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2017 January – July Proposed Bylaws Revisions
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ARTICLE III. Membership
Page Basic Responsibilities of Membership Each Member of the Medical Staff with clinical privileges shall: Insert: comply with Hospital policies regarding timely submission of expirable documents and timely completion of medical records. Failure to comply with Hospital policies shall result in administrative suspension until such time as documentation has been received and/or medical records completed. Any staff member who has been suspended and fails to remedy a suspension imposed under this Section within 90 days of notification shall be deemed to have voluntarily resigned from the medical staff and is not entitled to a hearing or any other procedural rights as a result of such voluntary resignation.
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ARTICLE III. MEMBERSHIP 3.4 General Rights of Medical Staff Members
Page 10 Medical Staff members (insert) shall be entitled to exercise independent judgment in the care of patients where alternate forms of diagnosis or therapy are readily available and which are generally accepted as being reasonably equivalent. Insert: and Affiliate Staff members as identified in section f i and ii (Midwives/Podiatrists)
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3.4 General Rights of Medical Staff Members
Page 10 No medical staff members shall be subject to sanctions related to: Refusal to allow house officers, nurse practitioners, (insert) paramedical personnel, or allied health professionals to write orders, see patients….. Insert: residents, Affiliate staff,
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3.6 Duration of Appointments/Expansion of Privileges
Page 11 Reappointments shall be for a period of (insert) two (2) years, unless there is a concomitant modification of appointment. Insert: no more than
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Termination of provisional status; Continuation of provisional status;
3.7 Provisional Period Page 11 The Credentials Committee shall...recommend one of the following: Termination of provisional status; Continuation of provisional status; Termination of appointment; Add: d. Termination of privilege
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ARTICLE IV. STRUCTURE OF THE MEDICAL STAFF 4.2.2 Courtesy Staff
Page 16-17 Rights and Responsibilities. A member of the Courtesy Staff shall : Insert: xi: Be assigned to supervise or collaborate with a member of the Affiliate staff at the discretion of the Department Chief;
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Delete: Entire provision
Affiliate Staff Pages 20 – 21 a. General Provisions iv. When more than one member of the Medical Staff is designated to supervise an Affiliate, the name of them ember responsible for the Affiliate’s services to a particular patient shall be noted in the medical record of the patient. Delete: Entire provision
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Page 21 b. Qualifications 4.2.7 Affiliate Staff
In the case of an Affiliate member who is an employee of the Hospital, appointment of the Affiliate shall be contingent upon continued employment by the Hospital and in accordance with its personnel policies. Delete: In entirety
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Insert: physician or dentist member of the Medical Staff
4.3 Emeritus Status Page 24 Procedures for Assignment. Emeritus status may be granted to any member of the Active or Senior Staff (insert) by the Board of Directors upon recommendation of the Credentials Committee and Medical Executive Committee. Insert: physician or dentist member of the Medical Staff
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ARTICLE V. PROCEDURE FOR APPOINTMENT AND REAPPOINTMENT
Application Form and Content for Initial Appointment Page 26 Insert f.vi. : a physical examination completed within 1 year prior to the application date signed by a licensed healthcare practitioner other than the applicant , including proof of immunization and/or immunity as may be required by Medical Staff policy. Page 27 Current licensure or current limited licensure and registration with (insert) photo ID and signature authentication. Insert: government-issued
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ARTICLE VI. CLINICAL DEPARTMENTS
Page 39 6.2 Clinical Sections Where appropriate, a Department may have clinical Sections which shall be organized as specialty subdivisions within a Department….Sections include…. Peripheral Vascular Intervention Delete: Peripheral Vascular Intervention
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6.4 Functions and Responsibilities of Departments
Page 40 The Medical Staff leadership of each Department shall assure that the Department: a. Maintain an ongoing review and evaluation of the activities and clinical work in the Department by agreeing on objective criteria to identify opportunities to improve care and to identify problems in patient care. The findings and recommendations as a result of this monitoring as well as the effectiveness of the actions taken shall be documented in Department minutes. Delete: In Department minutes.
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6.4 Functions and Responsibilities of Departments
Page 41 f. Conduct, participate in, and recommend continuing education programs. g. Establish standards for continuing education requirement for its members. Delete: f & g in entirety.
