MEDICAL STAFF BYLAWS, POLICIES, AND
RULES AND REGULATIONS
OF
OUR LADY OF LOURDES
MEMORIAL HOSPITAL

MEDICAL STAFF BYLAWS

Revised effective May 28, 2019 

MEDICAL STAFF BYLAWS

TABLE OF CONTENTS

PAGE

1.	GENERAL	1

1.A.	DEFINITIONS	1

1.B.	TIME LIMITS	1

1.C.	DELEGATION OF FUNCTIONS	1

1.D.	MEDICAL STAFF DUES	1

2.	CATEGORIES OF THE MEDICAL STAFF	2

2.A.	OVERVIEW	2

2.B.	ACTIVE STAFF	2

2.B.1.	Qualifications	2
2.B.2.	Prerogatives	2
2.B.3.	Responsibilities	3

2.C.	SENIOR ACTIVE STAFF	3

2.C.1.	Qualifications	3
2.C.2.	Responsibilities and Prerogatives	4

2.D.	CONSULTING STAFF	4

2.D.1.	Qualifications	4
2.D.2.	Prerogatives and Responsibilities	4

2.E.	COURTESY STAFF	5

2.E.1.	Qualifications	5
2.E.2.	Prerogatives and Responsibilities	5

PAGE

2.F.	AFFILIATE STAFF	6

2.F.1.	Qualifications	6
2.F.2.	Prerogatives and Responsibilities	6

2.G.	HONORARY STAFF	7

2.G.1.	Qualifications	7
2.G.2.	Prerogatives and Responsibilities	7

2.H.	TELEMEDICINE STAFF	7

2.H.1.	Qualifications	7
2.H.2.	Prerogatives and Responsibilities	8

2.I.	ALLIED HEALTH STAFF	8

2.I.1.	Qualifications	8
2.I.2.	Prerogatives and Responsibilities	8

3.	OFFICERS	9

3.A.	DESIGNATION	9

3.B.	ELIGIBILITY CRITERIA	9

3.C.	DUTIES	10

3.C.1.	President of the Medical Staff	10
3.C.2.	President-Elect	10
3.C.3.	Secretary-Treasurer	11
3.C.4.	Immediate Past President of the Medical Staff	11

3.D.	NOMINATION AND ELECTION PROCESS	11

3.D.1.	Nominating Committee	11
3.D.2.	Nominating Process	12
3.D.3.	Election	13

PAGE

3.E.	TERM OF OFFICE, VACANCIES AND REMOVAL	13

3.E.1.	Term of Office	13
3.E.2.	Vacancies	14
3.E.3.	Removal	14

4.	CLINICAL DEPARTMENTS AND SECTIONS	15

4.A.	ORGANIZATION	15

4.A.1.	Organization of Departments and Sections	15
4.A.2.	Assignment to Departments	15
4.A.3.	Functions of Departments	15

4.B.	DEPARTMENT CHAIRPERSONS AND VICE CHAIRPERSONS	16

4.B.1.	Qualifications 	16
4.B.2.	Selection of Department Chairpersons and Vice Chairpersons	16
4.B.3.	Term of Appointment and Performance Evaluation 
	for Department Chairpersons and Vice Chairpersons	17
4.B.4.	Duties of Department Chairpersons	17
4.B.5.	Removal of Department Chairpersons and Vice Chairpersons	19

4.C.	SECTIONS	19

4.C.1.	Qualifications, Selection and Removal of Section Chiefs	19
4.C.2.	Duties of Section Chief	20
4.C.3.	Functions of Sections	20

5.	MEDICAL STAFF COMMITTEES AND
	PERFORMANCE IMPROVEMENT FUNCTIONS	21

5.A.	GENERAL	21

5.A.1.	Appointment	21
5.A.2.	Medical Staff Functions	21

5.B.	EXECUTIVE COMMITTEE	22

5.B.1.	Composition	22
5.B.2.	Duties	22
5.B.3.	Meetings	23
PAGE

5.C.	PERFORMANCE IMPROVEMENT FUNCTIONS	24

5.D.	CREATION OF STANDING AND SPECIAL COMMITTEES	25

6.	VICE PRESIDENT FOR MEDICAL AFFAIRS	26

7.	MEETINGS	28

7.A.	GENERAL	28

7.A.1.	Meetings	28
7.A.2.	Regular Meetings	28
7.A.3.	Special Meetings	28

7.B.	PROVISIONS COMMON TO ALL MEETINGS	29

7.B.1.	Notice 	29
7.B.2.	Quorum 	29
7.B.3.	Voting	29
7.B.4.	Agenda	30
7.B.5.	Rules of Order	30
7.B.6.	Minutes	30
7.B.7.	Confidentiality	31

7.C.	ATTENDANCE	31

7.C.1.	Regular and Special Meetings	31
7.C.2.	Required Meetings	31

8.	BASIC STEPS AND DETAILS	32

8.A.	QUALIFICATIONS FOR APPOINTMENT	32

8.B.	PROCESS FOR CREDENTIALING AND  PRIVILEGING	32

8.C.	INDICATIONS AND PROCESS FOR RELINQUISHMENT	32

8.D.	INDICATIONS AND PROCESS FOR
	PRECAUTIONARY SUSPENSION	33

PAGE

8.E.	INDICATIONS AND PROCESS FOR PROFESSIONAL 
	REVIEW ACTIONS	34

8.F.	HEARING AND APPEAL PROCESS	34

9.	AMENDMENTS	36

9.A.	MEDICAL STAFF BYLAWS	36

9.B.	OTHER MEDICAL STAFF DOCUMENTS	37

9.C.	CONFLICT MANAGEMENT PROCESS	39

10.	HISTORY AND PHYSICAL	40

11.	ADOPTION	42

ARTICLE 1
GENERAL

1.A.  DEFINITIONS
The definitions that apply to terms used in all the Medical Staff documents are set forth in the Credentials Policy.

1.B.  TIME LIMITS
Time limits referred to in these Bylaws are advisory only and are not mandatory, unless it is expressly stated that a particular right is waived by failing to take action within a specified period.

1.C.  DELEGATION OF FUNCTIONS
Functions assigned to an identified individual or committee may be delegated to one or more designees.

1.D.  MEDICAL STAFF DUES
(1)	Annual dues may be as recommended by the Executive Committee and may vary by category.
(2)	Dues will be payable annually upon request.  Failure to pay dues will result in ineligibility for continued appointment.
(3)	The President of the Medical Staff and Secretary-Treasurer are signatories to the Hospital’s Medical Staff account.

ARTICLE 2
CATEGORIES OF THE MEDICAL STAFF

2.A.  OVERVIEW
(1)	Qualifications and conditions for appointment to the Medical Staff and the Allied Health Staff are outlined in the Credentials Policy.  The qualifications for appointment to the specific categories are outlined below.
(2)	Appointments will be made by the Board, upon recommendation of the Executive Committee, to one of the following categories:  Active, Senior Active, Consulting, Courtesy, Affiliate, Honorary, Telemedicine, or Allied Health.

2.B.  ACTIVE STAFF
2.B.1.  Qualifications:
The Active Staff consists of physicians, dentists, and podiatrists who:
(a)	are involved in at least 25 patient contacts at the Hospital during the appointment term; or 
(b)	routinely provide continuous care for patients at a hospital affiliated practice site; or
(c)	do not routinely admit to the hospital, but provide care in clinical specialties at the hospital.  Such physicians are granted privileges in accordance with their specialty; or
(d)	have demonstrated a commitment to the Medical Staff through service on Medical Staff or Hospital committees or active participation in performance/quality improvement functions.

