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| BYLAWS OF THE PROFESSIONAL STAFF OF
TABLE OF CONTENTS
ARTICLE I NAME AND PURPOSE .................................1
ARTICLE II MEMBERSHIP Section 2.01 - General; Malpractice Insurance...............1 Section 2.02 - Basic Qualifications for Membership..........2 Section 2.02.1 - Clinical Staff................2 Section 2.02.2 - Non-Clinical Staff............2 Section 2.03 - Categories of Clinical and Non-Clinical Professional Staff..........................................3 Section 2.03.1 - Active Staff..................3 Section 2.03.2 - Senior Staff..................4 Section 2.03.3 - Honorary Staff................4 Section 2.03.4 - Affiliate Staff...............4 Section 2.03.5 - Clinical Associate Staff......5 Section 2.03.6 - Clinical Assistant Staff......5 Section 2.03.7 - Consultant Staff..............6 Section 2.03.8 - Graduate Assistant Staff......6 Section 2.03.9 - Courtesy Staff................6 Section 2.03.10 - Resident Staff...............7 Section 2.03.11 - Fellow Staff.................7 Section 2.03.12 - Students.....................7 Section 2.04 - Allied Health Practitioner......8 ARTICLE III APPOINTMENT AND REAPPOINTMENT PROCEDURES Section 3.01 - General Procedure............................8 Section 3.02 - Initial Appointment Process..................8 Section 3.02.1 - Application Form...........................8 Section 3.02.2 - Procedure for Processing Applications (Credentials Review)........................................9
Section 3.03.1 - Application Form..........................10 Section 3.03.2 - Procedure for Processing Application................................................10 Section 3.04 - Terms of Appointment........................10 Section 3.05 - Leave of Absence; Medical Leave of Absence; Medical or Psychiatric Examination.........................11
Section 3.07 - Modification of Membership Status or Privileges.................................................11
ARTICLE IV DELINEATION OF PRIVILEGES Section 4.01 - Delineation of Privileges in General........12 Section 4.02 - Special Conditions for Podiatric Staff Privileges...........................................12 Section 4.03 - Special Conditions for Psychologist Staff Privileges...........................................12 Section 4.04 - Temporary Privileges........................12 Section 4.05 - Emergency...................................12
ARTICLE V CORRECTIVE ACTION; FAIR HEARING AND APPELLATE REVIEW Section 5.01 - Corrective Action; (General)................13 Section 5.02 - Corrective Action for Residents and Fellows................................................13 Section 5.03 - Reporting Conduct of Health Care Providers..13 Section 5.04 - Summary Suspension or Termination...........14 Section 5.05 - Preliminary Inquiry by Chief of Service or Department......................................14 Section 5.06 - Termination of Appointment or Denial of Reappointment; Reduction in Rank; Termination of Privileges..............................................15 Section 5.07 - Automatic Suspension and Duty to Notify.....16 Section 5.08 - Fair Hearing and Appellate Review...........17 Section 5.08.1 - Adverse Action............................17 Section 5.08.2 - Fair Hearing and Appellate Review Process.............................................17
ARTICLE VI ADMINISTRATIVE STRUCTURE AND ORGANIZATION Section 6.01 - Organization of Services, Departments and Centers...............................................19 Section 6.01.1 - Services.................................19 Section 6.01.2 - Departments..............................19 Section 6.01.3 - Centers..................................19 Section 6.02 - Chiefs of Service and Department...........20 Section 6.02.1 - Responsibilities.........................20 Section 6.02.2 - Appointment Process......................20 Section 6.03 - Titles.....................................21 Section 6.03.1 - Clinical Medical Staff...................21 Section 6.03.2 - Clinical Adjunct Staff...................22 Section 6.03.3 - Non-Clinical Staff.......................22 Section 6.04 - President..................................23 Section 6.05 - Committees.................................23 Section 6.05.1 - General Executive Committee..............23 Section 6.05.2 - Patient Care Assessment Committee ................................................25 Section 6.05.3 - Service Quality Assessment Committees ...............................................25 Section 6.05.4 - Medical Peer Review Committees................................................26 Section 6.06 - Massachusetts General Physicians Organization, Inc ........................................27
ARTICLE VII MEETINGS Section 7.01 - Meetings of Services.......................27
ARTICLE VIII AMENDMENTS................................27
OF THE GENERAL HOSPITAL
ARTICLE I - NAME AND PURPOSE 1.01 The name of this organization shall be "The Professional Staff of the General Hospital" ("Staff" and "Hospital", respectively), and its purpose shall be to: a. Provide care and treatment for all patients admitted to or treated in any unit of the Hospital; b. Provide medical education and education in related health sciences; c. Conduct research and contribute to the development of medical knowledge and other health sciences; and d. Carry on such other activities as may from time to time serve the welfare of patients of the Hospital and enhance its good name. 1.02 These Bylaws shall be interpreted in a manner which is consistent with Bylaws of The General Hospital Corporation (the "Hospital Bylaws"), as amended from time to time. In the event of a conflict, the Hospital Bylaws shall prevail. ARTICLE II - MEMBERSHIP 2.01 General; Malpractice Insurance Membership on the Staff is a privilege extended by written appointment by the Hospital's Board of Trustees ("Trustees") only to those professionals who continuously meet the qualifications, standards and requirements set forth in these Bylaws. No person is automatically entitled to Membership on the Staff merely because he or she is licensed to practice in this or any other state, is a member of a particular professional organization, is certified by a particular clinical board, or has privileges at another hospital, or by the fact of any previous appointment to the Staff. Each appointment to the Staff shall be made in accordance with these Bylaws and shall confer on the appointee only such privileges as have been granted in his or her written appointment by the Trustees or by virtue of his or her Staff category under these Bylaws. In discharging the duties and exercising the privileges of his or her appointment, each Staff Member shall be subject to these Bylaws and to all applicable rules and regulations and policies of the Hospital and shall be responsible to his or her Chief of Service or Department, the Hospital's President, and the Trustees. As a condition of appointment, each Member of the Staff who holds clinical privileges shall have malpractice insurance coverage for his or her activities at the Hospital in an amount acceptable to the Hospital.
