Mercy Hospital Medical Staff Bylaws - Mercy Health

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probation or limitation of practice by any state licensing agency; loss ofstaff membership or loss or restriction of privileges at any hospital orother health care institution; cancellation or restriction of professionalliability insurance coverage; revocation, suspension or voluntaryrelinquishment of Drug Enforcement Agency (DEA) registration number;the commencement of a formal investigation; the filing of charges by theInspector General, Department of Health and Human Services;3.3.9. make timely payment of dues and assessments as may be levied from timeto time;3.3.10. discharge such other Medical Staff obligations as may be lawfullyestablished from time to time by the Medical Staff or MEC;3.3.11. provide accurate, timely information on changes of address, contactnumbers and coverage arrangements;3.3.12. comply with rules, regulations and policies related to medical records; theMedical Record policy regarding completion of medical records: MedicalRecords policy requires the timely completion of medical records. Thisincludes completion of dictation and signing of appropriate records.When records are not completed in the designated time frame, they areconsidered delinquent. Physicians are notified of their delinquent statusaccording to the Medical Record policy. Failure to complete recordsaccording to the policy shall be monitored by the Medical RecordCommittee and reported to the Medical Executive Committee. Physicianswho are repeatedly delinquent may be required to appear before theMedical Executive Committee to explain their non-compliance. TheMedical Executive Committee shall have the power to recommendcorrective action which may include counseling, letters of reprimand forthe staff members credentials file, temporary suspension of privileges, ortermination of staff privileges, for repetitive non-compliance or failure tocomplete delinquent records while under temporary suspensionStaff members shall have the right to discuss their situation with theMedical Executive Committee prior to the committee makingrecommendations for sanctions. Staff members who are recommended fortermination of medical staff privileges under this section of the bylawsshall have been considered to have voluntarily resigned from the medicalstaff, and, as such, shall not be eligible for a Fair Hearing, as definedelsewhere in the bylaws3.3.13. will maintain professional liability insurance as required by Article 15.4of this Code consistent with your specialty and clinical privileges andscope of practice3.4. General Conditions of Medical Staff Membership3.4.1 Term of Appointment: No appointment or reappointment to the MedicalStaff may exceed two years. Modification of membership or privilegesshall not extend beyond the term of appointment. Modification of- 16 -
appointment, pursuant to Section 6.6, shall be for a period extending tothe end of the then current appointment period.3.4.2 Effect of Other Affiliations: No (physician, dentist, podiatrist, psychologistor chiropractor) person shall be (automatically) entitled to Membershipon the Medical Staff or to exercise particular clinical privileges, merelybecause (he is licensed to practice in this, or in any other state, or becausehe is a member of any professional organization, or because he is certifiedby any clinical board, or because he had or presently has) of his or herMembership, status or Clinical Privileges at any other organization orfacility.3.4.3 Privileges Required: Membership by itself confers no Clinical Privileges.Members must separately apply for and hold Clinical Privileges in orderto perform patient care services.3.4.4 Fees: The MEC, by Membership vote, may impose regular dues, specialassessments, late fees and other fines upon Members.4.2.1 PROVISIONAL STATUS3.4.1.1.Initial AppointmentExcept as otherwise determined by the Board, all initialappointments to any category of the Staff, except consulting,honorary and emeritus, shall be provisional. Eachprovisional appointee shall be assigned to a Department orsuch director’s designee. An initial appointment (andrenewals thereof) shall remain provisional until theDepartment Director or his designee:a) completes a “satisfactory” evaluation of thepractitioner’s professional practice and competence.The extent of this evaluation is determined by theDepartment Director or his designee, or(b) if there is insufficient practice volume at the Hospitalto evaluate the practitioners professional practice andcompetence, “satisfactory” quality data must beobtained from the hospital where the practitioner ismost active in order for the practitioner to be(c)reappointed.upon the Department Director’s completion of a“satisfactory” evaluation, such report shall be madeto the Credentials Committee which will recommendto the MEC and the Board removal of the practitionerfrom Provisional Status.3.4.1.2.Modification in Staff Category and Clinical PrivilegesThe Executive Committee of the Medical Staff mayrecommend to the Board that a change in staff category of a- 17 -
Page 1 and 2: Mercy HospitalMedical StaffBylaws
Page 3 and 4: 6. CLINICAL PRIVILEGES.............
Page 5: 14.2. CONFIDENTIALITY IN PROFESSION
Page 8 and 9: 1.1.15. Direct Economic Competition
Page 10 and 11: currently licensed to practice medi
Page 12 and 13: specifically stated, it does not re
Page 14 and 15: qualifications, standards and requi
Page 18 and 19: current staff member, or the granti
Page 20 and 21: 4.2. ActiveMembers of the Associate
Page 22 and 23: 4.4-1 Qualifications: The consultin
Page 24 and 25: Responsibilities: Each member of th
Page 26 and 27: conducting performance monitoring a
Page 28 and 29: and procedures; length of stay patt
Page 30 and 31: clause is invoked, the applicant pr
Page 32 and 33: 6.3.5.2 compliance with performance
Page 34 and 35: 8 TEMPORARY PRIVILEGES8.1 Temporary
Page 36 and 37: supervision. The wishes of the pati
Page 38 and 39: 10 OFFICERS9.2 Department Leadershi
Page 40 and 41: (2) Four members shall be represent
Page 42 and 43: take the form of a special notice,
Page 44 and 45: Give proper notice of all staff mee
Page 46 and 47: Develop and implement departmental
Page 48 and 49: 11.2 Medical Executive Committee11.
Page 50 and 51: 11.2.5.3 Evaluating Practitioners i
Page 52 and 53: In the event of a vacancy among the
Page 54 and 55: 13 At least fifteen (15) days’ no
Page 56 and 57: 12.3.5 Meeting Proceduresconstitute
Page 58 and 59: 13.2.1.2 Below accepted standards o
Page 60 and 61: 13.2.3.8.3 Requirement for remedial
Page 62 and 63: 13.3.3 Appeal: A Member may appeal
Page 64 and 65: 13.5.5.1 Dissolve the suspension; o
Page 66 and 67:
14.3. Notice of Adverse Recommendat
Page 68 and 69:
14.6.3.1.1.A hearing occasioned by
Page 70 and 71:
14.7.6. Official Noticewhere the he
Page 72 and 73:
14.8.3.1.1.1.The Senior Vice Presid
Page 74 and 75:
14.9.4.1.The Board shall determine
Page 76 and 77:
14.11.1.Within sixty (60) days afte
Page 78 and 79:
15.2.1. Members who serve on Profes
Page 80 and 81:
17.1. The organized Medical Staff h
Page 82:
The adoption of these Bylaws supers
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Mercy Hospital Medical Staff Bylaws - Mercy Health

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