2.B.2.  Prerogatives:
Active Staff Members:
(a)	may vote in all general and special meetings of the Medical Staff, and applicable department, section, and committee meetings;
(b)	may hold office;
(c)	may serve as department chairperson, section chief, or committee chairperson; and
(d)	are entitled to priority scheduling for non‑emergency/elective patients for the operating room and outpatient services.
2.B.3.  Responsibilities:
(a)	Active Staff members shall:
(1)	perform the functions and responsibilities of membership on the Active Staff, including care for unassigned patients, emergency call; 
(2) 	encourage committee services and teaching assignments;
(3)	participate in the ongoing professional practice evaluation, peer review and performance improvement process;
(4)	accept consultations when requested;
(5)	participate in continuing education programs;
(6)	assume medical responsibility for patients of members with co-admitting privileges;
(7)	attend applicable meetings; and 
(8)	pay application fees, dues and assessments.
(b)	Members of the Active Staff who have served on the emergency on-call roster for 25 years may request to be excused from emergency call.  The department chairperson and section chief will recommend to the Executive Committee whether to grant these requests based on need and the effect on others who serve on the call roster for that specialty.  The Executive Committee’s recommendation will be subject to final action by the Board.

2.C.  SENIOR ACTIVE STAFF
2.C.1.  Qualifications:
The Senior Active Staff consists of physicians, dentists, and podiatrists who:
(a)	meet the general qualifications for appointment;
(b)	are 60 years of age or older and have served on the Active Staff for at least 20 years; or
(c)	have attained the age of 70 regardless of years of service.

2.C.2.  Responsibilities and Prerogatives:
Senior Active Staff members:
(a)	are encouraged, but not required, to attend Medical Staff, department and section meetings;
(b)	may vote and hold office;
(c)	may, but are not required to, serve on committees; 
(d)	may be excused from emergency service on-call responsibilities (subject to a determination by the Executive Committee and Board that removal from call would not cause a hardship on others who serve for the specialty); and 
(e)	must pay application fees, dues and assessments.

2.D.  CONSULTING STAFF
2.D.1.  Qualifications:
The Consulting Staff consists of physicians, dentists, and podiatrists who:
(a)	are of recognized professional ability and expertise and provide a service that is not available on the staff;
(b)	are appointed to the Active Staff at another hospital where they are currently practicing, unless their clinical specialty does not support an active inpatient practice; and
(c)	provide consultation in the diagnosis and treatment of patients.

2.D.2.  Prerogatives and Responsibilities:
Consulting Staff members:
(a)	may treat (but not admit) patients in conjunction with another member of the Active, Senior Active, or Courtesy Staff;
(b)	are encouraged, but not required, to attend Medical Staff meetings;
(c)	may attend applicable department and section meetings (without vote) and applicable committee meetings (with vote);
(d)	may not hold office or serve as department chairperson, section chief, or committee chairperson;
(e)	will, at each reappointment time, provide evidence of clinical performance at their primary hospital in such form as may be requested, in order to allow for an appropriate assessment of continued qualifications for appointment and clinical privileges; and
(f)	must pay application fees, dues and assessments.

2.E.  COURTESY STAFF
2.E.1.  Qualifications:
(a)	The Courtesy Staff consists of physicians, dentists, and podiatrists who:
(1)	have fewer than 25 patient contacts, per appointment term, at the Hospital; and
(2)	are members of the Active Staff at another hospital, unless their clinical specialty does not support an active inpatient practice.
(b)	A Courtesy Staff member who has more than 25 patient contacts during the last appointment term will be given an opportunity to demonstrate to the Credentials Committee, at the time of reappointment, that his/her practice patterns have changed and/or that he/she will satisfy the activity requirements of this category going forward.  If a Courtesy Staff member cannot support this position to the Credentials Committee’s satisfaction, then the member will be transferred to the Active Staff for the upcoming term of appointment.

2.E.2.  Prerogatives and Responsibilities:
Courtesy Staff members:
(a)	may attend Medical Staff meetings (without vote);
(b)	are encouraged to attend department and section meetings (without vote);
(c)	may not hold office or serve as department chairperson, section chief, or committee chairperson;
(d)	may be invited to serve on committees (with vote);
(e)	must perform all functions and responsibilities assigned, including, where appropriate, care for unassigned patients, emergency service care, consultations, and teaching assignments; 
(f)	will cooperate in the peer review and performance improvement process; 
(g)	will, at each reappointment time, provide evidence of clinical performance at their primary hospital in such form as may be requested, in order to allow for an appropriate assessment of continued qualifications for appointment and clinical privileges; and
(h)	must pay application fees, dues and assessments.

2.F.  AFFILIATE STAFF
2.F.1.  Qualifications:
The Affiliate Staff will consist of physicians, dentists, and podiatrists who:
(a)	desire to be associated with, but who do not intend to establish an inpatient practice at, the Hospital; 
(b)	satisfy the qualifications for appointment to the Medical Staff, but are exempt from the eligibility criteria set forth in the Credentials Policy pertaining to residence, emergency call, and coverage; and
(c)	are interested in pursuing professional and educational opportunities, including continuing medical education, available at the Hospital.

2.F.2.  Prerogatives and Responsibilities:
(a)	Affiliate Staff members:
(1)	are not permitted to admit, consult, or attend to inpatients;
(2)	may visit their patients when hospitalized and review their medical records, but may not write orders or make medical record entries or actively participate in the provision or management of care to inpatients;
(3)	may attend Medical Staff and applicable department and section meetings (without vote);
(4)	may serve on committees, if appointed (with vote);
(5)	may attend educational activities of the Medical Staff and the Hospital;
(6)	are not granted clinical privileges to treat patients on an inpatient basis;
(7)	must accept referrals from the Emergency Department for follow-up care of patients treated there; and
(8)	must pay application fees, dues and assessments.
(b)	The grant of appointment to the Affiliate Staff is a courtesy only, which may be terminated by the Board upon recommendation of the Executive Committee, with no right to a hearing or appeal.

2.G.  HONORARY STAFF
2.G.1.  Qualifications:
(a)	The Honorary Staff will consist of physicians, dentists, and podiatrists who:
(1)	have a record of previous long‑standing service to the Hospital and have retired from the active practice of medicine; or
(2)	are recognized for outstanding or noteworthy contributions to the medical sciences.
(b)	None of the specific qualifications for appointment are applicable to members of the Honorary Staff.

2.G.2.  Prerogatives and Responsibilities:
Honorary Staff members:
(a)	may not consult, admit or attend to patients;
(b)	may attend staff, department, and section meetings (with vote);
(c)	may be appointed to committees (with vote); and
(d)	are not required to pay application fees, dues or assessments.

2.H.  TELEMEDICINE STAFF
2.H.1.  Qualifications:
The Telemedicine Staff will consist of physicians, dentists, and podiatrists who:
(a)	satisfy the qualifications for appointment to the Medical Staff, but are exempt from the eligibility criteria set forth in the Credentials Policy pertaining to residence, emergency call, and coverage; and
(b)	limit their practice at the Hospital exclusively to providing telemedicine services.

2.H.2.  Prerogatives and Responsibilities:
Telemedicine Staff members:
(a)	may not vote at department and section meetings;
(b)	may not serve on Medical Staff committees;
(c)	may not admit patients;
(d)	are subject to the history and physical requirements applicable to other members of the Medical Staff, but are not required to provide evidence of immunizations required of members who exercise privileges on the Hospital’s campus; and
(e)	must pay all staff dues and assessments.

2.I.  ALLIED HEALTH STAFF
2.I.1.  Qualifications:
The Allied Health Staff consists of allied health professionals who satisfy the qualifications and conditions for appointment to the Allied Health Staff contained in the Credentials Policy.  The Allied Health Staff is not a category of the Medical Staff, but is included in this Article of the Bylaws for convenient reference.

