LOURDES MEDICAL CENTER
OF
BURLINGTON COUNTY
MEDICAL STAFF
BYLAWS
TABLE OF CONTENTS
DISCLAIMERS 9
ARTICLE I. INTRODUCTION 10
ARTICLE II. DEFINITIONS 11
ARTICLE III. NAME 16
ARTICLE IV. PURPOSE 16
ARTICLE V. MEDICAL STAFF MEMBERSHIP 17
5.1 NECESSITY FOR MEMBERSHIP 17
5.2 GENERAL MEMBERSHIP QUALIFICATIONS – MAINTENANCE OF BOARD CERTIFICATION 17
5.2.1 Required General Membership Qualifications 17
5.2.2 Failure to Meet General Membership Qualifications 18
5.3 SPECIFIC QUALIFICATIONS 18
5.3.1 Physicians 18
5.3.2 Dentists and Oral Surgeon 18
5.3.3 Podiatrists 19
5.3.4 QP 19
5.4 NONDISCRIMINATION 19
5.5 EFFECT OF OTHER AFFILIATIONS 19
5.6 DURATION OF APPOINTMENT TO THE MEDICAL STAFF 19
ARTICLE VI. MEDICAL STAFF CATEGORIES 20
6.1 THE ACTIVE MEDICAL STAFF 20
6.1.1. Active Medical Staff Qualifications 20
6.1.2. Active Medical Staff Rights 21
6.2 THE AFFILIATE MEDICAL STAFF 22
6.2.1 Affiliate Medical Staff Appointment 22
6.2.2 Affiliate Medical Staff Rights 22
6.2.3. Affiliate Medical Staff Responsibilities 22
6.3 CONSULTANT MEDICAL STAFF 23
6.3.1 Consultant Medical Staff Qualifications 23
6.3.2 Consultant Medical Staff Rights 23
6.3.3 Consultant Medical Staff Responsibilities 23
6.4 THE EMERITUS MEDICAL STAFF 24
6.4.1 Emeritus Medical Staff Qualifications 24
6.4.2 Emeritus Medical Staff Rights 24
6.4.3 Emeritus Medical Staff Responsibilities 24
6.4.4 Removal of Emeritus Medical Staff 24
6.5 HOUSE MEDICAL STAFF 24
6.5.1 House Staff Qualifications 25
6.5.2 House Medical Staff Rights 25
6.5.3 House Medical Staff Responsibilities 25
6.6 DEPENDENT ALLIED HEALTH PRACTITIONERS 25
6.6.1 Dependent Allied Health Practitioner Qualifications 25
6.6.2 Dependent Allied Health Practitioner Categories 26
6.6.3 Dependent Allied Health Practitioner Rights 26
6.6.4 Dependent Allied Health Practitioner Responsibilities 26
6.6.5 Relationship between Physicians and Allied Health Practitioners 27
6.7 Military Medicine Staff 27
6.8 Administrative Practitioner 27
6.9 GENERAL REQUIREMENTS FOR MEDICAL STAFF MEMBERSHIP 28
6.10 LEAVES OF ABSENCE 32
6.10.1 General 32
6.10.2 Medical Leave of Absence 33
6.10.3 Military Leave of Absence 35
6.11 MODIFICATION OF MEMBERSHIP 35
6.12 HARASSMENT PROHIBITED 36
6.12.1 General Prohibition 36
6.12.2 Prohibited Activities 36
6.12.3 Sexual Harassment 36
6.12.4 Handling Harassment Allegations 37
ARTICLE VII. MEDICAL STAFF APPOINTMENT & REAPPOINTMENT 37
7.1 GENERAL 37
7.2 PROCEDURE FOR APPLICATION 37
7.3 APPLICANT’S RESPONSIBILITIES 40
7.4 CONSIDERATION OF APPLICATION 41
7.5 REAPPOINTMENT TO THE MEDICAL STAFF 45
7.5.1 Continuing Qualifications for Membership 47
7.6 AUTHORITY FOR DOCUMENTATION AND VERIFICATION SERVICES 48