2.02 Basic Qualifications for Membership The Professional Staff shall include the Clinical Staff and Non-Clinical Staff. The basic qualifications for membership in each shall be as follows: 2.02.1 Clinical Staff The Clinical Staff shall include the Medical Staff and the Adjunct Staff. a. Medical Staff Physicians and dentists who are currently licensed to practice in the Commonwealth of Massachusetts and whose documented professional education, training, experience, current competence, health status, ability to work with others, and professional ethics are adequate to ensure their ability to provide the optimal achievable care for patients of the Hospital shall be eligible for membership on the Medical Staff. By the terms of his or her written appointment form each Member of the Medical Staff shall be placed in one of the following categories: Active Staff, Senior Staff, Honorary Staff, Affiliate Staff, Clinical Associate Staff, Clinical Assistant Staff, Consultant Staff, Graduate Assistant Staff, Courtesy Staff, Resident Staff, or Fellow Staff. b. Adjunct Staff Podiatrists and psychologists who are currently licensed to practice in the Commonwealth of Massachusetts (except that pre-doctoral or post-doctoral psychology interns need not be licensed in order to be appointed to the Clinical Fellow Staff) and whose documented professional education, training and experience, current competence, health status, ability to work with others, and professional ethics are adequate to ensure their ability to provide the optimal achievable care for patients of the Hospital shall be eligible for membership on the Adjunct Staff. By the terms of his or her written appointment form, each Member of the Adjunct Staff shall be placed in one of the following categories: Active Staff, Senior Staff, Honorary Staff, Affiliate Staff, Clinical Associate Staff, Clinical Assistant Staff, Consultant Staff, Graduate Assistant Staff, Resident Staff, or Fellow Staff. 2.02.2 Non-Clinical Staff Professionals whose total activities are limited to research or other endeavors not directly related to patient care, and whose documented professional education, training, experience, current competence, health status, ability to work with others, professional ethics, and licensure or certification are adequate to ensure the highest quality performance of their activities shall be eligible for membership on the Non-Clinical Staff. By the terms of his or her written appointment form each Member of the Non-Clinical Staff shall be placed in one of the following categories: Active Staff, Senior Staff, Honorary Staff, Affiliate Staff, Consultant Staff, or Fellow Staff.
2.03 Categories of Clinical and Non-Clinical Professional Staff The Professional Staff shall consist of the following categories: Active Staff Senior Staff Honorary Staff Affiliate Staff Clinical Associate Staff Clinical Assistant Staff Consultant Staff Graduate Assistant Staff Courtesy Staff Resident Staff Fellow Staff Each Member of the Clinical Staff shall have duties and privileges as described in this section or elsewhere in these Bylaws, as described in his or her written appointment form, and as set forth in applicable policies and procedures of the Hospital and/or the Service or Department in which the Staff Member has an appointment(s). 2.03.1 Active Staff The Active Staff shall consist of Staff Members who contribute substantially to Hospital activities, regularly admit patients or are actively involved in the clinical care of patients at the Hospital or in research or other non-clinical activities conducted by the Hospital, and are actively involved in the teaching responsibilities of the Hospital. Members of the Active Staff: 1. Shall have privileges to admit and care for patients to the extent specified in their written appointment forms. 2. Shall be eligible, to the extent otherwise qualified, to serve as Chief of Service or Department, or chief or head of any unit, clinic or subdivision within any Service or Department of the Hospital. 3. Shall be eligible to serve on any Standing Committee or other committee of the Professional Staff, to chair any such committee, and to vote on matters that come before a committee of which he or she is a member. 4. Shall be expected to serve on committees if so appointed.
2.03.2 Senior Staff The Senior Staff shall consist of Staff Members who have served in a distinguished manner for a number of years but who have decided to limit their clinical activities. Although limited in their clinical activities, Senior Staff Members may be actively involved in research, teaching, and other non-clinical activities of the Hospital. Appointment to the Senior Staff may be made to Members whose services are requested by his or her Chief on the basis of advice and recommendation from a committee or other body established by each Service and Department pursuant to Section 6.05 to review the professional capability of applicants to the Staff and their continuing contribution to the Hospital. The discretion of the Chief of Service or Department in making a recommendation for appointment to the Senior Staff shall not be limited by any custom or by the fact of any past promotion or reappointment, but shall be based on a current review of the Member’s professional capability. Members of the Senior Staff: 1. Shall have privileges to admit and care for patients to the extent specified in his or her written appointment form. 2. Shall be eligible to serve on any Standing Committee or other committee of the Professional Staff, to chair any such committee, and to vote on matters that come before a committee of which he or she is a member. 3. Shall be eligible to vote at meetings of the Service or Department of which he or she is member. 4. Shall be expected to serve on committees if appointed. 2.03.3 Honorary Staff The Honorary Staff shall consist of former Members of the Active Staff or Senior Staff who may be appointed by the Trustees as an acknowledgment of honor and respect. Members of the Honorary Staff: 1. Shall not have privileges to admit or care for patients.
2.03.4 Affiliate Staff 1. The Affiliate staff shall consist of Staff Members whose primary association is elsewhere and who are either (1) a member 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) a member of Partners Community HealthCare, Inc.; (3) a member of the medical staff of the Brigham and Women’s Hospital or other Partners HealthCare System hospital; or (4) a member of the medical staff of an entity affiliated with the Hospital. An 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 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 membership in Partners Community HealthCare, Inc.; (3) upon the termination of the staff member’s medical staff membership at the Brigham and Women’s Hospital or other Partners HealthCare System hospital; or (4) upon termination of the staff member’s association with the affiliated entity. Members of the Affiliate Staff: 1. Shall have privileges to admit and care for patients if and to the extent specified in his or her written appointment form. 2. Shall be eligible to serve on any Standing Committee or other committee of the Professional Staff, to chair any such committee, and to vote on matters that come before a committee of which he or she is a member. 3. Shall be expected to serve on committees if appointed. 2.03.5 Clinical Associate Staff The Clinical Associate Staff shall consist of physicians, dentists, podiatrists and psychologists whose primary association is elsewhere than with the Hospital and who are given privileges to admit or care for an occasional patient in the Hospital or who contribute valuable services to the Hospital, such as clinical teaching or visiting in the Hospital. Each Chief shall establish for the Service or Department the maximum number of patients who may be admitted or cared for by a member of the Clinical Associate Staff during a one year period. Members of the Clinical Associate Staff: 1. Shall not have admitting privileges, except in special circumstances following special review by the General Executive Committee ("GEC"), and to the extent specified in his or her written appointment form, not to exceed the maximum set by the Service or Department. 2. Shall have privileges to care for patients to the extent specified in his or her written appointment form. 2.03.6 Clinical Assistant Staff The Clinical Assistant Staff shall consist of fully licensed physicians, dentists, podiatrists and psychologists who have completed their residency or other professional training requirements and whose primary association is with the Hospital.
