Franklin Memorial Hospital
MEDICAL STAFF BYLAWS
April 1982
Amended January 1984; January 1985; January 1987; June 1989; June 1991; August 1992; June 1993; June 1994; August
1995; June 1996; June 1997; May 2002; December 2002; July 2003; June 2004; March 2005; May 2005; December 2005;
March 2006; May 2006; March 2007; May 2008, December 2008, April 2009, April 2010, June 2010, February 2011, March
2011, April 2011, September 2011 Amended April 24, 2012
FRANKLIN MEMORIAL HOSPITAL
Medical Staff Bylaws
FRANKLIN MEMORIAL HOSPITAL
Medical Staff Bylaws
AMENDED THROUGH September 6, 2011
Approved by:
September 6, 2011
Robert O’Reilly, D.O.
Franklin Memorial Hospital
President, Medical Staff
Approved by:
August 23, 2011
Joseph Bujold
Franklin Memorial Hospital
Chair, Board of Trustees
FRANKLIN MEMORIAL HOSPITAL
Medical Staff Bylaws
MEDICAL STAFF BYLAWS
TABLE OF CONTENTS
DEFINITIONS ................................................................................................................................................................................. 1
PREAMBLE .................................................................................................................................................................................... 2
ARTICLE I - NAME ......................................................................................................................................................................... 2
ARTICLE II - PURPOSES AND RESPONSIBILITIES ................................................................................................................... 2
2.1
Purposes ......................................................................................................................................................... 2
2.2
Responsibilities ................................................................................................................................................ 2
ARTICLE III - MEDICAL STAFF MEMBERSHIP ...........................................................................................................................
3.1
Nature of Medical Staff Membership ...............................................................................................................
3.2
Basic Qualifications .........................................................................................................................................
3.3
Basic Responsibilities ......................................................................................................................................
3.4
Duration of Appointment ..................................................................................................................................
3.5
Provisional Status ............................................................................................................................................
3.6
Leave of Absence ............................................................................................................................................
3.7
Physician Health ..............................................................................................................................................
3
3
4
4
5
5
6
6
ARTICLE IV - CATEGORIES OF THE MEDICAL STAFF ............................................................................................................. 7
4.1
Categories ....................................................................................................................................................... 8
4.2
Active Staff ...................................................................................................................................................... 8
4.3
Provisional Staff ............................................................................................................................................... 9
4.4
Active Outpatient Staff ...................................................................................................................................... 9
4.5
Courtesy Staff ................................................................................................................................................ 10
4.6
Consulting Staff .............................................................................................................................................. 10
4.7
Active and Provisional Emergency Staff ......................................................................................................... 11
4.8
Honorary Staff ................................................................................................................................................ 11
4.9
Locum Tenens Staff ....................................................................................................................................... 11
4.10
Allied Health Professionals ............................................................................................................................. 12
4.11
Limitations of Prerogatives ............................................................................................................................. 16
4.12
Waiver of Qualifications .................................................................................................................................. 16
ARTICLE V - PROCEDURE FOR APPOINTMENT AND RE-APPOINTMENT ............................................................................
5.1
General Procedure .........................................................................................................................................
5.2
Application for Initial Appointment ..................................................................................................................
5.3
Effect of Application ........................................................................................................................................
5.4
Processing of Application ...............................................................................................................................
5.5
Re-appointment Process ................................................................................................................................
5.6
Requests for Modification of Appointment ......................................................................................................
16
16
17
18
18
21
23
ARTICLE VI - DETERMINATION OF CLINICAL PRIVILEGES ....................................................................................................
6.1
Exercise of Privileges .....................................................................................................................................
6.2
Delineation of Privileges in General................................................................................................................
6.3
Special Conditions for Dental Privileges .........................................................................................................
6.4
Special Conditions for Allied Health Professionals .........................................................................................
6.5
Temporary Privileges ......................................................................................................................................
6.6
Emergency Privileges .....................................................................................................................................
23
23
23
23
24
24
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6.7
Privileges During a Medical Emergency or Disaster ..…………………………… ………….. 25
6.8
Evidence of Malpractice Insurance……………………………………………………………………………………26
ARTICLE VII - CORRECTIVE ACTION .........................................................................................................................................
7.1
Routine Corrective Action ...............................................................................................................................
7.2
Summary Suspension ....................................................................................................................................
7.3
Automatic Suspension ....................................................................................................................................
26
26
27
28
ARTICLE VIII - HEARING AND APPELLATE REVIEW PROCEDURE .......................................................................................
8.1
Interview .........................................................................................................................................................
8.2
Hearings and Appellate Review......................................................................................................................
8.3
Removal from Office of Medico-Administrative Officer ...................................................................................
8.4
Initiation of Hearing .........................................................................................................................................
8.5
Hearing Prerequisites .....................................................................................................................................
8.6
Composition of Hearing Committee ................................................................................................................
8.7
Hearing Procedure .........................................................................................................................................
8.8
Hearing Committee Report and Further Action ..............................................................................................
8.9
Initiation and Prerequisites of Appellate Review.............................................................................................
8.10
Appellate Review Procedure ..........................................................................................................................
8.11
Final Decision of Governing Body ..................................................................................................................
8.12
General Provisions .........................................................................................................................................
8.13
Time Frames...................................................................................................................................................
28
28
29
29
30
31
31
32
33
34
34
36
36
37
ARTICLE IX - OFFICERS OF THE MEDICAL STAFF .................................................................................................................. 37
9.1
Officers of the Medical Staff ........................................................................................................................... 37
9.2
Additional Officers .......................................................................................................................................... 39
ARTICLE X - SERVICES ...............................................................................................................................................................
10.1
Organizational Structure .................................................................................................................................
10.2
Service Chiefs ................................................................................................................................................
10.3
Functions of Services .....................................................................................................................................
10.4
Service Assignment ........................................................................................................................................
40
40
40
41
42
ARTICLE XI - COMMITTEES AND FUNCTIONS ......................................................................................................................... 42
11.1
General Considerations .................................................................................................................................. 42
11.2
Standing Committees ..................................................................................................................................... 42
11.3
Appointment, Composition, Terms, Removal & Vacancies ............................................................................ 42
11.4
Meetings, Quorum, Minutes & Attendance ..................................................................................................... 43
11.5
Medical Staff Executive Committee ................................................................................................................ 43
11.6
Medical Staff Quality Committee .................................................................................................................... 44
11.7
Utilization Review & Medical Records Committee .......................................................................................... 45
11.8
Credentials Committee ................................................................................................................................... 46
11.9
Medical Staff Education Committee................................................................................................................. 46
11.10
Pharmacy & Therapeutics Committee ............................................................................................................ 47
11.11
Infection Control Committee ........................................................................................................................... 47
11.12
Disaster Planning Committee ......................................................................................................................... 48
11.13
Bylaws Committee .......................................................................................................................................... 48
11.14
Representation on Hospital Committees ........................................................................................................ 49
FRANKLIN MEMORIAL HOSPITAL
Medical Staff Bylaws
ARTICLE XII - MEETINGS OF THE MEDICAL STAFF ................................................................................................................
12.1
General Staff Meetings ...................................................................................................................................
12.2
Committee and Service Meetings ...................................................................................................................
12.3
Notice of Meeting ............................................................................................................................................
12.4
Quorum ...........................................................................................................................................................
12.5
Manner of Action ............................................................................................................................................
12.6
Minutes ...........................................................................................................................................................
12.7
Attendance Requirements ..............................................................................................................................
49
49
49
50
50
50
50
50
ARTICLE XIII - IMMUNITY FROM LIABILITY................................................................................................................................ 51
13.1
Conditions ....................................................................................................................................................... 51
ARTICLE XIV - GENERAL PROVISIONS .....................................................................................................................................
14.1
Staff Rules and Regulations ...........................................................................................................................
14.2
Service Rules and Regulations ......................................................................................................................
14.3
Professional Liability Insurance ......................................................................................................................
14.4
Staff Dues .......................................................................................................................................................
14.5
Forms .............................................................................................................................................................
14.6
Construction of Terms and Headings .............................................................................................................
14.7
Transmittal of Reports ....................................................................................................................................
52
52
52
52
53
53
53
53
ARTICLE XV - ADOPTION AND AMENDMENT OF BYLAWS, RULES & REGULATIONS & POLICIES.................................. 53
15.1
Regular Review of the Bylaws ........................................................................................................................ 53
15.2
Authority to Present Admendments ................................................................................................................ 53
15.3
MSEC Review & Recommendation ................................................................................................................ 54
15.4
Medical Staff Approval of Recommendation................................................................................................... 54
15.5
Urgent or Technical Action by the MSEC…………………………………………………………………………. .. 54
15.6
Medical Staff Disagreement with MSEC Action………………………………………………………………… ..... 54
15.7
MSEC & Medical Staff Disagreement …………………………………………………………………………. ....... 54
15.8
Medical Staff Authority to Adopt ………………………………………………………………………………… ...... 54
15.8
Board of Trustees Amendment Approval........................................................................................................ 54
15.10
Board of Trusteesy Amendment Initiation ..................................................................................................... 54
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FRANKLIN MEMORIAL HOSPITAL
Medical Staff Bylaws
DEFINITIONS
ALLIED HEALTH PROFESSIONAL or AHP – An individual granted privileges to perform specific patient care services
under the provisions of Article 6.4.
CHIEF EXECUTIVE OFFICER or CEO - means the individual appointed by the board to act on its behalf in the overall
management of the hospital.
CHIEF OF SERVICE - means the medical staff member duly appointed or elected in accordance with these bylaws to serve
as the head of a service.
CHIEF OPERATING OFFICER / COO or EXECUTIVE VICE PRESIDENT – means the individual appointed by the board or
the CEO to provide operations management to the hospital.
EX OFFICIO – means serves as a member of a body by virtue of an office or position held and, unless otherwise expressly
provided, means with no voting rights.
GOVERNING BODY/BOARD – means the board or governing board of the hospital.
HOSPITAL - means Franklin Memorial Hospital of Farmington, Maine.
MEDICAL STAFF - means the formal organization of all licensed allopathic and osteopathic physicians and dentists who are
privileged to attend patients in the hospital.
MEDICAL STAFF YEAR - begins July 1 and ends June 30.
MEDICAL STUDENT - is a student from an approved U.S. allopathic or osteopathic medical school who may be permitted
to perform medical services as part of a preceptorship program in Maine provided said student furnishes to the preceptor or
hospital, evidence of matriculation at said school. Records should indicate that services provided by said students are a
component of the preceptorship program. This advisory assumes proper supervision by the preceptor.
PRACTITIONER - means any appropriately licensed allopathic or osteopathic physician or dentist applying for or exercising
privileges in this hospital.
PRESIDENT OF THE MEDICAL STAFF – CHIEF ADMINISTRATIVE OFFICER means the President elected by the staff
pursuant to Article 9.
SPECIAL NOTICE - means written notification sent by certified or registered mail, return requested.
VICE PRESIDENT MEDICAL AFFAIRS & EDUCATION / VPMA – means the physician appointed by the CEO pursuant to
the provisions of Article 9.2-1 to the position of Vice President Medical Affairs & Education of Franklin Memorial Hospital.
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Medical Staff Bylaws
PREAMBLE
WHEREAS, Franklin Memorial Hospital is a non-profit corporation organized under the laws of the State of Maine for the
purpose of providing patient care, education, and research; and
WHEREAS, it is recognized that one of the aims and goals of the medical staff is to strive for quality patient care in the
hospital, that the medical staff must work with and is subject to the ultimate authority of the governing body, and that the
cooperative efforts of the medical staff, management, and the board are necessary to fulfill the hospital's aims and goals in
providing quality care to its patients;
THEREFORE, the physicians and dentists practicing in this hospital hereby organize themselves into a medical staff in
conformity with these bylaws and the hospital bylaws.
ARTICLE I - NAME
1.1
The name of this organization shall be the Franklin Memorial Hospital Medical Staff.
ARTICLE II - PURPOSES AND RESPONSIBILITIES
2.1
Purposes
The purposes of the medical staff are:
a. to be the formal organizational structure through which the benefits of staff membership may be obtained and
the obligations fulfilled.
b. to serve as the primary means for accountability to the board for the appropriateness of the professional
performance and ethical conduct of its members and allied health professionals, including that provided by
healthcare professionals under contract to the hospital. And to strive toward assuring that the pattern of patient
care is consistently maintained at the level of quality and efficiency achievable by the state of the healing arts
and resources locally available.
c. to provide a means through which the medical staff may participate in the hospital's policy-making and
planning, and provide one or more formal liaison mechanisms among the Medical Staff, Hospital Administration
and the Governing Body.
2.2
Responsibilities
The responsibilities of the medical staff are:
to account for the quality and appropriateness of patient care that is consistent with applicable professional
standards of quality and appropriateness by all practitioners and allied health professionals who practice in the
hospital through the following measures:
a. a credentials program, including mechanisms for appointment and reappointment and the matching of clinical
privileges to be exercised or of specific services to be performed with the verified credentials and current
demonstrated performance of the applicant practitioner or allied health professional.
2.2-1
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Medical Staff Bylaws
2.2-2
2.2-3
2.2-4
2.2-5
2.2-6
2.2-7
2.2-8
b. a continuing education program, fashioned in part on the needs demonstrated through the patient care audit
and other quality maintenance programs.
c. a utilization review program to allocate inpatient medical and health services based upon patient specific
determinations of individual medical needs.
d. an organizational structure that allows for monitoring of patient care practices.
e. review and evaluation of the quality of patient care based on valid and reliable patient care audit procedures.
f. participation in risk management activities in the hospital.
to recommend to the board action with respect to appointments, reappointments, staff category service
assignments, clinical privileges, specified services and corrective action for all practitioners and AHPs.
to account to the board for the quality and efficiency of patient care in the hospital through regular reports.
To initiate and pursue corrective action with respect to practitioners and allied health professionals when warranted.
to require that all practitioners and allied health professionals with clinical privileges be subject to all applicable
quality improvement activities, including peer review.
to assure accountability of all practitioners and allied health professionals by stipulating the disciplinary processes,
including, but not limited to corrective actions and administrative hearings.
The Medical Staff of FMH recognizes that patient safety and quality of care of patients is improved by maintaining a
collegial relationship within the health care team. We endeavor to treat all members of the health care team
(employees, physicians, contracted staff, members of the governing body, volunteers, students and vendors) with
respect. Providers are often called upon to be leaders of a team in a health care setting and are expected to try to
generate an atmosphere of mutual respect and cooperation. In concordance with FCHN’s Standards of
Professional Relations (Mutual Respect) policy, if a problem arises with the behavior of a member of the medical
staff, there exists under Section VII of these bylaws a mechanism for evaluation and discipline, and we encourage
the use of such to prevent abusive, disruptive or disrespectful behavior on the part of any provider.
A medical history and physical examination shall be completed no more than 30 days before or 24 hours after
admission or registration, but prior to surgery or a procedure requiring anesthesia services. The medical history and
physical examination must be completed and documented by a physician, an oral-maxillofacial surgeon, or other
qualified licensed individual in accordance with state law and hospital policy. When the medical history and
physical examination is completed within 30 days before admission or registration, the physician must complete
and document an updated examination of the patient within 24 hours after admission or registration, but prior to
surgery or a procedure requiring anesthesia services. The updated examination of the patient, including any
changes in the patient’s condition, must be completed and documented by a physician, an oral-maxillofacial
surgeon, or other qualified licensed individual in accordance with state law and hospital policy. The content of
complete and focused history and physical examinations is delineated in the rules and regulations.
ARTICLE III - MEDICAL STAFF MEMBERSHIP
3.1
3.1-1
Nature of Medical Staff Membership
Membership on the medical staff of Franklin Memorial Hospital is a privilege which shall be extended to
professionally competent physicians and dentists who continuously meet the qualifications, standards, and
requirements set forth in these bylaws. Appointment to and membership on the staff shall confer on the appointee
or member only such clinical privileges and prerogatives as have been granted by the board in accordance with
these bylaws.
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Medical Staff Bylaws
3.2
3.2-1
3.2-2
3.2-3
3.2-4
3.3
Basic Qualifications
Only physicians and dentists licensed to practice in the State of Maine who:
a. document his/her experience, background, training, demonstrated ability and physical and mental health
status, with sufficient adequacy to demonstrate to the medical staff and the Board that any patient treated
by them will receive care consistent with applicable professional standards of quality and appropriateness;
and
b. have completed a residency approved by the Accreditation Council for Graduate Medical Education or the
American Osteopathic Association, as applicable and have received board certification from a specialty
board recognized by the American Board of Medical Specialties or the Bureau of Osteopathic Specialists of
the American Osteopathic Association or are actively working toward board certification prior to applying
unless waived by the Board under the provisions of 4.11 of these Bylaws.
c. are determined, on the basis of documented references and prior experience to be willing and able to
participate in the discharge of staff responsibilities and to work cooperatively with hospital and medical
staff.
d. The requirement for board certification or actively working toward board certification is waived for
applicants who have graduated from medical school prior to 1985.
Effect of Other Affiliations
No physician or dentist is automatically entitled to membership on the medical staff or to the exercise of particular
clinical privileges merely because s/he is licensed to practice in this or any other state, or because s/he is a
member of any professional organization, or because he is certified by any clinical board, or because s/he had, or
presently has, staff membership of privileges at another health care facility or in another practice setting.
Non-Discrimination
Medical staff membership or particular clinical privileges shall not be denied on the basis of sex, race, creed, color,
sexual orientation national origin or on the basis of any other criterion unrelated to the delivery of quality patient
care in the hospital, professional ability or judgment.
Administrative and Medical-Administrative Personnel
A physician or dentist employed by the hospital in a purely administrative capacity with no clinical duties or
privileges is subject to the regular personnel policies of the hospital and to the terms of his/her contract or other
conditions of employment, and need not be a member of the medical staff. A medical-administrative officer, i.e. one
with clinical responsibilities, must be a member of the medical staff, achieving this status by the procedure provided
in Article V. His/her clinical privileges must be delineated in accordance with Article VI. The medical staff
membership and clinical privileges of any medical-administrative officer shall not be contingent on his/her continued
occupation of that position.