2.I.2.  Prerogatives and Responsibilities:
Allied Health Staff members:
(a)	may attend applicable department and section meetings (without vote);
(b)	may not hold office or serve as department chairperson, section chief, or committee chairperson;
(c)	may serve on a committee, if requested (with vote);
(d)	must cooperate in the peer review and performance improvement process; 
(e)	must pay applicable fees, dues, and assessments;
(f)    	may arrange/prepare for admission, including admission orders, to the service of the Active Medical Staff;
(g)        must practice within the scope of approved delineation of privileges.

ARTICLE 3
OFFICERS
3.A.  DESIGNATION
The Medical Staff will have the following officers:
(1)	President of the Medical Staff; 
(2)	President-Elect of the Medical Staff;
(3)	Secretary-Treasurer; and
(4)	Immediate Past President.

3.B.  ELIGIBILITY CRITERIA
Only those members who satisfy the following criteria initially and continuously will be eligible to serve as an officer of the Medical Staff.  They must:
(1)	be appointed in good standing to the Active or Senior Active Staff, and have served on the Active Staff for at least three years;
(2)	be certified by an appropriate specialty board or possess comparable competence, as determined through the credentialing and privileging process; 
(3)	be willing to faithfully discharge the duties and responsibilities of the position;
(4)	have experience in a leadership position, or other involvement in performance improvement functions;
(5)	have demonstrated an interest in maintaining quality medical care at the Hospital;
(6)	have demonstrated an ability to work well with others;
(7)	attend continuing education relating to Medical Staff leadership and/or credentialing functions prior to or during the term of the office;
(8)	have no pending adverse recommendations concerning staff appointment or clinical privileges;
(9)	not presently be serving as a Medical Staff officer, Board member, or department chairperson at any other hospital and will not so serve during their terms of office; 
(10)	and not have any financial relationship (i.e., an ownership or investment interest in or compensation arrangement) with an entity that competes with the Hospital or any affiliate.  This does not apply to services provided within a practitioner’s office and billed under the same provider number used by the practitioner.

3.C.  DUTIES
3.C.1.  President of the Medical Staff:
The President of the Medical Staff will:
(a)	act in coordination and cooperation with the Vice President for Medical Affairs, the Chief Executive Officer, and others in management positions in matters of mutual concern involving the care of patients in the Hospital;
(b)	represent and communicate the views, policies and needs, and report on the activities of the Medical Staff to the Chief Executive Officer, Vice President for Medical Affairs, and the Board;
(c)	provide day-to-day liaison on medical staff matters with the Chief Executive Officer, the Vice President for Medical Affairs, and the Board;
(d)	call, preside at, and be responsible for the agenda of all meetings of the Medical Staff and the Executive Committee;
(e)	appoint all committee chairpersons, in consultation with the Vice President for Medical Affairs, subject to approval by the Executive Committee, except as expressly stated in these Bylaws or the Organization and Functions Manual;
(f)	serve as chairperson of the Executive Committee (with vote, as necessary);
(g)	be a member of all other Medical Staff committees, ex officio, with vote;
(h)	promote adherence to these Bylaws, Medical Staff policies, the Rules and Regulations and to the policies and procedures of the Hospital;
(i)	recommend Medical Staff representatives to Hospital committees;
(j)	be the spokesperson for the Medical Staff in external professional and public relations; and
(k)	perform all functions authorized in all applicable policies, including collegial intervention in the Credentials Policy.

3.C.2.  President-Elect:
The President-Elect will:
(a)	assume all duties of the President of the Medical Staff and act with full authority as President of the Medical Staff in his or her absence;
(b)	serve on the Executive Committee;
(c)	automatically succeed the President of the Medical Staff at the expiration of the President’s term; and 
(d)	assume all such additional duties as are assigned to him or her by the President of the Medical Staff or the Executive Committee.

3.C.3.  Secretary-Treasurer:
The Secretary-Treasurer will:
(a)	be responsible for providing notices as specified in these Bylaws;
(b)	serve on the Executive Committee;  
(c)	cause to be kept accurate and complete minutes of Medical Staff and Executive Committee meetings;
(d)	be responsible for the collection of, accounting for, and disbursements of any funds collected, donated, or otherwise assessed and present in the Medical Staff Fund and report to the Medical Staff; and
(e)	attend to such other duties as ordinarily pertain to this office.
(f) 	Automatically succeeds President Elect. 

3.C.4.  Immediate Past President of the Medical Staff:
The Immediate Past President of the Medical Staff will:
(a)	serve on the Executive Committee;
(b)	serve as an advisor to other Medical Staff leaders; and 
(c)	assume all duties assigned by the President of the Medical Staff or the Executive Committee.

3.D.  NOMINATION AND ELECTION PROCESS
3.D.1.  Nominating Committee:
(a)	The Executive Committee will appoint five members of the Active or Senior Active Staff to serve on the Nominating Committee, including at least two Past Presidents of the Medical Staff, when possible.  Members of the Nominating Committee must meet the qualifications set forth in Section 3.B of these Bylaws.  
(b)	The Nominating Committee will nominate candidates for the following positions:
(1)	President-Elect of the Medical Staff;
(2)	Secretary-Treasurer of the Medical Staff; and
(3)	At-large members of the Executive Committee.
(c)	The President of the Medical Staff and the Chief Executive Officer will be ex officio members, without vote, on the Nominating Committee.

3.D.2.  Nominating Process:
(a)	The Nominating Committee will convene in August and prepare a slate of qualified nominees for each office and for the at-large members of the Executive Committee.  Immediately thereafter, notice of the nominees will be provided to the members of the Medical Staff who are eligible to vote.
(b)	Additional nominations may be submitted, in writing, by a petition signed by at least ten voting members of the Medical Staff.  The petition must be presented to the Chairperson of the Nominating Committee prior to its next meeting.
(c)	In order for a nomination to be placed on the ballot, the candidate must be willing to serve and must, in the judgment of the Nominating Committee, satisfy the qualifications in Section 3.B of these Bylaws.
(d)	The Nominating Committee will transmit the slate of nominees to the Board prior to the annual meeting.
(e)	Nominations from the floor will not be accepted.

3.D.3.  Election:
(a)	If there are two or more candidates for any office or position, the vote will be by written ballot.
(b)	If any voting member of the Medical Staff is unable to attend the meeting, the member may vote by absentee ballot.  An absentee ballot must be sealed and placed in a second envelope, which is signed.  Absentee ballots must be received by the Chief Medical Officer prior to the election.
(c)	The absentee ballots must be delivered to the Nominating Committee sealed and removed from the signed envelopes by the Chief Medical Officer in the presence of the Nominating Committee.
(d)	The candidates receiving a majority of written votes cast will be elected.
(e)	If no candidate receives a simple majority vote on the first ballot, a run‑off election will be held promptly between the two candidates receiving the highest number of votes.

3.E.  TERM OF OFFICE, VACANCIES AND REMOVAL
3.E.1.  Term of Office:
(a)	Medical Staff officers will serve for a term of three years or until a successor is elected.
(b)	Officers will assume office on the first day of the calendar year.
(c)	At-large members of the Executive Committee will serve a three-year term and may be elected to serve additional terms.
(d)	An individual serving as President of the Medical Staff is not eligible for nomination or election to the office of President-Elect until one year has elapsed since serving as Immediate Past President.  In case of catastrophic illness or injury rendering the President-Elect unable to hold office, the restrictions of this section will be waived.  An individual who has served as Secretary-Treasurer is eligible for re-election, but may serve no more than three successive three-year terms.