Members of the Clinical Assistant Staff: 1. Shall have privileges to care for patients to the extent specified in his or her written appointment form and only under the supervision of a Member of the Active Staff or pursuant to an express delegation of authority from him or her. 2.03.7 Consultant Staff The Consultant Staff shall consist of Staff Members who because of their role at an affiliated hospital or special expertise in a particular field may be called upon from time to time to consult with, teach, or otherwise assist members of the Staff. A Member of the Clinical Consultant Staff may recommend or participate in treatment of patients only pursuant to a request by a Member of the Active Medical Staff. There shall be a subcategory within the Consultant Staff known as the Senior Consultant Staff which shall consist of those Members of the Consultant Staff who serve in a position at an affiliated hospital that is equivalent to a Chief of Service at the Hospital. Members of the Clinical Consultant Staff: 1. Shall have privileges to care for patients to the extent specified in his or her written appointment form. 2.03.8 Graduate Assistant Staff The Graduate Assistant shall consist of fully licensed physicians, dentists, podiatrists and psychologists who have completed their residency or other professional training requirements and whose assignments at the Hospital are temporary and limited by the Chief according to the needs of the Service or Department. Members of the Graduate Assistant Staff: 1. Shall have privileges to care for patients to the extent specified in his or her written appointment form. 2.03.9 Courtesy Staff The Courtesy Staff shall consist of selected physicians, dentists, podiatrists and psychologists 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: 1. Shall not have privileges to admit or care for patients.
2.03.10 Resident Staff The Resident Staff shall consist of physician, dentist, or podiatrist graduates of recognized professional schools who have at least a limited license under the laws of the Commonwealth of Massachusetts to practice in the Hospital and who are participating in an approved resident training program. Each Member of the Resident 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 Trustees, unless otherwise authorized by the Chief of the Service or Department in which he or she serves. 2.03.11 Fellow Staff The Fellow Staff shall consist of Staff Members who occupy a training or special status and hold appropriate academic graduate degrees that qualify them to participate in the activities of the Hospital under professional supervision and shall include: a. Clinical Fellows: Fellows who are licensed to practice as physicians, dentists, podiatrists or psychologists under the laws of the Commonwealth of Massachusetts or who are qualified pre- or post-doctoral psychology interns, and who may care for and treat patients of the Hospital under the direction of Members of the Active Staff and in accordance with the approved fellowship training program. b. Research Fellows: Fellows whose activities are restricted to research. c. Clinical and Research Fellows: Fellows who meet the qualifications for Clinical Fellows and who, under the direction of Members of the Active Staff and in accordance with the approved fellowship training program, conduct research and engage in the care and treatment of patients of the Hospital. d. Visiting Fellows: Distinguished professionals who are appointed as visiting Members of the Staff to one of the Services or Departments of the Hospital and who, subject to applicable licensing requirements, may or may not assist in the care and treatment of patients as specified in the notice of appointment. A Member of the Fellow Staff 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 Trustees, unless otherwise authorized under policies adopted by the Service or Department of which he or she is a member. 2.03.12 Students Students, whether graduate or undergraduate, are not Staff Members. If and when any Student shall assist in the care and treatment of patients, he or she shall be subject to the supervision, direction, and control of a Member of the Staff. 2.04 Allied Health Practitioners Allied Health Practitioners ("Practitioners"), who shall include licensed physician assistants and nurses practicing in the expanded role, are not Members of the Professional Staff. A Practitioner may engage in direct clinical activities 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 the Hospital and in accordance with any applicable laws or regulations. The protocols or guidelines shall specify the activities or situations requiring 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 of registration or other certifying agency and must have appropriate authorization to practice in accordance with procedures established by law and by the appropriate board or agency. If there is not such board or agency, the minimum professional requirements for the Practitioner shall be those approved by the GEC.
ARTICLE III - APPOINTMENT AND REAPPOINTMENT PROCEDURES 3.01 General Procedure Appointments to the Professional Staff are made by the Trustees upon recommendation of the GEC. Each application for appointment or reappointment is initially considered and evaluated by the Chief of the Service or Department for which the application is made. Each initial appointee to the Professional Staff shall be given a copy of the Bylaws of the Professional Staff and shall agree to be bound by the Bylaws and all applicable rules and regulations of the Hospital and the Professional Staff. 3.02 Initial Appointment Process 3.02.1 Application Form Every application for Membership on the Staff shall be in writing, submitted on forms prescribed by the Hospital, and signed by the applicant. The application shall include without limitation a specific request stating the staff category or clinical privileges being applied for; verifiable information concerning the applicant's education, training and experience; the names of all health care facilities with which the applicant has been associated and the reasons for discontinuance of these associations; a listing and description of all malpractice claims pending or closed during the previous ten (10) years; a statement authorizing the applicant's insurance carrier to release specified information relating to claims or actions for damages; a statement authorizing any health care facility with which the applicant has been associated to release information which is relevant to the applicant's character and professional competence; a statement authorizing the Hospital to exchange information with any other health care facility or professional organization with which the applicant has been associated regarding any pending or final disciplinary action; and such other information as may be required from time to time by the Hospital or the applicable Service or Department. An applicant must submit a copy of his or her most recent Massachusetts licensure application form and must agree to undergo a mental or physical examination if requested. An application shall not be considered unless supplemented by written references attesting to the applicant's professional competence and ethical practice - at least three references in the case of Clinical Staff and at least two references in the case of Non-Clinical Staff. 3.02.2 Procedure for Processing Applications (Credentials Review) a. Each application shall be initially submitted to the appropriate Chief of Service or Department for evaluation of the applicant's qualifications, the ability of the Hospital to provide adequate facilities and supportive services for the applicant, and the needs of the Service or Department for additional Staff Members with the applicant's skills and training. The evaluation of the applicant's qualifications may include inquiries to each health care facility with which the applicant has been associated during the past ten years regarding the applicant's clinical skills, any pending or final disciplinary action or malpractice litigation, and any other information relevant to the applicant's character or professional competence. The evaluation shall also include the application of any criteria developed by the Service or Department. With respect to applicants for the Active Clinical Staff, the evaluation shall take into account any comments received from the Executive Committee of the Massachusetts General Physicians Organization, Inc. ("MGPO") or a subcommittee of that Executive Committee following their review of the application, supporting documentation and Clinical Involvement Questionnaire. b. If after the review of the application the Chief decides to recommend appointment, he or she shall forward to the GEC the application and all supporting documentation. In the case of applicants for the Clinical Staff other than the Resident Staff, Fellow Staff and Licensed Graduate Student Assistants, the Conditions of Appointment Form prepared by the Chief shall also accompany the request for appointment. c. The Hospital Registrar shall verify licensure for any applicant to the Clinical Staff whose appointment is recommended by the Chief. d. An application shall not be considered complete unless it complies with the requirements of Section 3.02.1 and the Chief has recommended appointment and the Registrar has verified information in accordance with subparagraphs (a) through (c) above. e. Within three months following presentation of the application by the Chief, the GEC shall recommend that the application be accepted, rejected, or deferred. Whenever the recommendation is to defer action, the GEC shall act again within thirty days by recommending to either accept or reject the application. When the recommendation is adverse, the Chief shall promptly notify the applicant. f. The President shall transmit to the Trustees every recommendation by the GEC for appointment. (The President may delegate to the Chief Medical Officer any responsibility or function assigned to the President in these bylaws.) The Trustees shall accept or reject the recommendation, or refer it to the GEC for further consideration specifying a time limit within which a subsequent recommendation shall be made. Whenever the Trustees do not concur with the GEC recommendation, they shall refer the matter to a combined committee of Staff and Trustee members appointed by the Trustees for review and recommendation before taking final action on the application. Notice of the Trustees' action shall be given to the applicant. 3.03 Reappointment Process 3.03.1 Application Form Every application for reappointment shall be in writing, submitted on forms prescribed by the Hospital and shall be signed by the applicant. The application shall be substantially similar to the application described in Section 3.02.1 for initial appointment.
