member must keep the hospital and credentials committee informed of his status with regard to all information pertinent to evaluate whether any question has arisen regarding his practice or professional actions or skills, and must also keep the hospital and Executive Committee informed of matters related to compliance with requirements as to malpractice insurance, licensure and any other requirements of staff membership. Therefore, staff members must provide, and any applicant accepting application agrees to provide, reasonably timely notice of the following:
1) any change in, including the loss surrender, or expiration of any medical, dental, osteopathic or podiatric license in any state, or restriction regarding the same.
2) any change of status (including loss, surrender, restriction or revocation of) related to approval to participate in the Medicare or Medicaid programs;
3) any change in status (including loss surrender, restriction or revocation) related the right to prescribe any controlled substances;
4) any change in status (including change of insurer, change in limits or loss in whole or part) related to medical malpractice insurance.
5) any action taken by another healthcare entity wherein the practitioner’s status and/or clinical privileges have been restricted, revoked, withdrawn, subject to monitoring or supervision including full disclosure and/or explanation of the contributing factors to that action, excluding actions taken for medical records infractions.
6) Any arrest or pending settlement of criminal, felony or misdemeanor charges, with the exclusion of minor traffic violations.
(b) Upon request by the hospital or any staff officer, or any member of the credentials or Executive Committee, every staff member must provide any information requested, including copies of licenses, certificate of insurance or any other information or material necessary to allow the hospital and medical staff to assess current compliance with any of the requirements of this policy or any part of the bylaws of the medical staff.
Section 4. Malpractice Insurance
Medical staff members must maintain malpractice insurance in such amount as the Board may establish but not less than $1,000,000 per occurrence and $3,000,000 aggregate, with respect to any period during which the staff member has privileges to practice at the hospital. Thus, if a staff member changes insurers or otherwise makes contractual changes in his insurance that might create a gap in coverage for a period during which the staff member had privileges, he shall obtain extended coverage (whether denominated, “tail,” “nose” or otherwise) to prevent the existence of any gap in coverage. To meet the requirements of this section the malpractice insurance must be issued by a company licensed to provide such insurance in the State of West Virginia or meet the requirements defined by state statute for self-funded trust in accordance with hospital policy and procedure. Determination of the acceptability of such trust will be determined by the Board on a case-by-case basis.
Section 5. Current Licensure:
Any appointee to the medical staff must maintain current state licensure as a condition of appointment. Licensure will be verified at the time of appointment, reappointment, request for additional privileges and expiration. Any physician who fails to renew state licensure will automatically surrender medical staff membership and privileges immediately upon expiration of the current licensure.
PART C. APPLICATION FOR INITIAL APPOINTMENT AND CLINICAL PRIVILEGES
Section 1. Information
Applications for appointment to the medical staff shall be made in writing and shall be submitted on forms prescribed by the Credentials Committee in compliance with West Virginia State Statute.
The following constitutes a complete application:
1. All blanks on the application form are completely filled in and any additional necessary explanations provided, and
2. Verification of required information is complete; that is, all information necessary to properly evaluate an applicant's qualifications has been received and is consistent with the information provided on the application form; and
3. Responsive letters of reference and information from past hospitals and other affiliations have been received, including letters from department chairmen and other physicians who have worked with or observed the applicant.
Applications must be completed within six (6) months of filing the initial application form. If applicant continues to have an incomplete application after reasonable requests by the hospital to complete it, processing of the application will cease. All application fees are non-refundable when the application is withdrawn, retired, rejected, etc.
The application shall require detailed information concerning the applicant's professional qualifications including:
(a) the names of at least three physicians or dentists, as appropriate, who have had extensive experience in observing and working with the applicant and who can provide adequate references pertaining to the applicant's relevant training and/or experience, professional competence and character;
(b) information as to whether applicant's medical staff appointment and/or clinical privileges have ever been revoked, suspended, reduced or not renewed at any other hospital or health care facility; and whether there has been voluntary or involuntary termination of medical staff membership, or voluntary or involuntary limitation, reduction or loss of clinical privileges at another hospital or health care facility;
(c) information as to whether his membership in local, state or national medical societies or his license or registration to practice any profession in any state, or his narcotic license or registration has ever been voluntarily or involuntarily suspended, terminated or relinquished. The submitted application shall include a copy of the applicant's current license to practice, as well as his narcotics license;
(d) information as to sanction or disciplinary action or current investigation by a hospital, state licensing agency or other professional health care organization;
(e) information indicating the applicant has currently in force professional liability insurance coverage in the amount required by these bylaws;
(f) information concerning the applicant's malpractice experience, including any final judgments or settlements by physician in excess of $25,000;
(g) a consent to the release of information from his present and past malpractice insurance carriers;
(h) a request delineating the specific clinical privileges desired by the applicant;
(i) such other information as the Board may require; and
(j) a statement from applicant that he has no impairments that could prevent the performance, either with or without accommodation, of the essential functions of the position or the privileges the applicant seeks.
Section 2. Undertakings
Every application for staff appointment shall be signed by the applicant and shall contain:
(a) the applicant's specific acknowledgment of his obligation upon appointment to the medical staff to provide continuous care and supervision to all patients within Hospital for whom he has responsibility;
(b) his agreement to abide by all such bylaws, policies and directives of Hospital, including all such bylaws, rules and regulations of the medical staff as shall be in force during the time he is appointed to the medical staff of Hospital;
(c) his agreement to accept committee assignments and such other reasonable duties and responsibilities as shall be assigned to him by the Board and the medical staff;
(d) a statement that the applicant has read a copy of such bylaws of Hospital and bylaws, rules and regulations of the medical staff as are in force at the time of his application and that he has agreed to be bound by the terms thereof in all matters relating to consideration of his application without regard to whether or not he is granted appointment to the medical staff and/or clinical privileges;