3.E.2.  Vacancies:
(a)	A vacancy in the office of President of the Medical Staff will be filled by the President-Elect, who will serve until the end of the unexpired term of the President of the Medical Staff.
(b)	A vacancy in the office of President-Elect will be filled by the Secretary-Treasurer who will serve until the end of the unexpired term of the President Elect. 
(c)	A vacancy in the office of Secretary-Treasurer or the at-large members of the Executive Committee will be filled by the Executive Committee, subject to approval by the Board, until a special election can be held.  If a regular election for the office will be held within 180 days, the appointed individual may serve until the elected individual assumes office.

3.E.3.  Removal:
(a)	Removal of an elected officer or an at-large member of the Executive Committee may be effectuated by a two-thirds vote of the Medical Staff or a three-fourths vote of the Executive Committee for:
(1)	failure to comply with applicable policies, Bylaws, or the Rules and Regulations;
(2)	failure to perform the duties of the position held;
(3)	conduct detrimental to the interests of the Medical Staff or the Hospital; or
(4)	an infirmity that renders the individual incapable of fulfilling the duties of that office.
(b)	Prior to scheduling a meeting to consider removal, a representative from the Executive Committee will meet with the individual in question and inform him or her of the reasons for the proposed removal proceedings.
(c)	The individual subject to removal will be given at least ten days’ special notice of the date of the meeting at which removal is to be considered.  The individual will be afforded an opportunity to speak to the relevant body that is seeking removal prior to a vote on removal.
(d)	Removal proceedings will be effective when approved by the Board.

ARTICLE 4
CLINICAL DEPARTMENTS AND SECTIONS

4.A.  ORGANIZATION
4.A.1.	Organization of Departments and Sections:
(a)	The Medical Staff will be organized into the departments or service lines as listed in the Organization and Functions Manual.
(b)	Subject to the approval of the Board, the Executive Committee may create new departments, eliminate departments, create sections within departments, or otherwise reorganize the department structure, including but not limited to the creation of service lines.

4.A.2.  Assignment to Departments:
(a)	Upon initial appointment to the Medical Staff, each member will be assigned to a clinical department.  Assignment to a particular department does not preclude an individual from seeking and being granted clinical privileges typically associated with another department.
(b)	An individual may request a change in department assignment to reflect a change in the individual’s clinical practice.

4.A.3.  Functions of Departments:
(a)	Departments will be organized for the purpose of implementing processes to monitor and evaluate the quality and appropriateness of the care of patients served by the department, and to monitor the practice of all those with clinical privileges in a given department.
(b)	Each department will oversee emergency call coverage for all patients who present to the Emergency Department and elsewhere in the Hospital, as may be needed.

4.B.  DEPARTMENT CHAIRPERSONS AND VICE CHAIRPERSONS
4.B.1.  Qualifications:
Each department chairperson and vice chairperson must satisfy the eligibility criteria in Section 3.B and be certified by an appropriate specialty board or waived by the Board due to the individual’s demonstration of comparable competence, as determined through the credentialing and privileging process.  

4.B.2.  Selection of Department Chairpersons and Vice Chairpersons:
(a)	Except as otherwise provided by contract, a department chairperson will be elected by the voting members of the department.  The election will be held, in even-numbered years, at the September meeting and the department chairperson’s term will commence in January.
(b)	When the department has failed to elect a chairperson, the Executive Committee shall present a list of individuals eligible to serve as department chairperson to the Board for confirmation. 
(c)	If the Executive Committee fails to present an individual who is acceptable to the Board, the Chief Executive Officer, in consultation with the President of the Medical Staff, will appoint a search committee, which will be chaired by the Vice President for Medical Affairs.
(d)	The search committee will evaluate each candidate with respect to professional expertise, leadership skills, administrative capabilities, and commitment to the support and development of the Medical Staff and the department and consider input from members of the department and other members of the Medical Staff.
(e)	At the conclusion of its work, the search committee will make a recommendation and forward the recommendation to the Executive Committee.  Thereafter, the recommendation of the search committee and any recommendation of the Executive Committee will be forwarded to the Chief Executive Officer.  The Chief Executive Officer will make a recommendation to the Board for final action on the selection of the department chairperson.
(f)	Each department chairperson may recommend the appointment of a vice chairperson.  This recommendation will be reviewed by the Executive Committee and subject to final approval by the Board.

4.B.3.  Term of Appointment and Performance Evaluation for Department
	Chairpersons and Vice Chairpersons:
(a)	Initial appointment and reappointment of a department chairperson will be for a period of two years or as otherwise set forth in the chairperson’s contract.
(b)	A performance evaluation of the department chairperson will be initiated by the Vice President for Medical Affairs, who may appoint a committee to assist in this function.
(c)	The following factors may be addressed as part of the evaluation:
(1)	quality and support of the department as it interfaces with other Hospital departments;
(2)	communication, coordination, quality and service of care within the department;
(3)	effectiveness of the performance improvement program; and
(4)	where appropriate, contribution to patient care, education and research.
(d)	The Chief Medical Officer will prepare a written report of the evaluation and provide a copy to the department chairperson concerned.  The Executive Committee will also receive a copy of the report and have an opportunity to comment on it.
(e)	The Chief Medical Officer will monitor the department chairperson’s improvement activities and report progress to the Executive Committee and the Board.
(f)	The department chairperson will evaluate the performance of the vice chairperson.

4.B.4.  Duties of Department Chairpersons:
Each department chairperson is responsible for the following functions, either personally or in collaboration with Hospital personnel:
(a)	all clinically-related activities of the department;
(b)	all administratively-related activities of the department, unless otherwise provided for by the Hospital;
(c)	continuing surveillance of the professional performance of all individuals in the department who have delineated clinical privileges;
(d)	recommending criteria for clinical privileges that are relevant to the care provided in the department;
(e)	evaluating requests for clinical privileges for each member of the department;
(f)	assessing and recommending off‑site sources for needed patient care, treatment, and services not provided by the department or the Hospital;
(g)	integrating the department into the primary functions of the Hospital;
(h)	coordinating and integrating interdepartmental and intradepartmental services;
(i)	developing and implementing policies and procedures that guide and support the provision of care, treatment, and services;
(j)	recommending a sufficient number of qualified and competent persons to provide care, treatment, and services;
(k)	determining the qualifications and competence of department personnel who are not licensed independent practitioners and who provide patient care, treatment, and services;
(l)	continuing assessment and improvement of the quality of care, treatment, and services provided;
(m)	maintaining quality monitoring programs, as appropriate;
(n)	orientation and continuing education of all persons in the department; 
(o)	recommending space and other resources needed by the department;
(p)	developing an on-call schedule to reflect the services that are available; 
(q)	appointing a vice chairperson for the department;
(r)	appointing special committees as necessary to fulfill the duties of the department;
(s)	conducting department meetings and convening meetings of the section chiefs as necessary;
(t)	serving as a member of the Executive Committee; and
(u)	performing functions authorized in the Credentials Policy.

4.B.5.  Removal of Department Chairpersons and Vice Chairpersons:
	 (a)	Removal of Department Chairpersons and Vice Chairpersons may 	be effectuated 			by 1) two-thirds vote of the department members forwarded to Executive 				Committee for consideration and review or, 2) three-fourths vote of the 				Executive Committee for: 
		(1)	failure to comply with applicable policies, Bylaws, or the Rules and 				Regulations;
		(2)	failure to perform the duties of the position held;
		(3)	an infirmity that renders the individual incapable of fulfilling the duties of 				that office.
	(b)	Prior to scheduling a meeting to consider removal, a representative from the 			Executive Committee will meet with the individual in question and inform him or 			her of the reasons for the proposed removal proceedings.
	(c)	The individual subject to removal will be given at least ten days special notice 			of the date of the meeting at which removal is to be 	considered.  The individual 			will be afforded an opportunity to speak to the relevant body that is seeking 			removal prior to a vote on removal.
	(d)	Removal proceedings will be effective when approved by the Board.