Basic Responsibilities
Each member of the medical staff shall:
a. provide his/her patients with care of the generally professionally recognized level of quality and
appropriateness.
b. abide by all applicable state and federal laws and regulations, Medical Staff Bylaws and Rules and
Regulations, the Franklin Memorial Hospital Code of Ethics, and the Principles of Medical Ethics as
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published by the American Medical Association or the American Osteopathic Association, whichever is
applicable.
c. discharge such staff, service, committee and hospital functions for which s/he is responsible by
appointment, election or otherwise.
d. prepare and complete in timely manner the medical and other required records for all patients cared for in
the hospital.
e. avoid personal and professional conflicts of interest in provision of patient care and fulfillment of functions
and obligations as a member of the Medical Staff, and promptly report any possible such conflicts to the
Medical Staff President. This provision shall apply to allied health professionals as well.
f. Be subject to all applicable quality improvement activities, including peer review.
3.4
3.4-1
3.4-2
3.5
3.5-1
3.5-2
Duration of Appointment
Duration and Renewal of Initial and Modified Appointments.
All initial appointments and modifications of appointments pursuant to Section 5.6 shall be for a period of one year.
Provisional staff may be renewed in accordance with Article 3.5-3 of these bylaws.
Reappointments
Reappointments to any category of the medical staff shall be for a period of not more than two years.
Provisional Status / Focused Reviews
Initial Appointments
Except as otherwise determined by the Board, all initial appointments to any category of the staff shall be
provisional. Appointees to the Consulting Staff, Courtesy Staff or Honorary Staff who have served on the Active
Staff immediately preceding his/her application shall not be required to serve provisionally prior to the appointment
to the Consulting, Courtesy Staff or Honorary Staff. Each provisional appointee shall be assigned to a service
where his/her performance shall be observed by the appropriate Chief of Service or his/her designee, and may be
observed by a committee of the service members appointed by the Chief, to determine his/her eligibility for regular
membership in the staff category to which s/he was provisionally appointed and for exercising the clinical privileges
provisionally granted. All provisional appointees will be subject to a process of focused review.
a. the Chief of Service or his/her appointed designee, at the end of 6 and 12 months, shall carry out a review
of the physician's standing which review includes, but is not limited to, the following: 1) prospective
proctoring (chart review), concurrent proctoring (observation), retrospective proctoring (case review) and/or
evidence of successful proctoring at another hospital (reciprocal proctoring) A written report setting forth
such information shall be forwarded to the Credentials Committee.
b. the Credentials Committee, after reviewing this report, shall forward its recommendations to the MSEC;
and
c. a statement signed by the MSEC Chair, that the appointee has satisfactorily demonstrated his/her ability to
exercise the clinical privileges provisionally granted to him/her.
Modification in Staff Category and Clinical Privileges
The MSEC may recommend to the Board that a change in staff category of a current staff member or the granting
of additional privileges to a current staff member pursuant to Section 5.6 be subject to focused review in
accordance with procedures similar to those outlined in Section 3.5-1 for initial appointments. Focused reviews
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3.5-3
3.6-1
3.6-2
3.6-3
3.7
3.7-1
3.7-2
may also be initiated when questions arise regarding a practitioner’s professional performance that may affect the
provision of safe, high-quality patient care.
Renewals
Provisional status may not be renewed for more than one twelve month period. If the provisional appointee fails
within that period to furnish the certifications required in Section 3.5-1, his/her staff membership or particular clinical
privileges, as applicable, shall automatically terminate. The appointee so affected shall be given special notice of
such termination and shall be entitled to the procedural rights afforded in Article VIII.3.6 Leave of Absence
Voluntary Leave
A staff member may obtain a voluntary leave of absence by submitting written notice to the MSEC and CEO stating
the period of time of the leave. Between the meetings of the MSEC, the President of the Staff or the Chief of
Service can act on behalf of the MSEC. During the period of leave, which may not exceed three years, the staff
member's privileges and prerogatives shall be suspended and all obligations, except for dues, shall be waived.
Termination of Voluntary Leave
At least 45 days prior to the termination of the leave, the staff member may request reinstatement of his/her
privileges and prerogatives by submitting a written notice to that effect to the CEO for transmittal to the MSEC. The
staff member shall submit a written summary of his/her relevant activities during the leave if the MSEC or Board so
requests. The MSEC shall make a recommendation to the Board concerning the reinstatement of the member’s
privileges and prerogatives. Failure, without good cause, to request reinstatement or to provide a requested
summary of activities as above provided shall result in automatic termination of staff membership without the right
of hearing or appellate review. A request for staff membership subsequently received from a staff member so
terminated shall be submitted and processed in the manner specified for applications for initial appointments.
Medical Leaves of Absence
A member of the staff, if unavailable in excess of three months for reasons of health, must apply for medical leave
of absence using the format outlined in 3.6-1. During such a period, the member's staff obligations, except for
dues, shall be waived. The MSEC shall determine what conditions may be attached to the member's return to the
Staff. Such conditions may include, but are not limited to, furnishing a physician's certificate and proctoring of the
physician for a period of time. At the very least, a physician's statement must be provided prior to returning to work,
stating that the staff member can return to his/her previous level of activity or should practice with limitations.
Physician Health
A member of the Medical Staff must maintain physical and mental health status sufficient to carry out his/her duties,
provide adequate patient care, and protect patients from harm.
Statement of Health: Each member of the Medical Staff must provide a statement during the initial appointment and
the biannual reappointment process attesting to his/her health sufficient to provide adequate and safe patient care.
The CEO, Medical Staff President, or Medical MSEC may require, for good cause that the member's physician or
an independent medical consultant provide a statement of fitness for providing adequate and safe patient care.
Evaluation of complaints, allegations, and concerns: Any complaint, allegation, or concern forwarded to the CEO or
a Medical Staff Officer which might result in required referral for evaluation and care must be evaluated for its
credibility prior to such referral. The evaluation may be performed by the Medical Staff MSEC, the President of the
Medical Staff or his/her designee, or the CEO. The evaluation must be in writing and must be forwarded to the
Medical Staff MSEC if not prepared by it.
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3.7-3
Personal meeting: Upon a finding that the evaluation has produced sufficient evidence of physician impairment, the
CEO and Medical Staff President or his/her designee(s) shall meet personally with the physician and shall tell the
physician that the evaluation indicates that the physician suffers from an impairment that affects his/her practice.
The sharing of the specific source of the complaints and allegations is not required during the meeting.
3.7-4 Action taken: Depending upon the severity of the problem and the nature of the impairment, the Medical Staff
MSEC may:
 Take no action with regard to the physician's appointment and privileges.
 Require that the physician undertake a rehabilitation program as a condition of continued appointment and
clinical privileges
 Impose appropriate restrictions or limitations on the physician's practice or privileges on a consensual
basis; or take corrective action pursuant to provisions of Article VIII if the physician does not agree to
voluntary limitation of practice or privileges or suspension of practice.
3.7-5 Education about physical and mental health promotion/prevention. The Medical Staff MSEC will periodically
arrange for appropriate education to the Medical Staff about the importance of personal health and of methods to
promote physician health, and impairment recognition issues specific to physicians.
3.7-6 Referral for care. When a member suffers from or may suffer from a physical or mental health problem which
interferes with adequate and safe patient care, the member may be referred to an appropriate health professional
for evaluation and treatment. The member may personally self-refer or request such referral. In addition, such
referral may be requested by the Chief of the member's assigned service, the President of the Medical Staff, the
VPMA, or the CEO. Referral may be required when the member's health problem has shown to be or threatens to
be an immediate risk to adequate and safe patient care.
3.7-7 Facilitation of Referral. The Hospital and Medical Staff will facilitate referral to appropriate health professionals or
evaluation, treatment, or rehabilitation programs such as those maintained by the Maine Medical Association
Physician Health Committee.
3.7-8 Confidential Records: The original report and descriptions of all actions taken shall be kept in a confidential file
separate from the physician's Medical Staff membership file. Except as otherwise required by law, regulation or
judicial or administrative process, or when the safety of a patient is threatened, Medical Staff officers and Hospital
staff must hold the health status of its members, referrals to care, and other related information to be confidential.
3.7-9 Monitoring of Members: When a member is referred for required evaluation, treatment, or rehabilitation, the MSEC
must maintain a process to monitor the member's fitness to provide adequate and safe patient care until the
completion of any rehabilitation or disciplinary process and for a suitable time period thereafter. This process must
include required reports from the physician's treating providers, and may include ongoing professional evaluation of
fitness independent from the member's treating providers, required drug screening, or other appropriate measures.
In addition, if the member continues to provide patient care during the evaluation, treatment, or rehabilitation
process, the MSEC will establish and maintain a system of ongoing clinical monitoring to insure patient safety and
the member's continued clinical performance.
3.7-10 Disciplinary and Corrective Action: Physicians who are unable to safely and adequately perform the privileges they
are granted may be referred for Corrective Action as specified in Article VII.
3.7-11 Reinstatement: When a physician's privileges have been suspended or limited subject to this article, those
privileges may be reinstated after completion of the appropriate rehabilitation. A statement from the physician's
treating providers must be obtained attesting to the physician's fitness. An independent professional fitness
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Medical Staff Bylaws
evaluation may also be required. The monitoring process as described in 3.7-9 must be continued for an
appropriate period of time after reinstatement.
ARTICLE IV - CATEGORIES OF THE MEDICAL STAFF
4.1
Categories
The medical staff shall be divided into active, provisional, courtesy, consulting, emergency, active outpatient, locum
tenens staff, and honorary categories.
4.2
4.2-1
Active Staff
Qualifications
The active staff shall consist of physicians and dentists, each of whom:
a. meets the basic qualifications set forth in Section 3.2-1.
b. is located closely enough to the hospital to provide continuous care to his/her patients
c. regularly admits patients to, or is otherwise regularly involved in the care of patients in the hospital.
Prerogatives
The prerogatives of the active staff shall be to:
a. admits patients to the hospital as follows:
 a physician member may admit without limitation
 a dentist member may admit provided that a physician member of the medical staff assumes
responsibility for the basic medical appraisal of the patient and for the care of any medical problems
that may be present or arise during hospitalization.
b. exercise such clinical privileges as are granted to s/he is pursuant to Article VI
c. vote on all matters presented at general and special meetings of the medical staff and hospital committees
of which they are a member
d. hold office in the staff organization and in the service and committees of which s/he is a member.
Responsibilities
Each member of the active staff shall:
a. meet the basic responsibilities set forth in Section 3.3
b. retain responsibility within his/her area of professional competence for the daily care and supervision of
each patient in the hospital for whom s/he is providing services, or arrange a suitable alternative for such
care and supervision
c. actively participate in the patient care audit and other quality maintenance activities required by the staff, in
supervising provisional appointees of his/her same profession, in the emergency services program, and in
discharging such other staff functions as may from time to time be required
d. satisfy the requirement set forth in Article XII for attendance at meetings of the staff and of the service and
committees of which they are a member.
e. participate in a system of continuous professional coverage in his/her specialty area for those patients
requiring emergent or urgent hospital-based care who have no existing professional relationship with a
member of the FMH Medical Staff who is qualified and available to provide that care. This requirement
may be waived by the Medical Staff MSEC in specialty area where continuous emergency coverage is
unnecessary, or for other meritorious reasons, or where there are too-few members of the Medical Staff in
a specialty to provide such continuous coverage.
4.2-2
4.2-3
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4.3
4.3-1
Provisional Staff
Qualifications
The provisional staff shall consist of physicians and dentists, each of whom
a. is eligible for advancement to active staff membership and will, in the ordinary course of events and unless
s/he requests otherwise, be advanced to active staff status after serving not less than 6 months and not
more than two years on the provisional staff
b. meets the qualifications specified in 4.2-1 for members of the active staff.
4.3-2 Prerogatives
The prerogatives of a provisional staff member shall be to:
a. admit patients to the hospital under the same conditions as specified in Section 4.2-2a for active staff
members
b. exercise such clinical privileges as are granted to him/her pursuant to Article VI
c. vote on all matters presented at meetings of the service and committees of which he is a member.
Provisional staff members shall not be eligible to vote on matters presented at general and special meetings of the
staff nor be eligible to hold office in the medical staff organization.
4.3-3 Responsibilities
Each member of the provisional staff shall be required to discharge the same responsibilities as those specified in
Section 4.2-3 for members of the active staff. Failure to fulfill those responsibilities shall be grounds for denial of
advancement to active staff status.
4.4
4.4-1
Active Outpatient Staff
Qualifications
The active outpatient staff shall consist of physicians and dentists, each of whom:
a. meets the basic qualifications set forth in Section 3.2-1
b. provides outpatient medical care within the service area of Franklin Memorial Hospital
c. is regularly involved in the outpatient care of patients in the hospital
d. Prerogatives
4.4-2 The prerogatives of the active outpatient staff shall be to:
a. admit up to 12 inpatients or perform 12 operative procedures per year at the hospital
b. exercise such clinical privileges as are granted to him/her pursuant to Article VI
c. vote on all matters presented at general and special meetings of the medical staff and hospital
committees of which s/he are a member
d. hold office in the staff organization and in the service and committees of which s/he is a member
4.4-3 Responsibilities
Each member of the active outpatient staff shall:
a. meet the basic responsibilities set forth in Section 3.3
b. retain responsibility within his/her area of professional competence for the daily care and supervision of
each outpatient at the hospital for whom s/he is providing services, or arrange a suitable alternative for
such care and supervision
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c. actively participate in the patient care audit and other quality maintenance activities required by the staff, in
supervising provisional appointees of his/her same profession, and in discharging such other staff functions
as may from time to time be required
d. satisfy the requirements set forth in Article XII for attendance at meetings of the staff and of the service and
committees of which s/he is a member.
4.5
4.5-1
4.5-2
Courtesy Staff
Qualifications
The courtesy staff shall consist of physicians and dentists, each of whom
a. meets the basic qualifications set forth in Section 3.2-1
b. is located closely enough to the hospital, or otherwise arranges, to provide continuous care to his/her patients
Prerogatives
The prerogatives of a courtesy staff member shall be to:
a. admit patients to the hospital under the same conditions as specified in Section 4.2-2a for active staff
members. At times of full hospital occupancy or of shortages of hospital beds or other facilities, as
determined by the Chief Executive officer, the admitting privileges of courtesy staff members shall be
subordinate to those of active and provisional staff members except for emergency admissions
b. exercise such clinical privileges as are granted to them pursuant to Article VI
c. admit not more than 12 patients per year to the hospital. Surgical procedures in the operating room shall
be considered to be an admission for purposes of this subsection. Patients admitted to another medical
staff member while providing night, weekend, or vacation coverage shall not be considered to be an
admission for purposes of this subsection.
d. attend meetings of the staff and the service of which they are a member and any staff or hospital
education programs.
e. Courtesy staff members shall not be eligible to vote or to hold office in the medical staff organization.
4.5-3
Responsibilities
Each member of the courtesy staff shall
a. be required to discharge the basic responsibilities specified in Section 3.3, and, further, shall retain
responsibility within his/her area of professional competence for the care and supervision of each patient in
the hospital for whom they are providing services, or arrange a suitable alternative
b. be required to actively participate in organized staff processes of evaluation and education specifically in
those instances where care provided by the member is being reviewed.
4.6
4.6-1
Consulting Staff
The consulting staff will consist of physicians and dentists, each of whom:
a. meets the basic qualifications set forth in Section 3.2-1
Prerogatives
The prerogatives of a consulting staff member shall be to:
a. exercise such clinical privileges as are granted to him/her pursuant to Article VI only as a consultant
and/or assistant to a member of the Active/Provisional or Courtesy medical staff
4.6-2
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b.
4.6-3
attend meetings of the staff and the service to which he is assigned and any staff or hospital education
programs.
Consulting staff members shall not have admitting privileges nor be eligible to vote or hold office in the medical staff
organization.
Responsibilities
Each member of the consulting staff shall be required to discharge the basic responsibilities specified in Section
3.3.
4.7
Active and Provisional Emergency Staff
The active and provisional emergency staff shall have the same qualifications, prerogatives, and responsibilities as
specified in Sections 4.2 and 4.3 with the exception that no member of the emergency staff shall have admitting
privileges.
4.8
4.8-1
Honorary Staff
Qualifications
The honorary staff shall consist of physicians and dentists recognized for his/her outstanding reputations, his/her
noteworthy contributions to the health and medical sciences, or his/her previous longstanding service to the
hospital. Honorary staff members granted clinical privileges must meet the basic qualifications set forth in Section
3.2-1 and must be located closely enough to the hospital, or otherwise arrange, to provide continuous care to
his/her patients.
4.8-2
Prerogatives
Generally, honorary staff members are not eligible to admit patients to the hospital or to exercise clinical privileges
in the hospital. However, the MSEC may grant an exception to this rule. When such an exception is granted, the
honorary staff member may admit patients to the hospital within the limitations provided in Section 4.2-2a for active
staff members and may exercise such clinical privileges as are granted him/her pursuant to Article VI. Otherwise,
the prerogatives of an honorary staff member shall be to attend staff and service meetings and any staff or hospital
education meetings. Honorary staff members shall not be eligible to vote or hold office in the medical staff
organization.
Responsibilities
Each member of the honorary staff shall be required to discharge the basic responsibilities specified in Section
3.3b; provided, however, that an honorary staff member granted clinical privileges shall be required:
a. to discharge all of the basic responsibilities specified in Section 3.3;
b. to satisfy the requirements set forth in Article XII for attendance at meetings of the service of which he is a
member; and
c. to retain responsibility within his/her area of professional competence for the care and supervision of each
patient in the hospital for whom they are providing services, or arranges a suitable alternative for such
care and supervision.
4.8-3
4.9
4.9-1
Locum Tenens Staff
Qualifications
The locum tenens staff shall consist of physicians and dentists, each of whom:
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a.
b.
c.