ARTICLE VIII. PRIVILEGES 49
8.1 PRIVILEGES EXTENDED TO THE MEDICAL STAFF 49
8.2 PROVISIONAL STATUS OF PRIVILEGES 49
8.3 ADDITIONAL PRIVILEGES 50
8.4 TEMPORARY PRIVILEGES 51
8.4.1 Temporary Privileges for Urgent Patient Care Need 51
8.4.2 Temporary Privileges pending Medical Executive and Board 51
8.5 DENIAL OR TERMINATION OF TEMPORARY PRIVILEGES 52
8.6 LOCUM TENENS 53
8.7 PROCTORING 53
8.7.1. General 53
8.7.2 Failure to Obtain Proctoring Certification 54
8.8 EMERGENCY PRIVILEGES 54
8.9 PRIVILEGES FOR NEW PROCEDURES 54
8.9.1 Recommendation for New Procedures 54
8.9.2 Criteria for Granting Privileges 54
8.10 PRIVILEGING OF LICENSED INDEPENDENT PRACTITIONERS 55
DURING DISASTERS 55
8.10.1 Disaster Plan – Disaster Privileges 55
8.10.2 Procedures for Granting Disaster Privileges 55
8.10.3 Oversight 56
8.11 TELEMEDICINE 56
8.11.1 Telemedicine Privileges 56
8.12 Clinical Privileges Crossing Specialty Lines 57
8.12.1 Criteria for Granting Privileges 57
ARTICLE IX. PEER REVIEW OF MEDICAL STAFF MEMBER CONDUCT 58
9.1 Collegial Intervention 58
9.2 Investigations 60
9.2.1 Initial Review: 60
9.2.2 Initiation of Investigation 60
9.2.3 Investigative Procedure 61
9.2.4 Executive Committee Action 64
9.3 Precautionary Suspension or Restriction of Clinical Privileges 66
9.3.1 Grounds for Precautionary Suspension or Restriction 66
9.3.2 Executive Committee Procedure: 66
9.3.3 Care of Patients: 67
9.4 AUTOMATIC SUSPENSION 68
9.4.1 General 68
9.4.2 Automatic Suspension due to Change in License Status 68
9.4.3 Automatic Suspension due to Change in Drug Enforcement Administration and or CDS Certificate Status 68
9.4.4 Automatic Suspension due to Medicare and Medicaid Sanctions 68
9.4.5 Automatic Suspension due to Lapse in Professional Liability Insurance 68
9.4.6 Automatic Suspension Medical Records Violation 69
9.4.7 Automatic Suspension due to Failure to Pay Dues and/or Fees 69
9.4.8 Automatic Suspension Related to Conviction of a Felony 70
9.4.9 Notice of Automatic Suspension; Transfer of Patients 70
ARTICLE X. FAIR HEARINGS AND APPELLATE REVIEWS 70
10.1 PREAMBLE 70
10.1.1 Exhaustion of Remedies 70
10.1.2 Definitions 70
10.1.3 Timely Completion of Process 71
10.1.4 Final Action 71
10.2 GROUNDS FOR FAIR HEARING 71
10.3 REQUESTS FOR FAIR HEARING; APPOINTMENTS 72
10.3.1 Notice of Action or Proposed Action 72
10.3.2 Request of Fair Hearing 72
10.3.3 Time and Place for Fair Hearing 72
10.3.4 Fair Hearing Committee 73
10.3.5 The Hearing Officer 73
10.3.6 Failure to Appear 73
10.3.7 Postponements and Extensions 73
10.4 FAIR HEARING PROCEDURE 74
10.4.1 Pre-hearing Procedure 74
10.4.2 Representation 77
10.4.3 Record of the Fair Hearing 77