4.C.  SECTIONS
4.C.1. Qualifications, Selection and Removal of Section Chiefs:
(a)	The relevant department chairperson may appoint qualified individuals to serve as chief of each section, subject to the approval of the Board.
(b)	Section chiefs must meet the same qualifications as department chairpersons.
(c)	The department chairperson has the authority, subject to consultation with the Vice President of Medical Affairs and President of the Medical Staff, to remove a section chief from office.
(d)	If requested by two-thirds of the members in a section, the department chairperson will evaluate the performance of a section chief to determine whether the section chief should be removed from office.
4.C.2.  Duties of Section Chief:
The section chief will carry out the duties requested by the department chairperson.  These duties may include:
(a)	review and reporting on applications for initial appointment and clinical privileges, including interviewing applicants;
(b)	review and reporting on applications for reappointment and renewal of clinical privileges;
(c)	evaluation of individuals during the provisional period;
(d)	participation in the development of criteria for clinical privileges;
(e)	review and reporting on the professional performance of individuals practicing within the section; and
(f)	delegation to a vice chairperson such duties as appropriate, including, but not limited to, the review of applications for appointment, reappointment, or clinical privileges or questions that may arise if the section chief has a conflict of interest with the individual under review.

4.C.3.  Functions of Sections:
(a)	Sections may perform any of the following activities:
(1)	continuing education;
(2)	discussion of policy;
(3)	discussion of equipment needs;
(4)	development of recommendations to the department chairperson or the Executive Committee;
(5)	participation in the development of criteria for clinical privileges (when requested by the department chairperson); and
(6)	discussion of a specific issue at the special request of a department chairperson  or the Executive Committee.
(b)	No minutes or reports will be required reflecting the activities of a section, except when a section is making a formal recommendation to a department, department chairperson, Credentials Committee, or Executive Committee.
(c)	Sections will not be required to hold regularly scheduled meetings.

ARTICLE 5
MEDICAL STAFF COMMITTEES AND
PERFORMANCE IMPROVEMENT FUNCTIONS

5.A.  GENERAL
5.A.1.  Appointment:
(a)	Except as otherwise provided by these Bylaws or the Organization and Functions Manual, the President of the Medical Staff, in consultation with the Vice President for Medical Affairs, will appoint the chairperson of each committee.  This appointment is subject to approval by the Executive Committee.
(b)	Committee chairpersons will be selected based on the criteria set forth in Section 3.B of these Bylaws.
(c)	The chairperson of each committee will select committee members subject to approval by the Executive Committee.  The chairperson will consult with and obtain the approval of the Chief Medical Officer in appointing non‑Medical Staff members to committees.
(d)	Chairpersons and members of standing committees will be appointed for an initial term of two years, but may be reappointed for additional terms.
(e)	Chairpersons and members of standing committees may be removed and vacancies filled at the discretion of the person who initially appointed them. 
(f)	The President of the Medical Staff will be an ex officio member, with vote, on all Medical Staff committees.
(g)	Except as otherwise provided, the Chief Executive Officer will be an ex officio member, without vote, on all Medical Staff committees.

5.A.2.  Medical Staff Functions:
Provision will be made for the effective performance of Medical Staff functions through committees as may be established by the Executive Committee.  The composition, duties and meeting requirements of additional committees are set forth in the Organization and Functions Manual.

5.B.  EXECUTIVE COMMITTEE
5.B.1.  Composition:
(a)	The Executive Committee will consist of the following:
(1)	the President of the Medical Staff;
(2)	the President-Elect of the Medical Staff;
(3)	the Secretary-Treasurer of the Medical Staff;
(4)	the Immediate Past President of the Medical Staff; 
(5)	the chairperson of each clinical department and, to ensure that the Executive Committee can represent the diverse interests of the Medical Staff, an Active Staff member(s) in any other specialty(ies), as determined and approved by 75% of the current Executive Committee members; and
(6)	any other Active Staff members elected at large.
(b)	The Chief Executive Officer will be a member, without vote, on the Executive Committee.  Other administrative personnel may be invited to attend meetings of the Executive Committee to provide input and support for the Committee.
(c)	A representative from the Board may serve as a member of the Executive Committee, without vote.
(d)	The President of the Medical Staff will serve as Chairperson of the Executive Committee.

5.B.2.  Duties:
(a)	The Executive Committee provides liaison among the Medical Staff, the Chief Executive Officer, the Vice President for Medical Affairs, and the Board.  The Executive Committee is delegated the primary authority over activities related to the functions of the Medical Staff. The Executive Committee is responsible for reviewing and making any necessary recommendations to the Board with regard to the following:
(1)	the structure of the Medical Staff;
(2)	the process used to review credentials and to delineate individual clinical privileges;
(3)	the appointment of Medical Staff and Allied Health applicants;
(4)	the delineation of clinical privileges for each eligible individual;
(5)	the participation of the Medical Staff in Hospital performance improvement activities;
(6)	the process by which Medical Staff and Allied Health appointment may be terminated;
(7)	the hearing procedures;
(8)	the sources of clinical patient care services to be provided through contracts;
(9)	the reports and recommendations from Medical Staff committees, departments, and other groups as appropriate;
(10)	the quality indicators to promote uniformity regarding patient care services;
(11)	the activities related to patient safety;
(12)	the process of analyzing and improving patient satisfaction;
(13)	continuing medical education activities;
(14)	compliance with applicable accreditation and regulatory requirements;
(15)	the Hospital’s safety and disaster preparedness programs in the development and maintenance of methods for the protection and care of Hospital patients and others at the time of internal or external disaster;
(16)	reviewing, at least every three years, the Bylaws, the Rules and Regulations, and associated documents of the Medical Staff and recommending such changes as may be necessary or desirable; and
(17)	performing any other functions as are assigned to it by these Bylaws, the Credentials Policy or other applicable policies.
(b)	The Executive Committee is empowered to act on behalf of the Medical Staff in the intervals between Medical Staff meetings (the officers are empowered to act in urgent situations between Executive Committee meetings).

5.B.3.  Meetings:
The Executive Committee will meet as often as necessary to fulfill its responsibilities and maintain a permanent record of its proceedings and actions.

5.C.  PERFORMANCE IMPROVEMENT FUNCTIONS
(1)	The Medical Staff is actively involved in the measurement, assessment and improvement of the following:
(a)	medical assessment and treatment of patients;
(b)	use of information about adverse privileging decisions for any practitioner privileged through the Medical Staff process;
(c)	medication usage;
(d)	the use of blood and blood components;
(e)	operative and other procedures;
(f)	appropriateness of clinical practice patterns;
(g)	significant departures from established patterns of clinical practice;
(h)	the use of developed criteria for autopsies;
(i)	sentinel event data;
(j)	patient safety data;
(k)	the Hospital’s and individual practitioners’ performance on Joint Commission and Centers for Medicare & Medicaid Services’ core measures; and
(l)	the required content and quality of history and physical examinations, as well as the time frames required for completion, all of which are set forth in Article 10.
(2)	The Medical Staff participates in the following activities:
(a)	education of patients and families;
(b)	coordination of care, treatment, and services with other practitioners and Hospital personnel;
(c)	accurate, timely, and legible completion of patient’s medical records;
(d)	review of findings of the assessment process that are relevant to an individual’s performance.  The Medical Staff is responsible for determining the use of this information in the ongoing evaluations of a practitioner’s competence; and
(e)	communication of findings, conclusions, recommendations, and actions to improve performance to appropriate staff members and the governing body.