Applications for reappointment shall be processed in substantially the same manner as specified in Section 3.02.2 for initial appointment, except that inquiries generally will be made only to health care facilities with which the applicant has been associated during the previous three (3) years. Each Service and Department shall have criteria for evaluation of the applicant's professional and clinical performance and judgment and ethical standards, taking into consideration the applicant's health status, utilization and quality assurance data, continuing education, malpractice claims, compliance with these Bylaws and with the Hospital Bylaws and compliance with rules and regulations of the Staff and of the Hospital, attendance at meetings and discharge of other Staff obligations, and his or her ability to work effectively with other Staff Members and with patients. The evaluation shall also include the application of any criteria developed by the Service or Department. 3.04 Terms of Appointment Every appointment to the Staff shall be for a term of not more than two years. Every initial appointment to the Staff shall be provisional. In addition, every initial appointment to the Active Staff or the Clinical Assistant Staff shall be provisional regardless of whether the Member has had a prior appointment to the Resident Staff or other category of Staff. A reappointment of a provisional Member of the Active Staff or Clinical Assistant Staff may also be made provisional by the written appointment by the Trustees; provided, however, that the sum of the terms of a Staff Member's provisional appointments shall not exceed four years. 3.05 Leave of Absence; Medical Leave of Absence; Medical or Psychiatric Examination a. Except as provided in paragraph (b) of this Section, every leave of absence extending beyond three months shall require the prior approval of the appropriate Chief of Service or Department, the GEC, the President, and the Trustees. No Staff Member shall be granted any leave of absence in excess of the term of his or her appointment. Every Staff Member upon returning to the Staff to serve the unexpired portion of the term of his or her appointment following expiration of any approved leave of absence shall be entitled to resume his or her rank and privileges for the unexpired portion of the term. b. Whenever a Staff Member is experiencing health problems that may impair his or her ability to care for patients, the President (or in his or her absence the Chief of Service or Department) may place the Member on an immediate medical leave of absence for a specified time or until such time as the Member and his or her physician demonstrate to the satisfaction of the President that the problems have been sufficiently resolved to enable the Member to provide the optimal achievable care for patients of the Hospital; provided, however, that such medical leave of absence may not extend beyond the term of the Staff Member's appointment. If any Member placed on medical leave of absence so requests in writing to the President within thirty days of receipt of notice of the leave of absence, the GEC shall promptly review the action. If, following its review, the GEC confirms and continues the medical leave of absence, the Member may be entitled to have the action further reviewed in accordance with the hearing and appellate review provisions under Section 5.05. c. A Member of the Staff, or an applicant for appointment to the Staff, may be required to have a medical or psychiatric examination upon request by the President, Chief of Service or Department, the Quality Assessment Committee or such other committee of the Service or Department as may be designated by the Chief, the Patient Care Assessment Committee or its Executive Committee, or the GEC. 3.06 Resignation Any Staff Member may at any time resign from the Staff by a written resignation submitted to his or her Chief of Service or Department and transmitted by the Chief to the President for presentation to the GEC and the Trustees. 3.07 Modification of Membership Status or Privileges A Chief of Service or Department may in connection with a recommendation for reappointment or at any other time request modification of a Staff Member's category or rank of membership, or clinical privileges. The request shall be processed in substantially the same manner as specified in Section 3.03.2 for reappointment. ARTICLE IV - DELINEATION OF PRIVILEGES 4.01 Delineation of Privileges in General Each appointment shall confer on the appointee only such privileges as have been granted in the written notice of appointment by the Trustees or by virtue of his or her staff category under these Bylaws. These privileges shall limit the appointee to activities in which he or she has demonstrated current competence and which are within the scope of his or her license to practice. The Chief of each Service and Department, following review and recommendation by the Quality Assessment Committee, and subject to review and approval of the GEC, shall develop criteria for use in the granting of privileges in that Service or Department. 4.02 Special Conditions for Podiatric Staff Privileges Podiatrists may be granted clinical privileges consistent with guidelines promulgated from time to time by the Chief of Orthopaedic Surgery in consultation with the Podiatric and Orthopaedic Staffs. Podiatrists shall be under the direct supervision of the chief of the podiatric unit and the overall supervision of the Chief of Orthopaedic Surgery. Admission of a podiatric inpatient may be made only with the concurrence of a physician member of the Staff, and a physician member of the Staff shall have the responsibility for non-podiatric medical care provided to a podiatric patient. 4.03 Special Conditions for Psychologist Staff Privileges Psychologists may be granted clinical privileges consistent with guidelines promulgated from time to time by the Chief of Psychiatry in consultation with the Psychology and Psychiatric Staff. Each Psychologist shall be under the supervision of the Chief of the Service in which the Psychologist is appointed. 4.04 Temporary Privileges After conferring with the Chairman of the GEC and the Chief of the Service or Department involved, the President or his designee may grant specified temporary privileges to a person who is qualified under these Bylaws for a limited period of time not to exceed that which is allowed by the Board of Registration in Medicine. A candidate shall have no right to a hearing or appellate review because of inability to obtain temporary privileges, failure of renewal of such privileges or termination of such privileges. 4.05 Emergency For purposes of this section, "emergency" is defined as any condition in which serious harm could result to a patient or in which the life of a patient is in immediate danger and any delay in administering treatment could add to that danger. In the case of an emergency any Member of the Staff shall be permitted and is expected to do everything possible to save the patient's life or save the patient from serious harm to the extent permitted by his or her license and regardless of clinical privileges.