4.9-2
meets the basic qualifications set forth in Section 3.2-1
provides service to the hospital on an occasional or periodic basis to fulfill community or hospital needs
regularly admits patients to, or is otherwise regularly involved in the care of patients in the hospital during
the period of his/her locum tenancy
d. expects to provide clinical services intermittently for more than six months.
e. Prerogatives
The prerogatives of the locum tenens staff shall be to:
a. admit patients to the hospital without limitations
b. exercise such clinical privileges as are granted to him/her pursuant to Article VI
Responsibilities
Each member of the locum tenens staff shall:
a. meet the basic responsibilities set forth in Section 3.3
b. retain responsibility within his/her area of professional competence for the daily care and supervision of
each patient in the hospital for whom s/he is providing services, or arrange a suitable alternative for such
care and supervision
c. actively participate in the patient care audit and other quality maintenance activities required by staff, in
supervising provisional appointees of his/her same profession, in the emergency services program, and in
discharging such other staff functions as may from time to time be required
d. participate in a system of continuous professional coverage in his/her specialty area for those patients
requiring emergency or urgent hospital-based care and not having an existing professional relationship
with a member of the FMH Medical Staff who is qualified and available to provide that care. This
requirement may be waived by the MSEC in a specialty area where continuous emergency coverage is
unnecessary, or for other meritorious reasons, or where there are too few members of the Medical Staff in
a specialty to provide such continuous coverage.
4.10 Allied Health Professionals
4.10-1 General considerations
The Allied Health Professional (AHP) staff will consist of health care professionals active in the care of patients who
are not eligible to participate in the governance of the Medical Staff, so appointed by the Board and practicing
within the scope of his/her licenses. They shall be granted specific privileges by the Board. The AHPs may include
practitioners, as may be defined in the Bylaws, Rules and Regulations, and who are certified, registered, licensed
or approved to practice by the State. AHP are not members of the Medical Staff, but may attend Medical Staff
meetings and serve as voting members of committees but may not vote at Medical Staff meetings or serve as
Medical Staff Service Chairs or as voting members of the MSEC. AHP members may, as a condition of continued
privileges, be required to attend meetings involving the clinical review of patient care in which they participated.
a. Independent Practitioners: For the purpose of this Article, Independent AHP’s shall be defined as those
who, when practicing within the scope of his/her licenses and delineated privileges, provide unsupervised,
independent direct patient care.
b. Dependent Practitioners: For the purpose of this Article, Dependent Practitioners shall be defined as
those Allied Health Professionals who, when practicing within the scope of his/her licenses and delineated
privileges, provide direct patient care under the supervision or sponsorship of a member of the Medical
Staff.
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4.10-2
General requirements
a. AHP’s shall render patient care that is consistent with applicable professional standards of quality and
appropriateness.
b. AHP’s shall comply with all applicable State and Federal laws, with the Bylaws, Rules and Regulations,
and Policies of the Medical Staff and with any applicable section or divisional rules, regulations, and
policies.
c. AHP’s shall require disclosure of personal or professional conflicts of interest in fulfilling any of the
functions of the Allied Health Staff or in the provision of patient care.
d. AHP’s shall adhere to applicable standards of his/her profession.
e. AHP’s are subject to all applicable quality improvement activities contained in these bylaws, including peer
review.
f.
AHP’s shall be subject to all of the disciplinary processes of the bylaws, including, but not limited to,
corrective action and administrative hearings.
4.10-3 Cross Reference
AHP’s shall be responsible for complying with Articles 3.2 through 3.7 and Articles 5 through 8 of these Bylaws.
4.10-4 Independent Allied Health Professional
This category of Allied Health Professional (AHP) shall consist of the following professionals:
a. Individuals with a doctorate in psychology or its equivalent from an accredited college or university, and
licensed in the State of Maine.
b. Individuals with a master’s degree in psychiatric social work from an accredited college or university with
appropriate academic and field experience.
c. Individuals with a degree of doctor of podiatric medicine from an accredited school of podiatric medicine
and licensed to practice podiatric medicine in the State of Maine.
d. Advanced Practice Registered Nurse (APRN)
 Certified Nurse Midwife who has received postgraduate education in a Nurse Midwifery program
approved by the American College of Nurse Midwives or the American College of Nurse Midwives
Certification Council, licensed to practice in the State of Maine and fulfilled the 2 year supervision (per
license) requirements.
 Certified Nurse Practitioner who has received a Master’s Degree in Nursing as well as been certified
in the Clinical Specialty by a national certifying organization that is acceptable to the Board of
Nursing, licensed to practice in the State of Maine and fulfilled the 2 year supervision (per license)
requirements.
 An Independent AHP may provide patient care services within the limits of his/her professional skills
and abilities as delineated in his/her application for privileges and as granted by the Board.
Independent AHP shall:
a. Exercise independent judgment in his/her areas of competence, provided that an active, provisional, or
courtesy member of the medical staff shall have the ultimate responsibility for patient care.
b. Participate directly in the management and care of patients under the general supervision of or in
collaboration with an active, provisional, or courtesy member of the medical staff.
c. Record reports and progress notes on the patients’ records and write orders for treatment to the extent
established in the rules and regulations of the medical staff, provided that such orders are within the
scope of his/her license, certificate or other legal credentials:
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d. Not admit or discharge patients at the hospital.
Applications for appointment and clinical privileges as an independent AHP member shall be processed in
accordance with the procedures as set forth in Article V of the medical staff bylaws for appointment to membership
on the medical staff. The application shall spell out in detail the specific procedures the applicant shall agree to
abide by including all applicable hospital and medical staff bylaws, rules and regulations.
4.10-5 Specific requirements of Independent Allied Health Staff
a. Doctors of Psychology
1. Doctors of psychology must: i) hold a doctoral degree in psychology from an accredited institution
which meets the criteria for licensure in the State of Maine; ii) have at least two years of supervised
clinical experience in an organized multi-disciplinary facility licensed to provide care, including at least
one year that is devoted to inpatient care; iii) hold a license to practice clinical psychology in the State
of Maine; and iv) carry malpractice insurance as defined necessary for members of the FMH medical
staff.
2. Upon completion of application, the Chief Executive office will transmit same along with pertinent
materials to the executive committee.
3. Doctors of psychology will be members of the adult medicine service.
4. Doctors of psychology may perform psychological, behavioral, and mental status screening and
assessments and provide consultations. They may conduct individual, group and family
psychotherapy on hospital inpatients and outpatients; perform behavior modification, hypnosis,
biofeedback, pain management, and emergency mental health evaluation and intervention.
5. Doctors of psychology may not initiate the admission of patients, nor may they be solely responsible
for the care of inpatients at the hospital.
b. Podiatrists
1. Upon completion of an application, the CEO will transmit same along with pertinent materials to the
executive committee.
2. The MSEC shall obtain from the Chief of Surgical Services and the Credentials Committee
recommendations and specific delineation of procedures that it deems the applicant competent to
perform in the hospital. Surgical and non-surgical procedures will in any case be limited to the
forefoot, defined as being distal to the tarsal-metatarsal joint.
3. The procedures pursuant to Article V of the medical staff bylaws will be followed in the recommending
or non-recommending of specific privileges in the hospital.
4. Each podiatrist approved by the board for the performance of specified procedures shall be under the
overall supervision of the medical staff.
5. A medical history and physical examination of each patient admitted for podiatric treatment shall be
made and recorded by active, provisional, active outpatient, or consulting member of the medical staff
before any such treatment shall be administered. The same member of the medical staff (or his/her
coverage) shall be responsible for the medical care of the patient throughout the period of
hospitalization.
6. The podiatrist is responsible for the podiatric care of the patient including podiatric orders, history and
physical examination.
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4.10-6
7. A podiatrist with clinical privileges may, with the concurrence of an appropriate member of the
surgical service, initiate the procedure for admitting a patient. Both names will appear on the patient
chart.
8. During the initial period of appointment, to be established individually by the surgical service, but not
to be less than six (6) months, all podiatric surgical procedures performed by the individual within the
hospital shall be monitored and evaluated by an appropriate member of the surgical service, as to the
appropriateness of diagnosis and competency of the individual in surgical skills. Thereafter, the
podiatrist shall conform to re-appointment procedures as delineated in Articles V and VI of the
medical staff bylaws.
c. Advance Practice Registered Nurses
1. An APRN (as defined in Section 4.10-4(d)) may work as a licensed independent practitioner.
2. APRN’s may perform medical diagnosis or prescribe therapeutic or corrective measures within their
independent scope of practice and pursuant to a written collaborative agreement with a physician
who is a member of the Medical Staff.
d. Specific Provisions for Certified Nurse Midwives
1. Certified Nurse Midwives may be granted privileges to admit patients if they meet the requirements of
sections 2 through 7 of this subsection.
2. The Certified Nurse Midwife must have competed two years of clinical practice as a Certified Nurse
Midwife at Franklin Memorial Hospital after training and certification.
3. The privilege to admit patients is limited to normal labor and delivery after an uncomplicated
pregnancy.
4. Certified Nurse Midwives must enter into a written collaborative agreement with a physician who is (i)
a member of the Medical Staff; (ii) is board-certified or board-eligible in Obstetrics and Gynecology;
and (iii) has full Obstetrics and Gynecology privileges.
5. The written collaborative agreement must specifically delineate the responsibilities of each party.
6. The written collaborative agreement must address consultation with or transfer of care to a physician
when a patient experiences a complication of pregnancy or has an independent medical condition
requiring physician treatment during hospitalization.
7. The written collaborative agreement must describe the obligation for the physician or physician group
to provide comprehensive backup to the Certified Nurse Midwife.
Dependent Allied Health Staff
a. This category shall include CNP’s and CNM’s in the first two years of supervisory practice, Clinical Nurse
Specialists, Physician Assistants and Surgical Assistants.
b. The medical staff member responsible for the individual seeking approval as a Dependent AHP member shall
present a written statement of the clinical duties and responsibilities of said individual to the executive
committee together with the appropriate application form as prescribed in Article V of the medical staff
bylaws. Further processing of the application shall be in accordance with procedures as set forth in the
aforementioned Article V of the medical staff bylaws.
c. Dependent AHP to whom clinical privileges are granted shall be individually assigned to an appropriate
service and shall be responsible to the chief of that service and under the primary supervision of a
supervising member of the medical staff. Secondary supervision of Dependent AHP may also be provided by
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other members of the Medical Staff. The primary supervisor is responsible for creating a written plan of
supervision for each AHP member, which shall include all of the following elements:
 the basic scope of practice and practice settings of the AHP member
 the delegation of medical tasks as appropriate to the AHP member
 the relationship of and access to the AHP member’s supervising physicians
 the process for evaluation of the AHP member’s performance
d. An updated copy of the plan of supervision must be provided as part of each dependent practitioner’s
application and reapplication for privileges and accepted as part of the credentialing and privileging process.
The supervising member of the medical staff shall assume full responsibility and be fully accountable for the
conduct of the individual Dependent AHP member. It is the further responsibility of the primary supervisor to
acquaint the Dependent AHP member with the applicable rules and regulations of the medical staff and the
hospital, as well as appropriate members of the medical staff and the hospital personnel with whom said
individual shall have contact at the hospital.
e. The care of hospital patients provided by Dependent AHP members must be directly supervised by a
supervising medical staff member. Evidence of supervision may be by means of record countersignature or
by means of submission of results of supervision activities no less than annually to the Medical Staff.
f. A physician of the medical staff must be available to supervise the Dependent AHP member at all times. If
the medical staff membership of the primary supervisor is terminated for any reason, the clinical credentials of
the Dependent AHP member shall be suspended until a new supervisory physician can be found.
g. Reappointment procedures will be the same as prescribed for the medical staff in Articles V and VI of the
medical staff bylaws. At the time of reappointment the supervising physician shall provide an evaluation of all
aspects of the performance of the dependent practitioner.
h. The following categories of non-physician professionals may provide surgical assisting: Physician assistants,
licensed nurse practitioners, certified nurse midwives, RN first assistants, and Certified Surgical Technician
first assistants. All non-physician surgical assistants shall be credentialed by the Medical Staff following all of
the requirements of this section and of Articles V and VI of the Medical Staff Bylaws.
4.10-7 Removal Procedures and Status
a. Persons maintaining any of the foregoing positions are not members of the medical staff and accordingly,
have none of the duties or prerogatives of medical staff member, except where otherwise provided in these
bylaws.
b. The hospital retains the right, upon recommendation of the MSEC, to suspend or terminate any or all of the
privileges or functions of any individual Allied Health Staff members, without recourse on the part of such
member or others to the review and appeal procedures of the medical staff bylaws.
c. Independent Allied Health Staff members who are terminated or curtailed shall be told the reasons for such
action, and if they so request, shall be entitled to have such action reviewed by the executive committee or a
committee appointed by said executive committee. At any review meeting, the individual may be present and
allowed to fully participate.
d. When a Dependent Allied Health Staff Member is terminated or privileges otherwise curtailed, the supervising
member of the medical staff shall be notified as to the reasons for such action and be afforded an opportunity
of review by the executive committee.
4.11
Limitations of Prerogatives
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The prerogatives set forth under each staff category are general in nature and may be subject to limitations by
special conditions attached to a physician's or dentist's staff membership, by other sections of these bylaws, or
other policies of the hospital.
4.12
Waiver of Qualifications
The basic qualification 3.2-1b requiring completion of an approved residency and board certification may be waived
at the discretion of the Board upon specific determination that such waiver will serve the best interests of patients
and the hospital. Board policy shall dictate the criteria under which such a waiver may be granted.
ARTICLE V - PROCEDURE FOR APPOINTMENT AND RE-APPOINTMENT
5.1
General Procedure
The medical staff through its designated services, committees, and officers shall investigate and consider each
application for appointment or re-appointment to the staff membership status and shall adopt and transmit
recommendations thereon to the Board. The medical staff shall perform these same investigations, evaluations,
and recommendation functions in connection with any medical affiliate or other individual who seeks to exercise
clinical privileges or provide specified services in any service of the hospital, whether or not such affiliate or
individual is eligible for medical staff membership.
5.2
5.2-1
Application for Initial Appointment
Application Form
All applications for appointment to the medical staff shall be in writing, signed by the applicant and submitted on a
form prescribed by the Board after consultation with the MSEC.
Content
The application form shall include:
a. Acknowledgment and Agreement: A statement that the applicant received and read the Bylaws, Rules and
Regulations of the medical staff and that they agree to be bound by the terms thereof in all matters
relating to consideration of the application without regard to whether or not membership and/or clinical
privileges are granted.
b. Qualifications: Detailed information concerning the applicant's qualifications, including information in
satisfaction of the basic qualifications specified in Section 3.2-1 and of any additional qualifications
specified in these bylaws for the particular staff category to which the applicant requests appointment
c. Requests: Specific requests stating the staff category, service and clinical privileges for which the
applicant wishes to be considered
d. References: The names of at least 3 persons who have worked with the applicant and observed his/her
professional performance and who can provide references as to the applicant's clinical ability, ethical
character, and ability to work with others. At least one of the references must be a physician who was in a
supervisory capacity over the applicant in the applicant's most recent clinical setting.
e. Legal Proceedings: Any history of felony conviction
f. Professional Sanctions: Information as to whether the applicant's membership status and/or clinical
privileges have ever been revoked, suspended, reduced or denied at any other hospital or heath care
institution, and as to whether any of the following have been suspended, revoked, or denied:
5.2-2
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i.
ii.
iii.
iv.
e.
f.
g.
h.
5.3
membership/fellowship in local, state, or national professional organization
specialty board certification
license to practice any profession in any jurisdiction
Drug Enforcement Administration (DEA) or Bureau of Narcotics and
Dangerous Drugs (BNDD) number
v. Sanction by any federal or state payor
If any such actions were taken, the particulars thereof shall be included.
Professional Liability Insurance - A statement that the applicant carries at least the minimum amount of
professional liability insurance established by the Board and information on his/her malpractice
experience, including any claims and verdicts or settlements, during the past ten years, including a
consent to the release of information by his/her present and past insurance carrier(s). The applicant shall
further be responsible to report any verdicts, claims or settlements which occur since completion of the
application and prior to the next reappointment period.
Information about voluntary or involuntary termination of medical staff membership or voluntary or
involuntary limitation, reduction, or loss of clinical privileges at another hospital.
Statement of Health - a statement fulfilling the requirements of Section 3.7 attesting to the applicant’s
physical and mental health sufficient to provide safe and competent patient care.
History of Substance Abuse - a statement of any history of alcohol or drug abuse.
Effect of Application
By applying for appointment to the medical staff, the applicant:
a. signifies his/her willingness to appear for interviews in regard to his/her application
b. authorizes hospital representatives to consult with others who have been associated with
him/her and/or who may have information bearing on his/her competence and
qualifications
c. consents to the inspection by hospital representatives of all records and documents that may be material
to an evaluation of his/her professional qualifications and ability to carry out the clinical privileges
requested as well as his/her professional ethical qualifications for staff membership
d. releases from any liability all hospital representatives for his/her acts performed in connections with
evaluating the applicant and his/her credentials
e. releases from any liability all individuals and organizations who provide information, including otherwise
privileged or confidential information, to hospital representatives concerning the applicant's ability,
professional ethics, character, physical and mental health, emotional stability, and other qualifications for
staff appointment and clinical privileges.
f. authorizes and consents to hospital representatives providing other hospitals, medical associations,
licensing boards, and other organizations concerned with provider performance and the quality of patient
care with any information relevant to such matters the hospital may have concerning the applicant, and
releases the hospital representatives for so doing, provided that such furnishing of information is done in
good faith and without malice. For purposes of this section, the term "hospital representative" includes the
Board, its Directors, and Committees, the CEO, all Medical Staff members, services and committees
which have responsibility for collecting or evaluating the applicant's credentials or acting upon his/her
application, and any authorized representative of any of the foregoing.
