UNIVERSITYHOSPITAL
MEDICAL STAFF BYLAWS
Approved by the Governing Body
December 20, 2007
Clarification: 9/09
UNIVERSITYHOSPITAL
AUGUSTA, GEORGIA
TABLE OF CONTENTS
PAGE
ADOPTION1
PREAMBLE2
DEFINITIONS3
ARTICLE I:NAME5
ARTICLE II:PURPOSES AND RESPONSIBILITIES6
ARTICLE III:MEDICAL STAFF MEMBERSHIP8
SECTION 1 - GENERAL8
SECTION 2 - SPECIFIC QUALIFICATIONS8
SECTION 3 - NO ENTITLEMENT TO MEMBERSHIP9
SECTION 4 - NON-DISCRIMINATION POLICY9
SECTION 5 - CONDITIONS AND DURATION OF
APPOINTMENT9
ARTICLE IV:CATEGORIES OF THE MEDICAL STAFF11
SECTION 1 - THE MEDICAL STAFF11
SECTION 2 - THE ACTIVE MEDICAL STAFF11
SECTION 3 - THE SENIOR ACTIVE MEDICAL STAFF11
SECTION 4 - THE COURTESY MEDICAL STAFF12
SECTION 5 - THE PODIATRIC STAFF12
SECTION 6 - THE CONSULTING MEDICAL STAFF13
SECTION 7 - THE PROVISIONAL MEDICAL STAFF13
SECTION 8 - THE HONORARY MEDICAL STAFF14
SECTION 9 - THE ASSOCIATE MEDICAL STAFF15
ARTICLE V:LEAVE OF ABSENCE16
SECTION 1 - REQUESTS FOR LEAVE OF ABSENCE16
ARTICLE VI:PROCEDURES FOR APPOINTMENT AND
REAPPOINTMENT17
SECTION 1 - BASIC RESPONSIBILITIES17
SECTION 2 - BURDEN OF PROVIDING
INFORMATION19
SECTION 3 - APPLICANT'S AUTHORIZATION19
SECTION 4 - APPLICATION AND PROCEDURE FOR
INITIAL APPOINTMENT21
SECTION 5 - APPLICATION AND PROCEDURE
FOR REAPPOINTMENT27
TABLE OF CONTENTS
PAGE 2
PAGE
ARTICLE VII:CLINICAL PRIVILEGES
SECTION 1 - GENERAL 33
SECTION 2 - CLINICAL PRIVILEGES FOR DENTISTS 35
SECTION 3 - CLINICAL PRIVILEGES FOR
PODIATRISTS35
SECTION 4 – TELEMEDICINE PRIVILEGES36
SECTION 5 - INTERNS AND RESIDENTS37
SECTION 6 - PROCEDURE FOR REQUESTING
ADDITIONAL PRIVILEGES37
SECTION 7 - VOLUNTARY RELINQUISHMENT
CLINICAL PRIVILEGES38
SECTION 8 - PROCEDURE FOR TEMPORARY
PRIVILEGES39
SECTION 9 - EMERGENCY CLINICAL PRIVILEGES41
SECTION 10 - DISASTER CLINICAL PRIVILEGES41
ARTICLE VIII:STRUCTURE OF THE MEDICAL STAFF44
SECTION 1 - OFFICERS OF THE MEDICAL STAFF 44
SECTION 2 - TERM OF OFFICE 44
SECTION 3 - ELECTION OF OFFICERS 44
SECTION 4 - DUTIES OF OFFICERS 45
SECTION 5 - REMOVAL OF OFFICERS 46
SECTION 6 - VACANCIES IN OFFICE 46
ARTICLE IX:CLINICAL DEPARTMENTS47
SECTION 1 - CLINICAL DEPARTMENTS,
DIVISIONS AND SECTIONS 47
SECTION 2 - ORGANIZATION OF DEPARTMENTS 49
SECTION 3 - ORGANIZATION OF DIVISIONS AND
SECTIONS 53
ARTICLE X:COMMITTEES 54
SECTION 1 - STANDING COMMITTEES 54
SECTION 2 - DUTIES/RESPONSIBILITIES OF
STANDING COMMITTEES 54
SECTION 3 - COMMITTEES FOR SPECIAL SERVICES
AND/OR FUNCTIONS 54
SECTION 4 - MANAGERIAL COMMITTEES 55
