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By-Laws of the Medical Staff

Major Hospital Shelbyville, Indiana 

PREAMBLE

The physicians practicing at Major Hospital, hereby organize themselves in conformity with the Bylaws, Rules and Regulations hereinafter stated.

For the purpose of these Bylaws, the words "Medical Staff" shall be interpreted to include all physicians who are privileged to attend patients at Major Hospital.  The terms "Governing Body" or "Board" shall be interpreted to refer to the Board of Directors.

It is recognized that the members of the Medical Staff are responsible for advising the Hospital Board on scientific and medical matters, including the monitoring of health care provided within the hospital and the credentialing and delineation of privileges for all health care providers within the hospital, and that the members of the Medical Staff must accept and carry out such responsibility as the agents of the Hospital Board in cooperation with Hospital Administration in order to fulfill the hospital's obligations to its patients.  The Hospital Board and the Medical Staff, in order to promote professional peer review activity designed to establish a stable and harmonious environment in which appropriate levels of patient care may be achieved, hereby constitute themselves as professional review bodies as defined by the Health Care Quality Improvement Act of 1986 (42 U.S.C. Section 11101 et. seq.), and the Indiana Peer Review Act (I.C. 34-4-12.1-1 et. seq.); and the Hospital Board and the Medical Staff claim all privileges and immunities afforded under those acts.

ARTICLE I NAME AND PURPOSE
1.1 Name. 

The name of this organization shall be the Medical Staff of Major Hospital.
1.2 Purpose. 

The purpose of this organization will be:

(a) To ensure that all recipients of hospital services shall receive care consistent with the highest standards afforded by the staff and facilities available to the hospital;
(b) To provide a means whereby medical-administrative problems may be addressed by the Medical Staff with the Board and Administration;
(c) To initiate and maintain rules and regulations for government of the Medical Staff; and,
(d) To maintain educational standards of the membership.
ARTICLE II MEMBERSHIP
2.1 Nature of Medical Staff Membership. 

Membership on the Medical Staff is a privilege which shall be extended only to professionally competent physicians who continuously meet the qualifications, standards and requirements set forth in these Bylaws, Rules and Regulations.  Acceptance to membership on the Medical Staff shall constitute the agreement of the member to strictly abide by the principles of ethics of the American Medical Association or American Osteopathic Association, whichever is applicable when practicing in the hospital, and adhere to pertinent corporate compliance and Health Insurance Portability and Accountability Act (HIPAA) rules and regulations.
2.2 Qualifications. 

Physicians licensed to practice medicine or osteopathic medicine in the State of Indiana who can document their background, experience, training, competence, adherence to professional ethics, and good reputation, with sufficient adequacy to assure the Medical Staff and the Governing Body that any patient treated by them in the hospital will be given high quality of medical care, shall be qualified for membership on the Medical Staff.  No physician shall be entitled to membership on the Medical Staff or to exercise clinical privileges in the hospital merely by virtue of the fact that he or she is duly licensed to practice medicine in this or in any other state, is a member of any professional organization, or has such privileges at another hospital.


(a) Effective, January 1, 2007, all members of the medical staff holding the degree of doctor of medicine or doctor of osteopathy who apply for medical staff membership to Major Hospital must be board certified or eligible to take a specialty board examination necessary to achieve certification in the specialty acceptable to the department for which the applicant has applied for privileges and the Medical Executive Staff.
(b) If board eligible, the applicant shall successfully complete, pass and be awarded initial board certification by a specialty of the ABMS, AOA or other boards duly recognized by the Medical Executive Staff and the Board of Directors. When specialty boards have not established a time frame for obtaining initial board certification, certification must be obtained within five (5) years of being granted membership to the Medical Staff.
(c) All physicians on the medical staff who obtain certification in an area for which they have been granted privileges shall maintain such certification.