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5.4
5.4-1
Processing of Application
Applicant's Burden
The applicant shall have the burden of producing adequate information for a proper evaluation of his/her
experience, background, training, demonstrated clinical ability, character and ability to work with others, as well as
physical and mental health status standards sufficient to provide safe and competent patient care. The applicant
shall have the burden of demonstrating to the satisfaction of the MSEC and the board that s/he fulfills each of the
basic qualifications set forth in Section 3.2, together with each of the other standards and criteria set forth in these
bylaws and such other standards as the medical staff or board may determine are appropriate to the evaluation of
the application.
5.4-2
Verification of Information
The applicant shall deliver a completed application form, copies of college and medical school certificates or
diplomas, certificates of completion of all residency and fellowship training, copy of post specialty board
certification, copy of registration in medicine from State of Maine, certificate of malpractice insurance coverage,
names and addresses of three professional references, a recent photograph, DEA registration, a curriculum vitae
accounting for all periods of time between graduation from professional school and present proof of immunity to
Rubella, Rubeola, Mumps, and Varicella either by providing documentation of (2) MMR vaccinations and (2)
Varicella immunizations OR laboratory titer results of all. Additional results from Tuberculin Skin Testing (ppd), and
Hepatitis B vaccination series and titer results to the CEO who shall, in timely fashion, assist the Credentials
Committee in seeking to collect references and to verify, professional school graduation, post-graduate training,
licensure, present hospital affiliations, and malpractice insurance. Within 90 days before the granting of
membership and privileges, the CEO or his/her designee shall obtain information on the applicant from relevant
licensure authorities and a federally designated clearinghouse pursuant to the provisions of the Health Care Quality
Improvement Act of 1986. When appropriate to the evaluation or consideration of the application, a statement of
health may be required and sought from the applicant's treating health professional or an independent consultant
designated by the Hospital and Medical Staff for that purpose. The CEO shall promptly notify the applicant of any
non-success in such collection or verification efforts. When collection and verification are accomplished, the CEO
shall transmit the application and all supporting materials to the Chief of each service in which the applicant seeks
privileges.
Service Action
Upon receipt, the Chief of each pertinent service or his/her designee shall in accordance with Bylaws 11.3-d shall
review the application and supporting documentation, and transmit to the Credentials Committee within 10 days; a
written report setting forth pertinent supporting information with respect to staff appointment, staff category, service
affiliation, clinical privileges to be granted, and any special conditions to be attached to the appointment. A service
chief may also ask that the Executive Committee defer action on the application. The reasoning used in each
report shall be stated and supported by reference to the completed application and all other documentation
considered by the Chief of Service, all of which shall be transmitted with the report.
MSEC Action
The MSEC shall review the application, the supporting documentation and the recommendations of the Service
Chief and Credentials Committee. Within 30 days of the receipt of all pertinent information, the Executive
Committee shall forward to the CEO for transmittal to the Board a written report and recommendations on the
5.4-3
5.4-4
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5.4-5
5.4-6
prescribed form as to staff appointment and, if appointment is recommended, as to staff category, service
affiliations, clinical privileges to be granted, and any special conditions to be attached to the appointment. The
committee may also defer action on the application pursuant to Section 5.4-5a. The reason for each
recommendation shall be stated and supported by reference to the completed application and all other
documentation considered by the Committee, all of which shall be transmitted with the report. Any minority views
shall also be reduced to writing, supported by reasons and references and transmitted with the majority report.
Effect of MSEC Action
a. Deferral: Action to defer the application for further consideration must be followed up within 30 days with a
subsequent recommendation for provisional appointment with specified clinical privileges, or for rejection
for staff membership
b. Favorable Recommendations: When the recommendation is favorable to the applicant, the CEO shall
promptly forward it, together with all supporting documentation, to the Board
c. Adverse Reaction: When the recommendation is adverse to the applicant, the CEO shall promptly so
inform the applicant by special notice. No such adverse recommendation need be forwarded to the Board
until after the applicant has exercised or has been deemed to have waived his/her right to a hearing as
provided in Article VIII of these bylaws
d. Reconsideration: If, after the MSEC has considered the report and recommendation of the hearing
committee and the hearing record, the reconsidered recommendation is favorable to the applicant, the
applicant shall be processed in accordance with Section 5.4-6b. If such recommendation continues to be
adverse, the CEO shall promptly so notify the applicant by special notice. The CEO shall also forward
such recommendation and documentation to the Board, but the Board shall take no action thereon until
after the applicant has exercised or has been deemed to have waived his/her right to appellate review as
provided in Article VIII of these bylaws.
Board Action
a. On favorable MSEC Recommendation:
The Board shall, in whole or in part, adopt or reject a favorable recommendation of the MSEC, or refer the
recommendation back to the MSEC for further consideration stating the reasons for such referral back and
setting a time limit within which subsequent recommendation shall be made. If the Board's decision is
adverse to the applicant in respect to either appointment or clinical privileges, the CEO shall promptly
notify him/her of such adverse decision by special notice and such adverse decision shall be held in
abeyance until the applicant has exercised or has been deemed to have waived his/her rights under
Article VIII of these bylaws and until there has been compliance with Section 5.4-9. The fact that the
adverse decision is held in abeyance shall not be deemed to confer privileges where none existed before.
b. After Procedural Rights:
In the case of an adverse MSEC recommendation pursuant to Section 5.4-5c or an adverse Board
decision pursuant to Section 5.4-6a, the Board shall take final action in the matter only after applicant has
exhausted or waived his/her procedural rights as provided in Article VIII. Action thus taken shall be the
conclusive decision of the Board, except that the Board may defer final determination by referring the
matter back for further reconsideration. Any such referral back shall state the reasons therefore, shall set
a time limit within which a subsequent recommendation to the Board shall be made, and may include a
directive that an additional hearing be conducted to clarify issues which are in doubt. After receipt of such
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subsequent recommendation and of new evidence in the matter, if any, the Board shall make a final
decision either to appoint or reject for staff membership.
5.4-7 Denial for Hospital Inability to Accommodate Applicant
A recommendation by the MSEC, or a decision by the Board, to deny staff membership, a service or staff category
assignment, or particular clinical privileges either:
a. on the basis of the hospital's inability as supported by documented evidence to provide adequate facilities
or supportive services for the applicant and his/her patients or
b. on the basis of inconsistency with the hospital's written plan of development shall be considered adverse
in nature and shall entitle the applicant to the procedural rights provided in Article VIII of these bylaws. If
the Board's final decision pursuant to Section 5.4-5c remains adverse, the notice of final decision required
by Section 5.4-9 shall state that upon written request by the applicant to the CEO, the application will be
kept in a pending status for the next succeeding 5 years. If during this period, the hospital finds it possible
to accept staff applications for which the applicant is eligible, and the hospital has no obligation to
applicants with prior pending status, the CEO shall promptly so inform the applicant by special notice.
Within 60 days of receipt of such notice, the applicant shall provide, in writing on the prescribed form, such
supplemental information as is required to update all elements of his/her original application. Thereafter,
the procedure provided in Section 5.4 for initial appointments shall apply.
5.4-8 Conflict Resolution
Whenever the Board's proposed decision will be contrary to the MSEC’s recommendation, and the Board has
completed, where applicable, the hearing and appellate review procedures set forth in Article VIII, the Board shall
submit the matter to the Joint Conference Committee for review and recommendation and shall consider such
recommendation before making its final decision required in Section 5.4-9.
5.4-9 Notice of Final Decision
a. Notice of the Board's final decision shall be given, through the CEO, to the Chair of the Executive
Committee and to the Chiefs of Service, and to the applicant by special notice
b. A decision and notice to appoint shall include:
i. the staff category to which the applicant is appointed
ii. the service assignment
iii. the clinical privileges allowed
iv. any special conditions attached to the appointment
5.4.10 Re-application After Adverse Appointment Decision
An applicant who has received a final adverse decision regarding appointment shall not be eligible to re-apply to
the medical staff for a period of three years. Any such re-application shall be processed as an initial application,
and the applicant shall submit such additional information as the medical staff or the board may require in
demonstration that the basis for the earlier adverse action no longer exists.
5.5
5.5-1
Re-appointment Process
Information for Re-appointment
The CEO shall, at least 120 days prior to the expiration date of the present staff appointment of each medical staff
member, provide each staff member with an interval information form for use in considering re-appointment. Each
applicant who desires re-appointment shall, at least 90 days prior to such expiration date, send his/her interval
information form to the CEO. Failure, without good cause, to so return the form shall result in automatic termination
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5.5-2
5.5-3
5.5-4
of membership at the expiration of the member's current term. If members and AHPs whose membership and
privileges have been so terminated subsequently wish to reapply for membership and privileges, his/her application
shall be considered an Application for Initial Appointment as described in Sections 5.2 – 5.4 of these Bylaws.
Content of Interval Information Form
The interval information form shall be a prescribed form and shall contain information necessary to maintain as
current the medical staff file on the staff member's health-care related activities other than as a member of the staff.
The interval information shall include information about:
a. continuing training, education, and experience that qualifies the staff member for the privileges sought in
re-appointment
b. current physical and mental status
c. the name and address of any other health care organization or practice setting where the staff member
provided clinical services during the preceding period
d. membership, awards or other recognitions conferred or granted by any professional health care societies,
institutions or organizations
e. professional sanctions and membership privileges limitations including but not limited to, reduction, or loss
of clinical privileges and whether such privileges have ever been voluntarily relinquished, limited, revoked,
suspended, reduced, or denied.
f.
details about malpractice insurance coverage, claims, suits, and settlements
g. other specific information about the staff member's professional ethics, qualifications and ability that may
bear on his/her ability to provide quality patient care in the hospital.
h. Information about voluntary or involuntary termination of medical staff membership or voluntary or
involuntary limitation, reduction, or loss of clinical privileges at another hospital.
i.
Statement of Health - a statement fulfilling the requirements of Section 3.7 attesting to the applicant’s
physical and mental health sufficient to provide adequate, safe and competent patient care.
j.
Attestation that the applicant is not abusing chemical substances.
k. History of felony convictions
l.
Arrangements made or pending to provide continuous care to patients (practice coverage arrangements)
Verification of Information
The CEO shall, in timely fashion, seek to collect or verify the additional information made available on each interval
information form and to collect any other materials or information deemed pertinent, including information regarding
the applicant’s professional activities, performance and conduct in this hospital. When appropriate, a statement of
health fulfilling the requirements of Section 3.7 may be required and sought from the applicant's treating health
professional or an independent consultant designated by the Hospital and Medical Staff for that purpose. The CEO
shall independently verify that the applicant holds a valid license to practice his/her profession and shall seek
information on the applicant from a federally designated clearinghouse pursuant to the provisions of the Healthcare
Quality Improvement Act of 1986. When collection and verification is accomplished, the CEO shall transmit the
information and supporting materials to each service in which the staff member requests privileges and to the
Credentials Committee.
Committee Action
The Credentials Committee shall review the information form and the staff member's file and shall transmit them to
the Executive Committee with its report regarding appointment renewal, renewal with modified staff category,
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service affiliation and/or clinical privileges, or termination. The committee may also request deferment of action.
Each such report shall satisfy the requirements of Section 5.5-7.
5.5-5 Executive Committee Action
The Executive Committee shall review each information form and all other relevant information available to it and
shall forward to the CEO for transmittal to the Board its report and recommendation that appointment be either
renewed, renewed with modified staff category, service affiliation, and/or clinical privileges, or terminated. The
committee may also defer action. Each such report shall satisfy the requirements of Section 5.5-7. Any minority
views shall also be reduced to writing and transmitted with the majority report.
5.5-6 Final Processing and Board Action
Thereafter, the procedure provided in Sections 5.4-5 through 5.4-10 shall be followed.
5.5-7 Bases for Recommendations
Each recommendation concerning the re-appointment of a medical staff or AHP member and the clinical privileges
to be granted upon re-appointment shall be based upon such applicant’s professional ability and clinical judgment
in the treatment of patients, his/her professional ethics, his/her discharge of staff obligations, his/her compliance
with the medical staff bylaws, rules and regulations, his/her cooperation with other practitioners and with patients,
and other matters bearing on his/her ability and willingness to contribute to good patient care practices in the
hospital.
5.5-8 Time Periods for Processing
Transmittal of the interval information form to a staff member and his/her return of it shall be carried out in
accordance with Section 5.5-1. Thereafter, and except for good cause, each person, service and committee
required by these bylaws to act thereon shall complete such action in timely fashion such that all reports and
recommendations concerning the re-appointment of a staff member shall have been transmitted to the executive
Committee for its consideration and action pursuant to Section 5.5-5 and to the Board for its action pursuant to 5.56, all prior to the expiration date of the staff membership of the member being considered for re-appointment.
5.6
Requests for Modification of Appointment
A medical staff or AHP member may, either in connection with re-appointment or at any other time, request
modification of his/her staff category, service assignment, or clinical privileges by submitting a written application to
the Credentials Committee. Such application shall be processed in substantially the same manner as provided in
Section 5.5 for re-appointment.
ARTICLE VI - DETERMINATION OF CLINICAL PRIVILEGES
6.1
Exercise of Privileges
Every practitioner or other professional providing direct clinical services at this hospital by virtue of medical staff
membership or otherwise shall, in connection with such practice and except as provided in Sections 6.6 and 6.7, be
entitled to exercise only those clinical privileges or specified services specifically granted by the Board.
6.2
6.2-1
Delineation of Privileges in General
Requests
Each application for appointment and re-appointment to the medical and AHP staff must contain a request for the
specific clinical privileges desired by the applicant. A request by a staff member pursuant to Section 5.6 for a
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6.2-2
6.2-3
modification of privileges must be supported by documentation of training and/or experience supportive of the
request.
Bases for Privileges Determinations
Requests for clinical privileges shall be evaluated on the basis of applicable licensure laws and regulations, the
applicant's education, training, experience and demonstrated ability and judgment. The bases for privileges
determinations to be made in connection with periodic re-appointment shall include observed clinical performance
and the documented results of the patient care audit and other quality maintenance activities required by these
bylaws to be conducted at the hospital. Privileges determinations shall also be based on pertinent information
concerning clinical performance obtained from other sources, especially other institutions and health care settings
where a practitioner exercises clinical privileges including but not limited to the applicant’s office setting or public or
private data bases. This information shall be added to and maintained in the medical staff file established for a
staff member.
All requests for clinical privileges shall be processed pursuant to the procedures outlined in Article V.
6.3
Special Conditions for Dental Privileges
Requests for clinical privileges from dentists shall be processed in the manner specified in Section 6.2. Surgical
procedures performed by dentists shall be under the overall supervision of the Chief of the Surgical Service. All
dental patients shall receive the same basic medical appraisal as patients admitted to other members of the
surgical service. A physician member of the medical staff shall be responsible for the care of any medical problem
that may be present at the time of admission or that may arise during hospitalization and shall determine the risk
and effect of the proposed surgical procedure on the total health status of the patient.
6.5
Special Conditions for Allied Health Professionals
Requests to perform specified patient care services by AHPs shall be processed in the manner specified in Section
6.2. An AHP may, subject to any licensure requirement or other legal limitations, exercise independent judgment
within the areas of his/her professional competence, and may participate directly in the medical management of
patients under the supervision of a physician who has been accorded privileges to provide such care and who has
ultimate responsibility for the patient's care.
6.6
6.5-1
Temporary Privileges
Circumstances
Upon the written concurrence of the Chair of the Executive Committee, or designee (appropriate Chief of Service or
VPMA) the CEO, or designee (Executive VP) may grant privileges in the following circumstances:
a. Pendency of Initial Application: After receipt of an application for staff appointment, including a request for
specific privileges and in accordance with the conditions specified in 6.5-2, an appropriately licensed
applicant may be granted temporary privileges for initial period of 90 days, with one subsequent renewal
not to exceed 30 days. In exercising such privileges, the applicant shall act under the supervision of the
Chief of Service to which s/he is assigned. The service chief or his/her appointee shall provide supervision
and documentation of performance in a monthly or quarterly report form.
b. Care of Specific Patients: Upon receipt of written request, an appropriately licensed practitioner who is
not an applicant for membership may be granted temporary privileges for the care of one or more specific
patients. Such privileges shall be restricted to the treatment of not more than 2 patients in any one year
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6.5-2
6.5-3
6.5-4
6.6
by any practitioner, after which such practitioner shall be required to apply for membership on the medical
staff before being allowed to attend additional patients. Any such practitioner must provide the same
information as applicants for initial appointment to the Medical Staff and must receive the same
verifications as required of such applicants.
c. Locum Tenens Staff: Upon receipt of a written request, an appropriately licensed practitioner who is
serving as a locum tenens for a member of the medical staff may without applying for membership on the
staff, be granted temporary privileges for an initial period of 90 days. Such privileges may be renewed for
1 successive period of 90 days, but not to exceed his/her services as locum tenens.
Conditions
All practitioners seeking temporary privileges must complete an application as outlined in Section 5.2 of these
bylaws. The CEO shall obtain independent primary source verification of the requesting practitioner's valid
professional license, information on the practitioner from a federally designated clearinghouse pursuant to the
provisions of the Health Care Quality Improvement Act of 1986, evidence of training and present competence, and
verification of present malpractice insurance coverage prior to granting temporary privileges. Verification of valid
licensure and information from the clearinghouse, as cited in 5.4-2, must be obtained within 90 days before the
granting of temporary privileges and before privileges are granted. Temporary privileges shall be granted only
where the information available shows no previous successful challenges to licensure or registration, no involuntary
denials, terminations, limitations, or reductions of privileges, and reasonably supports a favorable determination
regarding the requesting practitioner's qualifications, ability and judgment to exercise the privileges requested.
Special requirements of consultation and reporting may be imposed by the Chief of Service responsible for
supervision of a practitioner granted temporary privileges. Before temporary privileges are granted, the practitioner
must acknowledge in writing that he has received and read the medical staff bylaws, rules and regulations and that
he agrees to be bound by the terms thereof in all matters relating to temporary privileges.