SECTION 5 - EXECUTIVE COMMITTEE 55
ARTICLE XI:MEETINGS57
SECTION 1 - GENERAL MEDICAL STAFF MEETINGS 57
SECTION 2 - SPECIAL MEDICAL STAFF MEETINGS 57
SECTION 3 - QUORUM 57
TABLE OF CONTENTS
PAGE 3
PAGE
ARTICLE XII:RULES OF ORDER58
ARTICLE XIII:RULES AND REGULATIONS OF THE MEDICAL
STAFF 59
SECTION 1 - ADOPTION AND MODIFICATION 59
SECTION 2 - FINAL APPROVAL BY THE
GOVERNING BODY 61
SECTION 3 - DISAGREEMENT AND
CONTROVERSIES 61
SECTION 4 – POLICIES AND PROCEDURES
OF THE MEDICAL STAFF 62
SECTION 5 – FINAL APPROVAL BY THE
GOVERNING BODY OF POLICES
AND PROCEDURES 62
ARTICLE XIV:BYLAWS REVIEW AND AMENDMENTS63
SECTION 1 - REVIEW OF BYLAWS 63
SECTION 2- AMENDMENT OF BYLAWS 63
ARTICLE XV:NOMINATIONS TO THE GOVERNING BODY64
ARTICLE XVI:NOMINATIONS TO THE RICHMONDCOUNTY
HOSPITAL AUTHORITY 65
ARTICLEXVII:RULES OF CONSTRUCTION66
ARTICLE XVIII:CORRECTIVE ACTION67
SECTION 1 - CIRCUMSTANCES REQUIRING
PEER REVIEW 67
SECTION 2 - PRECAUTIONARY SUSPENSION
OF CLINICAL PRIVILEGES 70
SECTION 3 - AUTOMATIC VOLUNTARY
RELINQUISHMENT OF PRIVILEGES 71
ARTICLE IXX:HEARING AND APPEAL RIGHTS76
SECTION 1 - RIGHT TO HEARING 76
SECTION 2 - INITIATION OF APPELLATE REVIEW 77
SECTION 3 - FAIR HEARING PLAN 77
SECTION 4 - GOVERNING BODY FINAL ACTION 78
SECTION 5 - NUMBER OF HEARINGS AND REVIEWS 78
SECTION 6 - MEMBER'S PEER REVIEW FILE 78
SECTION 7 - IMMUNITY 79
UNIVERSITYHOSPITAL
Augusta, Georgia
1
ADOPTION
(A)These Medical Staff Bylaws are adopted and made effective upon approval of the Board
of Trustees of University Health Services, Inc., superseding and replacing any and all
previous Medical Staff Bylaws, and henceforth all activities and actions of the Medical
Staff and of each individual exercising clinical privileges at UniversityHospital shall
be taken under and pursuant to the requirements of these Bylaws.
(B)The present Rules and Regulations of the Medical Staff are hereby readopted and placed
into effect insofar as they are consistent with these Bylaws, until such time as they are
amended in accordance with the terms of these Bylaws.
Adopted by the Medical Staff on: 11/13/2007
______
Approved by the Board of Trustees on: 12/20/2007
______
Words used in this document shall be read as the masculine or feminine gender, and as the singular or plural, as the content requires. The captions or headings are for convenience only and are not intended to limit or define the scope or effect of any provision of this document.