5.D.  CREATION OF STANDING AND SPECIAL COMMITTEES
(1)	The Executive Committee may, by resolution, and without amendment of these Bylaws, establish additional committees to perform one or more staff functions, including peer review activities.
(2)	The Executive Committee may dissolve or rearrange the structure, duties, or composition of Medical Staff committees except the Executive Committee or the Credentials Committee.
(3)	Any function required to be performed by these Bylaws which is not assigned to an individual, a standing committee, or a special task force will be performed by the Executive Committee.
(4)	Special task forces will be created and their members and chairpersons will be appointed by the President of the Medical Staff.  Such task forces will confine their activities to the purpose for which they were appointed and will report to the Executive Committee.

ARTICLE 6
VICE PRESIDENT FOR MEDICAL AFFAIRS

The Chief Medical Officer will be appointed by the Board upon recommendation of the Chief Executive Officer and the Executive Committee.  The Chief Medical Officer will be responsible to the Chief Executive Officer as the chief medical officer of the Hospital.  The Chief Medical Officer will perform such duties and functions as may be delegated from time to time by the Chief Executive Officer, which may include but not be limited to the following:
(a)	serving as the medical advisor to Hospital Administration and the Board with respect to patient care and Medical Staff issues;
(b)	serving as an ex officio member of all departments and all Medical Staff committees (with vote);
(c)	participating in the Hospital and Medical Staff Quality Improvement program;
(d)	coordinating corrective and educational efforts with the respective clinical chairpersons and President of the Medical Staff;
(e)	developing an awareness among physicians and medical support personnel of relevant aspects of the health care delivery system;
(f)	assisting the Chief Executive Officer, the President of the Medical Staff, and other Medical Staff leaders in setting and attaining objectives for the continued improvement of the quality of medical care in the Hospital;
(g)	serving as an advisor to Hospital management and the President of the Medical Staff for interpretation and enforcement of these Bylaws, and related other Medical Staff documents, policies, and procedures;
(h)	assisting department chairpersons in the performance of their duties;
(i)	participating in the preparation of budgets for each department in conjunction with Hospital management;
(j)	acting as the Hospital’s medical liaison, after consultation with the Chief Executive Officer, to local, state and federal agencies and local, state and national medical societies;
(k)	endeavoring to maintain accreditation status;
(l)	coordinating medical education activities within the Hospital;
(m)	serving as liaison to all academic affiliations of the Hospital; and
(n)	performing such other duties as may be specified by the position description or agreement with the Hospital.

ARTICLE 7
MEETINGS

7.A.  GENERAL
7.A.1.  Meetings:
(a)	The Medical Staff will meet at least three times a year.  The date of any Medical Staff meeting can be changed with 14 days’ notice.
(b)	Except as provided in these Bylaws or the Organization and Functions Manual, departments, sections and committees will meet as often as necessary. 
(c)	Meetings may be conducted by telephone conference or by other electronic means at the discretion of the applicable chairperson.

7.A.2.  Regular Meetings:
(a)	At the beginning of each calendar year, the President of the Medical Staff, the chairperson of each department, and the chairperson of each committee, will schedule regular meetings for the year.  Notice of these meetings will be provided to members of the Medical Staff, and to members of the respective departments and committees.
(b)	The annual meeting of the Medical Staff will be held in November.

7.A.3.  Special Meetings:
(a)	A special meeting of the Medical Staff may be called by the President of the Medical Staff, a majority of the Executive Committee, the Chief Executive Officer, the Vice President for Medical Affairs, the Chairperson of the Board, or by a petition signed by at least 25% of the voting members of the Medical Staff.
(b)	A special meeting of any department, section, or committee may be called by or at the request of the President of the Medical Staff, the Vice President for Medical Affairs, the relevant chairperson or chief, or by a petition signed by at least 25% of the voting members of the department, section, or committee.
(c)	No business will be transacted at any special meeting except that stated in the meeting notice.

7.B.  PROVISIONS COMMON TO ALL MEETINGS
7.B.1.  Notice:
(a)	The notice of regular and special meetings will state the date, time, and place of the meeting.
(b)	Notice of any regular or special meeting of the Medical Staff, or of a department, section, or committee, will be sent to each voting member of the Medical Staff, department, section, or committee, via regular U.S. mail, e-mail, facsimile, or Hospital mail.
(c)	The attendance of any individual at any meeting will constitute a waiver of that individual’s notice of the meeting.

7.B.2.  Quorum:
(a)	Except as otherwise provided in these Bylaws, for any regular or special meeting of the Medical Staff, department, section, or committee, those voting members present will constitute a quorum.
(b)	For meetings of the Executive Committee and the Credentials Committee, the presence of at least 50% of the voting committee members will constitute a quorum.
(c)	Once a quorum is established, the business of the meeting may continue and actions taken will be binding.

7.B.3.  Voting:
(a)	Any individual, regardless of position or staff category, will be entitled to only one vote.
(b)	Recommendations and actions of the Medical Staff, departments, sections, and committees will be by consensus.  Except as otherwise provided in these Bylaws, in the event it is necessary to vote on an issue, the issue will be determined by a majority of the voting members.
(c)	Members of the Medical Staff and members of any department, section, or committee may also be presented with a question by mail, facsimile, e-mail, hand-delivery, or telephone, and their votes returned to the chairperson by the method designated in the notice.  A quorum for purposes of these votes will be the number of responses returned to the chairperson by the date indicated.  The question raised will be determined in the affirmative if a majority of the responses returned has so indicated. 
7.B.4.  Agenda:
(a)	The President of the Medical Staff will set the agenda for regular and special meetings of the Medical Staff.  
(b)	The chairperson of each department, section, and committee will set the agenda for general and special meetings of the respective department, section, and committee.

7.B.5.  Rules of Order:
The latest edition of Robert’s Rules of Order Revised may be used for reference at meetings and elections, but will not be binding.  Specific provisions of these Bylaws and Medical Staff, department, section, and committee custom will prevail at meetings, and the President of the Medical Staff, department chairperson, section chief or committee chairperson will have the authority to rule definitively on matters of procedure.

7.B.6.  Minutes:
(a)	Minutes of Medical Staff, department, and committee meetings will be prepared and signed by the presiding officer.
(b)	Minutes will include a record of the attendance of members and the recommendations made.
(c)	Minutes of Medical Staff, department, committee and, where applicable, section meetings will be forwarded to the Executive Committee.
(d)	The Chief Executive Officer and the Chief Medical Officer will receive a copy of minutes and reports of the Medical Staff, departments, committees and, where applicable, sections.  The Board will be kept apprised of and act on the recommendations of the Medical Staff.
(e)	A permanent file of the minutes of meetings will be maintained by the Hospital.

7.B.7.  Confidentiality:
(a)	Members of the Medical Staff who have access to or are the subject of credentialing and/or peer review information agree to maintain the confidentiality of this information.
(b)	Credentialing and peer review documents, and information contained therein, must not be disclosed to any individual not involved in the credentialing or peer review processes, except as authorized by the Credentials Policy or other applicable Medical Staff or Hospital policy.
(c)	A breach of confidentiality may result in the imposition of disciplinary action.

7.C.  ATTENDANCE
7.C.1.  Regular and Special Meetings:
(a)	Members of the Active Staff are expected to attend all regular Medical Staff meetings and applicable department and section meetings in accordance with the Medical Staff Rules and Regulations.
(b)	Members of the Consulting, Courtesy and Affiliate Staff are expected to attend and participate in applicable department and section meetings.
(c)	Members of the Executive Committee and the Credentials Committee are expected to attend at least one-half of the meetings held.

7.C.2.  Required Meetings:
(a)	Whenever there is an apparent or suspected deviation from standard clinical practice, or professional conduct, involving any individual, the department chairperson or the President of the Medical Staff may require the individual to attend a special conference with Medical Staff Leaders and/or with a standing or ad hoc committee of the Medical Staff.
(b)	The procedures for, and consequences of failing to abide by, these special attendance requirements are addressed in the Credentials Policy.

