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| BYLAWS OF THE MEDICAL STAFF OF THE BRIGHAM AND WOMEN'S HOSPITAL CONTENTS ARTICLE I: PURPOSE ARTICLE II: ORGANIZATION OF THE MEDICAL STAFF ARTICLE III: MEMBERSHIP ARTICLE IV: CATEGORIES OF THE MEDICAL STAFF ARTICLE V: ADVERSE ACTION ARTICLE VI: MEDICAL STAFF HEALTH PROGRAM ARTICLE VII: OFFICERS OF THE MEDICAL STAFF ARTICLE VIII: MEETINGS ARTICLE IX: COMMITTEES ARTICLE X: PATIENT CARE ASSESMENT ARTICLE XI: POLICIES AND PROCEDURES ARTICLE XIII: MISCELLANEOUS
The purpose of the organization is to bring medical staff members who practice at the Hospital together into a cohesive body to promote high quality patient care, research and medical education in order to meet the needs of the community it serves. To this end, among other activities, it will assist in screening applicants for staff membership, review privileges of members, evaluate and assist in improving the work done by the staff, and offer advice and assistance to the Chief Medical Officer and President. ARTICLE II: ORGANIZATION OF THE MEDICAL STAFF Section 1: Departments Anesthesiology, Perioperative and Pain Medicine 3. If, in the interest of departmental organization, it is desirable to subdivide the activities of a Department into formally constituted divisions, the Chairman of the Department may so recommend to the Chief Medical Officer with identification of the scope of the proposed division(s). The Chief Medical Officer will forward the proposal with his/her recommendation to the Board of Trustees. 4. Each Department shall be headed by a physician appointed by the Board of Trustees in consultation with the President, the Chief Medical Officer and the Medical Staff Executive Committee. Said appointment shall be based on criteria approved by the President, the Chief Medical Officer, the Medical Staff Executive Committee and the Board of Trustees. The Department Chairman shall have corresponding oversight and responsibilities within the Brigham and Women’s Physicians Organization (BWPO). The responsibilities of the Department Chairmen shall be carried out in concert with the functions and objectives of the Hospital and the BWPO. The Department Chairmen shall be responsible for formulating and directing educational, research and clinical activities within their Departments. Furthermore, Partners HealthCare System, Inc. (Partners) may from time to time appoint at the Partners level a Chairman to oversee the integration of a Department or Division at the Hospital and its counterpart at the Massachusetts General Hospital and/or other Partners affiliates, and the ongoing operation of the consolidated Department or Division. The relative authority and responsibilities of the Partners Chairman and the Hospital shall be delegated and described as necessary in appropriate documents. 5. Deputy, Vice, Associate or Assistant Department Chairmen shall be appointed upon recommendation by the Chairman of the Department with approval by the President and the Chief Medical Officer. 6. Division Directors shall be appointed upon recommendation by the Chairman of the Department with approval by the President and Chief Medical Officer. 7. All Medical Staff members shall have a primary departmental affiliation. Except as otherwise specifically approved by the Chief Medical Officer, the primary departmental affiliation must coincide with the medical staff member’s residency (or equivalent) training. In appropriate instances with the approval of the concerned Department Chairmen and of the Medical Staff Executive Committee, joint appointments to more than one Department may be made. In no instance, however, shall such individuals have more than one vote in Medical Staff affairs. 8. Physicians, dentists, psychologists, chiropractors and podiatrists responsible for patient care at BWH shallbe conferred staff titles within their Department upon nomination by its Chairman and approval of the Medical Staff Executive Committee as follows: (a) Associate xxxx (xxxx equals Anesthesiologist, Chiropractor, Dentist, Dermatologist, Physician, Neonatalogist, Obstetrician/Gynecologist, Orthopaedic Surgeon, Pathologist, Psychiatrist, Psychologist, Radiation Oncologist, Radiologist, Neurologist, Neurosurgeon or Surgeon as appropriate) – the usual entry level onto the staff of an individual who has completed residency and fellowship training; (b) xxxx – the usual grade reached by mature, well-known staff members who have established regional or national reputations (e.g., Anesthesiologist). (c) Senior xxxx – reserved for those staff members who have achieved international stature and distinction in their field and/or who have rendered unusual and conspicuous service to BWH (e.g., Senior Anesthesiologist). For those staff members without patient care responsibilities, staff titles will be conferred as follows: (a) Associate xxxx, Department of yyyy (e.g., Associate Biochemist, Department of Radiology); (b) xxxx, Department of yyyy (e.g., Biochemist, Department of Radiology); (c) Senior xxxx, Department of yyyy (e.g., Senior Biochemist, Department of Radiology). ARTICLE III: MEMBERSHIP Section 1: Qualifications The Medical Staff shall consist of physicians, dentists, psychologists, chiropractors and podiatrists who are licensed to practice in the Commonwealth of Massachusetts unless otherwise specified in these Bylaws, and other qualified personnel. Members of the Medical Staff shall be competent in their respective fields and worthy in terms of professional ethics. They shall meet and continue to meet the requirements in Article IV concerning the categories of the Medical Staff for which they apply, and all the applicable standards, criteria and policies of their respective Department and the Medical Staff, the Bylaws and policies and procedures of the Medical Staff, and the Bylaws and applicable policies of the Hospital and of Partners, and any condition or restriction imposed on any appointment or privilege granted by the Hospital in the credentialing or adverse action process. A member of the Medical Staff holding clinical privileges shall maintain in force malpractice insurance coverage in an amount and with a carrier acceptable to the Hospital. Section 2: Ethics and Ethical Relationships The principles and codes of ethics as adopted and amended by the American Medical Association, the American Dental Association, the American Psychological Association, the American Chiropractic Association and the American Podiatric Medical Association, as well as applicable policies of the Hospital and Partners shall guide the professional conduct of the members of the Medical Staff. Section 3: Term of Appointment Appointments to the Medical Staff shall be made by the Board of Trustees upon recommendation of the Medical Staff Executive Committee for a period of not longer than two years. Initial appointment to the Active, Affiliate and Adjunct Staffs shall be provisional. The reappointment of a provisional member of the Active, Affiliate and Adjunct staffs may also be made provisional; provided however, that the sum of the terms of the provisional appointments shall not exceed four (4) years. Section 4: Equal Opportunity No qualified applicant shall be rejected from membership in the Medical Staff on the basis of race, gender, creed, religion, color, national origin, age, disability or sexual orientation. Section 5: Balanced Use of Hospital Resources The Board of Trustees, or committee thereof, in order to fulfill its commitment to assure balanced use of Hospital resources, may impose restrictions upon or designate special conditions for Staff selection. (a) Depending upon the clinical and academic needs of the individual Departments and the availability of Hospital resources, membership in any Medical Staff category in a Department or part thereof may be limited in number or closed to new applicants by the Board of Trustees, or committee thereof, upon the recommendation of the Chairman of the Department and the Medical Staff Executive Committee. (b) Each Departmental Chairman, after consultation with Division Directors, the Departmental Executive Committee, the Chief Medical Officer and the President or his designee, shall regularly review the clinical and academic needs of the Department and the availability of Hospital resources, and recommend whether membership in any Medical Staff category or part thereof should be limited or closed. If a Department Chairman wishes to propose any such limit or closure, the Chairman shall submit a written recommendation to this effect to the Medical Staff Executive Committee. Any recommendation approved by the Medical Staff Executive Committee will be forwarded to the Board of Trustees, or committee thereof, for final action. (c) Any limit on the size of or closure of membership in any category of the Medical Staff in a Department or part thereof will apply prospectively only to new applicants for membership in the affected category or part thereof and will not affect existing members of the affected category or part thereof. (d) If any moratorium is imposed pursuant to this section on prospective membership in any category or part thereof of the Medical Staff in any Department, no applications for appointments to the positions covered will be evaluated during the moratorium. Persons whose applications are not reviewed due to such a moratorium are not entitled to the hearing and review process available pursuant to Article V, Section 10.