______
PREAMBLE
WHEREAS, the Board of Trustees of University Health Services, Inc. ("the Board") recognizes that each physician, dentist, and podiatrist appointed to the Medical Staff and/or privileged to attend patients at University Hospital has responsibility for the exercise of professional judgment in the care and treatment of patients; and
WHEREAS, the Board, in accordance with legal and accreditation requirements, has delegated to the Medical Staff through its departments and committees, the duties and responsibilities set forth in these Bylaws for supervising and monitoring the quality of care provided by physicians, dentists, podiatrists and others at the hospital, and for making recommendations concerning appointment, reappointment and clinical privileges; and
WHEREAS, the Medical Staff recognizes and accepts its role and responsibilities in the efforts of University Hospital to foster prevention, amelioration and cure of illness, disease and injury, and to provide or assist in providing medical education and continuing medical education for Medical Staff members, other health care professionals and residents, interns, medical students and nurses; and
WHEREAS, the cooperative efforts of the Medical Staff, the Administration and the Board are necessary to fulfill the hospital's obligation to its patients;
WHEREAS, it is the intention of UniversityHospital's medical staff to be in compliance with State and Federal laws and regulations; and
THEREFORE, to discharge those duties and responsibilities, and to provide for an orderly process concerning matters of election, meetings, duties and procedures, the officers, departments and committees of the Medical Staff as described in these Bylaws assume responsibility for fulfilling those duties and functions delegated to them by the Board, and in conformity with these bylaws organize themselves into a medical staff which is ultimately accountable to the Board of Trustees.
DEFINITIONS
For the purpose of these Bylaws, Rules and Regulations the following definitions shall apply:
(1)"Administration" means the non-medical personnel responsible for the operation of the hospital, including the Chief Executive Officer.
(2)“Allied Health Professional” (AHPs) shall be interpreted to include non-
physicians who work in the hospital under the supervision of the practitioner to
whom they are to be assigned. The appointment process and procedure are
addressed by a separate Medical Staff policy and not within these Bylaws.
(3)"Chief Executive Officer" means the individual appointed by the Governing Body to act in its behalf in the overall management of the hospital.
(4)“Chief Medical Officer” means the individual appointed to the position by the
Chief Executive Officer.
(5)"Clinical privileges" means the authorization of the Governing Body to provide specified diagnostic and/or therapeutic health care services independently at the hospital. An individual shall be granted clinical privileges in the hospital only in accordance with the process for delineation of such privileges as set forth in these Bylaws.
(6)"Department" refers to those clinical subsections of the Medical Staff enumerated in Article IX, Section 2.
(7)"Division" refers to those clinical subdivisions of the various departments
enumerated in Article IX, Section 3.
(8)"Executive Committee" means that committee of the Medical Staff with the duties and responsibilities delineated in Article X, Section 5.
(9)"Governing Body" means University Health Services, Inc. or a committee duly appointed by University Health Services, Inc.
(10)"Hospital" means the Board of Trustees of University Health Services, Inc. and the facilities operated by University Health Services, Inc. The hospital also means a "health care entity" as that term is defined under Sections 431(4) and 431(5) of the Health Care Quality Improvement Act.
(11)"House Staff" means those interns and residents who are receiving training at the hospital because of an affiliation with the training program of the Medical College of Georgia or any other recognized medical education institution.
(12)"Medical Staff" or "Practitioner" means all physicians, dentists, and podiatrists, who are privileged to attend patients at UniversityHospital and the facilities which it operates.
(13)"Physicians" shall be interpreted to include both doctors of medicine ("M.D.'s") and doctors of osteopathy ("D.O.'s").
(14)"Dentist" shall be interpreted to include a doctor of dental surgery (“D.D.S.’s) and doctor of dental medicine (“D.M.D.’s”).
(15)"Podiatrist" shall be interpreted to mean a doctor of podiatric medicine (D.P.M.’s).
(16)"Professional review activity" means a peer review activity of the hospital with respect to an individual staff member (a) to determine whether the staff member may have clinical privileges with respect to appointment; (b) to determine the scope and/or conditions of those clinical privileges and/or appointment; or (c) to change or modify such privileges and/or appointment.