ARTICLE 8
BASIC STEPS AND DETAILS
The details associated with the following Basic Steps are contained in the Credentials Policy and the Fair Hearing Plan.

8.A.  QUALIFICATIONS FOR APPOINTMENT
To be eligible to apply for initial appointment or reappointment to the Medical Staff or the Allied Health Staff, or for the grant of clinical privileges, an applicant must demonstrate appropriate education, training, experience, current clinical competence, professional conduct, licensure, and ability to safely and competently perform the clinical privileges requested as set forth in the Credentials Policy.

8.B.  PROCESS FOR CREDENTIALING AND PRIVILEGING
Complete applications for appointment and privileges will be transmitted to the applicable department chairperson, who will prepare a written report.  This report will be forwarded to the Credentials Committee for review and recommendation.  The recommendation of the Credentials Committee will be forwarded, along with the department chairperson’s report, to the Executive Committee for review and recommendation.  The recommendation of the Executive Committee will be forwarded to the Board for final action.

8.C.  INDICATIONS AND PROCESS FOR RELINQUISHMENT
(1)	Appointment and clinical privileges will be automatically relinquished if an individual:
(a)	fails to do any of the following:
(i)	timely complete medical records;
(ii)	satisfy threshold eligibility criteria;
(iii)	meet provisional period requirements; 
(iv)	provide requested information;
(v)	attend a special conference to discuss issues or concerns; 
(vi)	in the case of a resident who is moonlighting, maintain an employment relationship within the Hospital’s training program; 
(b)	is convicted or pleads guilty or no contest pertaining to any felony, or to any misdemeanor involving (i) controlled substances; (ii) illegal drugs; (iii) Medicare, Medicaid, or insurance or health care fraud or abuse; (iv) violence; or (v) sexual misconduct;
(c)	makes a misstatement or omission on an application form; or
(d)	in the case of an allied health professional, fails, for any reason, to maintain an appropriate supervision relationship with a Supervising/Collaborating Physician as defined in Appendix B of the Credentials Policy.
(2)	Automatic relinquishment will take effect immediately and will continue until the matter is resolved, if applicable.

8.D.  INDICATIONS AND PROCESS FOR PRECAUTIONARY SUSPENSION
(1)	Whenever failure to take action may result in imminent danger to the health and/or safety of any individual, the Chief Executive Officer, the President of the Medical Staff, the chairperson of the relevant clinical department, the Vice President for Medical Affairs, the Executive Committee, or the Board chairperson is authorized to suspend or restrict all or any portion of an individual’s clinical privileges pending an investigation.
(2)	A precautionary suspension is effective immediately and will remain in effect unless it is modified by the Chief Executive Officer or the Executive Committee.
(3)	The individual will be provided a brief written description of the reason(s) for the precautionary suspension.
(4)	The Executive Committee will review the reasons for the suspension within a reasonable time.
(5)	Prior to, or as part of, this review, the individual will be given an opportunity to meet with the Executive Committee.

8.E.  INDICATIONS AND PROCESS FOR PROFESSIONAL REVIEW ACTIONS
Following an investigation, the Executive Committee may recommend, subject to final Board action, suspension or revocation of appointment or clinical privileges based on concerns about:
(1)	clinical competence or practice;
(2)	violation of ethical standards or these Bylaws, the Rules and Regulations or policies of the Medical Staff or the Hospital; or
(3)	conduct that is considered lower than the standards of the Hospital or disruptive to the orderly operation of the Hospital or its Medical Staff.

8.F.  HEARING AND APPEAL PROCESS
(1)	The hearing will begin no sooner than 30 days after the notice of the hearing, unless an earlier date is agreed upon by the parties.
(2)	The Hearing Panel will consist of at least three members.
(3)	The hearing process will be conducted in an informal manner; formal rules of evidence or procedure will not apply.
(4)	A stenographic reporter will be present to make a record of the hearing.
(5)	Both sides will have the following rights, subject to reasonable limits determined by the Presiding Officer:
(a)	to call and examine witnesses, to the extent they are available and willing to testify;
(b)	to introduce exhibits;
(c)	to cross-examine any witness on any matter relevant to the issues;
(d)	to have representation by counsel who may call, examine, and cross‑examine witnesses and present the case; and
(e)	to submit proposed findings, conclusions, and recommendations to the Hearing Panel.
(6)	The personal presence of the affected individual is mandatory.  If the individual who requested the hearing does not testify, he or she may be called and questioned.
(7)	The Hearing Panel may question witnesses, request the presence of additional witnesses, and/or request documentary evidence.
(8)	The affected individual and the Executive Committee may request an appeal of the recommendations of the Hearing Panel to the Board.

ARTICLE 9
AMENDMENTS

9.A.  MEDICAL STAFF BYLAWS
(1)	Amendments to these Bylaws may be proposed by a petition signed by 25% of the voting members of the Medical Staff, by the Bylaws Committee, or by the Executive Committee.
(2)	All proposed amendments must be reviewed by the Executive Committee prior to a vote by the Medical Staff.  The Executive Committee will provide notice of all proposed amendments, including amendments proposed as set forth above, to the voting members of the Medical Staff.  The Executive Committee may also report on any proposed amendments, either favorably or unfavorably, at the next regular meeting of the Medical Staff, or at a special meeting called for such purpose.
(3)	The proposed amendments may be voted upon at any meeting provided the amendments have been provided to all voting members of the Medical Staff at least 14 days prior to the meeting.  To be adopted, the amendment must receive a majority of the votes cast by the voting staff at the meeting.
(4)	The Executive Committee may also present any proposed amendments to the voting staff by written or electronic ballot, returned to the Medical Staff Office by the date indicated by the Executive Committee, provided the amendments have been provided to all voting members of the Medical Staff at least 14 days prior to the return date requested for the vote.  Along with the proposed amendments, the Executive Committee may, in its discretion, provide a written report on them either favorably or unfavorably.  To be adopted, an amendment must receive a majority of the votes cast, so long as the amendment is voted on by at least 25% of the members who are eligible to vote. 
(5)	The Executive Committee will have the power to adopt such amendments to these Bylaws which are needed because of reorganization, renumbering, or punctuation, spelling or other errors of grammar or expression.
(6)	All amendments will be effective only after approval by the Board.
(7)	If the Board has determined not to accept a recommendation submitted to it by the Executive Committee or the Medical Staff, the Executive Committee may request a conference between the officers of the Board and the officers of the Medical Staff.  Such conference will be for the purpose of further communicating the Board’s rationale for its contemplated action and permitting the officers of the Medical Staff to discuss the rationale for the recommendation.  Such a conference will be scheduled by the Chief Executive Officer within two weeks after receipt of a request.