(1) A practitioner who does not become recertified may request an extension of privileges for a period of three (3) years from expiration of certification while he/she is seeking recertification. The practitioner must submit documentation of twenty (20) hours Category I CME credits in his/her specialty for each year of extension.
(2) The practitioner must submit a written request for extension of clinical privileges to the Service Chief/Director of his/her designee documenting: 1) expiration date of board certification, 2) reason board certification not completed, and 3) length of extension request (maximum three (3) years) from expiration date.
(3) Upon approval of the request by the Service Chief/Director of his/her designee, a request will be made to the Medical Executive Committee for an extension of clinical privileges for the practitioner.
(4) Upon approval of the Medical Executive Committee and the Board of Directors, the practitioner will be notified in writing by the President/CEO or his/her designee of approval of the extension of clinical privileges, identifying date of expiration.
(5) The practitioner is responsible to provide documentation of twenty (20) hours Category I CME credits in his/her specialty to the Medical Executive Committee.
(d) Members of Major Hospital's Honorary Medical Staff are exempted from the board certification requirements.
(e) Notwithstanding anything to the contrary herein above, all medical staff members of Major Hospital who have an existing membership prior to January 1, 2007 shall be exempted from initial board certification requirements stated above, but must continue to document their background, experience, training, competency, adherence to professional ethics and good reputation.

2.3 Appointment and Reappointment. 

(a)

Initial appointments and reappointments to the Medical Staff shall be made by the Governing Board after receiving credentials information and a recommendation from the Executive Committee of the Medical Staff. 

(b)

No applicant for Medical Staff membership shall be denied membership or clinical privileges solely on the basis of sex, race, creed, physical handicap, color or national origin, or on the basis of any other criterion lacking professional justification.

(c)

Initial appointments are made on a provisional basis for a minimum period of one (1) year.Reappointments shall be for a period of two (2) years. 
(d)

The procedure for making application to the Medical Staff and for the appointment and reappointment of members shall be specified in the Rules and Regulations.

2.4 Membership Categories. 

The Medical Staff shall be divided into five (5) categories of membership: active, consulting, courtesy, emergency and honorary.

(a)

Active Medical Staff. 

The Active Medical Staff shall consist of physicians licensed to practice medicine or osteopathic medicine in the State of Indiana who conduct an active practice at Major Hospital and who have been appointed by the  Board to transact all business of the Medical Staff.  Members of the Active Medical Staff shall be:

(1)

Privileged to admit patients to the hospital;

(2)

Eligible to vote and hold office after completing provisional status; and,

(3)

Required to attend Medical Staff meetings, serve on committees and assume other responsibilities as specified in the Bylaws, Rules and Regulations. 
(b)

Consulting Medical Staff. 

The Consulting Medical Staff shall consist of those physicians, eligible for membership as provided herein, who conduct a routine specialty practice at Major Hospital.  They shall be privileged to admit a limited number of patients, and serve on committees, but are not eligible to vote or hold office.
(c)

Courtesy Medical Staff. 

The Courtesy Medical Staff shall consist of those physicians eligible for membership as provided herein, who conduct a limited practice at Major Hospital.  They shall be privileged to admit a limited number of patients, and serve on committees, but are not eligible to vote or hold office.
(d)

Emergency Service Medical Staff. 

The Emergency Service Medical Staff shall consist of physicians licensed to practice medicine or osteopathic medicine in the State of Indiana who conduct an Emergency Service practice at Hospital.  Members of the Emergency Service Medical Staff shall not admit inpatients to the hospital and, with the exception of the Emergency Service Director, are not required to attend meetings but are encouraged to participate.  The Emergency Service Director is required to attend meetings in the same manner as Active Staff Members in accordance with Section 3 of the Medical Staff Rules and Regulations.
(e)

Honorary Medical Staff. 

The Honorary Medical Staff shall consist of physicians who are not active in the hospital and who are honored by emeritus position.  These may include physicians of outstanding reputation who are not necessarily residents of the county.  Honorary Staff members shall not be eligible to attend patients, vote, hold office or serve on standing committees.  They may be appointed to special committees.
2.5 Provisional Status. 

The initial appointment of a member to the Active, Consulting and Courtesy Medical Staff shall be made on a provisional basis as specified in the Rules and Regulations.