(17)"Professional review action" means an action or recommendation which is taken or made in the conduct of professional peer review activity, which is based on the competence or professional conduct of a staff member, and which affects or may affect adversely the clinical privileges or appointment of the individual.
(18)"Section" refers to those organized subspecialties of the various departments whose administrative quality assurance activities are merged with the department to which that subspecialty belongs.
(19)"Suspension" means an adverse action resulting in a temporary loss of staff status or privileges which will end at the expiration of a specified period of time or upon the fulfillment of specified conditions.
(20)“Leadership Position” means any Medical Staff officer, Department Chief, Division Chief, Section Chief, or Committee Chair position as described in these Bylaws, any position with equivalent duties and responsibilities of any other hospital’s medical staff, and any medical school faculty leadership position, including any position equivalent to that of a dean, assistant or associate dean, faculty department chair, and assistant or associate faculty department chair.
(21)"Peer" means a professional health care provider as defined by Georgia law at Official Code of Georgia Section 31-7-131. The term peer includes, but is not limited to, any physician, dentist, podiatrist, psychologist, pharmacist, nurse, physical therapist, occupational therapist, or health care facility administrator licensed by the state of Georgia or any other state.
ARTICLE I: NAME
The name of this organization shall be the Medical Staff of University Hospital.
ARTICLE II: PURPOSES AND RESPONSIBILITIES
PURPOSES:
The purposes of the medical staff are:
to be the formal organizational structure through which the benefits of membership
on the staff may be obtained by individual practitioners and the obligations of staff membership may be fulfilled.
to serve as the primary means for accountability to the Board for the appropriateness of the quality of the medical care, treatment, and services provided to patients and appropriateness of the professional performance and ethical conduct of its members as well as of all designated professional personnel; and to strive to assure that a high level of patient care efficiently delivered, achievable by the state of the healing arts.
develop an organizational structure, reflected in Medical Staff Bylaws, Rules and Regulations, Policies and Procedures, and Protocols, that adequately defines the responsibility and when appropriate, the authority and accountability of each organizational component.
to provide a means through which the medical staff may participate in the hospital's policy-making and planning procedures.
RESPONSIBILITIES:
The responsibilities of the medical staff are to provide oversight and account for the activities of the organized medical staff includingfor the quality and appropriateness of patient care, treatment and services rendered by all practitioners and designated professional personnel, authorized to provide patient care services in the hospital through the following measures:
a credentials program, including mechanisms for the matching of clinical privileges to be exercised or of specified services to be performed with the certified credentials and current demonstrated performance of the applicant, staff member or affiliate.
providing continuing education that is relevant to patient care provided in the hospital as determined, to the degree reasonably possible, from the findings of quality related activities.
providing an effective utilization review program for allocation of medical/health services based upon patient-specific determinations of individual medical needs.
an organization structure that allows for continuous monitoring of patient care practices.
review and evaluation of the quality of patient care through a valid and reliable process.
to recommend to the Board of Trustees action with respect to appointments, reappointments, staff category, departmental and service assignments, clinical privileges, specified services for affiliates and corrective action.
to initiate and pursue corrective action with respect to practitioners, when warranted.
to initiate, develop, and approve bylaws, rules and regulations, and any amendments thereto to be forwarded to the Board for final approval, as well as seek compliance with these bylaws, rules and regulations and policies and procedures.
to assist in identifying community health needs and in setting appropriate institutional goals and implementing programs to meet those needs.
to provide leadership in performance improvement activities to improve quality of care, treatment, and services.
to provide leadership in activities related to patient safety.
to provide oversight in the process of analyzing and improving patient satisfaction.
to exercise the authority granted by these bylaws as necessary to adequately fulfill the foregoing responsibilities.
ARTICLE III: MEDICAL STAFF MEMBERSHIP
SECTION 1 - GENERAL
(A)Membership on the Medical Staff of University Hospital is a privilege that shall be extended only to professionally competent individuals who continuously meet the qualifications, standards and requirements set forth in these Bylaws, Rules and Regulations, and policies of the hospital.