Termination
On the discovery of any information or the occurrence of any event of a professionally questionable nature about a
practitioner's qualifications or ability to exercise any or all of the temporary privileges granted, the CEO may, after
consultation with the responsible Chief of Service or the President of the Medical Staff may terminate any or all of
such practitioner's privileges, provided that where the life or well-being of a patient is determined to be endangered
by continued treatment by the practitioner, the termination may be effected by any person entitled to impose
summary suspensions under Article 7.2-1. In the event of any such termination, the practitioner's patients then in
the hospital shall be assigned to another practitioner by the Service Chair responsible for supervision with the
consent of the substitute practitioner. In cases where the Service Chair is not readily able to obtain the consent of
a substitute practitioner, the Service Chair shall assign such patient to him/herself, or another physician of his/her
choosing.
Rights of the Practitioner
A practitioner shall not be entitled to the procedural rights afforded in Article VIII because of his/her inability to
obtain temporary privileges or because of any termination or suspension of temporary privileges.
Emergency Privileges
In case of an emergency in which serious permanent harm or aggravation of injury or disease is imminent, or in
which the life of a patient is in immediate danger, and any delay in administering treatment could add to the danger,
any practitioner holding privileges at the hospital, to the degree permitted by his/her license and regardless of
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service, staff status or clinical privileges, is authorized to do everything possible to save the patient’s life or to save
the patient from serious harm. Emergency privileges exercised under this provision shall be for a maximum of
seventy-two hours and are not renewable. After termination of such privileges, the patient shall be assigned to an
appropriate member of the medical staff.
6.7
6.7-1
6.7-2
6.7-3
6.7-4
6.7-5
6.7-6
6.8
Privileges During Medical Emergency or Disaster
During a period when a medical emergency or disaster has been declared and the hospital’s emergency or disaster
management plan has been activated and the hospital is unable to handle immediate patient needs without
additional support, it may be necessary for physicians and other practitioners who are not Medical Staff members
or AHPs to be granted privileges to provide care at the hospital.
Granting Authority: In such circumstances, the CEO, COO or Medical Staff President may grant such privileges. In
the cases where neither the CEO, COO or Medical Staff President is available, the disaster Incident Commander
may grant such privileges.
Identification: The granting authority must ascertain the identity of the practitioner being granted disaster privileges
by any of the following:
 A current picture hospital ID
 A current license to practice and a valid picture ID issued by a state, federal, or regulatory agency
 Identification indicating that the individual is a member of a Disaster Medical Assistance Team
 Identification from a federal, state, or municipal entity indicating that the individual has been granted
authority to render patient care, treatment, and services in disaster circumstances
 Presentation by a current hospital or medical staff member with personal knowledge regarding the
practitioner’s identity
Supervision: The CEO, Medical Staff President, or Incident Commander must appoint a medical supervisor who will
oversee and manage all practitioners who have been granted disaster privileges.
Verification Process: Verification of the credentials of individuals granted disaster privileges must be carried out as
described in 6.5-2 within 72 hours of the practitioner’s arrival
ID Badges: Practitioners granted disaster privileges must wear hospital-issued identification at all times showing
his/her disaster privileges.
Termination: Disaster privileges will be automatically terminated when the disaster is declared over, the immediate
situation is under control, and Medical Staff members and other practitioners are able to assume patient care duties
without disaster assistance.
Evidence of Malpractice Insurance
As an ongoing condition of holding of clinical privileges, each practitioner shall be required to furnish the CEO with
a current certificate of insurance setting forth minimum professional liability coverage of at least $1,0000,000 per
claim, which coverage is provided with respect to each individual staff member and on a "shared limit" basis, and
which certificate has been issued by an insurer which complies with one of the following alternative conditions:
a. The Insurer currently holds a certificate of authority from the Maine Superintendent of Insurance; or
b. The Insurer is currently listed as an approved surplus lines company by the Superintendent; or
c. The Insurer is otherwise licensed or approved by the Superintendent to do business in Maine; or is
otherwise permitted or legally authorized to do business in Maine.
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6.8-1
Lapses in Insurance and Non-renewal or Termination. In the event that the insurance coverage of any medical staff
member lapses through non-renewal or termination or the member has otherwise failed to comply with the
preceding requirements, the privileges of such member shall be automatically suspended by the CEO. The
member shall have the right to request a hearing with respect to such a suspension consistent with the applicable
provisions of Article VIII. Such privileges may thereafter be terminated consistent with applicable provisions of
Article VIII in the event the member does not present a certificate of insurance complying with this section within 30
days.
ARTICLE VII - CORRECTIVE ACTION
7.1
Routine Corrective Action
7.1-1 Criteria for Initiation
Whenever the activities or professional conduct of any practitioner with clinical privileges are, or are reasonably
probable of being detrimental to patient safety or to the delivery of quality patient care, or are reasonably probable
of being disruptive to hospital operations, corrective action against such practitioner may be initiated by any officer
of the medical staff, by the Chair of any standing committee of the medical staff, by the CEO, or by the Board.
7.1-2 Request and Notice
All requests for corrective action shall be in writing, submitted to the Executive Committee, and supported by
reference of the specific activities or conduct which constitute the grounds for the request. The Chair of the
Executive Committee shall promptly notify the CEO in writing all requests of corrective action received by the
committee and shall continue to keep the CEO fully informed of all action taken in conjunction therewith.
7.1-3 Investigation by a Service
The Executive Committee shall forward the request for corrective action to the service chief of the service in which
the questioned activities or conduct occurred or appoint an ad hoc committee to investigate it. The service chief or
ad hoc committee shall immediately investigate the matter or appoint an ad hoc committee to investigate it. The
medical staff member under review has an opportunity to informally meet with the Service Chief during the
investigation. Within 30 days after the receipt of the request, the Service Chief or ad hoc committee shall forward
the written report of the investigation to the Executive Committee.
7.1-4 Executive Committee Action
Within 30 days following receipt of the written report from the service or committee, the Executive Committee shall
take action upon the request. Such action may include without limitation:
a. rejecting the request for corrective action
b. issuing a warning, a letter of admonition, or a letter of reprimand
c. recommending terms of probation or requirements of consultation
d. recommending reduction, suspension or revocation of clinical privileges
e. recommending reduction of staff category or limitation of any staff prerogatives directly related to patient
care
f.
recommending suspension or revocation of staff membership.
7.1-5 Procedural Rights
Any action by the Executive Committee pursuant to Section 7.1-4(c), (d), (e), or (f), or any combination of such
actions, shall entitle the practitioner to the procedural rights as provided in Article VIII.
7.1-6 Other Action
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If the Executive Committee's recommended action is as provided in Section 7.1-4(a) or (b), such recommendation
together with all supporting documentation shall be forwarded to the Board for action as provided in Section 5.4-7
and 5.4-9, as applicable.
7.2
7.2-1
7.2-2
7.2-3
7.3
7.3-1
7.3-2
7.3-3
Summary Suspension
Criteria and Initiation
Whenever a practitioner willfully disregards these bylaws or other hospital policies, or whenever his/her conduct
requires that immediate action be taken to protect the life of any patient(s) or to reduce the substantial likelihood of
immediate injury or damage to the health or safety of any patient, employer or other person present in the hospital,
the Chair of the Executive Committee, the Chief of Service, the CEO, or the Executive Committee of either the
medical staff or the Board shall have the authority to summarily suspend the medical staff membership status or all
or any portion of the clinical privileges of such practitioner. Such summary suspension shall become effective
immediately upon imposition, and the CEO shall promptly give special notice of the suspension to the practitioner.
Executive Committee Action
As soon as possible after such summary suspension, a meeting of the Executive Committee shall be convened to
review and consider the action taken. The Executive Committee may recommend modification, continuation or
termination of the terms of the summary suspension.
Procedural Rights
Unless the Executive Committee recommends immediate termination of the suspension and cessation of all further
corrective action, the practitioner shall be entitled to the procedural rights as provided in Article VIII. The terms of
the summary suspension as sustained or as modified by the Executive Committee shall remain in effect pending a
final decision by the Board.
Automatic Suspension
License
A staff member or AHP whose license, certificate or other legal credential authorizing him/her to practice in this
state is revoked or suspended shall immediately and automatically be suspended from practicing in the hospital. It
is the responsibility of the practitioner to report any revocation or suspension of his/her license within 24 hours to
the CEO.
Drug Enforcement Administration
A staff member or AHP whose drug enforcement administration number is revoked or suspended shall immediately
and automatically be divested of his/her right to prescribe medications covered by such number. As soon as
possible after such automatic suspension, the Executive Committee shall convene to review and consider the facts
under which the drug enforcement administration number was revoked or suspended. The Executive Committee
may then take such further action as is appropriate to the facts disclosed in its investigation.
failure to complete medical records in timely fashion as defined in the rules and regulations. Such suspension shall
take the form of withdrawal of a practitioner's admitting prerogative or consulting privileges and shall be effective
until medical records are completed. For the purpose of enforcing this Section 7.3-3 justified reasons for delay in
completing medical records shall include, without limitation:
a. that the attending physician or any other individual contributing to the record is ill, on vacation, out of town,
or otherwise unavailable for a period of time.
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b.
7.3-4
that a practitioner is waiting for the results of a late report which is necessary for the completion of the
discharge summary and establishment of a final diagnosis.
c. that a practitioner has dictated reports and is waiting for hospital personnel to transcribe them.
Procedural Rights
A practitioner under automatic suspension by operation of Section 7.3-3 shall be entitled to the procedural rights
provided in Article VIII.
ARTICLE VIII - HEARING AND APPELLATE REVIEW PROCEDURE
8.1
Interview
When the Executive Committee or Board receives or is considering an adverse recommendation concerning a
practitioner, the practitioner may be afforded an interview. The interview shall not constitute a hearing, shall be
preliminary in nature, and need not be conducted according to the procedural rules provided with respect to
hearings. The practitioner shall be informed of the general nature of the circumstances and may present
information relevant thereto. A record of such interviews shall be made. Interviews with the practitioner may be
held at any stage during the Hearing and Appellate Review process. These interviews need not comply with all of
the procedural requirements applicable to hearing and appellate review procedures in this article but shall afford
the practitioner a full and fair opportunity to present his/her position, to respond to questions, and to address
concerns.
8.2
8.2-1
Hearings and Appellate Review
Hearing Right following Adverse Executive Committee Recommendation
When any practitioner receives notice of a recommendation of the executive committee that, if ratified by decision
of the board, will adversely affect his/her appointment to or status as a member of the medical staff or his/her
exercise of clinical privileges, he shall be entitled to a hearing before an ad hoc committee of the medical staff. The
hearing committee shall be composed of impartial members of the medical staff. If the recommendation of the
executive committee following such hearing is still adverse to the affected practitioner, he shall then be entitled,
upon request, to an appellate review by the board before a final decision is rendered.
Adverse Board Decision
When the board is considering taking action or rendering a decision that is adverse to the practitioner and either (a)
is contrary to a favorable recommendation by the executive committee under circumstances where no prior right to
a hearing existed, or (b) is being made on the board's own initiative without benefit of a prior recommendation by
the executive committee, such practitioner shall be entitled, upon request, to a hearing by an ad hoc committee
appointed by the board before the board takes final action or renders a final decision. Impartial committee
members will be appointed by the board.
Appellate Review
When any practitioner receives notice of a board decision or action which will adversely affect his/her appointment
to or status as a member of the medical staff or his exercise of clinical privileges as defined in 8.12-4, he shall be
entitled to an Appellate Review under the procedures outlined in 8.9 and 8.10 before the board decision or action
becomes final.
Procedure and Process
8.2-2
8.2-3
8.2-4
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8.2-5
8.3
8.3-1
8.3-2
8.3-3
8.3.4
8.3.5
All hearings and appellate review shall be in accordance with the procedure and safeguards set forth in this Article
VIII to assure that the affected practitioner is accorded all rights to which s/he is entitled.
Exceptions
Actions or recommendations of the MSEC or the board that are not adverse to the practitioner, as defined in
Section 8.12-4, shall not give rise to a hearing or appellate review. Examples of actions or recommendations that
do not trigger rights to a hearing or appellate review include, but are not limited to, the issuance of a warning, a
letter of admonition, and a letter of reprimand. In addition, the denial, termination or reduction of temporary
privileges shall not give rise to any right to a hearing or appellate review.
Removal From Office of Medical-Administrative Officer
General Manner of Removal
Removal from office of a medical-administrative officer for grounds unrelated to his professional clinical capability
and his exercise of clinical privileges may be accomplished in accordance with the usual personnel policies of the
hospital or the terms of such officer's employment agreement, if any. To the extent that the grounds for removal
include matters relating to competence in performing professional clinical tasks or in exercising clinical privileges,
resolution of the matter shall be in accordance with Articles VII and VIII.
Statement of Grounds
Prior to removal of a medical-administrative officer, the Board, through the Chief Executive Office, shall transmit to
such medical-administrative officer and to the president of the medical staff a written notice of the proposed
removal from office together with a statement specifying the grounds for such removal. To the extent that such
grounds explicitly relate to professional clinical capability or to the exercise of clinical privileges, the notice to the
officer whose removal is sought shall take the form of a special notice and, for hearing purposes, the proposed
removal shall be deemed equivalent to an adverse recommendation of the executive committee. If the stated
grounds for dismissal are based solely on non-clinical matters, the procedure specified in Section 8.3-3 through
8.3-5 shall apply.
Ad Hoc Medical Staff Committee
Within one week of the receipt by the Medical Staff President of the notice as provided in Section 8.3-2, the staff
shall, by appointment by the president, select 5 staff members as an Ad Hoc Committee to review the statement of
dismissal and to conduct such other inquiry as it may deem appropriate for the purpose of forming an opinion as to
whether the Board's asserted grounds for removal relate solely to non-clinical matters, or to both clinical and nonclinical matters. Within 4 weeks of its appointment, the Ad Hoc Committee shall, by written memorandum to the
president of the staff and to the board, submit its opinion in the matter. The activities of the Ad Hoc Committee
shall not be deemed a hearing as that term is used in Section 8.2 and need not be conducted as such.
Agreement on Grounds for Removal
If the Ad hoc Committee's opinion is in agreement with the statement that the grounds for removal are solely nonclinical, the officer's remedies under these bylaws shall be deemed to have been exhausted and the removal shall
be effected consistent with Section 8.3-1.
Non agreement on Grounds for Removal
If the Ad hoc Committee's opinion does not accord with the Board's statement of grounds, the officer shall be so
notified and the Joint Conference Committee shall be convened within 14 days of the Ad Hoc Committee's
decision. The Joint Conference Committee shall review the statement of dismissal and the ad hoc committee's
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memorandum and conduct such other inquiry as it may deem appropriate for the purpose of rendering an advisory
opinion on the categorization of the grounds for removal. Within 30 days of its deliberations, the Joint Conference
Committee shall issue its opinion to the board. The Joint Conference Committee consideration shall not be
deemed a hearing as that term is used in Section 8.2 and need not be conducted as such, but a record shall be
kept. After considering the Joint Conference Committee's opinion, the board shall make its final decision as to the
categorization of the grounds for dismissal. Removal of the officer shall be effected in the manner appropriate to
the board's final categorization and consistent with Section 8.3-1.
8.4
8.4-1
8.4-2
8.5
8.5-1
8.5-2
8.6
8.6-1
Initiation of Hearing
Notice of Adverse Recommendation on Action
The CEO shall be responsible for giving prompt written notice of an adverse recommendation or decision to any
affected practitioner who is entitled to a hearing or an appellate review, by special notice.
Waiver by Failure to Request a Hearing
a. The failure of a practitioner to request a hearing to which he is entitled by these bylaws within the time and in
the manner herein provided shall be deemed a waiver of his right to such hearing and to any appellate review
to which he might otherwise have been entitled on the matter.
b. When the waived hearing of appellate review relates to an adverse recommendation of the Executive
Committee of the medical staff or of a hearing committee appointed by the board, the same shall thereupon
become and remain effective against the practitioner in the same manner as a final decision of the board
provided for in Article VIII. In either of such events, the CEO shall promptly notify the affected practitioner of his
status by special notice.
Hearing Prerequisites
Notice of Hearing
Within 30 days after receipt of a request for a hearing from a practitioner entitled to the same, the Executive
Committee or the Board, whichever is appropriate, shall schedule and arrange for such a hearing and shall,
through the CEO, notify practitioner of the time, place and date so scheduled, by special notice. The hearing date
shall not be less than 30 days, nor more than 60 days from the receipt of the request for hearing; provided,
however, that a hearing for a practitioner who is under suspension which is then in effect shall be held as soon as
arrangements therefore may reasonably by made, but not later than 60 days from the receipt of such practitioner's
request for hearing.
Statement of Changes
The notice of hearing shall state in concise language the acts or omissions with which the practitioner is charged, a
list of specific or representative charts being questioned, and/or other reasons or subject matter that was
considered in making the adverse recommendations or decision.
Composition of Hearing Committee
By Medical Staff
When a hearing relates to an adverse recommendation of the Executive Committee such hearing shall be
conducted by an Ad hoc Hearing Committee of not less than three members of the medical staff appointed by the
President of the Medical Staff in consultation with the Executive Committee. One of the members so appointed
shall be designated as Chair by the Staff President. No staff member who has actively participated in the
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8.6-2
8.7
8.7-1
8.7-2
8.7-3
8.7-4
8.7-5
8.7-6
8.7-7
consideration of the adverse recommendation shall be appointed a member of this hearing committee unless it is
otherwise impossible to select a representative group due to the size of the medical staff. In no case shall any
individual who is in direct economic competition with the practitioner be on the hearing panel. Practitioners who are
not members of the Hospital's Medical Staff but are members of the Medical Staffs of other Maine hospitals may
also be appointed, if it is not possible to put a hearing panel together from medical staff members
By the Board
When a hearing is related to an adverse decision of the board that is contrary to the recommendation of the
Executive Committee, the Board shall appoint a hearing committee to conduct such hearing and shall designate
one of the members of his/her committee as Chair. The committee shall be made up of at least three members,
two of whom are members of the Board. At least one representative from the medical staff shall be included on this
committee when feasible. Practitioners who are not members of the medical staff may be appointed if necessary to
assure that no practitioner who is in direct competition with the practitioner serves on the hearing panel. In no case
shall any individual who is in direct economic competition with the practitioner be on the hearing panel.