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6.9 Chief of Section Page 45 Term Each Chief of a Section shall serve a term of four (4) years and shall be eligible for reappointment so long as he fulfills his responsibilities and duties to the satisfaction of the Section members, Department Chief, and the Medical Executive Committee. Delete and replace with: The Section Chief shall remain in the position until a new Section Chief is appointed by the Department Chief.
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6.10.5 Quality and Clinical Reporting
Page Medical Director Quality and Clinical Reporting a. The Medical Director shall regularly report to and collaborate with the appropriate Department Chief on the quality and clinical activities within the division. Delete: report to and
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ARTICLE VII. DETERMINATION OF PRIVILEGES AND SERVICE
Page 47-48 Visiting Health Care Providers 1. Observer Current health assessment. Delete and replace with: a physical examination completed within 1 year prior to the application date signed by a licensed healthcare practitioner other than the applicant , including proof of immunization and/or immunity as may be required by Medical Staff policy.
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7.1.4 Visiting Health Care Providers
Page 48 Education Proof of malpractice insurance covering participation at Crouse Hospital, current health assessment, National Practitioner Data Bank query….. Delete and replace with: a physical examination completed within 1 year prior to the application date signed by a licensed healthcare practitioner other than the applicant , including proof of immunization and/or immunity as may be required by Medical Staff policy.
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7.2 Special Consultative Privileges
Page Practitioners requesting such privileges shall submit the following items to the Medical Staff Office….current health assessment…. Delete and replace with: a physical examination completed within 1 year prior to the application date signed by a licensed healthcare practitioner other than the applicant , including proof of immunization and/or immunity as may be required by Medical Staff policy.
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7.3 Temporary Privileges Page General Temporary privileges may be granted… (insert) under the following circumstances: Insert: and be required to pay a temporary privilege application fee as determined by Medical Staff policy; Important Patient Need Temporary privileges shall be granted to meet an important patient care need……upon verification of….current competence. (Insert) The request for such privileges… Insert: , in addition to a physical examination completed within 1 year prior to the application date signed by a licensed healthcare practitioner other than the applicant , including proof of immunization and/or immunity as may be required by Medical Staff policy.
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7.7 Locum Tenens Privileges
Page 53 Locum tenens practitioners shall not be required to pay a fee for application of locum tenens privileges or to pay Medical Staff dues; (insert) Delete: pay a fee for application of locum tenens privileges or to Insert: however, such practitioners shall be required to pay an application fee as determined by the Medical Staff.
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ARTICLE VIII. OFFICERS OF THE MEDICAL STAFF
Page Qualifications Each officer of the Medical Staff shall…. …promptly disclose to the Medical Executive Committee any compensation or (insert) other financial relationship the officer has with the Hospital. Delete: any compensation or Insert: any
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9.6.4 Medical Executive Committee
Page 62 Composition and Chair The Medical Executive Committee shall be chaired by the President of the Medical Staff and shall consist of…..Medical Director of Normal Obstetrics….. Delete: Medical Director of Normal Obstetrics
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9.6.4 Medical Executive Committee
Page 63 Duties and Meetings ii. receive and act upon reports and recommendations from the clinical Departments, Medical Staff committees, officers of the Medical Staff, Hospital Quality Committee, the Quality Improvement Committee and Board of Directors; Delete and replace with: Patient Care Improvement Council and the Quality Improvement Committee of the Board of Directors.
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ARTICLE X. MEETINGS OF THE MEDICAL STAFF
Page 67 Special Appearance Any Medical Staff member whose patient’s case is scheduled to be presented for discussion…and whose presence at presentation is deemed appropriate…shall be notified, in writing, at least ten (10) days prior to (insert) the meeting that his presence is required. Delete: , in writing, at least ten (10) days Insert: …reasonably in advance of
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9.6.4 Medical Executive Committee
Page 64 Executive Sessions Proceedings of the Medical Staff executive session shall remain confidential and resolutions shall be recorded in minutes approved by the President of the Medical Staff. Delete and replace with: “Proceedings of the Medical Staff executive session shall remain confidential, provided, however, any proposed resolution or other formal action discussed in executive session shall be made and voted upon in a reconvened regular session and recorded in the minutes of such session.”
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