A. Procedures for Initial Appointment to the Medical Staff (a) Applications for membership to the Medical Staff shall be presented in writing to the Chairman of the relevant Department on a form prescribed by the Hospital. They shall set forth qualifications and references of the applicant and signify his or her agreement to abide by the Bylaws and policies and procedures of the Medical Staff. (b) Applicants for clinical privileges shall provide evidence of current Massachusetts licensure or a pending application for Massachusetts licensure. (c) Applicants for clinical privileges and any others who have applied for licensure must submit copies or their most recent Massachusetts licensure application forms including all attachments and other explanatory materials submitted with the application. (d) References shall be provided by individuals knowledgeable about the applicant’s competence, ethics and character. (e) Each application form must provide verifiable information relative to medical, dental, psychological, chiropractic or podiatric education and training. (f) Each application form must provide the names of all health care facilities with which the applicant has been associated and the reasons for discontinuance of these associations. (g) Applicants shall agree to the release by the facilities with which they have been associated of any information which is relevant to the assessment of their ethics, character or competence to practice medicine. (h) Applicants for clinical privileges shall provide information about malpractice insurance coverage and a listing of all malpractice claims pending or closed during the previous ten (10) years. (i) Applicants for clinical privileges shall agree to the release to the Hospital by their malpractice liability insurance carriers of information as to claims or actions for damages, whether or not there has been a final disposition. (j) Applicants shall provide a description of any pending, threatened or final disciplinary or other adverse action (whether voluntary or involuntary), as defined in Article V, Section 1, by any healthcare facility, professional organization, or licensing or regulatory agency. (k) Each applicant shall authorize the Hospital and its agents to exchange information with any other health care facility and with any professional organization with which the applicant is or was associated, regarding any pending, threatened or final disciplinary or other adverse action (whether voluntary or involuntary). (l) Each applicant must agree to undergo a mental or physical examination prior to or during the term of his/her appointment if requested to determine whether the applicant is able to perform the essential functions of the position for which he/she has applied or the privileges he/she has requested according to accepted standards of professional performance and without posing a threat to patients. (m) Applicants shall provide evidence that the Commonwealth of Massachusetts requirement for continuing education has been met (or waiver received). (n) Each applicant for clinical privileges shall complete a clinical delineation form, specifying the areas in which he/she seeks clinical privileges, and provide such supporting documentation of competence in these areas as requested by the Hospital. (o) Prior to review pursuant to Section 6.A.2 below, the Chairman
of any Department may recommend that the Medical Staff Credentialing
Committee grant, and this Committee may grant, preliminary privileges
for a limited period of time not to exceed that which is allowed by
the Board of Registration in Medicine pending credentialing to any
applicant concerning whom the Chairman has received his/her: (1) most
recent application for a license to practice medicine, dentistry,
podiatry, chiropractics or psychology, as applicable in Massachusetts;
(2) Drug Enforcement Administration number; (3) evidence of malpractice
insurance; (4) any information required pursuant to the Hospital’s
health screening policy of subsection l above; and (5) appropriate
references, and has found them satisfactory. 2. Application Review and Investigation (a) The Chairman of each Department shall transmit the application to the Credentials Committee of the Department, which shall review the character, qualifications, and standing of the applicant. (b) The review of each application shall include inquiries of each health care facility with which the applicant has been associated during the past ten years, regarding the health care facility’s assessment of professional skills, and information regarding any pending or final disciplinary or other adverse action, and any other information relevant to the applicant’s character or professional competence. With respect to applicants for clinical privileges, these inquiries shall also cover clinical skills and malpractice claims pending or closed during the previous ten (10) years. (c) The names of the applicants to a particular Department may be circulated among the members of that Department. Comments on the applicant from Staff members may be made to and should considered by the appropriate Departmental Credentials Committee prior to its decision. (d) The Departmental Credentials Committee shall make the appointment decision concerning all applications by those individuals who are not seeking clinical privileges and/or who are not licensed to practice medicine in Massachusetts or seeking such licensure. The Departmental Credentials Committee shall submit through its Department Chairman a report of all other applications it recommends for approval to the Medical Staff Credentialing Committee. In both cases, all applications shall be accompanied by the completed application forms, all references obtained, and evidence of the verification of relevant data. (e) Every recommendation for appointment by the Departmental Credentials Committee shall include a recommendation concerning appropriate staff category and, with respect to applicants for clinical privileges, a delineation of any clinical privileges recommended. The recommendation of the Departmental Credentials Committee for those applicants seeking clinical privileges shall be forwarded to the Medical Staff Credentialing Committee. (f) Following a review of the applications and the report submitted by the Departmental Credentials Committee, those applicants who satisfy criteria adopted by the Medical Staff Credentialing Committee, the Medical Staff Executive Committee and the Board of Trustees or committee thereof (“Category 1 Applicants”) shall be reviewed by an expanded Medial Staff Credentialing Committee which includes at least one (1) representative from the Medical Staff Executive Committee with the authority to act on behalf of the Medical Staff Executive Committee. (g) The expanded Medical Staff Credentialing Committee shall prepare a recommendation concerning such Category 1 Applicants. Category 1 Applications recommended for approval by the expanded Medical Staff Credentialing Committee shall be transmitted along with all relevant application materials to the Care Improvement Council or other designated Board of Trustees Committee. Applications recommended for rejection or approval with limitations by the expanded Medical Staff Credentialing Committee shall be transmitted to the full Medical Staff Executive Committee for review. (h) The Care Improvement Council or other designated Board of Trustees Committee shall either accept the recommendation of the expanded Medical Staff Credentialing Committee with respect to such Category 1 Applicants or shall reject or refer such applicants to the full Medical Staff Executive Committee for review. The Care Improvement Council or other designated Board of Trustees Committee shall state the reasons for its decision to reject or refer any such Category 1 Application. The appointment and privileges requested shall be effective upon approval by the Care Improvement Council or other designated Board of Trustees Committee. (i) The Board of Trustees shall consider such appointments at its next regularly scheduled meeting, and, if it deems appropriate, shall ratify the decision of the Care Improvement Council or other designated Board of Trustees Committee. Alternatively, the Board of Trustees may reverse or amend the decision of the Care Improvement Council or other designated Board of Trustees Committee or may refer such applicant to the Medical Staff Executive Committee for further review. (j) Following a review of the applications and the report submitted by the Departmental Credentials Committee, those applicants who do not satisfy criteria adopted by the Medical Staff Credentialing Committee, the Medical Staff Executive Committee and the Board of Trustees or committee thereof (“Category 2 Applicants”) shall be reviewed by the Medical Staff Credentialing Committee. (k) The Medical Staff Credentialing Committee shall prepare a recommendation with respect to each such Category 2 Applicant it reviews, and shall submit such recommendation with all relevant application materials to the Medical Staff Executive Committee. (l) On receipt of the report of the Medical Staff Credentialing Committee, the Medical Staff Executive Committee shall recommend that each Category 2 Application submitted to it be accepted, deferred, or rejected. Where a recommendation to defer is made, it must be followed by one to accept or reject the applicant within a reasonable time, in no case to exceed three (3) months. (m) The recommendation of the Medical Staff Executive Committee with respect to such Category 2 Applicants shall be transmitted to the Care Improvement Council for consideration. (n) Upon receipt of the report of the Medical Staff Executive Committee, the Care Improvement Council shall recommend that each Category 2 Application submitted to it be accepted, deferred or rejected. Where a recommendation to defer is made, it must be followed by one to accept or reject the applicant within a reasonable time, in no case to exceed three (3) months. (o) The recommendation of the Care Improvement Council with respect to such Category 2 applicants shall be transmitted to the Board of Trustees for consideration. (p) The Board of Trustees shall either accept the recommendation of the Care Improvement Council or shall reject or recommit the recommendation for further consideration, stating the reasons for such rejection of recommittal. (q) These credentialing requirements do not apply when the Hospital grants temporary privileges in accordance with the regulations of the Massachusetts Board of Registration in Medicine or disaster privileges in accordance with Hospital policy. B. Procedures for Reappointment to the Medical Staff 2. The completed reappointment form must be submitted to the Chairman of the member’s Department. The Chairman or the Departmental Credentials Committee shall verify licensure status, required reports from other health care facilities, and other relevant information provided by the member. 3. Reappointment to the Medical Staff shall be contingent upon an appraisal of the Staff member’s character, qualifications, and standing by the Chairman of the relevant Department in conjunction with the Departmental Credentials Committee. Such appraisal shall include, as applicable, a review of the member’s professional and clinical performance, utilization and quality assurance data, malpractice claims, disciplinary or other adverse actions, patient complaints, continuing education, attendance at Staff and Committee meetings, and compliance with the applicable standards, criteria and policies of their respective Departments, the Medical Staff, the Hospital and Partners, the Bylaws and policies and procedures of the Medical Staff, the Bylaws of the Hospital, and any condition or restriction imposed on the member’s appointment. 4. The recommendations of the Department Chairmen will be forwarded to their Departmental Credentials Committees. The relevant Departmental Credentials Committee shall make the reappointment decision concerning all those individuals in the Department who are not seeking clinical privileges and/or who are not licensed to practice medicine in Massachusetts or seeking licensure. The recommendations of the Department Chairmen and Departmental Credentials Committees concerning all other applicants in the Department for reappointment will be forwarded for review and action pursuant to the same process and according to the same schedule applicable to applicants for initial appointment.
