Medical Staff Bylaws - Arkansas Children's Hospital

Approved: August 2011

ARKANSAS CHILDREN'S HOSPITALBYLAWS OF THE MEDICAL STAFFTABLE OF CONTENTSARTICLE 1: NAME ................................................................................................................................ 1ARTICLE 2: PURPOSES ....................................................................................................................... 1ARTICLE 3: MEDICAL STAFF MEMBERSHIP .............................................................................. 23.1 Nature of Medical Staff Membership ................................................................................. 23.2 Conditions of Membership ................................................................................................. 23.3 Contract Staff ...................................................................................................................... 33.4 Practitioners in Administrative Roles ................................................................................. 3ARTICLE 4: CATEGORIES OF THE MEDICAL STAFF ............................................................... 44.1 The Medical Staff ............................................................................................................... 44.2 Active Medical Staff Membership ...................................................................................... 44.3 Courtesy Medical Staff Membership .................................................................................. 64.4 The Honorary/Emeritus Medical Staff ................................................................................ 6ARTICLE 5. HOUSE STAFF AND MEDICAL STUDENTS............................................................. 85.1 Nature of the House Staff.................................................................................................... 85.2 Supervision of House Staff ................................................................................................. 85.3 Role, Responsibilities, and Patient Care Activities ............................................................ 85.4 Graduate Medical Education Committee (UAMS)............................................................. 85.5 Medical Students ................................................................................................................. 9ARTICLE 6: AFFILIATED HEALTH PROFESSIONAL STAFF.................................................. 106.1 Nature of Affiliated Health Professional Staff .................................................................. 106.2 Conditions of Appointment .............................................................................................. 106.3 Appointment, Reappointment ........................................................................................... 116.4 Clinical Privileges ............................................................................................................. 116.5 Violations of Appointment ............................................................................................... 116.6 Allied Health Personnel .................................................................................................... 11ARTICLE 7: APPOINTMENT AND REAPPOINTMENT .............................................................. 127.1 General Conditions ........................................................................................................... 127.2 Application for Appointment ............................................................................................ 137.3 Appointment Process ........................................................................................................ 14i

10.13 Release .................................................................................................................. 4910.14 Exceptions To Hearing And Appellate Review Procedures ................................. 50ARTICLE 11: OFFICERS .................................................................................................................... 5211.1 Officers of the Medical Staff ............................................................................................ 5211.2 Qualifications of Officers.................................................................................................. 5211.3 Election of Officers ........................................................................................................... 5211.4 Term of Office .................................................................................................................. 5311.5 Vacancies of Office ........................................................................................................... 5311.6 Duties of Officers .............................................................................................................. 5311.7 Removal of an Officer....................................................................................................... 5411.8 Medical Director ............................................................................................................... 5411.9 Associate Medical Director(s ............................................................................................ 55ARTICLE 12: SERVICES .................................................................................................................... 5612.1 Organization of Services ................................................................................................... 5612.2 Assignment to Services ..................................................................................................... 5612.3 Qualifications, Selection, and Tenure of Service Chiefs and Vice-Chiefs ....................... 5612.4 Functions of Service Chiefs .............................................................................................. 5712.5 Functions of Vice-Chiefs .................................................................................................. 5812.6 Appointment and Functions of Section Chiefs ................................................................. 5812.7 Physician Directors of Specialized Patient Care Areas and Programs.............................. 58ARTICLE 13: COMMITTEES ............................................................................................................ 5913.1 Standing Committees ........................................................................................................ 5913.2 Appointment to Committees ............................................................................................. 5913.3 Notice of Meetings ............................................................................................................ 6013.4 Manner of Action .............................................................................................................. 6013.5 Rights of Ex Officio Members .......................................................................................... 6013.6 Removal of Members ........................................................................................................ 6013.7 Minutes ............................................................................................................................. 6013.8 Scope and Authority of Committees ................................................................................. 6113.9 Committees ....................................................................................................................... 61ARTICLE 14: MEDICAL STAFF MEETINGS ................................................................................ 7214.1 Regular Meetings .............................................................................................................. 7214.2 Special (Called) Meetings ................................................................................................. 7214.3 Agenda .............................................................................................................................. 7214.4 Delegation of Authority .................................................................................................... 7214.5 Removal of Delegated Authority ...................................................................................... 73ARTICLE 15: ATTENDANCE AND QUORUM REQUIREMENTS ............................................. 7415.1 Medical Staff General (MSG) ........................................................................................... 74iii

15.2 Medical Staff Executive Committee (MSEC) .................................................................. 7415.3 Medical Staff Committees ................................................................................................ 7415.4 Special Requirements ........................................................................................................ 74ARTICLE 16: IMMUNITY FROM LIABILITY ............................................................................... 7516.1 Confidentiality of Information .......................................................................................... 7516.2 Release from Liability ....................................................................................................... 75ARTICLE 17: RULES AND REGULATIONS .................................................................................. 77ARTICLE 18: AMENDMENTS TO BYLAWS AND RULES AND REGULATIONS ................. 78ARTICLE 19: POLICIES ..................................................................................................................... 79ARTICLE 20: ADOPTION .................................................................................................................. 8020.1 Bylaws Review ................................................................................................................. 8020.2 Approval ........................................................................................................................... 80DEFINITIONS ........................................................................................................................................ 81iv