Hearing Procedure
Committee Presence
All members of the hearing committee must be present when the hearing takes place, and no member may vote by
proxy.
Records
An accurate record of the hearing must be kept. The mechanism shall be established by the Ad hoc Hearing
Committee, and may be accomplished by use of a court reporter, electronic recording unit, or by detailed
transcription
Personal Presence. The personal presence of the practitioner for whom the hearing has been scheduled shall be
required. A practitioner who fails without good cause to appear and proceed at such hearing shall be deemed to
have waived his rights in the same manner as provided in Section 8.4-2a and to have accepted the adverse
recommendation or decision involved, and the same shall thereupon become and remain in effect as provided in
Section 8.4-2b.
Postponement
Postponement of hearings beyond the time set forth in these bylaws shall be made only with the approval of the Ad
hoc Committee. Granting of such postponements shall only be for good cause shown and in sole discretion of the
hearing committee.
Presiding Officer
Either a hearing officer, if one is appointed pursuant to Section 8.12-1, or the Chair of the hearing committee shall
preside over the hearing to determine the order of procedure during the hearing, to assure that all participants in
the hearing have a reasonable opportunity to present relevant oral and documentary evidence and to maintain
decorum.
Representation
The affected practitioner shall be entitled to be represented by an attorney or other person of the practitioner's
choice.
Rights of Parties
During a hearing, each of the parties shall have the right to:
a. call, examine and cross-examine witnesses
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b.
8.7-8
8.7-9
8.8
8.8-1
8.8-2
introduce and present evidence determined to be relevant by the Chair of the Panel without regard to its
admissibility in a court of law
c. question any witness on any matter relevant to the issue of the hearing
d. challenge any witness
e. rebut any evidence; and
f.
submit a written statement at the close of the hearing.
If the practitioner does not testify in his own behalf, he may be called and examined as if under cross examination.
Procedure and Evidence
a. The hearing need not be conducted strictly according to rules of law relating to the examination of
witnesses or presentation of evidence. Any relevant matter upon which responsible persons customarily
rely in the conduct of serious affairs shall be considered, regardless of the existence of any common law
or statutory rule which might make evidence inadmissible over objection in civil or criminal action. The
practitioner for whom the hearing is being held shall, prior to or during the hearing, be entitled to submit
memoranda concerning any issue of procedure or of fact and such memoranda shall become a part of the
hearing record.
b. The Executive Committee, when its action has prompted the hearing, shall appoint one of its members or
some other medical staff member to represent it at the hearing, to present the facts in support of its
adverse recommendation, and to examine witnesses. The Board, when its action has prompted the
hearing, shall appoint one of its members to represent it at the hearing, to present the facts in support of
its adverse decision and to examine witnesses. It shall be the obligation of such representative to present
appropriate evidence in support of the adverse recommendation, action, or proposed decision or action,
but the affected practitioner shall thereafter be responsible for supporting his challenge to the adverse
recommendation, action, or proposed decision or action, by an appropriate showing that the adverse
recommendation, action, or proposed decision or action, charges or grounds involved lack sufficient
factual basis or that such basis of any action based thereon is arbitrary, unreasonable or capricious.
Recesses and Adjournment
The hearing committee may, without special notice, recess the hearing and reconvene the same for the
convenience of the participants or for the purpose of obtaining new or additional evidence or consultation. Upon
the conclusion of the presentation of oral and written evidence, the hearing shall be closed. The hearing committee
shall, thereupon, at a time convenient to itself, conduct its deliberations outside the presence of the parties and
complete its report under the procedures described in the next section.
Hearing Committee Report and Further Action
Hearing Committee Report
Within ten days after final adjournment of the hearing, the hearing committee shall make a written report and
recommendation and shall forward the same together with the hearing record and all other documentation
considered by it, to the Executive Committee or to the Board, whichever appointed it. The report may recommend
confirmation, modification, or rejection of the original adverse recommendation of the Executive Committee or the
proposed decision or action of the Board.
Action on Hearing Committee Report
Within 30 days after receipt of the report of the hearing committee, the Executive Committee or the Board, as the
case may be, shall consider the same and affirm, modify, or reverse its prior recommendation or action in the
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8.8-3
8.8-4
8.9
8.9-1
8.9-2
8.9-3
matter. It shall transmit the result, together with the hearing record, the report of the hearing committee, and all
other documentation considered, to the CEO.
Notice
The CEO shall promptly send a copy of the result to the practitioner by special notice; to the President of the
Medical Staff and to the Board.
Effect of Favorable Result
a. Adopted by the Board: If the board's result pursuant to Section 8.8-2 is favorable to the practitioner, such
result shall become the final decision of the board and the matter shall be considered finally closed.
b. Adopted by the Executive Committee: If the Executive Committee's recommendation pursuant to Section
8.8-2 is favorable or unfavorable to the practitioner, the CEO shall promptly forward it, together with all
supporting documents, to the Board for its final action. The Board shall take action thereon by adopting or
rejecting the Executive Committee's recommendation in whole or in part or by referring the matter back to
the Executive Committee for further reconsideration. Any such referral back shall state the reasons
therefore, set a time limit within which a subsequent recommendation to the Board must be made, and
may include a direction (i) that an additional hearing by the ad hoc committee be conducted to clarify
issues that are in doubt, or (ii) that the executive committee carry out other proceedings or take other
actions that the board may request. After receipt of such subsequent recommendation and any new
evidence in the matter, the board shall take final action, with the right of appellate review. The CEO shall
promptly send the practitioner special notice, informing him/her of each action taken pursuant to this
Section 8.8-4b. Favorable action shall become the final decision of the Board, and the matter shall be
considered finally closed. If the Board's action is adverse, the special notice shall inform the practitioner
of his right to request an appellate review as provided in Sections 8.9 and 8.10 of these bylaws.
Initiation and Prerequisites of Appellate Review
Request for Appellate Review
A practitioner shall have 15 days following his special notice pursuant to Section 8.8-4b or 8.8 to file a written
request for an appellate review. Such request shall be delivered to the CEO either in person or by special notice,
and may include a request for a copy of the report and record of the hearing committee and all other material,
favorable or unfavorable, that was considered in making the adverse action or result. Such notice may request that
the appellate review be held only on the record on which the adverse recommendation or decision is based, as
supported by the practitioner's written statement provided for in Section 8.10-2 or may also request that oral
argument be permitted as part of the appellate review.
Waiver by Failure to Request Appellate Review
A practitioner who fails to request an appellate review within the time and in the manner specified in Section 8.9-1
waives any right to such review. Such waiver shall have the same force and effect as that provided in Section 8.42.
Notice to Time and Place for Appellate Review
Upon receipt of a timely request for appellate review, the CEO shall deliver such request to the Board. Within 15
days after receipt for such request, the Board shall schedule and arrange for such review, including a time and
place for oral argument if such has been requested, which shall not be less than 25 days nor more than 60 days
from the date of receipt of the appellate review requested provided, however, that an appellate review for a
practitioner who is under suspension then in effect shall be held as soon as the arrangements for it may reasonably
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8.9-4
be made. At least 5 days prior to the appellate review, the CEO shall send the practitioner notice by special notice
of the time, place and date of the review. The time for the appellate review process may be extended by the
appellate review body for good cause.
Appellate Review Body
The Board shall determine whether the appellate review shall be conducted by the Board as a whole or by an
appellate review committee composed of at least five members of the board, appointed by the Chair. If a
committee is appointed, one of its members shall be designated as Chair. No person on the review committee
shall have participated previously in the matter.
8.10
Appellate Review Procedure
8.10-1 Nature of Proceedings
The proceedings by the review body shall be in the nature of an appellate review based upon the record of the
hearing before the hearing committee, that committee's report, and all subsequent results and actions thereon.
The appellate review body shall also consider the written statements submitted pursuant to Section 8.10-2 and
such other materials as may be presented and accepted under Section 8.10-4 and 8.10-5.
8.10-2 Written Statements
The practitioner seeking the review shall submit a written statement detailing the findings of fact, conclusions and
procedural matters with which he disagrees, and his reasons for such disagreement. This written statement may
cover any matters raised at any step in the hearing process, and legal counsel may assist in its preparation. The
statement shall be submitted to the appellate review body through the CEO at least 15 days prior to the scheduled
date of the appellate review. A written statement in reply may be submitted by the Executive Committee or by the
Board, and if submitted, the CEO shall provide a copy thereof to the practitioner at least seven days prior to the
schedule date of the appellate review.
8.10-3 Presiding Officer
The Chair of the appellate review body shall be the presiding officer. S/he shall determine the order of the
procedure during the review, make all required rulings, and maintain decorum.
8.10-4 Oral Statement
The appellate review body, in its sole discretion, may allow the parties or his/her representatives to personally
appear and make oral statements in favor of his/her positions. Any party or representative so appearing shall be
required to answer questions put to him/her by any member of the appellate review body.
8.10-5 Consideration of New or Additional Matters
New or additional matters or evidence not raised or presented during the original hearing or in the hearing report
and not otherwise reflected in the record shall be introduced at the appellate review only under unusual
circumstances. The appellate review body, in its sole discretion, shall determine whether such matters or evidence
shall be considered or accepted.
8.10-6 Powers
The appellate review body shall have all the powers granted to the hearing committee, and such additional
powers as are reasonably appropriate to the discharge of its responsibilities.
8.10-7 Recesses and Adjournment
The appellate review body may recess the review proceedings and reconvene the same without additional notice
for the convenience of the participants or for the purpose of obtaining new or additional evidence or consultation.
Upon the conclusion of oral statements, if allowed, the appellate review shall be closed. The appellate review body
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thereupon, at a time convenient to itself, conducts its deliberations outside the presence of the parties. Upon the
conclusion of those deliberations, the appellate review shall be declared finally adjourned.
8.10-8 Action Taken
a. If the appellate review is conducted by the Board, it may affirm, modify, or reverse its prior decision or, in its
discretion, refer the matter back to the Executive Committee for further review and recommendation within 15
days. Such referral may include a request that the Executive Committee arrange for a further hearing to
resolve specified disputed issues.
b. If the appellate review is conducted by a committee of the Board, such committee shall within 7 days after the
scheduled or adjourned date of the appellate review, either make a written report recommending that the board
affirm, modify, or reverse its prior decision, or refer the matter back to the Executive Committee for further
review and recommendation within 15 days. Such referral may include a request that the Executive Committee
consider reformulating its recommendation or consider taking such further action as the board committee
requests. Within 10 days after the Board committee's receipt of such recommendation after referral, the
committee shall make its recommendation to the full Board as provided above.
8.10-9 Conclusions
The appellate review shall not be deemed to be concluded until all of the procedural steps provided in this Section
8.10 have been completed or waived.
8.11
Final Decision by Governing Body
8.11-1 Within 30 days after the conclusion of the appellate review, the Board shall make its final decision in the matter and
shall send notices thereof to the Executive Committee and, through the CEO, to the affected practitioner, by special
notice. If this decision is in accordance with the Executive Committee's last recommendation in the matter, it shall
be immediately effective and final and shall not be subject to further hearing or appellate review. If this decision is
contrary to the Executive Committee's last such recommendation, before this decision is made final, the Board shall
refer the matter to the Joint Conference Committee for further review and recommendation.
8.11-2 Joint Conference Committee Review
Within 15 days of its receipt of a matter referred to it by the board pursuant to Section 8.11-1, the Joint Conference
Committee shall convene to consider the matter and shall submit its recommendation to the Board. At its next
meeting following the receipt of the Joint Conference Committee's recommendation, the Board shall make its final
decision which shall be immediately effective and final and subject to no further hearing or appellate review. The
CEO shall send special notice of this final decision to the affected practitioner.
8.12
General Provisions
8.12-1 Hearing Officer
The use of a hearing officer to preside at an evidentiary hearing is optional. The use and appointment of such
officer shall be determined by the hearing committee after consultation with the President of the Medical Staff. A
hearing officer may or may not be an attorney at law but must be experienced in conducting hearings. He shall act
in an impartial manner as the presiding officer of the hearing. If requested by the hearing committee, he may
participate in its deliberation, but he shall not be entitled to vote.
8.12-2 Attorneys
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In the hearings provided for in these bylaws, the affected practitioner has a right to be represented by an attorney
or other person of his choice. Likewise, the Board or Executive Committee may in their discretion, seek counsel
and representation by an attorney.
8.12-3 Number of Reviews
Notwithstanding any other provisions of these bylaws, no practitioner shall be entitled as a matter of right to more
than one hearing to take place before either: (i) an ad hoc committee appointed by the Medical Executive
Committee; or (ii) an ad hoc committee of the board; and one appellate review with respect to an adverse
recommendation or action.
8.12-4 Adverse Actions or Recommendations
The following recommendations or actions are deemed adverse pursuant to Section 8.2:
a. denial of initial staff appointment
b. denial of re-appointment
c. suspension of staff membership
d. revocation of staff membership
e. denial of requested advancement in staff category
f. reduction in staff category
g. limitation of admitting prerogatives
h. denial of requested clinical privileges
i. reduction of clinical privileges
j. suspension of clinical privileges
k. revocation of clinical privileges
l. terms of probation
8.13
Time Frames
All reasonable steps will be taken to adhere to the time frames set forth in this article. However, the times may be
deviated from for good reason as determined by the MSEC or the Board in the exercise of their sound discretion.
The MSEC or Board may delegate the authority to deviate from these time frames in appropriate circumstances to
the Medical Staff President, the CEO, ad hoc committees or others who have responsibilities under these bylaws.
The affected practitioner may request a deviation and such a request may be granted for good reason.
ARTICLE IX - OFFICERS OF THE MEDICAL STAFF
& VICE PRESIDENT OF MEDICAL AFFAIRS
9.1
9.1-1
9.1-2
Officers of the Medical Staff
Identification
The officers of the medical staff shall be:
a. president
b. president elect
c. secretary-treasurer
Qualification
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9.1-3
9.1-4
9.1-5
9.1-6
9.1-7
9.1-8
Officers must be members of the active medical staff at the time of nomination and election and must remain
members in good standing during his/her term of office. Failure to maintain such status shall immediately create a
vacancy in the office involved.
Nominations
a. By nominating committee: The nominating committee shall consist of members of the active medical staff
appointed by the President of the Medical Staff. Each service shall be represented. The committee shall
convene and submit to the secretary of the staff one or more qualified nominees for each office. The names of
such nominees shall be reported to the staff at least 15 days prior to the annual meeting.
b. By other means: Nominations may also be made from the floor at the time of the annual meeting.
Election
Officers shall be elected at the annual meeting of the staff. Only members of the active medical staff shall be
eligible to vote. Voting will be by secret ballot if requested by any member and voting by proxy shall not be
permitted. A nominee shall be elected upon receiving a majority of the valid votes cast. If no candidate for the
office receives a majority vote on the first ballot, a runoff election will be held by successive balloting, such that the
name of the nominee receiving the fewest votes is omitted from each successive slate until a majority vote is
obtained by one nominee.
Exceptions
Sections 9.1-3 and 9.1-4 shall not apply to the office of president. The president elect shall, upon completion of his
term of office in that position, immediately succeed to the office of the president.
Term of Office
Each officer shall serve a one-year term, commencing on the first day of the medical staff year following his
election. Each officer shall serve until the end of his term and until a successor is elected.
Vacancies in Elected Office
Vacancies in office during the medical staff year, other than president or president-elect, shall be filled by the
Executive Committee. If there is a vacancy in the office of president, the president-elect shall serve in it for the
remaining term. A vacancy in the office of president-elect shall be filled by special election following the
mechanism in Sections 9.1-3 and 9.1-4.
Duties of Elected Officers
a. President: The president shall serve as the Chief Administrative Officer of the Medical Staff. As such s/he
shall:
i.
act in coordination and cooperation with the CEO in all matters of mutual concern within the
hospital.
ii.
be accountable to the Board, in conjunction with the Executive Committee, for the quality and
efficiency of clinical services and performance within the hospital of the patient care audit and
other quality maintenance functions delegated to the staff.
iii.
be responsible for the enforcement of medical staff bylaws, rules and regulations, for
implementation of sanctions where these are indicated, and for the medical staff's compliance
with procedural safeguards in all instances when corrective action has been requested against a
practitioner.
iv.
represent the views, policies, needs and grievances of the medical staff to the governing body
and to the CEO.
v.
receive and interpret the policies of the governing body to the medical staff.
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vi.
9.1-9
9.2
9.2-1
appoint committee members to standing, special and multi disciplinary medical staff committees
and medical staff representatives to hospital management committees.
vii.
call, preside at, and be responsible for the agenda of all general meetings of the medical staff.
viii.
serve as Chair of the Executive Committee, as a medical staff representative to the Joint
Conference Committee and as an ex officio member without vote of all other medical staff
committees.
ix.
be responsible for the educational activities of the medical staff
x.
serve as a member of the board.
xi.
be the spokesman for the medical staff in its external
professional and public relations.
b. President-elect: The president-elect shall be Chair of Bylaws Committee, a member of the Executive
Committee, and a medical staff representative to the Joint Conference Committee. In the temporary absence of
the President, they shall assume all duties and have the authority of the president. For the purposes of this
subsection, “temporary absence” shall mean the inability of the President to fulfill his/her duties for a period in
excess of six days or for whatever shorter period may be requested by the President.
c. Secretary-Treasurer: The secretary-treasurer shall be a member of the Executive Committee and the Bylaws
Committee. His/her duties shall be to:
i.
give proper notice of all staff meetings on order of the appropriate authority.
ii.
prepare accurate and complete minutes for all meetings.
iii.
supervise the collection and accounting for any funds that may be collected in the form of staff
dues, assessments, or application fees.
iv.
perform such other duties as ordinarily pertain to his office.
Removal of Officers
Elected officers of the Medical Staff may be removed for failure to satisfactorily meet the qualifications for Officers
of the Medical Staff set forth in 9.1-2, or for failure to carry out the duties of Officers of the Medical Staff as set forth
in 9.1-8. Removal shall occur by a 2/3 vote of the Active Medical Staff present at any special or regular meeting
where the agenda includes the proposed action as an agenda item.