1. Temporary privileges may be extended to any qualified physician, dentist, psychologist, chiropractor or podiatrist who is not a member of the Medical Staff after authorization by a Department Chairman or the Chief Medical Officer and the Medical Staff Credentialing Committee. Such privileges shall be for a limited period of time not to exceed that which is allowed by the Board of Registration in Medicine. In the exercise of such privileges, the physician, dentist, psychologist, chiropractor or podiatrist shall be under the supervision of the Chairman of the Department or his designee in which the temporary appointment is made. 2. Temporary privileges shall be immediately terminated by the Chief Medical Officer (or designee) at his/her discretion or upon the request of the Department Chairman or the Medical Staff Credentialing Committee. 3. The granting of temporary privileges is a courtesy on the part of the Hospital and the granting, denial, restriction or termination of such temporary privileges shall not entitle the individual concerned to any of the procedural rights provided in Article V of these Bylaws, including but not limited to those procedures with respect to preliminary inquiry, hearings and appellate review.
Section 1: The Medical Staff The Medical Staff shall consist of the following categories: Section 2: Active Staff The Active Staff shall consist of selected physicians, dentists, psychologists, chiropractors and podiatrists who have been granted clinical and/or admitting privileges upon the recommendation of the relevant Department Chairman at the time of the appointment or reappointment, and who either: (1) care for at least a majority of their patients at the Hospital or (2) care for at least a majority of their patients at the Hospital in the particular subspecialty and/or for the particular procedure(s) for which they have been granted privileges. Members of the Active Staff must contribute substantially to the Hospital including: (a) An active participation in caring for patients in the Hospital or in ambulatory care settings; and/or (b) Conducting research; and (c) An active participation in the teaching program, to be defined by the relevant Department Chairman. Members of the Active Staff: (a) Must hold a current Harvard University appointment. (b) Shall be eligible to hold office, vote and serve on committees. (c) Shall be expected to serve on Hospital committees if so appointed. Section 3: Affiliate Staff The Affiliate Staff shall consist of selected physicians, dentists, psychologists, chiropractors and podiatrists who have been granted clinical and/or admitting privileges upon the recommendation of the relevant Department Chairman at the time of the appointment or reappointment, and who are either: (1) members of a health maintenance organization or any other practice association that has contracted with the Hospital for the provision of care for its patients by its own staff; (2) employed by or affiliated with Partners Community HealthCare, Inc.; (3) members of the medical staff of the Massachusetts General Hospital or other Partners HealthCare System, Inc. hospitals; or (4) members of the Harvard Medical School faculty whose principal base is at another institution affiliated with Harvard Medical School or at a medical research organization. Any appointment to the Affiliate Staff will terminate automatically upon the termination of the basis for the staff member’s appointment at the Hospital, namely: (1) upon the termination of the staff member’s affiliation with the HMO or other practice association or upon the termination of the organization’s contract with the Hospital; (2) upon the termination of the staff member’s employment by or affiliation with Partners Community HealthCare, Inc.; (3) upon the termination of the staff member’s relevant medical staff membership or (4) upon the termination of the staff member’s appointment at Harvard Medical School or of his or her appointment at an institution other than the Hospital which is affiliated with Harvard Medical School, or at a medical research organization. Members of the Affiliate Staff must demonstrate: (a) An active participation in caring for patients in the Hospital or its ambulatory care settings, and (b) An active participation in the teaching program, to be defined by the relevant Department Chairman. Members of the Affiliate Staff: (a) Shall be eligible to hold office, vote, and serve on committees. (b) Shall be expected to serve on Hospital committees if so appointed. (c) Shall not be required to have a Harvard University appointment. Section 4: Adjunct Staff The Adjunct Staff shall consist of selected physicians, dentists, psychologists, chiropractors and podiatrists who are given privileges to admit or care for an occasional patient in the Hospital. Each Department Chairman shall establish the maximum number of patients that may be admitted or cared for by a member of the Adjunct Staff in that Department during a two year period. Admission or care of more that this designated maximum number of patients shall require the individual to seek membership on the Active or Affiliate Staff. Adjunct Staff Members may neither vote nor hold office nor serve
on committees. An appointment at Harvard University shall not be required. Section 5: Senior Consulting Staff The Senior Consulting Staff shall consist of selected physicians, dentists, psychologists, chiropractors and podiatrists of outstanding reputation in their respective fields who have various skills and areas of competence to provide consultation services upon request of any member of the Medical Staff. Members of the Senior Consulting Staff: (a) Shall not be granted clinical or admitting privileges. (b) Shall not be required to have a Harvard University appointment. (c) Need not be credentialed pursuant to these bylaws, but may be credentialed as deemed appropriate by the relevant Department Chairman. (d) May neither vote nor hold office. (e) May serve on committees as requested by the Hospital. (f) The provisions of Article V, Adverse Action, shall not apply to the Senior Consulting Staff. Section 6: Honorary Staff The Honorary Staff shall consist of: (a) Former members of the Medical Staff who, by their long and meritous service to the Hospital, warrant such recognition; and (b) Other distinguished professionals of outstanding reputation in medicine and the allied health sciences. Members of the Honorary Staff shall have no privileges. They may neither vote, nor hold office, nor serve on committees. They need not be credentialed pursuant to these bylaws, but may be credentialed as deemed appropriate by the relevant Department Chairman. Members of the Honorary Staff shall not be required to have a Harvard University appointment. Section 7: Research Staff Membership on the Research Staff may be conferred on those whose sole activity is to conduct medical research. An appointment at Harvard University is required. As Research Staff are not granted clinical privileges, they need not be licensed to practice medicine in the Commonwealth of Massachusetts. Research Staff need not be credentialed pursuant to these bylaws, but may be credentialed as deemed appropriate by the relevant Department Chairman. Research Staff members may neither vote nor hold office. They may serve on committees as requested by the Hospital. Section 8: Visiting Staff Membership on the Visiting Staff may be conferred on faculty visiting from other institutions to conduct medical education. Visiting Staff are not granted clinical privileges. They may neither vote nor hold office. They need not be credentialed pursuant to these bylaws, but may be credentialed as deemed appropriate by the relevant Department Chairman. Members of the Visiting Staff shall not be required to have a Harvard University Appointment. Section 9: House Staff, Clinical Fellows and Research Fellows (a) The House Staff shall consist of residents. Each member of the House Staff is considered to be in training and shall provide professional services only at the Hospital under the supervision of members of the Medical Staff or at other hospitals or locations under a resident training program which has been approved by the Hospital, unless otherwise authorized by the Chairman of the Department in which he or she serves. (b) Clinical Fellows are professionals in postdoctoral training who carry on study and research in clinical subjects and who have patient care responsibility. An appointment at Harvard University shall be required. A Clinical Fellow who occupies a training status shall provide professional services only at the Hospital under appropriate supervision or at other hospitals or locations under a training program approved by the Hospital, unless otherwise authorized by the Chairman of the Department in which he or she serves or under policies adopted by the Department of which he or she is appointed. (c) Research Fellows are professionals in postdoctoral training with primary activity in research. Clinical privileges may or may not be conferred depending upon the interest, education, and training of the applicant. Research Fellows who are not granted clinical privileges need not be licensed to practice in the Commonwealth of Massachusetts. An appointment at Harvard University shall be required. (d) House Staff, Clinical Fellows and Research Fellows shall be appointed to the Medical Staff pursuant to Article III, Section 6. However, Research Fellows who do not seek clinical privileges and who do not have or are not seeking licensure to practice medicine in the Commonwealth of Massachusetts need not be credentialed pursuant to these bylaws, but may be credentialed as deemed appropriate by the relevant Department Chairman. (e) The adverse action process in Article V shall not apply to House Staff, Clinical Fellows and Clinical and Research Fellows enrolled in any clinical or clinical and research training program sponsored by the Hospital (whether or not such a program is nationally accredited) except as specifically provided in these Bylaws. Adverse actions involving such individuals shall ordinarily be governed by the Partners Graduate Trainee Adverse Action Process. (f) House Staff, Clinical Fellows and Research Fellows may serve as members of various Medical Staff and Hospital committees. They may not vote nor hold office on the Medical Staff. (g) Any appointment to the Medical Staff as a member of the House Staff or as a Clinical or Research Fellow will terminate automatically at the end of the member’s residency program or fellowship, if the member’s two-year term of appointment has not expired prior to this date. Section 10: Allied Medical Staff Allied Medical Staff may include but are not limited to audiologists,
physicists, geneticists, engineers, and biochemists. (b) The provisions of Article III, Section 6 shall not apply to Allied Medical Staff. The procedure for their appointment and reappointment shall be established by the relevant Departments. (c) The provisions of Article V, Adverse Action, shall not apply to Allied Medical Staff. (d) Allied Medical Staff may serve as members of the various Medical Staff and Hospital committees as requested by the Hospital. (e) Allied Medical Staff may neither vote nor hold office on the Medical Staff. (f) No new or additional appointments shall be made to the Allied Medical Staff after December 10, 2001. Section 11: Courtesy Staff The Courtesy Staff shall consist of selected physicians, dentists
and podiatrists who have demonstrated a commitment to the goals and
purposes of the Hospital, but who at present have no active role in
patient care, teaching or research at the Hospital. Members of the Courtesy Staff: (a) Shall not be granted clinical or admitting privileges. (b) Shall not be required to have a Harvard University appointment. (c) Need not be credentialed pursuant to these bylaws, but may be credentialed as deemed appropriate by the relevant Department Chairman. (d) May attend various medical staff events and educational programs. (e) The provisions of Article V, Adverse Action, shall not apply to the Courtesy Staff.