10.4.4 Rights of the Parties 78
10.4.5 Miscellaneous Rules 78
10.4.6 Burdens of Presenting Evidence and Proof 79
10.4.7 Adjournment and Conclusion 79
10.4.8 Basis for Decision 79
10.4.9 Decision of Fair Hearing Committee 79
10.5 APPEAL 80
10.5.1 Time for Appeal 80
10.5.2 Grounds for Appeal 80
10.5.3 Time, Place and Notice 80
10.5.4 Appeal Board 80
10.5.5 Appeal Procedure 81
10.5.6 Decision 81
10.5.7 Right to One Fair Hearing 82
10.6 EXCEPTIONS TO FAIR HEARING RIGHTS 82
10.6.1 Appropriateness of Exclusive Contracts 82
10.7 NATIONAL PRACTITIONERS DATA BANK REPORTING 84
10.8 DISPUTING REPORT LANGUAGE 85
ARTICLE XI. ELECTED OFFICERS OF MEDICAL STAFF 85
11.1 ELECTED OFFICERS 85
11.1.1 Identification 85
11.1.2 Qualifications 85
11.1.3 Nominations 85
11.1.4 Elections 86
11.1.5 Term of Elected Office 86
11.1.6 Vacancies in Elected Office 86
11.1.7 Recall of Officers 86
11.2 DUTIES OF OFFICERS 87
11.2.1 President 87
11.2.2 Vice President 87
11.2.3 Secretary 88
11.2.4 Treasurer 88
11.3 SPECIAL APPOINTMENTS 88
ARTICLE XII. MEETINGS 88
12.1 MEETINGS OF THE MEDICAL STAFF 88
12.1.1 Semi-Annual Meetings 88
12.1.2 Special Meetings 89
12.1.3 Quorum 89
12.1.4 Agenda 89
12.1.5 Special Meeting Agenda 90
12.1.6 Direct Access to Board 90
12.2 MINUTES 90
12.3 ATTENDANCE REQUIREMENTS 90
ARTICLE XIII. DUES, ASSESSMENTS, PROCESSING FEES, BUDGET AND DONATIONS 91
13.1 DUES 91
13.2 ASSESSMENTS 91
13.3 PROCESSING FEES 91
13.4 BUDGET 91
13.5 DONATIONS 91
ARTICLE XIV. VOTING 92
14.1 VOTING 92
14.1.1 Who May Vote 92
14.1.2 The Voting Process 92
ARTICLE XV. COMMITTEES 92
15.1 DESIGNATION 92
15.2 GENERAL PROVISIONS 92
15.2.1 Terms of Committee Members 92
15.2.2 Removal 93
15.2.3 Original Appointments 93
15.2.4 Vacancies 93
15.2.5 Compliance with Standards 93
15.3 EXECUTIVE COMMITTEE 93
15.3.1 Composition 93
15.3.2 Duties 94
15.3.3 Regular and Special Meetings 95
15.3.4 Committee Chair 96
15.3.5 Executive Committee Minutes 96
15.4 CREDENTIALS COMMITTEE 96
15.4.1 Composition 96
15.4.2 Duties 96
15.4.3 Meetings 97
15.5 BYLAWS COMMITTEE 97
15.5.1 Composition 97
15.5.2 Meetings 97
15.5.3 Duties 97
15.6 INFECTION CONTROL COMMITTEE 97
15.6.1Composition 97
15.6.2 Meetings 97
15.6.3 Duties 98
15.7 PHARMACY AND THERAPEUTICS COMMITTEE 98
15.7.1 Composition 98
15.7.2 Meetings 98
15.7.3 Duties 98
15.8 CANCER COMMITTEE 99
15.8.1 Composition 99
15.8.2 MEETINGS 99
15.8.3 DUTIES 99
15.9 PROFESSIONAL AFFAIRS COMMITTEE 100
15.9.1 Composition 100
15.9.2 Meetings 100
15.9.3 Duties 100
15.10 OSTEOPATHIC GRADUATE MEDICAL EDUCATION COMMITTEE 101
15.10.1 Composition 101
15.10.2 Duties 101
15.10.3 Meetings, Reports and Recommendations 102