Additional Officers
The CEO or Board may, after considering the advice and recommendations of the medical staff, appoint additional
practitioners to medical-administrative positions within the hospital to perform such duties as prescribed by the
Executive Committee and the Board or as defined by amendment to these bylaws. To the extent that any such
officer performs any clinical function, he must become and remain a member of the staff.
Vice President Medical Affairs & Education
The CEO may, with the advice and consent of the MSEC and the FMH Board of Trustees, appoint a physician to
the post of VPMA of Franklin Memorial Hospital.
a. Basic Qualifications:
The VPMA must be a physician licensed to practice allopathic or osteopathic medicine by the appropriate
Maine licensing agency and must be a member of the Active or Provisional Medical Staff of Franklin Memorial
Hospital with all membership rights and responsibilities as defined in these bylaws. A physician applying for the
VPMA position, who is not presently a member of the Medical Staff, may be granted the position on a
provisional basis for a period of up to 90 days, only after completing an application for Medical Staff
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9.2-2
membership and only after being granted temporary privileges until Active or Provisional membership is
granted.
b. Responsibilities:
i.
The basic responsibilities of the VPMA shall be to provide liaison between Franklin Memorial
Hospital and its Medical Staff. In this regard, the VPMA shall sit as an ex-officio member on all
Medical Staff service meetings and committees. The VPMA shall retain all rights to vote and hold
office as a member of the Medical Staff. Otherwise, the ex-officio appointments of the VPMA
shall be without vote on Medical Staff services and committees.
ii.
The VPMA shall provide assistance to the Medical Staff and its officers to fulfill its responsibilities
in the credentialing of members, the assurance of quality of care provided by its members as
reflected in these Bylaws and the FMH Quality Management Plan, and other matters as may
come before the Medical Staff.
c. Reporting:
The VPMA shall report to the hospital CEO, who shall seek the counsel of Medical Staff Officers in the periodic
performance review of the VPMA.
d. Removal:
The VPMA may be removed from his or her position by the CEO, a majority vote of the Board of Trustees, or a
majority vote of the Medical Staff.
Clinical Service Medical Directors
a. Appointment:
The Board, after receiving recommendation from the Medical Staff, may appoint physician members of the
Medical Staff to serve as medical directors of hospital clinical services. If appointed by the Board or CEO, the
appointments shall be approved by a majority vote of the MSEC). Authority Medical directors thus appointed
shall be delegated authority on behalf of the Medical Staff to establish clinical policies and procedures and
oversee the quality, appropriateness, and effectiveness of the care delivered in those clinical services
b. Reporting:
From time to time, but no less frequently than annually, clinical service medical directors so appointed shall
provide reports to the MSEC of the activities, quality, appropriateness, and effectiveness of his/her clinical
services.
c. Removal:
Clinical service medical directors appointed under this article may be removed by the CEO or majority votes of
the Board or MSEC.
ARTICLE X - SERVICES
10.1
Organizational Structure
The medical staff shall be non-departmental. There will be clinical services of Adult Medicine, Surgery and
Maternal Child Health. Each service shall be headed by a Chief of Service and shall function under the Executive
Committee.
10.2
Service Chiefs
10.2-1 Qualifications
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Each chief shall be a member of the active staff and a member of the service which s/he is to head shall be
qualified by training, experience, interest and demonstrated current ability in the clinical area covered by the
service.
10.2-2 Selection
Each chief shall be elected by a majority of the active staff of his/her service prior to the annual meeting of the
medical staff.
10.2-3 Term of Office
Each service chief shall serve a one-year term commencing on his appointment. Removal of a service chief may
be initiated by the Board acting upon the recommendation of the Executive Committee or a two-thirds majority vote
of all active staff members of the service and shall be accomplished pursuant to Section 8.3.
10.2-4 Functions of Service Chiefs
Each chief shall:
a. account to the Executive Committee for all professional and administrative activities within his/her service
b. develop and implement in cooperation with the Executive Committee, programs for credentials review and
privileges delineation, continuing medical education, concurrent monitoring of practice and retrospective patient
care audit
c. be a member of the Executive Committee, giving guidance on the overall medical policies of the hospital and
making specific recommendations and suggestions regarding his/her own service in order to assure quality
patient care
d. maintain continuing review of the professional performance of all practitioners with clinical privileges and of all
AHPs assigned to his/her service and report regularly thereon to the Executive Committee
e. transmit to the appropriate authorities as required by Articles V and VII, his/her service's recommendations
concerning appointment and classification, re-appointment, delineation of clinical privileges or specified
services, and corrective action with respect to practitioners to his/her service
f. enforce the hospital and medical staff bylaws, rules and regulations and medical staff and service policies
within his/her service
g. implement within his/her service actions taken by the Executive Committee
h. participate in every phase of administration of his/her service through cooperation with the nursing service and
the hospital administration in matters affecting patient care, including personnel, supplies, special regulations,
standing orders and techniques
i. assist in the preparation of such annual reports, including budgetary planning, pertaining to his/her service as
may be required by the Executive Committee, the CEO, or the Board.
j. lead the ongoing quality improvement activities of the service and participates in organization-wide quality
improvement activities.
10.3
Functions of Services
10-3-1 Establishment of Criteria
Each clinical service shall establish its own criteria, consistent with policies and bylaws of the medical staff or of the
Board, for the granting of clinical privileges to practitioners or specified services to AHPs in the service.
10.3-2 Reviews
Each service shall conduct reviews of records of patients and other pertinent sources of medical information
relating to patient care for the purpose of presentation at staff meeting to contribute to the continuing education of
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every practitioner and to the process of developing criteria to assure optimal patient care. Each service shall meet
no less than 6 times a year for these purposes.
10.3-3 Specific Reviews
Each service shall include in the review process consideration of all deaths, of patients with infections,
complications, errors in diagnosis and treatment, of patients currently in the hospital with unsolved clinical
problems, of proper utilization of hospital facilities and of other significant patient care matters. The review of
surgical matters shall also include a comprehensive tissue review for justification of all surgery performed, whether
tissue was removed or not, for acceptability of the procedure chosen, and for agreement or disagreement between
preoperative and pathological diagnosis.
10.3-4 Reports
The service representatives shall submit a report at each staff meeting detailing analysis of selected case material
for group evaluation.
10.4
Service Assignment
The Executive Committee shall, after consideration of the recommendations of the clinical services, recommend
initial service assignments for all medical staff members and for AHPs with special service appointments.
ARTICLE XI - COMMITTEES AND FUNCTIONS
11.1
General Considerations
Committees exist to perform such functions and to carry out such business of the Medical Staff as outlined in these
bylaws and to provide a forum for the ongoing review of clinical care rendered by staff; committees also exist to
assist the Medical Staff and the Governing Board with compliance with the goals and objectives of hospital-wide
and Medical Staff quality improvement plans. Unless otherwise provided for in these bylaws, all committees shall
report to the Executive Committee, which shall provide general oversight of all such committees. Committee
functions shall include, at a minimum, the following:
a. Review and investigation of the credentials of applicants for initial appointment or reappointment to the
Medical Staff or Allied Health Professional Staff;
b. Quality management including Medical Staff quality improvement projects and initiatives;
c. Development, implementation, and enforcement of policies pertaining to medical records and ensuring
that medical records accurately reflect and appropriately document the clinical care rendered.
d. Infection control
e. Review of pharmacologic agents used in treatment, including maintenance of a hospital formulary; and
f. Utilization and risk management.
g. Promotion of Physician Wellness
In addition to the standing committees listed below, the Executive Committee may, by resolution, establish a staff
committee to perform one or more of the required staff functions. Those functions requiring participation of, rather
than direct oversight by, the staff may be discharged by medical staff representation on such hospital management
committees as are established to perform such functions. Whenever these bylaws require that a function be
performed or that a report or recommendation be submitted to a named medical staff committee and no such
committee exists, the Executive Committee shall perform such function or receive such report.
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11.2
Standing Committees
The following committees shall be considered Standing Committees of the Medical Staff:
a. Executive Committee
b. Medical Staff Quality Committee
c. Utilization Review & Medical Records Committee
d. Credentials Committee
e. Education Committee
f. Pharmacy and Therapeutics Committee
g. Infection Control Committee
h. Disaster Planning Committee
i.
Bylaws Committee
11.3
Appointment, Composition, Terms, Removal and Vacancies
11.3-1 Appointment and Composition.
Committees shall be comprised of members of the active, provisional, allied health professional and courtesy
staffs and may include, where appropriate, representation from hospital administration, nursing service, medical
records service, pharmaceutical service, social service and such other hospital departments as are appropriate to
the function(s) to be discharged by the committee. Unless otherwise specifically provided, the medical staff and
allied health staff members shall be appointed by the President of the staff and the administrative staff members
shall be appointed by the CEO. Each committee shall, with the approval of the Executive Committee, selects its
Chair and secretary where the same are not provided for otherwise in these bylaws. The President of the Staff
and the CEO, or his/her respective designees, shall serve as ex officio members without vote on all committees,
unless otherwise expressly prohibited by these bylaws.
11.3-2 Term and Prior Removal.
Unless otherwise specifically provided, a committee member shall continue as such until the end of his/her period
of staff appointment and until his successor is elected or appointed. A medical staff committee member, other
than one serving ex officio, may be removed by a majority vote of the Executive Committee. An administrative staff
committee member may be removed by action of the CEO.
11.3-3 Vacancies.
Unless otherwise specifically provided, vacancies on any staff committee shall be filled in the same manner in
which original appointment to such committee is made.
11.4
Meetings, Quorum, Minutes & Attendance
11.4-1
Meetings
A committee established under this Article shall meet as often as is necessary to discharge its
assigned duties, but no less often than quarterly, except that committees formed for the
purpose of assuring and improving quality of care shall meet no less than six (6) times per
year. The Executive Committee shall meet not less than ten (10) times per year.
11.4-2
Quorum.
Fifty percent of the voting members of a committee, but not less than two members, shall
constitute a quorum of any meeting of the committee.
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11.4-3
11.4-4
Minutes
Minutes of all meetings shall be prepared by the secretary of the committee or his/her designee and shall
include a record of attendance, agendas, discussions, decisions made, votes taken, remedial actions and
follow-up on all issues raised. Copies of such minutes shall be signed by the presiding officer, approved by the
attendees, forwarded to the Executive Committee, and made available to the staff. A permanent file of the
minutes of each committee meeting shall be maintained.
Attendance.
Attendance requirements for committee meetings shall be as stated in Article XII (Section 12.7).
11.5
Medical Staff Executive Committee (MSEC)
11.5-1
Composition
The MSEC shall consist of at least six (6) voting members, including the three medical staff officers. The
President of the Staff shall serve as the Chair and preside at meetings unless another member has been
designated by the President to do so. The CEO and the Vice-President of Nursing shall be ex-officio, nonvoting members of the Committee. The Service Chiefs shall be committee members. The remaining members
of the committee shall include at least one-member elected by a majority of the active medical staff.
11.5-2 Duties
The duties of the MSEC shall be to:
a. act for the Medical Staff at intervals between Medical Staff meetings, subject to such limitations as may be
imposed by these bylaws.
b. be accountable to and report to the Medical Staff and the Governing Board
c. review and act on reports and recommendations of all Medical Staff committees, services, officers and
other assigned activity groups.
d. review credentials and requests for clinical privileges of applicants for appointment and reappointment to
the Medical Staff and Allied Health Professional Staff, assuring that privileges granted are supported by
evidence of clinical experience and competence.
e. make recommendations concerning appointments and privileges to the Governing Board.
f.
organize, oversee and ultimately be accountable to the Governing Board for the quality management
activities of the Medical Staff and Allied Health Staff.
g. implement disciplinary processes as specified in the Bylaws, and oversee any remedial actions required
as result of such processes.
h. investigate any reported breach of the Bylaws, Rules and Regulations, professional ethics, standards of
behavior, or clinical competence by any member of the Medical Staff and Allied Health Staff.
i.
make recommendations on medical-administrative matters and hospital operations.
j.
Promote medical staff/hospital administration relationships
k. inform the Medical Staff of the accreditation program and accreditation status of the hospital.
l.
participate in identifying community health needs and in setting hospital goals and implementing programs
to meet those needs.
m. present to the staff qualified candidates for elective positions in the staff organization when nominations
are made.1
1
CMS, JC, MS.02.01.01
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11.5-3
Meetings:
The Executive Committee shall meet at least ten (10) times a year.
11.6
11.6-1
Medical Staff Quality Committee
Composition
The Medical Staff Quality Committee shall consist of at least two members of the Active Medical Staff, one
Allied Health Professional Staff and such other administrative and nursing representatives as shall be
appointed by the CEO. The representatives of administration and nursing shall serve ex-officio, without vote.
11.6-2
Duties
The duties of the committee shall include the following:
a. adopt, subject to the approval of the Executive Committee and the Governing Board, specific programs
and procedures for reviewing, evaluating, and maintaining the quality and appropriateness of patient
care, patient safety, and patient satisfaction within the hospital, including mechanisms for: i)
establishing objective criteria; ii) measuring actual practice against the criteria; iii) peer analysis of
practice variations; iv) taking appropriate action to correct identified problems; v) following up on action
taken; and vi) reporting the findings and results of the audit activity to the medical staff and Governing
Board.
b. review and act upon factors affecting the quality and appropriateness of patient care provided in the
hospital and in its affiliated medical practices.
c. review the findings and results of working groups as defined in the FMH Quality Management Plan.
11.6-3 Meetings
The committee shall meet at least six (6) times a year.
Utilization Review & Medical Records Committee
11.7-1 Composition
The Utilization Review & Medical Records Committee shall consist of at least two members of the Active Medical
Staff and appropriate representatives of administration and nursing. Representatives of administration and
nursing shall serve as ex officio members, without vote.
11.7-2 Duties.
The duties of the committee shall include the following:
a. oversee the utilization review functions in the hospital.
b. develop a utilization review plan that is appropriate to the hospital and that meets the requirements of
state and federal law and of any applicable accreditation organizations. Such plan must include
provision for at least: i) review of admissions and of continued hospital stay; ii) discharge planning;
and iii) data collection and reporting.
c. require that the utilization review plan is in effect, known to staff members, and functioning at all times.
d. conduct such studies, take such actions, submit such reports, and make such recommendations as
are required by the utilization plan.
e. review and evaluate medical records to determine that they: i) properly describe the condition and
progress of the patient, the therapy provided, the results thereof, and the identification of responsibility
for all actions taken: ii) are sufficiently complete at all times as to facilitate continuity of care and
communications between all those providing patient care services in the hospital; iii) meet the
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standards of patient care usefulness and of historical validity required by the staff and by
acknowledged authorities, including the Joint Commission and iv) are adequate, in form and content,
to permit patient care audit and other quality maintenance activities to be performed.
f. review staff and hospital policies, rules and regulations relating to medical records, including medical
records completion, forms, formats, indexing, storage, and availability and recommend methods of
enforcement thereof and changes therein.
g. act upon recommendations from the Executive Committee and the services or other committees
responsible for patient care audit and other quality maintenance and monitoring functions.
h. provide liaison with hospital administration and the medical records professionals in the employ of the
hospital on matters relating to medical records practice.
i. maintain a permanent record of all actions taken and submit periodic reports and recommendations to
the Executive Committee concerning medical records practices in the hospital including that:
11.7-3 Meetings
The committee shall meet at least four (4) times a year.
11.7
Credentials Committee
11.8-1 Composition
The Credentials Committee shall consist of at least two members of the Active Medical Staff and one
or more representatives of administration. The representatives of administration shall serve as exofficio members, without vote.
11.8-2 Duties
The duties of the committee shall include the following:
a. review and evaluate the qualifications of each applicant for initial appointment, reappointment, or
modification of appointment and for clinical privileges and in connection therewith to obtain and consider the
recommendations of the appropriate service chief.
b. review and evaluate the qualifications of each Allied Health Professional applying to perform specified
services, and in connection therewith to obtain and consider the recommendations of the service chief.
c. submit a report, in accordance with Article V and VI, to the Executive Committee on the qualifications of
each applicant for staff membership for particular clinical privileges and of each AHP, clinical privileges or
specified services, and special conditions attached thereto.
d. investigate, review, and report on matters, including the clinical or ethical conduct of any practitioner,
assigned or referred to it by: i) the President of the Staff; ii) the Executive Committee; or iii) those
responsible respectively, for functions described in Sections 11.4.
11.8-3 Meetings. The committee shall meet at least six (6) times per year.
11.9
Medical Staff Education Committee
11.9-1 Composition
The committee shall consist of a minimum of two members of the medical staff, one member of the allied health
staff and representatives of administration and nursing. The representatives of administration and nursing shall
serve as ex-officio members, without vote.
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11.9-2
Duties
The duties of the committee shall include the following:
a. coordinate educational opportunities and programs with the FMH Education Department.
b. develop and plan, or participate in, programs of continuing education that are designed to keep the medical
staff and allied health professionals informed of significant new developments and new skills in medicine
and that are responsive to any relevant audit findings.
c. evaluate the effectiveness of the educational programs developed and implemented.
d. analyze, on a continuing basis, the hospital’s and staff’s needs for professional library services.
e. act upon continuing education recommendations from the Executive Committee, the services, or other
committees responsible for patient care audit and other quality maintenance and monitoring functions.
f.
maintain a permanent record of education and library activities and submit periodic reports to the Executive
Committee concerning these activities, specifically including his/her relationship to the findings of the
patient care audit and other quality maintenance and monitoring functions of the staff.
11.9-3 Meetings
The committee shall meet a least four (4) times a year.
11.10 Pharmacy & Therapeutics Committee
11.10-1 Composition
The committee shall consist of at least two members of the active medical staff or the allied health staff and
appropriate representatives of other services including pharmacy and nursing.