An appointment to the Graduate Assistant Staff may be requested as a secondary appointment by members of the House Staff (PGY-3 and above), Clinical Fellows, and Research Fellows. Appointment to the Graduate Assistant Staff is temporary and limited by the Department Chairman according to the need of the Department and/or Hospital. Members of the Graduate Assistant Staff: (b) Shall not be granted admitting privileges. (c) May be granted clinical privileges to the extent specified in his/her delineation of privileges form or equivalent document(s). (d) Must comply with all applicable Department, Hospital and Partners policies including but not limited to the Partners Graduate Trainee Moonlighting Policy. The denial, restriction or termination of an appointment to the Graduate
Assistant Staff shall not be considered an “adverse action”
under these Bylaws and shall not entitle the individual concerned
to any of the procedural rights provided in Article V of these Bylaws,
including but not limited to those procedures with respect to preliminary
inquiry, hearings and appellate review. Section 13: Effective Date The Staff Categories described in Sections 1 through 12 above and the respective qualifications and requirements for each shall be applicable for initial appointments and reappointment which are to be considered by the Board of Trustees or committee thereof (or considered by the respective Department, if consideration by the Board of Trustees or committee thereof is not required by these Bylaws) on or after the effective date of these Bylaws. Section 14: Change in Staff Category Except as otherwise provided in these Bylaws, in the event that a Department Chairman concludes during the term of a Medical Staff member’s appointment that the Medical Staff member no longer satisfies the requirements for membership in the staff category to which she/he was appointed, and the Department Chairmen determines that the member satisfies the requirement for membership in another staff category, the Department Chairman may elect to change the Medical Staff member’s staff category to the appropriate one. Such a change in staff category shall not be considered an “adverse action” and shall not entitle the individual concerned to any of the procedural rights provided in Article V of these Bylaws, including but not limited to those procedures with respect to preliminary inquiry, hearing and appellate review. Section 15: Allied Health Practitioners Allied Health Practitioners (“Practitioners”), who shall
include licensed physician assistants and nurses practicing in an
expanded role, are not members of the Medical Staff. A Practitioner
may engage in direct clinical activities and be granted clinical and/or
admitting privileges only to the extent defined in written protocols
or guidelines that have been reviewed and approved by the appropriate
committees of the Medical Staff and Hospital and in accordance with
any applicable laws or regulations. The protocols or guidelines shall
specify the activities or situations requiring referral to or consultation
with a member of the Medical Staff and shall limit the Practitioner
to activities in which he or she has documented appropriate professional
education, training and experience, and current competence. Each Practitioner
must meet at a minimum all requirements for professional education,
clinical training and experience established by the appropriate state
board or agency. If there is no such board or agency, the minimum
professional requirements for the Practitioner shall be those approved
by the Medical Staff Executive Committee and the Care Improvement
Council. ARTICLE V: ADVERSE ACTION Section 1: Definitions (a) “Adverse action” includes any of the following actions by the Hospital: revocation of a right or privilege; suspension; censure; written reprimand; fine; required performance of public service; or a course of education, counseling or monitoring arising out of the filing of a complaint or a formal charge reflecting on professional competence. The following actions are also included, only if related to professional competence or to a complaint or allegation regarding any violation of law, regulation or bylaw: restriction, non-renewal or denial of a right of privilege; resignation; leave of absence; withdrawal of an application; or termination or non-renewal of a contract. Such adverse actions shall be taken in accordance with this Article V, except as otherwise provided in these Bylaws. However, “adverse action” shall not include the following actions, among others: (i) an action based upon failure to complete medical records or perform minor administrative functions in a timely fashion that does not relate to professional competence or to a complaint or allegation regarding any violation of law or regulation, and which the Hospital takes pursuant to a process independent of these Bylaws; (ii) denial of a Staff member’s request to change staff category or add new privileges; (iii) supervision and proctorship provided they are for evaluative purposes and for a limited period of time; and (iv) automatic termination of appointment to the Affiliate Staff upon the termination of the basis for the professional’s appointment with the Hospital. This list is not intended to be exhaustive. (b) “Adverse Action Process” is a medical peer review committee process intended to review, evaluate and determine certain recommended actions with respect to a Staff member’s privileges or appointment. Section 2: Grounds for Adverse Action Adverse action may be taken for due cause, including but not limited to any of the following reasons: (a) professional incompetence, or conduct that might be inconsistent with or harmful to good patient care or safety, lower than the standards of the Medical Staff, or disruptive to Hospital operations; (b) conduct that calls into question the Staff member’s integrity, ethics or judgement, or that could prove detrimental to the Hospital’s employees or operations; (c) violation of the bylaws or policies and procedures of the Medical Staff, the Hospital, Partners, or Harvard Medical School; (d) misconduct in science; (e) failure to perform duties. Section 3: Initiation of Adverse Action Process The process leading to potential adverse action may be initiated by the relevant Department Chairman, the Chief Medical Officer, the Medical Staff Executive Committee, or the Board of Trustees, upon any allegation of due cause for adverse action. The process shall be initiated by the prompt submission to the relevant Department Chairman of notice of the allegation, supported by reference to the specific activity or conduct that constitutes the grounds for the allegation. The Department Chairman shall apprise the Chief Medical Officer forthwith of such submission. Any allegation of misconduct in science by any member of the Medical Staff, including a member of the House Staff, a Clinical or Research Fellow, or an Allied Medical Staff member shall be addressed and resolved pursuant to the process initiated in accordance with Section 6. An allegation of non-compliance in human subjects research (which is not required to be referred to Harvard Medical School pursuant to Section 6) against any member of the Medical Staff, including a member of the House Staff, a Clinical Fellow or Research Fellow shall be addressed and resolved as described in Section 7. Section 4: Summary Action (a) The Chief Medical Officer or his designee may make an immediate summary suspension of any member of the Medical Staff, or take other summary adverse action, whenever such action is deemed necessary to maintain acceptable standards of care, safety, operation, integrity, or ethics at the Hospital. (b) The person effecting a summary suspension or other adverse action shall send