(a) Provisional status shall be in effect for a minimum of one (1) year and a maximum of two (2) years.  During this period, the Medical staff will monitor the performance of the appointee, pursuant to the Rules and Regulations.
(b)

The Governing Board shall make decisions regarding the completion of the provisional status of an appointee based upon a recommendation from the Executive Committee of the Medical Staff.  If the provisional status of a member has not been completed after two years, the appointee shall have his or her membership and privileges revoked.
ARTICLE III SPECIFIED PROFESSIONAL PRACTITIONERS
3.1 Non-Member Professionals. 

Professional Staff Practitioners, Allied Health Professionals and Auxiliary Physicians may be appointed and granted clinical privileges or specified services to provide professional services in the hospital.

3.11

Professional Staff. 

The Professional Staff shall consist of doctors of dentistry, podiatry and optometry licensed to practice in the State of Indiana who are appointed by the Board under the provisions of these Bylaws.  Professional Staff Practitioners shall be privileged to co-admit patients with a Medical Staff member and serve on committees to which they are appointed.  They shall not be eligible for membership on the Medical Staff but are subject to the provisions of the Medical Staff Bylaws, Rules and Regulations.
3.12

Allied Health Professionals. 

Allied Health Professionals shall consist of non-physician health professionals who have been licensed or certified by their respective licensing or certifying agencies, or have been granted a variance pursuant to the Medical Staff Rules and Regulations, and who are appointed to provide professional services in the hospital under supervision.  Allied Health Professionals may only engage in acts within the scope of practice specifically approved by the Medical Staff and Board and/or any applicable governmental law or regulation.  The rights, privileges, responsibilities and supervision requirements of Allied Health Professionals are governed more specifically by the Rules and Regulations of the Medical Staff.  They shall not be eligible for membership on the Medical Staff but are subject to the provisions of the Medical Staff Bylaws and Rules and Regulations.
3.13

Auxiliary Physicians. 

Auxiliary Physicians are physicians currently in a residency training program who provide additional support for physicians who maintain medical staff membership and clinical privileges.  Auxiliary Physicians may be appointed and granted clinical privileges to provide professional services in the hospital.  The description of the role/ responsibility of these individuals does not lend itself to appointing these individuals to the Medical Staff and thereby receiving all the rights and privileges of membership (including a full hearing and appeal process in accordance with the Medical Staff Bylaws and Rules and Regulations). Auxiliary Physicians are nevertheless bound by the Medical Staff Bylaws, Rules and Regulations.

ARTICLE IV CLINICAL PRIVILEGES
4.1 Delineation of Privileges.

(a)

Every practitioner practicing at this hospital by virtue of Medical Staff membership or otherwise, shall be entitled to exercise only those clinical privileges specifically granted by the Governing Body, except as provided in Sections 4.2 and 4.3 of this Article.

(b)

Every initial application for appointment must contain a request for the specific clinical privileges desired by the applicant. The evaluation of such requests shall be based upon the applicant's education, training and experience, demonstrated competence, references and other relevant information.  The applicant shall have the burden of establishing his or her qualifications and competence in the clinical privileges he or she requests.
(c)

Each new member of the Medical Staff, Professional Staff, Allied Health Professional, Auxiliary Physician category shall be granted clinical privileges or specified services which will be monitored by the Executive Committee of the Medical Staff who will evaluate the new member based upon the direct observation of care provided and review of the records of patients, quality assessment/ improvement and outcomes and the Medical Staff in association with the provisional status of the appointee.
(d)

Periodic redetermination of clinical privileges and the increase or curtailment of same shall be based upon the criteria listed in paragraph 4.1 (c).

4.2 Temporary Privileges.
(a)

The President/CEO may, with concurrence of the Chief of Staff, grant temporary admitting and clinical privileges to an applicant for Medical Staffmembership or status as a Professional Staff practitioner, Allied Health Professional or Auxiliary Physicianduring review and consideration of the application, to a physician/ practitioner for care of specific patient(s), a physician serving as a locum tenens for a member of the Medical Staff.
(b)

Special requirements of supervision and reporting may be imposed by the Chief of Staff on any practitioner granted temporary privileges. Temporary privileges shall be immediately terminated by the Administrator/ CEO upon notice of any failure by the practitioner to comply with such special conditions.
(c)

The termination, reduction, or denial of temporary privileges shall not give rise to the hearing and appeal procedures of Section 9 of these Bylaws, unless such termination, reduction or denial is based on the professional competence or conduct of the practitioner.
4.3 Emergency Services. 