(B)All processes described in this Article shall be subject to the confidentiality provisions described in these Bylaws.
SECTON 2 - SPECIFIC QUALIFICATIONS
Only physicians, dentists and podiatrists who satisfy the following threshold conditions as described in these Bylaws, shall be qualified for appointment to the Medical Staff:
The specific qualifications that apply to Associate Staff are addressed under Article IV, Section 9.
(A)are currently licensed to practice in this state;
(B)are located within the geographic service area of the hospital, close enough to provide timely care for their patients;
(C)possess current, valid professional liability insurance coverage in such form and in amounts satisfactory to the hospital as specified in the current medical staff policy;
(D)can document the following with sufficient adequacy to assure the medical staff and governing board that any patient treated by the physician in the hospital will be given a high quality of medical care:
(1)background, experience, education, training and demonstrated competence,
(2)adherence to the ethics of their profession,
(3)good reputation and character, including current health status, and
ability to work with others sufficiently to convince the hospital that all patients treated by them at the hospital will receive quality care and that the hospital and its Medical Staff will be able to operate in an orderly manner,
(4) board certification (see Article XVIII, Section 3, (3)),
(5)willingness to appear for an interview with regard to his/her application, if requested,
(6)willingness to undergo a criminal background check,
(7)eligible to participate in federal healthcare programs (Medicare/Medicaid), and
(8)provision of appropriate call coverage in specialty.
(9)commitment to using the electronic medical record system adopted by the organization and to obtaining the required training for its use in the safe effective care of patients
SECTION 3 - NO ENTITLEMENT TO MEMBERSHIP:
No individual shall be entitled to membership to the Medical Staff or to the exercise of particular clinical privileges in the hospital merely by virtue of the fact that such individual:
(A)is licensed to practice a profession in this or any other state,
(B)is a member of any particular professional organization,
(C)has had in the past, or currently has, Medical Staff appointment or privileges at any hospital or health care facility, or
(D)resides in the geographic service area of the hospital.
SECTION 4 - NON-DISCRIMINATION POLICY:
No individual shall be denied appointment on the basis of age, sex, race, creed, religion, color or national origin, or on the basis of any criteria unrelated to the delivery of quality patient care at the hospital, to professional qualifications or to the hospital's purposes, needs and capabilities.
SECTION 5 - CONDITIONS AND DURATION OF APPOINTMENT
(A)Duties of Appointees and Duration of Appointment:
Appointment to the Medical Staff shall require that each staff member assume such reasonable duties and responsibilities as the Medical Staff or the Governing Body shall require. Every application for staff appointment shall be on a form approved by the Chief Executive Officer and provided by the Medical Staff Office and signed by the applicant and shall contain the applicant's specific acknowledgement of every medical staff members' obligations to provide continuous care and supervision of his/her patients, to abide by the medical staff Bylaws, Rules and Regulations and Policies and Procedures.
Initial appointments and reappointments to the medical staff shall be made by the Governing Body. They shall act on initial appointments, reappointments, or revocation of appointments only after there has been a recommendation from the medical staff as described in these bylaws; provided that in the event of unwarranted delay on the part of the medical staff, the Governing Body may act without such recommendation on the basis of documented evidence of the applicant's or staff member's professional and ethical qualifications obtained from reliable sources.
Initial appointments shall be for a period of one year from date of appointment. At that time, applicants are reappointed for a two year period unless a second provisional year is required.
Appointments to the medical staff shall confer on the appointee only such clinical privileges as have been granted by the governing board, in accordance with these bylaws.
(B)Professional Conduct:
Individuals appointed to the Medical Staff shall be expected to relate in a positive and professional manner to other health care professionals, and to cooperate and work collegially with the Medical Staff leadership and hospital management and personnel.
(C) Meeting Requirement:
Medical Staff appointees shall be encouraged to attend a minimum of two (2) quarterly general medical staff meetings each year.