forthwith a written report of such action and the reason(s) therefor to the Staff member involved, and to the Chief Medical Officer and the relevant Department Chairman. (c) The Committee on Medical Staff Conduct shall review the summary suspension or other adverse action. Within fourteen (14) days of the time the summary suspension or other adverse action was initiated, the Committee shall decide whether it appears substantiated by fact and reasonable and should be continued in force, or whether it should be lifted. The Committee shall send prompt written notice of the decision to the Staff member involved, the Chief Medical Officer, the relevant Department Chairman, and the Board of Trustees or duly appointed committee thereof. Section 5: Automatic Revocation, Restriction or Suspension (a) Lack of Minimum Malpractice Insurance Whenever it is discovered that a Staff member with clinical privileges does not carry the minimum malpractice insurance coverage required by Article III, Section 1, the Staff member shall be given immediate written notice thereof, and the Chief Medical Officer or his/her designee may impose summary action pursuant to Section 4. If the Staff member does not give the Hospital satisfactory proof he or she has obtained the requisite coverage within thirty (30) days of receipt of the notice, his or her Staff appointment shall be immediately and automatically revoked. (b) License Revocation, Non-Renewal, Restriction, or Suspension Whenever a Staff member’s license, certificate or other legal credential authorizing practice in the Commonwealth of Massachusetts is revoked or not renewed, his or her Staff appointment and privileges shall be immediately and automatically revoked. Whenever a Staff member’s license, certificate or other legal credential is suspended, his or her Staff appointment and privileges shall be immediately and automatically suspended. Whenever a Staff member’s license, certificate or other legal credential is limited or restricted by the applicable licensing or certifying authority, those privileges granted which have been so limited or restricted shall be immediately and automatically limited or restricted in the same manner. When a licensing or certifying authority ends a suspension, limitation
or restriction, or reinstates a license, certificate or other legal
credential, the individual may apply for Staff appointment, or appointment
without such limitation or restriction, and shall be evaluated as
an applicant for initial appointment. (c) Drug Enforcement Agency (“DEA”) Registration Revocation, Non-Renewal, Restriction or Suspension Whenever a Staff member’s DEA registration number is revoked or not renewed, he or she shall immediately and automatically be divested of his or her right to prescribe or dispense controlled substances authorized by the registration. Whenever a Staff member’s DEA registration is suspended, he or she shall be automatically divested of his or her right to prescribe or dispense controlled substances authorized by the registration effective upon and for at least the term of the suspension. Whenever a Staff member’s DEA registration is restricted, his or her right to prescribe or dispense controlled substances shall be immediately and automatically limited in accordance with the terms of the restriction. (d) Federal Excluded Provider Whenever a Staff member is (i) excluded, debarred or otherwise ineligible to participate in the Federal health care programs (including but not limited to Medicare, Medicaid, Champus or Veterans Administration) or in Federal procurement or non-procurement programs or (ii) has been convicted of a criminal offense related to the provision of health care items or services, but has not yet been excluded, debarred or otherwise declared ineligible, his or her Staff appointment and privileges shall be immediately and automatically revoked. When a Staff member’s exclusion, debarment or ineligibility to participate in Federal health care programs or in Federal procurement or non-procurement programs has ended, such Staff member may apply for appointment, and shall be evaluated as an applicant for initial appointment. (e) Duty to Notify The Staff member involved shall immediately notify the relevant Department Chairman, who will immediately notify the Chief Medical Officer: (i) Whenever the Staff member has knowledge that he or she is being
investigated by a licensing, certifying or regulatory authority for
possible revocation, non-renewal, restriction, suspension or probation
of his or her license to practice or DEA registration, or for any
other possible disciplinary or adverse action or as a result of a
complaint or an allegation regarding any violation of law, regulation
or bylaw; or (iii) whenever the Staff member has knowledge that another health care facility, employer or professional medical association has taken disciplinary or other adverse action against the Staff member or that proceedings for disciplinary or other adverse action have been initiated; or (iv) whenever the Staff member has knowledge that he or she is (a) excluded, debarred or otherwise ineligible to participate in Federal health care programs or in Federal procurement or non-procurement programs or that proceedings for such exclusion, debarment or ineligibility have been initiated or (b) has been convicted of a criminal offense related to the provision of health care services or items, but has not yet been excluded, debarred or otherwise declared ineligible. (f) Applicability to House Staff, Clinical and Research Fellows, and Allied Medical Staff This Section 5 shall apply to all members of the Medical Staff, including House Staff, Clinical Fellows, Research Fellows, and Allied Medical Staff. Section 6: Referral of Certain Matters to Harvard Medical School for Inquiry and Investigation The Chief Medical Officer shall immediately refer to Harvard Medical School for inquiry and if necessary, investigation, any allegation of misconduct in science funded through Harvard Medical School by any member of the Staff, including a member of the House Staff or a Clinical or Research Fellow, or any other allegation initiated pursuant to Section 3 which Harvard Medical School bears the primary responsibility for resolving. Any report and recommendation(s) of Harvard Medical School upon the
completion of its inquiry and investigation shall be referred to the
Committee on Medical Staff Conduct, for recommendation pursuant to
Section 11, of appropriate adverse action, if any, by the Hospital. Section 7: Referral of Certain Matters to Partners Institutional Review Boards and Human Research Affairs The Chief Medical Officer, after consultation with the Hospital’s Senior Vice President for Research, may refer any allegation described in Section 2, pertaining to non-compliance in human subjects research (which is not required to be referred to Harvard Medical School pursuant to Section 6) to the Partners Institutional Review Boards (IRBs) and/or Human Research Affairs (HRA) for review and appropriate action, if any. Alternatively, the Chief Medical Officer, after consultation with the Hospital’s Senior Vice President for Research, may elect for the Hospital to jointly review the alleged non-compliance in human subjects research with the Partners IRB and/or HRA in accordance with policies and procedures duly adopted by the Hospital and its IRBs. The Chief Medical Officer shall refer any report and recommendation from the referral or joint review which may result in adverse action by the Hospital to the Medical Staff Conduct Committee pursuant to Section 12 for recommendation of appropriate adverse action, if any, by the Hospital. Section 8: Hospital Acceptance of
Fact Findings The inquiry shall include consultation with the Staff member involved.