15.11 ALLOPATHIC GRADUATE MEDICAL EDUCATION COMMITTEE 102
15.11.1 Composition 102
15.11.2 Duties 102
15.11.3 Meetings, Reports and Recommendations 103
15.12 MEDICAL STAFF PERFORMANCE IMPROVEMENT COMMITTEE 103
15.12.1 Composition 103
15.12.2 Meetings 104
15.12.3 Duties 104
15.13 CONTINUING MEDICAL EDUCATION COMMITTEE 104
15.13.1 Composition 104
15.13.2 Meetings 104
15.13.3 Duties 105
ARTICLE XVI. CLINICAL ORGANIZATION OF THE MEDICAL STAFF 105
16.1 ORGANIZATION OF CLINICAL DEPARTMENTS AND SECTIONS 105
16.2 CURRENT DEPARTMENTS AND SECTIONS 105
16.3 ASSIGNMENT TO DEPARTMENTS AND SECTIONS 106
16.4 FUNCTIONS OF DEPARTMENTS 106
16.4.1 Preamble 106
16.4.2 Department Emergency Call 107
16.5 FUNCTIONS OF SECTIONS 108
16.6 DEPARTMENT CHAIRS 108
16.6.1 Qualifications 108
16.6.2 Selection 108
16.6.3 Term of Office 109
16.6.4 Removal 109
16.6.5 Duties 109
16.7 SECTION CHIEFS 110
16.7.1 Qualifications 111
16.7.2 Selection 111
16.7.3 Term of Office 111
16.7.4 Removal 111
16.7.5 Duties 111
ARTICLE XVII. GENERAL PROVISIONS 111
17.1 RULES AND REGULATIONS 111
17.2 ACCEPTANCE OF PRINCIPLES 112
17.3 NOTICES 112
17.4 PROFESSIONAL LIABILITY INSURANCE 112
17.4.1 Professional Liability Insurance 113
17.4.2. Disposition and/or Final Judgment 113
17.5 DISCLOSURE OF INTEREST 113
17.6 NOMINATION OF MEDICAL STAFF REPRESENTATIVES 113
17.7 CONFLICTS OF INTEREST 113
ARTICLE XVIII. AMENDMENT OF BYLAWS 114
18.1 PROCEDURE 114
18.2 ACTION ON BYLAW CHANGE 115
18.3 APPROVAL 115
18.4 URGENT AMENDMENTS; PROCEDURES FOR ADOPTION 115
18.5 EXCLUSIVITY 116
18.6 SUCCESSOR IN INTEREST/AFFILIATIONS 116
18.6.1 Successor in Interest 116
18.6.2 Affiliations 116
ARTICLE XIX CONFIDENTIALITY AND IMMUNITIES 116
19.1 CONFIDENTIALITY OF INFORMATION 116
19.1.1 General 116
19.2 IMMUNITY FROM LIABILITY 117
19.2.1 For Action Taken 117
19.2.2 for Providing Information 117
19.3 ACTIVITIES AND INFORMATION COVERED 117
19.4 RELEASES 118
19.5 INDEMNIFICATION 118
ARTICLE XX. ADOPTION 118
DISCLAIMERS
· The captions or headings in these Bylaws and Other Related Documents are for convenience only and are not intended to limit or define the scope or effect of any provision of these Bylaws and Other Related Documents.
· For the purposes of these Bylaws and Other Related Documents, the term “his” or “her” as well as any other title or pronoun descriptive of gender shall not be construed to discriminate against either gender.
· For the purpose of these Bylaws and Other Related Documents, the term “Patient Care” is inclusive of both inpatient and outpatient care, provided such care is delivered under the auspice of the Medical Center as defined within these Bylaws and Other Related Documents.