ARTICLE V - CORRECTIVE ACTION; FAIR HEARING AND APPELLATE REVIEW 5.01 Corrective Action; General Through their designated departments, committees and officers, the Staff shall provide continuous monitoring of the Clinical and Non-Clinical Staff for the purpose of maintaining high professional standards of clinical care, research, and other activities conducted by the Hospital. Whenever a Member of the Staff engages in conduct that is or may be detrimental to the quality of patient care or disruptive to Hospital research or other operations, appropriate remedial or corrective action shall be initiated by the Chief of Service or Department, the Quality Assessment Committee of the Service or Department or other appropriate committee of the Professional Staff, or by the President. If an allegation is made that a Member of the Staff has engaged in misconduct in scientific research, the Chief of the Service or Department, or the President, as the case may be, shall notify the Corporate Vice President for Research and Technology of The Massachusetts General Hospital, and the investigation of the matter shall be conducted in accordance with the MGH's Procedures for Investigating Reports of Misconduct in the Performance of Scientific Research. Corrective action may include the issuance of a warning or reprimand, the imposition of terms of probation or a requirement for consultation, the partial or temporary suspension or limitation of privileges, the conduct of peer review, the summary suspension of all privileges, termination of Staff appointment, denial of reappointment, reduction in rank, or the termination of all privileges, but is not limited to these actions. Some but not all corrective actions may constitute an Adverse Action, as defined in Section 5.06(b), which entitles a Staff Member to the fair hearing and appellate review mechanisms described in Section 5.08.
5.02 Corrective Action for Residents and Fellows Residents and Fellows shall be subject to an adverse action process as described in the document titled "Partners Graduate Trainee Adverse Action Process". Residents and Fellows shall not be eligible for the fair hearing and appellate review process described in Sections 5.05, 5.06 and 5.08 of these Bylaws.
5.03 Reporting Conduct of Health Care Providers. The procedure for reporting conduct of a licensed health care provider that indicates incompetency in the provider's specialty, conduct which might be inconsistent with or harmful to good patient care and safety, or conduct that may disrupt or interfere with Hospital operations, shall be as follows: a. If the report is about a Staff Member, it shall be directed to the Chief of the Service or Department in which the Staff Member is appointed and the Quality Assessment Committee for the Service or Department. The Chief shall direct the review, investigation and resolution of the report and take appropriate corrective or other action in accordance with such procedures as may be specified in these Bylaws and such other procedures as may be established by the Patient Care Assessment Committee. The Chief shall inform the Patient Care Assessment Coordinator of the report and any action taken. b. If the report is about a provider who is not a Staff Member, it shall be directed to the head of the clinical department in which the provider works who shall review, investigate and resolve the report in accordance with such procedures as may be established by the Patient Care Assessment Committee. The head of the department shall inform the Patient Care Assessment Coordinator of the report and any action taken. c. If the report is about a Chief of Service or Department or the head of a clinical department, it shall be directed to the President who shall direct the review and investigation of the report and take appropriate action. The President shall inform the Patient Care Assessment Coordinator of the report and any action taken.
5.04 Summary Suspension or Termination When necessary to maintain acceptable standards of care, safety, operation, integrity or ethics at the Hospital, upon recommendation of the Chief of Service or Department involved, the President (or in his or her absence the Chief) may summarily suspend any Staff Member from practice or terminate his or her privileges at the Hospital. In the case of such summary action, the Chief shall be responsible for ensuring that alternative coverage is provided for the patients of the suspended Staff Member, taking into account the desires of the patients. The President or Chief shall promptly notify the Staff Member in writing of such action. If any Member so suspended or terminated submits a written request for review to the President within thirty days of receipt of notice of the suspension or termination, the GEC shall promptly review such summary suspension or termination. The GEC may confirm or disapprove the suspension or termination. If the GEC confirms and continues the summary suspension or termination, the Staff Member’s right to a hearing shall be governed by Section 5.06(b).
5.05 Preliminary Inquiry by Chief of Service or Department a. With respect to a report or complaint raised pursuant to Section 5.01 or 5.03, the relevant Chief of Service or Department shall cause to be conducted a prompt inquiry to ascertain whether there is a factual basis for the report and whether corrective action is appropriate. This inquiry shall not be in the form of a hearing, and the procedures described in Section 5.08 with respect to fair hearing and appellate review shall not apply. The inquiry shall include notice to and 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 corrective action. b. If, at the conclusion of the preliminary inquiry, the Chief of Service or Department determines that there was no factual basis for a report or complaint or that no corrective action is warranted, no further action shall be taken under these Bylaws, although the Chief may take remedial action as he deems appropriate. c. If, at the conclusion of the preliminary inquiry, the Chief of Service or Department decides to take corrective action other than one of the actions listed in Section 5.05(d), he or she shall implement the action and it shall be final. d. If, at the conclusion of the preliminary inquiry, the Chief of Service or Department determines that one or more of the actions listed below should be taken, he or she shall make a recommendation to the GEC which shall follow the process described in Section 5.06: termination of Staff appointment (except for automatic termination
of an appointment at the Hospital), (ii) termination of privileges (iii) denial of reappointment for a member of the Active Staff, Senior Staff, or Clinical Assistant Staff (unless the preceding appointment was provisional), or (iv) reduction in rank for a member of the Active Staff, Senior Staff, or Clinical Assistant Staff. These actions do not include a reduction in compensation, or any other action except those specified in this Section. 5.06 Termination of Appointment or Denial of Reappointment; Reduction in Rank; Termination of Privileges a. Any Chief of Service or Department may recommend to the GEC the termination of the appointment, denial of reappointment, reduction in rank, or the termination of privileges of any Staff Member within his or her Service or Department. In every such case, the GEC shall review the recommendation. In the course thereof, the Committee may invite the Staff Member to meet with it. This meeting shall not be a formal hearing and the procedures described in section 5.08 shall not apply. The GEC shall complete its review within thirty days of the recommendation. b. If, at the conclusion of its review, the GEC confirms a recommendation that an Adverse Action should be taken, as defined in this section 5.06(b), the Staff Member shall be entitled to the fair hearing and appellate review mechanisms described in Section 5.08. Generally, an Adverse Action shall include an action taken for reasons relating to an individual's qualifications and performance requirements as described in these Bylaws but may also include action taken to reduce or terminate clinical privileges for fiscal or budgetary reasons. An Adverse Action shall include the termination of the Staff appointment, termination of privileges, or a summary suspension or termination under Section 5.04 or a Medical Leave of Absence under Section 3.05(b), except that the automatic termination or suspension of appointment to the Affiliate Staff upon termination of the basis for the professional’s appointment with the Hospital shall not be an Adverse Action. With respect to a Member of the Active Staff, Senior Staff, and Clinical Assistant Staff, Adverse Action shall also include a reduction in rank and the denial of reappointment (other than the denial of reappointment to a Member of the Staff whose appointment is provisional pursuant to Section 3.04). Adverse Action shall not include the failure to appoint an initial applicant to the Staff; the denial, termination or reduction of temporary privileges; the issuance of a warning or a letter of admonition or reprimand; the imposition of terms of probation or a requirement for consultation; the conduct of peer review or quality care monitoring; an action based upon a Staff Member's failure to complete medical records in a timely fashion; a reduction in compensation; or any other action except those specified in this Section. c. If, at the conclusion of its review, the GEC confirms the recommendation that action should be taken, other than an Adverse Action as defined in Section 5.06(b) above, it shall forward its recommendation to the President and the Trustees. The Trustees shall adopt or reject such recommendation or take other action they may deem appropriate. The President shall notify the Staff Member of the action, which shall be final and binding on all parties. 5.07 Automatic Suspension and Duty to Notify a. Whenever a Clinical Staff Member's license or registration or other legal credential authorizing him or her to practice in the Commonwealth of Massachusetts is suspended, revoked or not renewed, the Member's appointment to the Professional Staff and associated clinical privileges immediately shall end. Whenever a Clinical Staff Member's license or registration or other legal credential authorizing him or her to practice in the Commonwealth of Massachusetts is limited or restricted, the Member's appointment to the Professional Staff and associated clinical privileges immediately shall be limited or restricted in the same manner. When the suspension, limitation or restriction is ended or the legal credential reinstated, the individual may apply for appointment and shall be evaluated as an applicant for initial appointment. b. A Member of the Staff shall immediately notify his or her Chief of Service or Department upon learning that: i. his or her license or registration or other legal credential authorizing him or her to practice in the Commonwealth of Massachusetts has been suspended, revoked, not renewed, limited or restricted; or ii. he or she is the subject of disciplinary action by another health care facility, employer or professional medical association; or iii. he or she is the subject of a formal investigation or disciplinary action by a licensing, certifying or regulatory authority.