Failure of the Staff member to cooperate with such inquiry or with
any other inquiry or investigation described in these Bylaws shall
be grounds for adverse action. Section 10: Recommendation Concerning Appropriate Adverse Action, if Any At the conclusion of the preliminary inquiry, the relevant Department Chairman or Chief Medical Officer shall issue or cause to be issued a written report of findings of fact and recommendation(s). Copies shall be sent to the affected Staff member and the Chief Medical Officer or Department Chairman, as appropriate. (a) If the Department Chairman or Chief Medical Officer determines there was no reasonable basis for any allegation referred to him/her, or that no adverse action by the Hospital is warranted, no further action under these bylaws shall be taken, but the Department Chairman or Chief Medical Officer may take other remedial or corrective action as he/she deems appropriate. (b) If the Department Chairman or Chief Medical Officer determines that adverse action other than one referred to in Section 10 (c) is warranted, the Board of Trustees shall review this determination. The Board may provide for such review by a committee of the Board especially appointed for the purpose. The review of the Board of Trustees or committee thereof shall be based on the report and recommendations of the relevant Department Chairman or Chief Medical Officer and any written response which the affected Staff member and the initiator of the adverse action process wish to make. They shall be apprised of their right to make such a response. At the sole discretion of the Board of Trustees or committee thereof, it may also consider new or additional information. If it does so, it shall share this information with the affected Staff member, the initiator of the adverse action process, and the relevant Department Chairman or Chief Medical Officer and give them the opportunity to respond. If the Board of Trustees of the Board review committee recommends an adverse action referred to in Section 10(c), the Staff member shall be given an opportunity to a hearing under Section 11. Prompt written notice of the decision of the Board of Trustees or the Board review committee shall be sent to the affected Staff member, the Chief Medical Officer and the relevant Department Chairman. (c) If, at the conclusion of the preliminary inquiry, the relevant Department Chairman or Chief Medical Officer recommends one or more of the following adverse actions, the Staff member involved shall be given an opportunity to a hearing under Section 11:
(d) Notwithstanding any provision in these Bylaws to the contrary, the following actions or recommendations shall not constitute an adverse action under these Bylaws, and do not entitle Staff members to any of the procedural rights provided in this Article V, including but not limited to those procedures with respect to preliminary inquiry, hearing and appellate review: (i) the issuance of a verbal warning; (ii) a written reprimand or admonition; (iii) the imposition of a probationary period involving review of cases but with no requirement either for direct, concurrent supervision or for mandatory consultation; (iv) censure, fine or required performance of public service; (v) any adverse action or recommendation which is taken with respect to temporary privileges, or which is automatic pursuant to Article V, Section 5 of these Bylaws; (vi) termination from a medical administrative position; (vii) the non-renewal of a provisional appointment; or (viii) any other action except those specified in Section 10 (c). Section 11: Right to Hearing (a) In any case where an adverse action referred to in Section 10 (c) is recommended, or where an application for appointment or reappointment is denied or withdrawn in the course of the credentialing process (other than the non-renewal of a provisional appointment) for any reason related to professional competence or to a complaint or an allegation regarding any violation of law, regulation or bylaw, the applicant or member shall be entitled to a hearing as described below. The Chief Medical Officer shall give notice of the adverse recommendation or action to the applicant or member. This shall include a statement of the reason(s) for the recommendation or action, and a statement of the applicant or member’s right to a hearing. The Chief Medical Officer shall also advise the applicant or member of his or her right to appear with legal counsel and right to introduce witnesses or evidence, subject to the limitations imposed pursuant to Section 8. The applicant or member shall have thirty (30) days to request a hearing in writing. (b) If the applicant or member does not so request a hearing, the Board of Trustees shall review the adverse recommendation or action in accordance with the procedure set forth in Section 10 (b). The Board may provide for such review by a committee of the Board especially appointed for the purpose. If the Board of Trustees or the Board review committee wishes to propose a stricter adverse action, the applicant or member shall be given another opportunity to request a hearing pursuant to paragraph (a). If no such stricter adverse action is proposed, the decision of the Board of Trustees or the Board review committee shall be final decision of the Hospital in the matter. Within seven (7) days after the conclusion of the Board of Trustees or the Board review committee, it shall issue its decision in writing. A copy shall be sent to the affected applicant or member, the Chief Medical Officer, and the relevant Department Chairman. (c) If the applicant or member requests a hearing pursuant to paragraph (a), the committee before which the hearing shall be held shall consist of not fewer than three (3) persons appointed by the Chief Medical Officer, one of whom shall be the chair of the credentialing committee or his/her designee. One of the hearing committee members shall be designated Chairman. No person who has actively participated in the initiation of the adverse recommendation or action shall be appointed to the hearing committee. (d) The hearing need not be conducted strictly according to rules of law relating to the examination of witnesses or presentation of evidence. The hearing committee shall consider such evidence as reasonable persons are accustomed to rely on in the conduct of serious affairs. The hearing committee may take notice of any general, technical, or scientific fact within the specialized knowledge of the committee, and shall decide all other procedural matters not specified herein. (e) The relevant Department Chairman, committee or person whose adverse recommendation or action occasioned the hearing, or their designee, shall have the initial obligation to present evidence in support of the findings of fact in the preliminary inquiry. Thereafter, the applicant or member requesting the hearing shall have the burden of proving that these findings of fact are unsupported by substantial evidence. (f) Within thirty (30) days after adjournment of the hearing, the hearing committee shall issue a written report of its findings of fact. A copy shall be sent to the affected applicant or member, the Medical Staff Conduct Committee, the Chief Medical Officer, the relevant Department Chairman, and any other committee or person whose adverse recommendation or action occasioned the hearing. Section 12: Recommendation Concerning Adverse Action By Medical Staff Conduct Committee The Medical Staff Conduct Committee shall make the final recommendations to the Board of Trustees concerning what adverse action(s), if any, should be taken by the Hospital. The Medical Staff Conduct Committee shall have available for its consideration the initial allegation of due cause for adverse action, the Departmental report at the conclusion of the preliminary inquiry, the record of the hearing, and the report of the hearing committee. The affected applicant or member, the initiator of the adverse action process, and the relevant Department Chairman or designee may also present a written or oral statement. These persons shall be notified of their right to make such a statement. At the sole discretion of the Medical Staff Conduct Committee, it may also consider new or additional information. If it does so, it shall share this information with the affected applicant or member, the initiator of the adverse action process, and the relevant Department Chairman or designee, and give them the opportunity to respond. The recommendations of the Medical Staff Conduct Committee to the Board of Trustees shall be in writing and a copy shall be sent to the affected applicant or member, the Chief Medical Officer, the relevant Department Chairman, and any other committee or person whose adverse recommendation or action initiated the disciplinary process. Section 13: Board of Trustees Review The Board of Trustees shall review the matter. It may provide for such review by a committee of the Board especially appointed for the purpose. The Board of Trustees or Board review committee shall have available for its review the materials referred to in Section 12, as well as any written response which the affected applicant or member, the initiator of the adverse action process, and the relevant Department Chairman or designee wish to make. These persons shall be notified of their right to make such a response. At the sole discretion of the Board of Trustees or Board review committee, it may also consider new or additional information. If it does so, if shall share this information with the affected applicant or member, the initiator of the adverse action process, the relevant Department Chairman or designee and the Committee on Medical Staff Conduct, and give them the opportunity to respond. The Board of Trustees or Board review committee shall issue its decision in writing. A copy shall be sent to the affected applicant or member, the Chief Medical Officer, the relevant Department Chairman, the Medical Staff Conduct Committee and any other committee or person whose adverse recommendation or action initiated the disciplinary process. It shall be the final decision of the Hospital in the matter. Section 14: Reporting of Adverse Actions The Hospital will comply with all statutory and regulatory requirements
with respect to the reporting of adverse actions. Section 1: Objectives The objectives of the Medical Staff Health Program (“Program”) are to (a) safeguard patients (b) to assist Staff members in recovering from illness with the least interference with their ability to practice their profession consistent with patient safety; and (c) to satisfy the requirements of federal and state law. Section 2: Definition of “Affected Medical Staff Member” “Affected Medical Staff Member” is a Staff member who has been deemed by a duly convened Health Status Committee on the basis of credible information or an admission, to be affected by a physical, mental or emotional illness, condition or disability and/or by drugs and/or alcohol which has or may potentially impair his or her ability to practice medicine, dentistry, chiropractry, psychology or podiatry as applicable, or to otherwise exercise his or her privileges or Medical Staff membership. Section 3: The Program Credible evidence or admission that a Staff member is an Affected