In the case of an emergency, any physician, dentist, podiatrist, optometrist or Allied Health Professional, to the degree permitted by his or her license and regardless of staff status or lack thereof, shall be permitted to do everything possible to save the life of a patient using every facility of the hospital necessary, to include calling for consultation.  When an emergency situation no longer exists, such practitioner must request the privileges necessary to continue to treat the patient.  In the event such privileges are not requested or are denied, the patient shall be assigned to an appropriate member of the Medical Staff.  For the purpose of this section, an "emergency" is defined as a condition in which serious permanent harm would result to a patient or in which the life of a patient is in immediate danger and any delay in administering treatment would add to that danger. Patients with an "urgent" condition are patients for whom definitive care may be delayed for up to two (2) hours without negative outcome.
4.4 Emergency Management Plan. 

Emergency privileges of licensed independent practitioners may be granted when the Hospital’s Emergency Management Plan is activated and the organization is unable to handle immediate patient needs.  The President/CEO or designee may grant emergency temporary privileges to a physician based upon presentation of appropriate identification and licensure as outlined in hospital policy.  Formal verification of credentials and privileges will begin as soon as the immediate emergency situation is under control.
ARTICLE V MEDICAL STAFF ORGANIZATION
5.1 Non-Departmental Organization. 

Due to its size and functions, the Medical Staff is organized on a non-departmental basis.
5.2 Officers. 

The officers of the Medical Staff shall be the President, Vice-President and Secretary.  Officers must be members of the Active Medical Staff at the time of election and must remain members during their term of office.  Failure of any officer to maintain such status shall be immediate cause for that person to vacate his or her office.

(a)

President and Chief of Staff. 

The President shall preside at all meetings and shall be an ex-officio member of all committees. He or she shall also serve as Chief of Staff and be  responsible for the function of the Medical Staff and general supervision of the clinic work done in the hospital.
(b)

Vice President and Vice Chief of Staff. 

The Vice-President shall assume all duties and have the authority of the President in his or her absence.  He or she shall also be expected toperform such duties of supervision as may be assigned to him or her by the President.  The Vice-President shall automatically succeed the President when the latter fails to serve for any reason.

(c)

Secretary. 

The Secretary shall keep minutes of meetings of the Active Medical Staff and the Executive Committee, call meetings on order of the President, attend to all correspondence, oversee the credentials function and perform such other duties as ordinarily pertain to his or her office.

5.3 Clinical Services.
 

(a)  Services. 

The Medical Staff shall assign all members to and shall monitor and evaluate the following clinical services.

  (1) Medicine (Internal Medicine)
  (2) Family Practice
  (3)

Surgery
  (4) Obstetrics
  (5) Pediatrics
  (6) Emergency
  (7) Radiology
  (8) Pathology
  (9) Anesthesia

(b)

Service Chiefs and Directors. 

The Medicine, Family Practice, Surgery, Obstetric and Pediatric Services shall each have a Chief and the Anesthesia, Emergency, Pathology and Radiology Services shall each have a Director who is a member of the Active Medical Staff and is qualified by training, experience and demonstrated ability for the position.  The responsibilities of Service Chiefs and Directors are specified in the Rules and Regulations.
5.4 Elections and Removal.

(a)

Officers of the Medical Staff, Service Chiefs and an at-large member of the Executive Committee shall be elected on the even years to serve a two-year term at the November meeting by a majority vote of those members of the Active Medical Staff eligible to vote and present at the meeting.  A slate of officers will be prepared in advance by the Executive Committee of the Medical Staff. Office holders shall serve until the next election or until a successor has been duly elected. 
(b)

 Removal of an office holder during his or her term of office may be initiated by a two-thirds majority vote of all Active Medical Staff members.  Criteria for removal may include, but is not limited to, any corrective actions as stated under Sections 9 and 10 of the Rules & Regulations or failure to perform duties of said office.
5.5 Committees.