BYLAWS
ARTICLE I. INTRODUCTION
WHEREAS, LOURDES MEDICAL CENTER OF BURLINGTON COUNTY (“LMCBC”) is a non-profit corporation organized under the laws of the State of New Jersey; and
WHEREAS, its mission is that of being a healing presence within the communities it serves in that it treats all patients with respect and is sensitive to the physical, emotional and spiritual needs of its patients, their families, the community and each other, it strives for excellence in our responsibility to provide quality health care services that are both caring and compassionate, and promotes healthy communities to seek ways to assure easy access to all, especially those most in need; and
WHEREAS, it is recognized that the Medical Staff is responsible to the Executive Committee or its Designee, the Professional Affairs Committee, and the LMCBC Board for the quality of professional care performed at LMCBC;
THEREFORE, the Practitioners who practice in LMCBC hereby organize themselves into a Medical Staff in conformity with these Bylaws and Other Related Documents.
ARTICLE II. DEFINITIONS
1. ACCESS
Term used to refer to the granting of Privileges to community Practitioners to utilize Medical Center-based services or laboratories.
2. ACTIVE MEDICAL STAFF
The Active Medical Staff shall consist of Physicians, Dentists, Oral Surgeons, and Podiatrists, each of whom shall meet the General and Specific Medical Staff qualifications set forth in Article V of these Bylaws and regularly admits patients to the Medical Center or is otherwise regularly involved in the care of patients at the Medical Center; Any Physician who is a member of the Active Medical Staff, other than one who practices in the Department of Primary Care, shall have completed a residency in their specialty, as recognized and approved by the Department within which one practices.
3. Administrative Practitioner
A practitioner employed by the Medical Center in a purely administrative capacity with no clinical duties or privileges and is subject to the regular personnel policies of the Medical Center and to the terms of any contract employment.
4. AFFILIATE MEDICAL STAFF
The Affiliate Medical Staff shall consist of Physicians, Dentists, Oral Surgeons, and Podiatrists, each of whom shall meet the General and Specific Medical Staff Qualifications set forth in Article V of these Bylaws who desire to be associated with Lourdes Medical Center of Burlington County but do not intend to admit or care for patients. The primary purpose of the Affiliate Staff is to promote professional and educational opportunities, including continuing medical education, and to permit these individuals to access Lourdes Medical Center of Burlington County’s services for the patients by referral of patients to Active Staff members for admission and care. Members in this category are exempt from board certification.
5. ADMITTING PRIVILEGES
The right of Medical Staff Members to admit their patients to the Medical Center.
6. QUALIFIED PRACTITIONER (QP)
An individual other than a Physician, Dentist, Oral Surgeon or Podiatrist who is licensed, certified or registered in the Applicant’s profession or occupation by the State of New Jersey and whose practice in the fields of patient care, public health, and/or health research consists of providing services under specific privileges as defined by the
the department to which they are assigned and who provides services under the supervision of a Physician.
7. APPLICANT
An individual who may meet the requirements for membership to a category of the Medical Staff and makes an application for membership to such category.
8. BOARD
The Board of Trustees of LMCBC.
9. CHIEF EXECUTIVE OFFICER (“CEO”)
The individual appointed by the Board to act on its behalf in the overall executive management of the Medical Center.
10. CLINICAL PRIVILEGES (“PRIVILEGES”)
Permission granted to a Practitioner to render specific diagnostic, therapeutic, medical, dental or surgical services within the Medical Center, as set forth in these Bylaws and Other Related Documents.
11. CONSULTANT MEDICAL STAFF
A collection of Practitioners who are Physicians, Dentists, Oral Surgeons, and Podiatrists each of whom meets the General and Specific Medical Staff qualifications set forth in Article V of these Bylaws and who, because of their highly specialized skills, have been requested to render assistance to a particular clinical department.
12. DENTIST or Oral Surgeon
An individual who is licensed by the State of New Jersey Board of Dentistry.
13. DESIGNEE
Any reference to an individual who has been granted authority to act by an authorized body or entity under these Bylaws and Other Related Documents.