PREAMBLEWHEREAS, Arkansas Children's Hospital is a nonprofit corporation organized under the laws ofthe State of Arkansas; andWHEREAS, its purpose is to serve as Arkansas Children's Hospital providing patient care,education, and research; andWHEREAS, it is recognized that the Medical Staff is responsible for the quality of medical carein the hospital and must accept and discharge this responsibility, subject to the ultimate authority of thehospital Board of Directors, and that the cooperative efforts of the Medical Staff, the Chief ExecutiveOfficer, and the Board of Directors are necessary to fulfill the hospital's obligations to its patients;THEREFORE, THE Board of Directors hereby organizes Physicians and Dentists into a MedicalStaff under Medical Staff Bylaws developed by the Medical Staff and approved by the Board ofDirectors. Responsibilities for medical care, for evaluation of care, and for recommendations necessaryto accomplish these functions are assigned through these Bylaws to Medical Staff Committees and/or toChiefs of Services. The Medical Staff Executive Committee is authorized by the Medical Staff to act onits behalf and to serve as its administrative representative by receiving and acting upon reports fromcommittees, Chiefs of Services, members of the Medical Staff, and hospital leadership.v

ARTICLE 1: NAMEThe name of this organization shall be the Arkansas Children's Hospital Medical Staff.The purposes of this organization are:ARTICLE 2: PURPOSES2.1 to ensure that all patients admitted to or treated in any of the facilities, departments, or services ofthe Hospital shall receive quality care;2.2 to provide a mechanism to ensure a uniform standard of quality patient care, treatment, andservices,2.3 to insure a high level of professional performance of all practitioners authorized to practice in thehospital through the appropriate delineation of the clinical privileges that each practitioner may exercisein the hospital and through ongoing review and evaluation of each practitioner's performance in thehospital;2.4 to provide an appropriate educational setting that will maintain scientific standards and that willlead to continuous advancement in professional knowledge and skill;2.5 to develop, adopt and amend Medical Staff Bylaws to be approved by the Board of Directors andto develop and maintain rules, regulations and policies for self-governance of the Medical Staff; and2.6 to create a system of rights and responsibilities between the organized Medical Staff and theBoard of Directors, and between the organized Medical Staff and its members, and2.7 to provide a means by which issues concerning the Medical Staff and the hospital may bediscussed by the Medical Staff with the Board of Directors and the Chief Executive Officer/President.2.8 to enforce the Medical Staff Bylaws, Rules, Regulations, and policies by recommending action tothe Board of Directors.1

3.1 Nature of Medical Staff MembershipARTICLE 3: MEDICAL STAFF MEMBERSHIP3.1.1 Only Physicians and Dentists licensed to practice in the State of Arkansas, who candocument their background, experience, training and demonstrated competence, their adherence to theethics of their profession, their good reputation, their ability to work with others, and who attest that theyare physically and mentally qualified to carry out their required professional duties, with sufficientadequacy to assure the Medical Staff and the Board of Directors that any patient treated by them in theHospital will be given a high quality of medical care, shall be qualified for membership on the MedicalStaff.3.1.2 No Physician or Dentist shall be entitled to membership on the Medical Staff or to theexercise of clinical privileges in the Hospital merely by virtue of the fact that he/she is duly licensed topractice medicine or dentistry in this or any other state, or that he/she is a member of any professionalorganization, or that he/she had in the past, or presently has, such privileges at another hospital.3.1.3 Qualified professionals may apply for membership in the Affiliated Health ProfessionalStaff, as described in these Bylaws.3.2 Conditions of Membership3.2.1 Acceptance of membership on the Medical Staff shall constitute the staff member'sagreement that he/she will strictly abide by the general principles of medical and/or dental ethics and theCode of Conduct of Arkansas Children’s Hospital, and will conduct professional Medical Staff servicesin a manner that complies with all relevant governmental statutes, rules and regulations.3.2.2 Every application for staff membership shall be signed by the Applicant and shall containthe Applicant's specific acknowledgment of each Medical Staff member's obligations to providecontinuous care and supervision of his/her patients, to abide by the Bylaws, Rules andRegulations/policies and procedures of Arkansas Children's Hospital and its Medical Staff, to acceptcommittee assignments and to accept consultation assignments.3.2.3 As a condition of Medical Staff membership and/or the exercising of clinical privileges,staff members agree to cooperate with for cause drug testing and evaluation for mood-alteringsubstances, if so requested by an officer of the Medical Staff and/or representative of the Medical StaffHealth Committee, and with random drug screening as designed by the Medical Staff Health Committeeand approved by the MSEC. Further, as a condition of Medical Staff membership, Applicants will agreeto abide by the recommendations/contracts set forth by the MSHC.3.2.4 Practitioners, who do not participate in the teaching program, are not subject to denial ofMedical Staff membership or limitation of clinical privileges for this reason alone.2