(a)

Executive Committee. 

The Executive Committee shall consist of the Officers, the Chiefs of the Medicine, Family Practice, Surgery, Obstetric and Pediatric Services and the Immediate Past Chief of Staff.  The duties of the Executive Committee shall be to represent and act on behalf of the Medical Staff in all matters between meetings of the Medical Staff, to undertake investigations and actions, and to implement the approved policies of the Medical Staff, subject only to any limitations imposed by the Bylaws, Rules and Regulations. 

(b)

Other Committees. 

Other committees shall be appointed as specified in the Rules and Regulations.
5.6 Conduct of Meetings. 

The primary purpose of staff meetings is to conduct business relating to the improvement in the care and treatment of

patients at the hospital.  The frequency of meetings and attendance requirements shall be set forth in the Rules and Regulations.
> ARTICLE VI CORRECTIVE ACTION
6.1 Corrective Action. 

All matters relating to corrective action of Medical Staff members and non-member Professionals shall be governed by the Medical Staff Rules and Regulations under Sections 9 and 10 therein unless otherwise modified by these Bylaws or other Rules and Regulations.
6.2 Medical Staff Responsibility. 

Under Indiana law (IC 16-10-1-6.5), the Medical Staff is responsible to the Governing Board for the clinical and scientific work of the hospital and advice regarding professional matters and policies.  It has the responsibility of reviewing the qualifications of applicants for membership and of on-going peer review of the qualifications and performance of members of the Medical Staff.
6.3 Peer Review Process. 

The provisions of the Medical Staff Bylaws, Rules and Regulations with regard to appointment, reappointment,investigations, actions, provisions and appeals are designed to be conducted by "Peer Review Committees" in accordance with the Indiana Peer Review Statute (IC 34-4-12.6), in order that all such proceedings shall be confidential and privileged.  The records, determinations and communications involved in the process shall not be subject to subpoena or discovery or admissible as evidence in any judicial or administrative proceedings, as provided in the Indiana Peer Review Statue.
6.4 Governing Board Authority. 

The Board of Directors is the supreme authority in the hospital in accordance with Indiana law.  The Board shall have the responsibility of hearing appeals of the decisions of the Hearing Committee following its hearings, and the decisions of the Board thereon shall be final.
ARTICLE VII RULES AND REGULATIONS
 

The Medical Staff shall adopt such Rules and Regulations as may be necessary for the proper conduct of its work.  The Rules and Regulations shall be made a part of these Bylaws, except that they may be amended at any regular meeting, after previous written notice, by a majority vote of the total membership of the Active Medical Staff eligible to vote.  Such amendments shall become effective when approved by the Board of Directors, approval not to be unreasonably withheld.

ARTICLE VIII AMENDMENTS
  These Bylaws may be amended at any regular meeting, after previous written notice, by majority vote of the total membership of the Active Medical Staff eligible to vote.  Such amendments shall be effective when approved by the Board of Directors, approval not to be unreasonably withheld.
ARTICLE IX ADOPTION
 

These Bylaws, together with the appended Rules and Regulations, may be adopted at any meeting of the Active Medical Staff and shall replace any previous Bylaws, Rules and Regulations, and shall become effective when approved by the Board of Directors of the hospital.  They shall, when adopted and approved, be equally binding on the Board and the Medical Staff.

The Bylaws, Rules and Regulations are to be reviewed and updated no less often than every two years to assure congruence with medical staff practice.

These Bylaws have been approved by the Medical Staff at the meeting held on the             day of                                   , 2005. 

MEDICAL STAFF OF MAJOR HOSPITAL

BY:                                                                                     

President

ATTEST:                                                                                                                                                 

Secretary

These Bylaws have been approved by the Board of Directors at its meeting held on the            day of                                            , 2005.

BOARD OF DIRECTORS OF MAJOR HOSPITAL

BY:                                                                                                

President

ATTEST:                                                                                                                                                              

Secretary




  



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