9.B.  OTHER MEDICAL STAFF DOCUMENTS
(1)	In addition to the Medical Staff Bylaws, there are the Rules and Regulations and policies and procedures that are applicable to all members of the Medical Staff and other individuals who have been granted clinical privileges or a scope of practice.  The Rules and Regulations and Medical Staff policies and procedures will be considered an integral part of the Medical Staff Bylaws, but amended in accordance with this Section.
(2)	An amendment to the Credentials Policy may be made by a majority vote of the members of the Executive Committee provided that the written recommendations of the Credentials Committee concerning the proposed amendments have first been received and reviewed by the Executive Committee.  Notice of all proposed amendments to this document will be provided to each voting member of the Medical Staff at least 14 days prior to the vote by the Executive Committee.  Any voting member may submit written comments on the amendments to the Executive Committee.
(3)	An amendment to the Medical Staff Organization Manual or the Medical Staff Rules and Regulations may be made by a majority vote of the members of the Executive Committee.  Notice of all proposed amendments to these two documents will be provided to each voting member of the Medical Staff at least 14 days prior to the vote by the Executive Committee.  Any voting member may submit written comments on the amendments to the Executive Committee.
(4)	The Executive Committee and the Board will have the power to provisionally adopt urgent amendments to the Rules and Regulations that are needed in order to comply with a law or regulation, without providing prior notice of the proposed amendments to the Medical Staff.  Notice of all provisionally adopted amendments will be provided to each member of the Medical Staff as soon as possible.  The Medical Staff will have 14 days to review and provide comments on the provisional amendments to the Executive Committee.  If there is no conflict between the Medical Staff and the Executive Committee, the provisional amendments will stand.  If there is conflict over the provisional amendments, then the process for resolving conflicts set forth below will be implemented.
(5)	All other policies of the Medical Staff may be adopted and amended by a majority vote of the Executive Committee.  No prior notice is required.
(6)	Amendments to Medical Staff policies and Rules and Regulations may also be proposed by a petition signed by a majority of the voting members of the Medical Staff. Notice of any such proposed amendment to these documents will be provided to each voting member of the Medical Staff 14 days in advance of forwarding the proposed recommendation to the Executive Committee.  Any such proposed amendments will be reviewed by the Executive Committee, which may comment on the amendments before they are forwarded to the Board for final action.
(7)	Adoption of and changes to the Credentials Policy, Medical Staff Organization Manual, Medical Staff Rules and Regulations, and other Medical Staff policies will become effective only when approved by the Board.
(8)	The present Medical Staff Rules and Regulations are hereby readopted and placed into effect insofar as they are consistent with these Bylaws, until such time as they are amended in accordance with the terms of these Bylaws. To the extent any present Rule or Regulation is inconsistent with these Bylaws, it is of no force or effect.

9.C.  CONFLICT MANAGEMENT PROCESS
(1)	When there is a conflict between the Medical Staff and the Executive Committee with regard to:
(a)	proposed amendments to the Medical Staff Rules and Regulations,
(b)	a new policy proposed by the Executive Committee, or
(c)	proposed amendments to an existing policy that is under the authority of the Executive Committee,
a special meeting of the Medical Staff will be called.  The agenda for that meeting will be limited to the amendment(s) or policy at issue.  The purpose of the meeting is to resolve the differences that exist with respect to Medical Staff Rules and Regulations or policies.
(2)	If the differences cannot be resolved at the meeting, the Executive Committee will forward its recommendations, along with the proposed recommendations pertaining to the Medical Staff Rules and Regulations or policies offered by the voting members of the Medical Staff, to the Board for final action.
(3)	This conflict management section is limited to the matters noted above.  It is not to be used to address any other issue, including, but not limited to, professional review actions concerning individual members of the Medical Staff.
(4)	Nothing in this section is intended to prevent individual Medical Staff members from communicating positions or concerns related to the adoption of, or amendments to, the Medical Staff Rules and Regulations or other Medical Staff policies directly to the Board.  Communication from Medical Staff members to the Board will be directed through the Chief Executive Officer, who will forward the request for communication to the Chair of the Board.  The Chief Executive Officer will also provide notification to the Executive Committee by informing the President of the Medical Staff of all such exchanges. The Chair of the Board will determine the manner and method of the Board’s response to the Medical Staff member(s).

ARTICLE 10
HISTORY AND PHYSICAL

(1)	A complete medical history and physical examination must be performed and documented in the patient’s medical record within 24 hours after admission or registration (but in all cases prior to surgery or an invasive procedure requiring anesthesia services) by an individual who has been granted privileges by the Hospital to perform histories and physicals.  The scope of the medical history and physical examination will include, as pertinent:
(a)	patient identification;
(b)	chief complaint;
(c)	history of present illness;
(d)	review of systems, to include at a minimum:
(i)	cardiovascular;
(ii)	respiratory;
(iii)	gastrointestinal;
(iv)	neuromusculoskeletal; and
(v)	skin;
(e)	personal medical history, including medications and allergies;
(f)	family medical history;
(g)	social history, including any abuse or neglect;
(h)	physical examination, to include pertinent findings in those organ systems relevant to the presenting illness and to co-existing diagnoses;
(i)	data reviewed;
(j)	assessments, including problem list;
(k)	plan of treatment; and
(l)	if applicable, signs of abuse, neglect, addiction or emotional/behavioral disorder, which will be specifically documented in the physical examination, and any need for restraint or seclusion will be documented in the plan of treatment.
In the case of a pediatric patient, the history and physical examination report must also include:  (i) developmental age; (ii) length or height; (iii) weight; (iv) head circumference (if appropriate); and (v) immunization status.
(2)	If a medical history and physical examination has been completed within the 30‑day period prior to admission or registration, a durable, legible copy of this report may be used in the patient’s medical record, provided that the patient has been reassessed within 24 hours of the time of admission/registration or prior to surgery/invasive procedure, whichever comes first.  The update of the history and physical examination must reflect any changes in the patient’s condition since the date of the original history and physical or state that there have been no changes in the patient’s condition.
(3)	When the history and physical examination is not performed or recorded in the medical record before a surgical, diagnostic operative or invasive procedure, the operation or procedure will be canceled unless the attending physician states in writing that an emergency situation exists.  If it is an emergency situation and a history and physical has been dictated but has not been transcribed, there will be a statement to that effect in the patient’s chart, with an admission note by the attending physician.  The admission note must be documented immediately prior to surgery (same day as surgery) and will include, at a minimum, an assessment of the patient’s heart rate, respiratory rate and blood pressure.
(4)	A Short-Form history and physical, containing the chief complaint or reason for the procedure, relevant history of the present illness or injury, and the patient’s present clinical condition/physical findings, may be used for ambulatory or same‑day procedures as approved by the Executive Committee.
(5)	The current obstetrical record will include a complete prenatal record.  The prenatal record may be a legible copy of the admitting physician’s office record transferred to the Hospital before admission.  An interval admission note must be written that includes pertinent additions to the history and any subsequent changes in the physical findings.

ARTICLE 11
ADOPTION

(a)	These Bylaws are adopted and made effective upon approval of the Board, superseding and replacing any and all previous Medical Staff Bylaws, Rules and Regulations, policies, manuals or Hospital policies pertaining to the subject matter thereof.
(b)	The present Rules and Regulations of the Medical Staff are hereby readopted and placed into effect insofar as they are consistent with these Bylaws, until such time as they are amended.  To the extent they are inconsistent, the Rules and Regulations are of no force or effect.

Adopted by the Medical Staff on September 18, 2012

Approved by the Board January 18, 2013

Adopted by the Medical Staff:  September 18, 2012
Approved by the Board:  January 18, 2013

Amendments to the Medical Staff Bylaws:

1.	Amendment to Article 2.B.1., Active Staff Qualifications to add definitions for Active Staff Qualifications.	
	Approved by Medical Executive Committee:  February 11, 2014
	Approved by Board of Directors, February 21, 2014

Amendments to the Medical Staff Bylaws:

l.          Amendment to Article 2. I. 2., Allied Health Staff Prerogatives & Responsibilities.
            Approved by Medical Executive Committee: May 9, 2017
            Approved by the Board of Directors: May 23, 2017

Amendments to the Medical Staff Bylaws:

l.          Amendment to Article 2.B.3 Responsibilities
            Amendment to Article 3.C.3 Secretary Treasurer / Succession
            Amendment to Article 3.D.2 Nominating Process	
            Amendment to Article 3.E.2 Vacancies 
            Amendment to Article 4.B.5 Removal of Department Chairpersons and Vice Chairperson
            Approved by Medical Executive Committee: March 12, 2019
            Approved by the Board of Directors: May 28, 2019