Medical (b) Health Status Committee (“HSC”). The HSC is a medical peer review committee and shall be composed
of the (c) The HSC will meet promptly to review the evidence and interview the Staff member in question to determine whether evidence supports the conclusion that the practitioner is an Affected Medical Staff Member. The HSC shall have the authority to require an independent physical and/or psychiatric evaluation by an evaluator acceptable to both parties. Failure of the Staff member to cooperate with the evaluation process shall be grounds for adverse action pursuant to Article V of these Bylaws. The evaluator’s findings shall be reported to the HSC. (d) If the HSC finds no reasonable basis to conclude that the Staff member is “affected”, the HSC shall report such findings to the Chief Medical Officer who shall have the option of initiating the Adverse Action process pursuant to Article V, if appropriate. No further action or reporting will be undertaken by the HSC. (e) If the HSC finds a reasonable basis to conclude that the Staff member is “affected”, the HSC shall recommend that the Staff member participate in the Program, and may recommend that the Staff member take a leave of absence for the purpose of evaluation, treatment and counseling. (f) Participation Recommendation Accepted. If the Staff member agrees to participate in the Program, the HSC will develop and recommend a remedial plan in consultation with the Staff member as provided below. The findings, recommendations and actions of the HSC will not be used in an Adverse Action Process under Article V, so long as the Staff member remains compliant with his or her remedial plan. Provided, however, the Hospital may be required to report certain aspects of the remedial plan to regulatory agencies and/or other entities. The Staff member shall be apprised of any potential reporting obligations prior to making a decision as to whether to participate in the Program. (g) Participation Recommendation Rejected. If the staff member refuses to participate in the Program, the HSC shall so notify the Chief Medical Officer, who, if appropriate, shall initiate the Adverse Action Process pursuant to Article V of these Bylaws. Failure of the Staff member to respond within a reasonable time to a recommendation by the HSC for participation in the Program shall be construed as refusal to participate in the Program. (h) Upon acceptance of the recommendation by the Staff member to participate in the Program, the HSC shall develop a remedial plan in consultation with the Staff member, and may revise the plan from time to time after consultation with the Staff member. A remedial plan and any modifications to a remedial plan must be approved by the Chief Medical Officer. (i) In addition to a leave of absence, a remedial plan may include, but is not limited to, counseling and treatment, urine screening or other surveillance for drug or alcohol use, voluntary curtailment or other change in clinical privileges, and the use of monitors, proctors, chaperones, or supervised practice. (j) The HSC shall monitor the compliance of a Staff member with the terms of the Staff member’s remedial plan. The HSC may require, as part of its monitoring, that the Staff member agree to communication between the HSC and the Staff member’s physician, therapist, or others as determined by the HSC. The HSC may condition the Staff member’s return from a leave of absence or other changes or modifications in the remedial plan upon an independent physical and/or psychiatric evaluation by an evaluator acceptable to both parties. (k) The HSC may initiate a request for Adverse Action under Article V when a Staff member fails or refuses to comply with the recommendation of leave or any provision of a remedial plan adopted by the HSC. (l) The HSC will approve the termination of the Staff member’s participation in the Program once the Staff member has demonstrated successful completion of the terms and conditions of his or her remedial plan and current capacity to meet the qualifications, standards and requirements established in these Bylaws. ARTICLE VII: OFFICERS OF THE MEDICAL STAFF Section 1: Officers The Officers of the Medical Staff shall be the Chair, Chair-elect, Vice Chair, Secretary, and Private Staff Representative. Section 2: Eligibility for Office Members of the Active and Affiliate Staffs, other than Department Chairmen, shall be eligible to hold office. Section 3: Subdivisions for Election of Officers The following subdivisions for election of Officers shall be recognized, solely for the purpose of an equitable distribution of the respective offices of the Medical Staff. Group 1 Group 2 Group 3 Group 4 Section 4: Election and Term of Office (a) Initially under these Bylaws beginning in 1987, the Chair of the Medical Staff was elected from Group 1, the Chair-elect from Group 2, the Vice Chair from Group 3, and the Secretary from Group 4. (b) Each subsequent year, the Chair-elect shall become the Chair, the Vice Chair shall become the Chair-elect and the Secretary shall become Vice Chair. The group represented by the outgoing Chair shall elect the Secretary. The outgoing Chair may not be elected Secretary. (c) At least thirty (30) days prior to each Annual Meeting of the Medical Staff, the Chair of the Medical Staff shall appoint a Nominating Committee composed of him or herself and no fewer than three members of the Active Staff of the group described in Section 3 above then responsible for the election of a Secretary. This Nominating Committee shall present a nominee or nominees for Secretary to that group. (d) Election shall thereupon take place by mail ballot by members of the Active and Affiliate Staff of those Departments, and shall be decided by a plurality of the votes cast. The election shall be announced at the next Annual Meeting of the Medical Staff. (e) Vacancies in the offices of the Chair, the Chair-elect, the Vice Chair and the Secretary shall be filled by election by the Chairmen of the Departments in the appropriate group eligible to vote. The newly elected incumbent shall serve only for the unexpired term which he or she is elected to fill. (f) The Private Staff Representative shall be a member of the Private Staff Association and shall be nominated by a Nominating Committee of at least three members of the Private Staff Association and chaired by the outgoing representative. This representative shall be elected by a majority vote of the Private Staff Association through the use of mail ballot at the time of the Annual Meeting of the Medical Staff. Section 5: Duties of Officers (a) The Chair of the Medical Staff shall call and preside at all meetings of the entire Staff. The Chair shall serve on the Medical Staff Executive Committee. (b) The Chair-elect of the Medical Staff, in the absence of the Chair of the Medical Staff, shall assume all of the duties of the Chair and have all of the Chair’s authority. The Chair-elect shall also be expected to perform such duties as may be assigned by the Chair of the Medical Staff. The Chair-elect shall serve on the Medical Staff Executive Committee. (c) The Vice Chair, in the absence of both the Chair and the Chair-elect, shall assume all of the duties of the Chair and have all of the Chair’s authority. The Vice Chair shall also be expected to perform such duties as may be assigned by the Chair of the Medical Staff. The Vice Chair shall serve on the Medical Staff Executive Committee. (d) The Secretary, in the absence of any other Officers, shall assume all of the Chair’s authority. The Secretary shall also be expected to perform such duties as may be assigned by the Chair of the Medical Staff. The Secretary shall serve on the Medical Staff Executive Committee. (e) The Private Staff Representative shall serve on the Medical Staff Executive Committee. Section 6: Removal of an Officer Officers of the Medical Staff shall serve without regard to the
group from which they are elected and shall perform the duties of
their respective offices as provided in these Bylaws. Any officer
who neglects the exercise of his/her duties may be removed by a majority
vote of the Medical Staff Executive Committee.
Section 1: General Meeting of the Medical Staff (a) There shall be at least one general meeting of the Medical Staff each year, which shall be the Annual Meeting of the Medical Staff. It shall generally be in the fall. The Chair of the Medical Staff shall preside. (b) Staff members shall be notified of the time, place, and agenda at least three (3) weeks in advance. (c) Accurate and complete minutes including attendance of members shall be kept. Copies of minutes shall be filed with the Chair. Section 2: Quorum and Voting Attendance of ten (10) percent of the Active and Affiliate Staff in person or by proxy at any General or Special Meeting of the Medical Staff shall constitute a quorum. If there is a quorum, action may be taken by a majority of the Active and Affiliate Staff present in person or by proxy. Section 3: Special Meetings (a) Special Meetings of the Medical Staff may be called at any time by the Chairman of the Medical Staff at the request of the Board of Trustees, the Medical Staff Executive Committee, or any twenty-five (25) members of the Medical Staff. At any Special Meeting no business shall be transacted except the agenda items slated in the notice calling the meeting. (b) Written notice and agenda of such Special Meetings shall be given to all members of the Staff at least ten (10) days prior to the date set for the meeting. (c) Accurate and complete minutes including attendance of members shall be kept. Copies of minutes shall be filed with the Chair. ARTICLE IX: COMMITTEES Section 1: Committees of the Medical Staff 1.1 Standing Committees The Standing Committees of the Medical Staff include but are not limited to the following: Executive 1.2 Other Committees The Medical Staff Executive Committee following consultation with the Chief Medical Officer may establish such other committees of the Medical Staff as it deems appropriate. 1.3 General Provisions Regarding Medical Staff Committees Except as otherwise provided in these Bylaws, the following provisions shall apply to all Medical Staff Committees: (a) The Chairman of each Department is generally expected to designate a Departmental representative for each committee. Other members of the Committee shall be appointed by the Chief Medical Officer. The majority of each Medical Staff Committee shall be composed of Members of the Medical Staff. (b) Except as otherwise provided in these Bylaws, a majority of members of any committee shall constitute a quorum thereof and if a quorum is present, a majority of the committee members eligible to vote and voting may take any action on its behalf. (c) References in this section to “members,” as to any committee having non-voting members, shall refer only to voting members. 