5.08 Fair Hearing and Appellate Review 5.08.1 Adverse Action. A Member of the Staff who is the subject of a recommendation that an Adverse Action be taken shall be entitled to the fair hearing and appellate review mechanisms as described in Section 5.08.2. 5.08.2 Fair Hearing and Appellate Review Process a. Notice of Proposed Adverse Action Any Staff Member against whom an Adverse Action has been recommended shall be given prompt written notice of the proposed action by the Chief of Service or the President. The notice shall specify the nature of the Adverse Action, and shall advise the Member of his or her right to a hearing and review of any Adverse Action under these Bylaws if a request for such hearing and review is made within the specified time period. b. Request for Hearing A Staff Member shall have thirty days following receipt of the notice of proposed Adverse Action to file with the President a written request for a hearing. Failure to request a hearing within the time and in the manner specified waives any right to such hearing and to any appellate review to which he or she might otherwise have been entitled. c. Staff Review Committee Hearing Upon receipt of a Staff Member's written request for hearing, the President shall submit the request to the GEC, which shall appoint a Staff Review Committee ("Staff Committee") to conduct the hearing. The Staff Committee shall consist of three Staff Members, one of whom shall have the same rank as the aggrieved Member and none of whom shall have been actively involved in formulating the recommendation upon which the Trustees have acted. The hearing by the Staff Committee shall commence within sixty days of the receipt by the President of the request for hearing. The Staff Committee shall give the aggrieved Member reasonable written notice of the date, hour, and place of the hearing and shall transmit to the aggrieved Member a statement of the basis for the recommendation or action. This statement shall have been prepared by the Chief of Service or Department and submitted to the Staff Committee. Failure of the aggrieved Member to appear at the hearing waives his or her right to such hearing and any appellate review. d. Conduct of Hearing In conducting the hearing, the Staff Committee: 1. Shall determine the time and location of the hearing and any continuance thereof; 2. Shall determine whether the hearing shall be open or closed to witnesses and/or spectators; 3. Shall require all witnesses to be sworn and to testify under oath; 4. Shall admit and give probative effect to only such evidence as reasonable persons are accustomed to rely on in the conduct of serious affairs, but shall not be required to observe the rules of evidence followed by the Courts of the Commonwealth; 5. May take notice of any fact that may be judicially noticed by the Courts of the Commonwealth and of any general, technical, or scientific fact within the specialized knowledge of the Staff Committee; 6. Shall allow the aggrieved Member, the Chief of Service or Department, and any other Staff Member acting as a party adverse to the aggrieved Member to be represented by counsel, to call and examine witnesses, to cross-examine any witness who shall testify, to offer documentary evidence, and to submit rebuttal evidence; 7. Shall have a transcript of the hearing made by a reporter qualified to serve in the Courts of the Commonwealth and to take the oaths of witnesses; 8. Shall make such transcript, or a copy thereof, available to the aggrieved Member without charge upon the request of the Member; and 9. Shall decide all other procedural matters not specified herein. e. Staff Committee Reports to Trustees Within thirty days after the close of such hearing, the Staff Committee shall prepare and submit to the aggrieved Member, the President, the GEC, and the Trustees a written report containing its findings as to whether the challenged Adverse Action is unreasonable and its recommendation that the Adverse Action be approved, modified, or disapproved, or that other appropriate action shall be taken. f. Trustee Appellate Review Within twenty-one days of receipt of the report and recommendation of the Staff Committee, the aggrieved Member or the GEC may request in writing that a review be conducted by a committee of no fewer than three Trustees designated by the Chairman of the Trustees' ("Trustees' Committee"). Failure to appeal and request a review within the ten day period shall constitute a waiver of any right to review. The Trustees' Committee shall notify the aggrieved Member in writing of the date on which it shall commence its review. It shall review a transcript of the Staff Committee hearing, the report of the Staff Committee and any report which the aggrieved Member may submit. The Trustees' Committee shall determine all procedures for carrying out its review. It may, but need not, hold a formal hearing. If the procedure includes a formal hearing, it shall be conducted in a manner consistent with the provisions of Sections 5.08(d). The Trustees' Committee shall complete its review within thirty days following the date on which, pursuant to the Committee's notice to the aggrieved Member, the review shall have begun. If the Trustees' Committee determines that the recommendation is supported by substantial evidence, it shall adopt the recommendation. If the Trustees' Committee determines the recommendation is arbitrary or capricious, it may reject or modify the recommendation, or take such other action as it deems appropriate, which shall be final and binding on all parties.
ARTICLE VI - ADMINISTRATIVE STRUCTURE AND ORGANIZATION 6.01 Organization of Services, Departments and Centers The administrative structure of the Staff shall include Services, Departments and Centers as follows: 6.01.1 The Services shall include Anesthesia and Critical Care, Pediatric, Dermatology, Emergency, Medicine, Neurology, Neurosurgery, Oral and Maxillofacial Surgery, Orthopaedic Surgery, Pathology, Pediatric Surgery, Psychiatry, Radiation Oncology, Radiology, Physical Medicine and Rehabilitation, Surgery, Urology and Vincent Memorial Obstetrics and Gynecology Services. 6.01.2 The Departments shall include the Molecular Biology and Neurobiology Departments. 6.01.3 The Centers shall include the Cancer and Neuroscience Centers. 6.01.4 The ophthalmological and otolaryngological needs of the Hospital shall be served by physicians on the Active Clinical Staff of the Massachusetts Eye and Ear Infirmary (MEEI). While not a Staff Member, any such physician from the MEEI may be called upon from time to time to assist any Member of the Hospital's Active Staff.