11.10-2 Duties
The duties of the committee shall include developing and maintaining surveillance over the
drug utilization policies and practices, including the following:
a. assist in the formulation of broad professional policies regarding the evaluation, appraisal, selection,
procurement, storage, distribution, use, safety procedures, and all other matters relating to drugs in the
hospital.
b. advise the medical staff and the hospital’s pharmaceutical department on matters pertaining to the choice
of available drugs.
c. make recommendations concerning new drugs to be stocked on the nursing unit floors and by other
services.
d. develop and review periodically a formulary or drug list for use in the hospital.
e. evaluate clinical data concerning the use and control of investigational drugs and of research in the use of
recognized drugs.
f.
maintain a permanent record of all activities relating to the pharmacy and therapeutics function and submit
periodic reports and recommendations to the Executive Committee concerning drug utilization policies
and practices in the hospital and in the associated physician practices.
g. maintain a permanent record of all activities relating to infection control and antibiotic usage and submit
periodic reports thereon to the MSEC and to the hospital CEO.
11.10-3 Meetings
The committee shall meet as frequently as its duties require but not less than six (6) times a year.
11.11
Infection Control Committee
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11.11-1 Composition
The committee shall consist of at least two members of the medical staff or allied health staff
and appropriate members of administration, nursing and other hospital services that are
appropriate to the functions and duties of the committee.
11.1-2 Duties
The duties of the committee include preventing, investigating, and controlling hospital-acquired
infections, and include the following specific responsibilities:
a. maintain surveillance of hospital infection potentials
b. identify and analyze the incidence and cause of all infections
c. develop and implement a preventive and corrective program designed to minimize infection hazards
d. supervise infection control in all phases of the hospital’s activities, including: operating rooms, delivery
rooms, special care units; sterilization procedures by heat, chemicals, or otherwise; isolation procedures;
prevention of cross-infection by anesthesia apparatus or inhalation therapy equipment; testing of
hospital personnel for carrier status; disposal of infectious material; and other situations as requested by
the Executive Committee.
11.1-3 Meetings
The committee shall meet as frequently as required to fulfill its duties but no less than four (4)
times a year.
11.12 Disaster Planning Committee
11.12-1 Composition
The committee shall consist of at least one member of the active medical staff or the allied health professional and
such other hospital representatives as shall serve to meet the needs of the committee.
11.12-2 Duties
The duties involved in planning to provide appropriate response to, and the protection and care of hospital patients
and others at the time of internal and external disasters include:
a. develop and periodically review, in cooperation with the hospital administration, a written plan designed
to safeguard patients at the time of an internal disaster and participate in all types of disaster drills as
scheduled.
b. develop and periodically review, in cooperation with the hospital administration, a written plan for the
care, reception and evacuation of mass casualties, epidemics and assure that such plan is coordinated
with the inpatient and outpatient services of the hospital, that it adequately relates to other available
resources in the community and coordinates the hospital’s role and nearby communities, and that the
plan is rehearsed by all personnel involved at least twice yearly.
11.12-3 Meetings
The committee will meet as frequently as needed to accomplish its duties But not less than
annually.
11.13
Bylaws Committee
11.13-1 Composition
The committee shall consist of at least two members of the active medical staff.
11.13-2 Duties
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The duties involved in maintaining the appropriate bylaws, rules, regulations, and other
organizational documents pertaining to staff including:
a. conduct an annual review of the bylaws and the rules, regulations procedures, and forms promulgated in
connection therewith,
b. submit recommendations to the Executive Committee and to the board for changes in these documents.
c. act upon all matters as may be referred by the Board, the Joint Conference Committee, the Executive
Committee, the services, the President of the Medical Staff, the CEO, and the committees of the staff.
11.13-3 Meetings
The committee shall meet as frequently as needed to accomplish its duties but not less than annually.
11.14
Representation on Hospital Committees
Staff functions and responsibilities relating to liaison with the board and hospital administration, hospital
accreditation, and disaster planning shall be discharged by the appointment of medical staff members to hospital
management committees as are established to perform those functions. One of the medical staff representatives
to each such committee shall be designated as the Chair of the medical staff delegation to that committee.
Appointments of medical staff members to any hospital management committees shall be made, and such
committees shall operate, in accordance with the hospital corporate bylaws and the written policies of the hospital
and of the staff.
ARTICLE XII - MEETINGS OF THE MEDICAL STAFF
12.1
General Staff Meetings
12.1-1 Regular Meetings
a. The Executive Committee shall, by standing resolution, designate the time and place for all regular staff
meetings. Notice of the original resolution and any changes thereto shall be given to each member of the staff
in the same manner as provided in Section 12.3 for notice of meetings.
b. A regular annual staff meeting will be held each year in the month of June.
c. The Medical Staff shall meet as a whole at least 4 times a year.
12.1-2 Order of Business and Agenda
The order of business at a regular meeting shall be determined by the President. The agenda shall include at
least:
a. reading and acceptance of the minutes of the last regular and of all special meetings held since the last regular
meeting.
b. administrative reports from the CEO, the President of the Staff, services and committees
c. the election of officers and or representatives to staff and hospital committees, when required by these bylaws.
d. reports by responsible officers, committees, and services on the overall results of patient care audit and other
quality maintenance activities of the staff and the fulfillment of the other required staff functions.
e. recommendations for improving patient care within the hospital
f. new business
12.1-3 Special Meetings
Special meetings of the medical staff may be called at any time by the Board, President of the Medical Staff or
upon written request of not less than one-fourth of the members of the active staff and shall be held at the time and
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place designated in the meeting notice. No business shall be transacted at any special meeting except that stated
in the meeting notice.
12.2
Committee and Service Meetings
12.2-1 Regular meetings
Committees and services may, by resolution, provide the time for holding regular meetings and no notice other than
such resolution shall then be required. The frequency of service meetings shall be no less than 6 times per year;
otherwise, the frequency of such meetings shall be no less than as required by these bylaws.
12.2-2 Special Meetings
A special meeting of any committee or service may be called by, or at the request of, the Chair thereof, the Board,
the President of the Medical Staff or by one-third of the group's current members. No business shall be transacted
at any special meeting except that stated in the meeting notice.
12.3
Notice of Meetings
Written or printed notice stating the place, day and hour of any general staff meeting, of any special meeting, or of
any regular committee or service meeting not held pursuant to resolution shall be delivered either personally or by
mail to each person entitled to be present thereat not less than four days nor more than 10 days before the date of
such meeting. Notice of service or committee meetings may be given orally. If mailed, the notice of the meeting
shall be deemed delivered 48 hours after deposited, postage prepaid, in the United States mail addressed to each
person entitled to such notice as his/her address as it appears on the records of the hospital. Personal attendance
at a meeting shall constitute a waiver of notice of such meeting.
12.4
Quorum
12.4-1 General Staff Meetings
The presence of two-thirds of the voting members of the active medical staff at any regular or special meeting shall
constitute a quorum for the purposes of amendment to these bylaws. The presence of 50% of such members shall
constitute a quorum for the transaction of all other business.
12.4-2 Service and Committee Meetings
Fifty percent of the voting members of a service or committee, but not less than two members, shall constitute a
quorum of any meeting of such service or committee,
12.5
Manner of Action
Except as otherwise specified, the actions of a majority of the members present and voting at a meeting at which a
quorum is present shall be the action of the group. Action may be taken without a meeting by a service or
committee by a written instrument setting forth the action so taken signed by each member entitled to vote thereat.
12.6
Minutes
Minutes of all meetings shall be prepared by the secretary of the meeting or his/her designee and shall include a
record of attendance and the vote taken on each matter. Copies of such minutes shall be signed by the presiding
officer, approved by the attendees, forwarded to the executive committee, and made available to the staff. A
permanent file of the minutes of each meeting shall be maintained.
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12.7
Attendance Requirements
12.7-1 Regular Attendance
Each member of a staff category required to attend meetings under Article IV shall be required to attend:
a. at least 50 percent of the required four meetings per year and all other medical staff meetings duly convened
pursuant to these bylaws
b. at least 50 percent of the required four meetings per year of each service and committee of which they are a
member.
c. In the case where a practitioner maintains active staff privileges at more than one hospital, the practitioner must
attend at least 25% of staff and service meetings at Franklin Memorial Hospital.
12.7-2 Absence from Meetings
Any member who is compelled to be absent from any medical staff, service or committee meeting shall promptly
contact the Medical Staff Office or the presiding officer thereof, the reason for such absence. Unless excused for
good cause by such presiding officer, failure to meet the attendance requirements of Section 12.7-1 may be
grounds for any of the corrective actions specified in Section 7.1-4, and including, in addition, removal from such
service or committee. Re-instatement of a staff member whose membership has been revoked because of
absence from meetings shall be made only on application, and any such application shall be processed in the
same manner as an application for initial appointment.
12.7-3 Special Appearance
A practitioner whose patient's clinical course of treatment is scheduled for discussion at a regular service or
committee meeting shall be so notified. The Chair of the meeting shall give the practitioner at least 10 days
advance written notice of the time and place of the meeting. Whenever apparent or suspected deviation from
standard clinical practice is involved, special notice shall be given and shall include a statement of the issue
involved and that the practitioner's appearance is mandatory. Failure of a practitioner to appear at any meeting
with respect to which he was given such notice shall, unless excused by the Executive Committee upon a showing
of good cause, result in an automatic suspension of all or such portion of the practitioner's clinical privileges as the
Executive Committee may direct. Such suspension shall remain in effect until the matter is resolved by subsequent
action of the Executive Committee or of the Board or through corrective action, if necessary.
ARTICLE XIII - IMMUNITY FROM LIABILITY
13.1
Conditions
The following shall express conditions to any practitioner's or allied health professional’s application for or exercise
of clinical privileges at this hospital:
13.1-1 that any act, communication, report, recommendation or disclosure, with respect to any such practitioner or allied
health professional, performed or made and at the request of an authorized representative of this or any other
health care facility, for the purpose of achieving and maintaining quality patient care in this or any other health care
facility, shall be privileged to the fullest extent permitted by law.
13.1-2 that such privilege shall extend to members of the hospitals' medical staff or allied health professional and of its
governing body. It’s other practitioners, its CEO and his/her representatives, and to third parties, who supply
information or otherwise assist to any of the foregoing authorized to receive, release or act upon the same. For the
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13.1-3
13.1-4
13.1-5
13.1-6
13.1-7
purpose of this Article XIII, the term "third parties" means both individuals and organizations from which information
has been requested by an authorized representative of the governing body or of the medical staff.
that there shall, to the fullest extent permitted by law, be absolute immunity from civil liability arising from any such
act, communication, report recommendation, or disclosure.
that such immunity shall apply to all acts, communications, reports, recommendations, or disclosures performed or
made in connection with this or any other health care institution's activities related, but not limited to:
a. applications for appointment or clinical privileges
b. periodic re-appraisals for re-appointment or clinical privileges
c. corrective action, including summary suspension
d. hearings and appellate reviews
e. medical case evaluations
f. utilization reviews and
g. other hospital, service or committee activities related to quality patient care and inter professional conduct.
that the acts, communications, reports, recommendations and disclosures referred to in this Article XIII may relate
to a practitioner's or allied health professional’s professional qualifications, clinical competency, character, mental
or emotional stability, physical condition, ethics, or any other matter that might directly or indirectly have an effect
on patient care.
that in furtherance of the foregoing, each practitioner or allied health professional shall upon request of the hospital
executes releases in accordance with the tenor and import of this Article XIII in favor of the individuals and
organizations specified in paragraph 13.1-2, subject to such requirements, as may be applicable under the laws of
this State.
that the consents, authorizations, releases, rights, privileges and immunities provided by Section 5.2 and 5.3 of
these bylaws for the protection of this hospital's practitioners or allied health professionals, other appropriate
hospital officials and personnel and third parties, in connection with applications for initial appointment, shall also
be fully applicable to the activities and procedures covered by this Article XIII.
ARTICLE XIV - GENERAL PROVISIONS
14.1
Staff Rules and Regulations
Subject to approval by the Board, the medical staff shall adopt such rules and regulations as may be necessary to
implement more specifically the general principles found within these bylaws. These shall relate to the proper
conduct of medical staff organizational activities as well as embody the level of practice that is to be required of
each staff member or AHP in the hospital. Such rules and regulations shall be a part of these bylaws, except that
they may be amended or repealed at any regular meeting at which a quorum is present and without previous
notice, or at any special meeting on notice, by a two-thirds vote of those present and eligible to vote. Such
changes shall become effective when approved by the Board.
14.2
Service Rules and Regulations
Subject to the approval of the service, executive committee and the board, each service shall formulate its own
rules and regulations for the conduct of its affairs and the discharge of its responsibilities. Such rules and
regulations shall not be inconsistent with these bylaws, the general rules and regulations of the medical staff, or
other policies of the hospital.
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14.3
Professional Liability Insurance
Each practitioner granted clinical privileges in the hospital shall maintain in force professional liability insurance.
Minimum acceptable coverage will be $1,000,000 per incident. Practitioners with privileges in effect as of February
14, 2003 who presently carry less than this amount of coverage are exempt from this requirement, but are not
allowed to drop malpractice insurance or decrease his/her coverage from limits in force as of this date.
14.4
Staff Dues
Subject to approval of the board, the Executive Committee shall have the power to set the amount of annual dues
for each category of staff membership and the amount of the processing fee for initial applications and to determine
the manner of expenditure of funds received. The amount of annual dues may vary among the staff categories, but
shall not exceed $100.00 per member for any category.
14.5
Forms
Application forms and any other prescribed forms required by these bylaws for use in connection with staff
appointments, re-appointments, delineation of clinical privileges, corrective action, notices, recommendations,
reports, and other matters shall be adopted by the board after considering the advice of the executive committee.
14.6
Construction of Terms and Headings
Words used in these bylaws shall be read as the masculine or feminine gender and as the singular or pleural, as
the context requires. The captions or heading in these bylaws are for convenience only and are not intended to
limit or define the scope or effect of any provision of these bylaws.
14.7
Transmittal of Reports
Reports and other information which these bylaws require the medical staff to transmit to the board shall be
deemed so transmitted when delivered, unless otherwise specified, by the CEO.
ARTICLE XV-ADOPTION AND AMENDMENT OF BYLAWS, RULES AND REGULATIONS, AND POLICIES
15.1.
Regular Review of Bylaws.
These bylaws will be reviewed not less than annually, pursuant to section 11.13-2a, for consideration of changes
that may be necessary or advisable.
15.2
Authority to Propose Amendments. The Medical Staff Executive Committee, Officers of the Medical
Staff, and Voting Medical Staff Members will have the authority to propose amendments to these Bylaws,
the Medical Staff Rules and Regulations, and the Medical Staff Policies.
15.3
Medical Staff Executive Committee Review and Recommendation.
The proposed amendments will be referred to the Medical Staff Executive Committee and shall make a
recommendation of approval, rejection, or request for modification to the Medical Staff on the proposed
amendments.
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15.4
Medical Staff Approval of Recommendation. Affirmation or rejection of the Medical Staff Executive Committee
recommendation will be obtained by a majority vote of the voting Medical Staff Members for Bylaws amendment.
In the case of amendments to Medical Staff Rules and Regulations and Medical Staff Policies, affirmation or
rejection of the Medical Staff Executive Committee recommendation will be obtained by a majority vote of the
Voting Medical Staff members present at any regular or special Medical Staff meeting.
15.5
Urgent or Technical Action by Medical Staff Executive Committee.
In the event of a documented need for a technical clarification or an urgent amendment to the Medical Staff Bylaws,
Rules and Regulations or policies necessary to comply with law or regulation, the Medical Staff Executive
Committee may provisionally approve such urgent amendments and submit such to the Board of Trustees for
provisional approval without prior notification to the Medical Staff. The Medical Staff Executive Committee shall
then notify the Medical Staff immediately after submitting any such technical clarification or urgent amendment and
seek Medical Staff approval pursuant to section 15.1-3.
15.6
Medical Staff Disagreement with Medical Executive Committee Action. The voting medical staff members may
propose a revised amendment pursuant to section 15.1 .B should there be disagreement with the Medical Staff
Executive Committee provisionally approved technical clarification or urgently approved amendments.
15.7
Medical Staff Executive Committee and Medical Staff Disagreement.
Should the Medical Staff majority vote reject the recommendations of the Medical Staff Executive Committee, the
matter may be referred by either the Medical Staff or the Medical Staff Executive Committee or to the Joint
Conference Committee for further deliberations. The result of the Medical Staff vote will remain in effect, and will
not be stayed, pending a recommendation of the Joint Conference Committee.
15.8
Medical Staff Authority to Adopt.
The Medical Staff has the ability to adopt Medical Staff Bylaws, Rules and Regulations, and Policies, and
amendments thereto, and to propose them directly to the Board of Trustees without review or recommendation
from the Medical Staff Executive Committee. Such direct action requires approval of 2/3 of the Voting Medical Staff
Members for Bylaws changes and a majority vote for Medical Staff Rules and Regulations and Policies changes.
15.9
Board of Trustees Approval.
Upon approval of amendments to the Bylaws, Rules and Regulations, Policies as outlined in section 15.1A-F, the
Medical Staff President, acting on behalf of the Medical Staff, shall propose such amendments directly to the Board
of Trustees. Such amendments shall be effective only when approved by the Board of Trustees.. In the event that
the Board of Trustees does not approve such proposed amendments, the matter will be referred to the joint
conference committee for further deliberations involving the interested parties and recommendations.
15.10
Board of Trustees Amendment Initiation.
The Medical Staff Bylaws, Rules and Regulations, or policies cannot be unilaterally amended by either the Board of
Trustees or the Medical Staff.i2 . Notwithstanding anything in this article 15 to the contrary, the Governing Body
may on its own motion, after consultation with the Medical Staff, amend these Bylaws, Medical Staff Rules and
2
MS.01.01.03 EP1
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Regulations, Policies, in whole or in part, at any meeting, if such amendment is necessary to comply with
applicable law or regulation or necessary to maintain accreditation, and the Medical Staff has not proposed an
appropriate amendment or will be unable to propose an appropriate amendment within the time required.
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