1.4 Medical Staff Executive Committee (a) The Medical Staff Executive Committee shall consist of the Chief Medical Officer, the President or designee, a senior member of each Department enumerated in Article II, Section 1 who has been designated by the Department Chairman, the elected Staff Officers, the Clinical Vice Presidents, the Vice President for Patient Care Services and two members of the Affiliate Staff, who shall be appointed by the Chief Medical Officer to a three-year term. (b) The Chief Medical Officer shall appoint a physician from the Active Staff to preside at meetings for a two year term and he/she shall become a voting member of the Committee. The chair of the Medical Staff shall serve as Vice Chair of the Committee. (c) The Medical Staff Executive Committee shall meet monthly or as required. Minutes of all meetings shall be kept. (d) The Medical Staff Executive Committee shall act for the Staff in all professional matters pertaining to the Hospital, as further specified in the policies and procedures of the medical staff. The Medical Staff Executive Committee shall be responsible for medical staff quality assurance and shall receive and implement recommendations from the Care Improvement Council (the Patient Care Assessment Committee). (e) The Medical Staff Executive Committee shall participate in the credentialing procedures for new appointments and reappointments as provided in these Bylaws. The Medical Staff Executive Committee may vote to designate one or more of its members to act on its behalf with respect to credentialing matters in accordance with the provisions of Article III of these Bylaws. (f) Any member of the Medical Staff may, upon request, attend a meeting of the Medical Staff Executive Committee for the purpose of discussing any matter germane to the Hospital, or the Medical Staff Executive Committee may require the presence of a member if the agenda includes a topic in his or her area of concern. 1.5 Medical Staff Conduct Committee The Committee on Medical Staff Conduct shall consist of at least three of the Chairmen of Departments enumerated in or created pursuant to Article II, Section 1 who shall be appointed by the Chief Medical Officer from time to time. No Department Chairman shall participate in the deliberations of the Committee concerning any matter for which he or she initiated the Adverse Action Process pursuant to Article V, Section 3. The Chief Medical Officer (or his or her designee) may also serve on the Committee, as he/she so chooses. 1.6 Medical Staff Credentialing Committee The Medical Staff Credentialing Committee shall consist of at least one representative from each of the Departments appointed by the Chairman of each Department and a non-voting representative from Administration. This Committee shall serve as the Hospital-wide Credentialing Committee, and shall review applications for appointments and requests for reappointments, as provided in these Bylaws. 1.7 Cancer Committee (a) The Cancer Committee shall consist of representatives from Surgery, Medical Oncology, Radiology, Pathology, Nursing, Care Coordination, Quality Improvement and the Cancer Registry, and may include representatives from other Departments as appropriate. (b) The Cancer Committee shall meet quarterly or as needed. Minutes of all meetings shall be kept. (c) The Cancer Committee shall develop and evaluate annual goals
and objectives for the clinical educational and programmatic activities
related to cancer; promote a coordinated, multidisciplinary approach
to patient management; ensure educational and consultative cancer
conferences covering all major sites and related issues; ensure an
active, supportive care system is in place for patients, families
and staff; perform quality improvement studies with focus on quality,
access to care and outcomes; promote clinical research; oversee the
Cancer Registry; conduct quality review of annual Cancer Registry
data; encourage data usage and regular reporting; and report of its
activities. 1.8 Quality Assurance/Risk Management Committee Section 2: Department Committees The Departments may appoint such Committees as they deem appropriate in their respective organization plans. ARTICLE X: PATIENT CARE ASSESSMENT Section 1: Patient Care Assessment Program The programs, policies and procedures existing throughout the Hospital which are designed to foster optimal patient care shall be known collectively as the Patient Care Assessment Program. Section 2: Care Improvement Council The Care Improvement Council, a medical peer review committee established at the governing board level, is a joint committee of the Board of Trustees and the Medical Staff. It shall also be known as the Hospital’s Patient Care Assessment Committee, and shall carry out the functions required of such a committee by the regulations of the Board of Registration in Medicine. It is responsible for the Patient Care Assessment Program. It shall include at least one trustee. It shall also consist of members of the Medical Staff, and administrators, including a high level nursing administrator, who are essential to the quality of patient care. In addition to the functions otherwise specified in these Bylaws, the Care Improvement Council or others acting on its behalf shall establish the elements of the Patient Care Assessment Program. Section 3: Patient Care Assessment Coordinator The Care Improvement Council shall also serve as the Patient Care
Assessment Coordinator, as defined in the regulations of the Board
of Registration in Medicine. Section 4: Patient Care Assessment Plan There shall be a written Patient Care Assessment Plan, approved by the Board of Trustees and filed with the Board of Registration in Medicine, which describes the policies and procedures constituting the Patient Care Assessment Program. Section 5: Medical Peer Review Committee (a) The “medical peer review committees” of the Hospital include the Care Improvement Council (the Patient Care Assessment Committee), and all other committees, agents of such committees or individuals charged under these Bylaws, policies and procedures or the Patient Care Assessment Plan with any responsibility for (1) the evaluation or improvement of the quality of health care rendered by providers, (2) the determination whether health care services were performed in compliance with applicable standards of care, (3) the determination whether the cost of health care services rendered was considered reasonable by the providers of health services in the area, (4) the determination whether the actions of a provider call into question his or her fitness to provide health care services, or (5) the evaluation and assistance of providers impaired or allegedly impaired by reason of alcohol, drugs, physical disability, mental instability or otherwise. Without limiting the foregoing, the peer review activities conducted by the Department Chairmen or their designees, shall be considered the activities of a medical peer review committee. All committees, agents and individuals designated as medical peer review committees hereunder shall be deemed to be “professional review bodies” as that term is defined in the Health Care Quality Improvement Act. (b) The proceedings, reports, records, findings, recommendations,
evaluations, opinions, deliberations or other actions by a medical
peer review committee in its discharge of the medical peer review
functions set forth in subsection (a) above, and the identity of and
information provided to such peer review committee by witnesses or
any other individuals, shall be treated as confidential to the extent
permitted by law and public regulations. This confidentiality shall
not prevent or be waived by the transmission of necessary information
to the Board of Trustees (or committees thereof) or to other committees
or individuals within the Hospital to enable them to fulfill their
responsibilities under the Patient Care Assessment Program or otherwise.
Nor shall this confidentiality prevent or be waived by the transmission
of information required by law or regulation, including responses
to requests from other health care providers for information relevant
to their credentialing activities. Section 6: Procedure for Investigation and Resolution of Reports Concerning Health Care Providers (a) Reports made to the Hospital from whatever source, other than those pursuant to Article V, Section 3 or parallel disciplinary rules for other providers, concerning the conduct of any health care provider (“provider”) at the Hospital, including all members of the medical staff, medical students, and all other licensed health care providers, that allege incompetence in the provider’s specialty or conduct which might be inconsistent with or harmful to good patient care and safety, shall be brought to the attention of the Care Improvement Council, the Quality Assurance/Risk Management Committee, any other medical peer review committee, the respective Department Chairman or the Director of Patient Relations. (b) All reports, records, findings, recommendations, evaluations, or opinions received by any of the above committees or individuals pursuant to this Section shall be accorded the confidentiality provided by the Bylaws of the Medical Staff and the laws and regulations of Massachusetts for the records of a “medical peer review committee”. (c) Reports concerning providers who are not members of the Medical Staff Reports concerning providers who are not members of the Medical Staff shall be investigated and resolved in accordance with the procedures described in the Patient Care Assessment Plan. (d) Reports concerning members of the Medical Staff except in the case of reports which are determined by the Director of Patient Relations to lack sufficient basis to warrant further investigation, the Director of Patient Relations shall promptly forward all written requests concerning any member of the Medical Staff to the Chairman of the provider’s Department for inquiry, investigation if necessary, and resolution. The Director of Patient Relations shall be advised of the resolution of the matter. ARTICLE XI: POLICIES AND PROCEDURES The Medical Staff Executive Committee shall adopt such Policies and
Procedures as may be necessary or desirable for the proper conduct
of the work of the Medical Staff and are not inconsistent with the
Charter and Bylaws of the Hospital and the Bylaws of the Medical Staff. ARTICLE XII: AMENDMENTS (a) Amendments to these Bylaws shall become effective when approved by the Board of Trustees or committee thereof after adoption by the Medical Staff, at a Meeting of the Medical Staff. Adoption of amendments shall require a majority vote of Staff members present in person or by proxy and eligible to vote at a duly called Medical Staff meeting, such meeting to be called no sooner than twenty-one (21) days following the date when notice of the proposed amendment(s) to the Bylaws was issued. Neither the Board of Trustees nor the Medical Staff may amend these Bylaws unilaterally. (b) These Bylaws shall be reviewed at least once every five (5) years by the Chief Medical Officer, the Medical Staff Executive Committee, and a Hospital attorney, who, after such review, shall propose amendments to the Bylaws as are appropriate.
Section 1: Severability
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