6.02 Chiefs of Service and Department 6.02.1 Responsibilities Each Service and Department shall have a Chief ("Service Chief", "Department Chief" or "Chief") and each Center shall have a Director. Each Chief and Director shall be responsible for the general administration of his or her Service, Department or Center and for all activities within the Service, Department or Center. The responsibilities of each Chief and Director shall be carried out in concert with the functions and objectives of the Hospital and the Massachusetts General Physicians Organization (MGPO) and shall include oversight over the: a. Quality of care and treatment of all patients within his or her Service or Clinical Department; b. Conduct and discipline of all Staff Members within his or her Service or Clinical Department; and c. Conduct and administration of all programs of education, research, and clinical care within his or her Service, Department or Center. Each Chief shall have corresponding oversight and responsibilities within the MGPO. Furthermore, Partners HealthCare System, Inc. (Partners) may from time to time appoint at the Partners level a chairman to oversee the integration of a Service, Department or Center at the General Hospital and its counterpart at the Brigham and Women’s Hospital, and the ongoing operation of the consolidated Service, Department or Center. The relative authority and responsibilities of the Partners Chairman and the General Hospital Chief shall be delegated and described as necessary in appropriate documents. 6.02.2 Appointment Process The Chief of each Service and Department shall serve a term of one year or less. The Chief or Director shall be appointed by the Trustees, following consideration of recommendations made to them by the President of the Hospital and the CEO of the MGPO. Any Chief of a Clinical Service or Department shall be required to be a physician or dentist and any Chief or Director of a Non-Clinical Department or Center shall be required to be a physician or to have a doctoral degree in an appropriate field. As determined from time to time by the Hospital and Harvard Medical School, the initial recommendation for an appointment as Chief or Director of certain Services, Departments or Centers shall be required to include a report made by a special committee jointly constituted by the Hospital and the Harvard Medical School for the purpose of reviewing candidates for the appointment. Following consideration of a recommendation or recommendations made to them by the President of the Hospital or the CEO of the MGPO, the Trustees may at any time terminate the appointment of any Chief of Service or Department or any Director of a Center, and in the course of considering the recommended termination the Trustees may invite the Chief or Director to meet with them. Termination under this section shall not of itself result in the loss or reduction of any clinical privileges or status of Membership on the Staff. 6.03 Titles The following titles shall be used in designating the rank and title of Staff Members. The designation as Physician, Surgeon, or other professional designation, may be substituted with an equivalent specialty designation, such as Dermatologist for Physician, or Urologist or Oral and Maxillofacial Surgeon for Surgeon, according to the custom and practice of each Service or Department. 6.03.1 For the Clinical Medical Staff (applicable discipline to be added where required): a. Active: Physician; (Visiting) Surgeon; Dentist; Associate Physician; Associate (Visiting) Surgeon; Associate Dentist; Assistant Physician; Assistant (Visiting) Surgeon; Assistant Dentist; Assistant in; b. Senior: Senior Physician, Surgeon or Dentist; c. Honorary: Honorary Physician, Surgeon or Dentist; d. Affiliate: Affiliate Physician, Surgeon or Dentist e. Clinical Associate Staff: Clinical Associate in; f. Clinical Assistant Staff: Clinical Assistant in; g. Consultant: Consultant in; Senior Consultant in; h. Courtesy Staff: Courtesy Staff in; i. Graduate Assistant: Graduate Assistant in; j. Resident: Chief Resident in; First Year, Second Year, Third Year, Fourth Year, Fifth Year Resident in; k. Fellows: Clinical Fellow in; Clinical and Research Fellow in; Visiting Fellow in; and
6.03.2 For the Clinical Adjunct Staff (applicable discipline to be added where required): a. Active: (Visiting) Podiatrist; Psychologist; Associate (Visiting) Podiatrist; Associate Psychologist; Assistant (Visiting) Podiatrist; Assistant Psychologist; Assistant in; b. Senior: Senior Podiatrist or Psychologist; c. Honorary: Honorary Podiatrist or Psychologist; d. Affiliate: Affiliate Podiatrist or Psychologist e. Clinical Associate Staff: Clinical Associate in; f. Clinical Assistant Staff: Clinical Assistant in; g. Consultant: Consultant in; h. Graduate Assistant: Graduate Assistant in i. Resident: Chief Resident in; First Year, Second Year, Third Year Resident in; j. Fellows: Clinical Fellow in; Clinical and Research Fellow in; Visiting Fellow in. 6.03.3 For the Non-Clinical Staff (applicable discipline to be added where required): a. Active: Biochemist, Biologist, or other applicable professional designation; Associate of the same designation; Assistant of the same designation; Assistant in Biochemistry, Biology, or other applicable discipline; b. Senior: Senior Biochemist, Biologist, or other applicable professional designation; c. Honorary: Honorary Biochemist, Biologist, or other applicable professional designation; d. Affiliate: Affiliate Biochemist, Biologist, or other applicable professional designation; e. Consultant: Consultant in; and f. Fellows: Research Fellow in; Visiting Fellow in. 6.04 President The President is the agent of the Trustees authorized and directed to act on their behalf as the Hospital Bylaws shall provide. 6.05 Committees 6.05.1 General Executive Committee. ("GEC") a. Members The GEC shall consist of: five representative Chiefs of Service appointed by the Chiefs' Council; the President of The Massachusetts General Hospital; the Chief Executive Officer of the MGPO; the President of The General Hospital Corporation; the Chairs of the Executive Committee on Research and the Executive Committee on Teaching and Education; a representative of the research community appointed by the President of The Massachusetts General Hospital; two executives of The General Hospital Corporation appointed by its President; and four Members of the Active Medical Staff who shall be the two elected primary care practitioners and the two elected specialty or subspecialty practitioners who are then serving one of the last two years of their three year term on the Executive Committee of the MGPO. If at any time the membership of the GEC does not include six Chiefs of Service, the Chiefs' Council shall appoint additional Chiefs of Service as is required to increase to six the number of Chiefs of Service serving as members.
The GEC shall have a Chairperson who shall be the President of The Massachusetts General Hospital or his designee. The GEC shall constitute, determine the composition of, make appointments to, and charge committees, including standing committees, it deems necessary or appropriate for the effective discharge of its duties and the proper operation of the Hospital, taking into account any requirements of the Hospital Bylaws and Standards of the Joint Commission on Accreditation of Healthcare Organizations. The GEC may authorize one of its committees to take on its behalf any of the actions reserved to it under these Bylaws. The committees shall include but not be limited to the following standing committees: i. the Chiefs' Council which shall include all Chiefs of the Services listed in Section 6.01.1; ii. the Administrative Council; iii. the Executive Committee on Research ("ECOR"); iv. the Executive Committee on Teaching and Education ("ECOTE"); v. the Health Professions Staff Committee; and the Medical Policy Committee. c. Meetings The GEC shall meet at least twelve times annually. d. Duties The duties of the GEC and its committees shall be to: 1. Consider and, on behalf of the Trustees, adopt policies and procedures relating to patient care and medical education and, at the request of the Trustees, other matters affecting the optimal operation of the Hospital; 2. Consider and recommend to the appropriate committees policies and procedures relating to research; 3. Act in an advisory capacity to the President and the Trustees of the Hospital and the President of The Massachusetts General Hospital on all matters affecting the optimal operation of the Hospital, and serve as a liaison between the Professional Staff and the administration of the Hospital; 4. Consider and recommend to the Trustees appointments and other actions relative to the Professional Staff; 5. Recommend to the Trustees the adoption, amendment, and repeal of any Bylaws of the Professional Staff or any rules and regulations applicable to the Staff; and 6. Disseminate information with respect to its actions, recommendations and discussions to the Professional Staff through the Service Chiefs and through the representatives of the Active Medical Staff.
6.05.2 Patient Care Assessment Committee a. The Committee’s membership, officers and meeting schedule and the identification of a Patient Care Assessment Coordinator shall be as provided for in the Patient Care Assessment Plan. b. Duties The duties of the Patient Care Assessment Committee shall be to: 1. Oversee the programs of the Hospital which are designed to assure the effective assessment of patient care in all departments of the Hospital. These programs shall include activities relating to quality assurance, utilization review, risk management, peer review, impaired providers, and such other programs as the Committee or the Trustees may deem appropriate, and shall be known collectively as the Patient Care Assessment Program ("Program"); 2. Ensure that the policies and procedures for implementing the Program comply with the requirements of all applicable laws, including without limitation the regulations of the Board of Registration in Medicine, as they may be amended from time to time; and 3. Report its findings and make other recommendations relative to patient care assessment to the Trustees, the Medical Policy Committee and the GEC from time to time. 6.05.3 Service Quality Assessment Committees a. Members The Chief of each Service shall establish a Quality Assessment Committee which shall consist of at least three members, including (a) the Chief of the Service or the Staff Member designated by the Chief with responsibility for quality assessment in the Service (or in the unit or division within the Service), (b) the Staff Member responsible for the residency training program in the Service (or the unit or division), and (c) a member of the nursing staff working in the Service, who shall be recommended by the Chief Nurse Executive. b. Officers Each Quality Assessment Committee shall have a Chairperson who shall be appointed by the Chief of the Service and shall be ex officio a member of the Patient Care Assessment Committee of the Hospital.
c. Duties Each Quality Assessment Committee shall be responsible on an ongoing basis for the monitoring and evaluation of the quality of care within the Service and for recommendations with respect to criteria for evaluating the qualifications and performance of applicants for appointment or reappointment to the Staff, and shall participate in the review of the applicants pursuant to such criteria. Each Committee shall make periodic reports to the Patient Care Assessment Coordinator. 6.05.4 Medical Peer Review Committees a. The "medical peer review committees" include the GEC, the various committees of the GEC including the Patient Care Assessment Committee, its Coordinator, and the Medical Policy Committee (and its subcommittees), the Quality Assessment Committee for each Service, any Staff Review Committee and all other committees (including other committees of the medical staff of the Hospital as well as committees of the MGPO acting as agent of the Hospital and in conjunction with the quality assurance activities conducted by the Hospital), agents of such committees or individuals charged with any responsibility for (a) the evaluation or improvement of the quality of health care rendered by health care providers, (b) the determination whether health care services were performed in compliance with the applicable standards of care, (c) the determination whether the cost of health care services were performed in compliance with the applicable standards of care, (d) the determination whether the cost of health care services rendered was considered reasonable by the providers of health services in the area, (e) the determination whether the actions of a provider call into question his or her fitness to provide health care services, or (f) the evaluation and assistance of providers impaired or allegedly impaired by reason of alcohol, drugs, physical disability, mental instability or otherwise. 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 are confidential, are not subject to subpoena or discovery, and may not be introduced into evidence in any judicial or administrative proceeding, and no person who was in attendance at a meeting of a medical peer review committee shall be permitted or required to testify in any such proceeding as to the proceedings, deliberations, or other actions of such medical peer review committee or any members thereof, except as specifically provided in Massachusetts General Laws Chapter 111, Section 204. 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. 6.06 Massachusetts General Physicians Organization, Inc.("MGPO") A member of the Clinical Staff of the Hospital may be affiliated with the MGPO in such capacities as defined in the Bylaws of the MGPO. The MGPO shall provide for effective discussion and dissemination of information among these affiliated Clinical Staff members and facilitate other opportunities to enhance their professional association. In furtherance of these efforts, the MGPO shall provide for meetings of these Clinical Staff members at least annually. Meetings shall be held at the call of the Executive Committee of the MGPO, at such times and places as it determines.
ARTICLE VII - MEETINGS 7.01 Meetings of Services Each Service shall hold meetings at least once every month to review, analyze, and discuss clinical work, deaths, unimproved cases, infections, complications, diagnoses, results in significant discharged cases, and other appropriate matters, including administrative matters. Written records of such meetings shall be made and filed with the records of the Service.
ARTICLE VIII - AMENDMENTS 8.01 These Bylaws shall supersede all prior Bylaws of the Staff and similar or related documents. 8.02 Any Staff Member may initiate any proposal to supplement, amend, or repeal any or all of these Bylaws by submitting such proposal in writing to the GEC and the Executive Committee of the MGPO for consideration. If either or both of the GEC and the said Executive Committee shall vote to recommend approval of such proposal, whether with or without modification, the President shall submit the proposal to a meeting of the Voting Members of the MGPO, the notice of which meeting shall contain the text of the proposal and such recommendation or recommendations regarding it. The Voting Members of the MGPO shall be as defined in the Bylaws of the MGPO, provided, however, that for purposes of this section they shall include all members of the Active Clinical Staff and the Senior Clinical Staff. If a quorum, as defined in the Bylaws of the MGPO, is present in person or by proxy, the affirmative vote of at least two-thirds (2/3) of those staff members shall determine the Staff's action on the proposal; and if such action shall result in any proposal to supplement, amend, or repeal these Bylaws, the President shall submit such proposal to the Trustees. 8.03 These Bylaws may not be supplemented, amended, or repealed without prior approval by the Trustees. 8.04 These Bylaws shall be reviewed at least every five years by a special committee established by the GEC for that purpose. Each new printing of the Bylaws shall indicate the date of their most recent amendment or review.
* * * I hereby certify that the foregoing is a true copy of the Bylaws of the Professional Staff of The General Hospital Corporation as amended through July 21, 2000, and that the said Bylaws continue to be in full force and effect as of the date set forth below.
_______________________ Date Ernest M. Haddad, Secretary #37415 |
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