3.3 Contract Staff3.3.1 Certain Physicians and licensed independent practitioners may from time to time beengaged by ACH under exclusive contract, either full or part-time, to provide clinical, administrative,teaching or support services that necessitate staff appointment and delineation of specific clinicalprivileges.3.3.2 Such contracts shall be entered into with the concurrence of the MSEC and suchappointment and privileges shall be obtained in accordance with procedures set forth in these Bylaws.3.3.3 Appointment and privileges extended pursuant to such contracts shall be contingent uponcontinuation of the contract. Upon termination of such contract for any reason or if he/she ceases to beaffiliated with the contract group, the Physician’s or Practitioner's appointment and clinical privilegesextended pursuant to such contract shall automatically terminate. In the event of such termination ofstaff appointment and/or clinical privileges, no rights to a fair hearing or appeal process provided inthese Bylaws shall apply. Any such termination shall not be considered an adverse action for thepurposes of these Bylaws or any state or federal reporting requirements.3.4 Practitioners in Administrative Roles3.4.1 Each Physician/Practitioner serving in a medical-administrative position by contract oragreement shall exercise only such clinical privileges as are granted to him/her and must meet the basicresponsibilities for staff appointment in addition to any required by the express terms of his/her contractor agreement with the Hospital.3.4.2 The resignation or removal of a Physician or Dentist from a medical administrativeposition within the hospital will not in itself be cause for that practitioner to lose his or her Medical Staffmembership and privileges.3

ARTICLE 4: CATEGORIES OF THE MEDICAL STAFF4.1 The Medical Staff4.1.1 The Medical Staff shall be divided into Active, Courtesy, and Honorary/Emeritus.4.1.2 Unless otherwise specified during the credentialing process, active Medical Staff haveadmitting privileges and are granted clinical privileges.4.1.3 Each member of the Medical Staff is assigned to a clinical department.4.1.4. Members of the Medical Staff may participate in educational activities.4.1.5 Visiting Faculty or Visiting Physicians may be granted privileges consistent withrequirements in these Bylaws. Visiting Faculty and Visiting Physicians are not given appointments asmembers of the Medical Staff.4.2 Active Medical Staff Membership4.2.1 Active Medical Staff members are Physicians and Dentists who meet at least one of thefollowing criteria:A. admit or treat patients at an ACH site, defined as treating no less than five (5)patients per year, averaged over two (2) years,B. provide care in the ACH EmergencyDepartment,C. provide consultations at an ACH site, orD. are assigned call coverage at ACH on a regular basis in accordance with MedicalStaff Rules and Regulations.4.2.2 Active Medical Staff members are eligible to vote and to hold office.4.2.3 Active Medical Staff members may be assigned to Medical Staff committees and arerequired to attend the annual meeting of the Medical Staff unless excused.4.2.4 Active Medical Staff members, who treat less than five (5) patients per year, averagedover two (2) years, are required to provide adequate volume and clinical performance data , as definedby the Chief of Service and approved by the Credentials Committee of the Medical Staff.4.2.5 Medical Staff members who do not meet the criteria for Active staff status will bechanged to courtesy status at the time of reappointment.4

4.2.6 Active Medical Staff are responsible for History and Physical Examinations (H&P). Acomplete admission history and physical examination will be recorded within 24 hours after admissionbut prior to surgery or a procedure requiring anesthesia.4.2.6.1 The H&P shall include, at a minimum, the following information for allinpatient admissions.1. Chief complaint, reason for the admission or procedure, description of present illness2. Medical history (including past and present diagnoses, illnesses, operations,medications, and allergies), family history, age-appropriate social/developmentalhistory3. Full review of systems and relevant physical findings4. Documentation of medical decision-making including a review of diagnostic testresults; response to prior treatment; assessment, clinical impression or diagnosis; planof care; evidence of medical necessity and appropriateness of diagnostic and/ortherapeutic services; counseling provided, and coordination of care4.2.6.2 A focused H&P examination may be used for non-complex outpatienttreatments or procedures on non-complex patients that do not require general anesthesia. The focusedH&P examination report should, at a minimum, include the following:1. Chief complaint or reason for the procedure;2. A problem-focused history; past medical history including allergies and currentmedications;3. Physical examination including an examination of the heart and lungs and the affectedbody area necessitating the outpatient treatment or procedure; pertinent laboratory orradiologic testing results;4. Clinical impression and plan of care.4.2.6.3 When using an H & P that was completed within 30 days before admission, anupdate documenting any changes in the patient’s condition is completed within 24 hours after admission,but prior to surgery or a procedure requiring anesthesia services. The update must include a statementthat the patient was examined and any changes noted during this exam. When an H&P older than 24hours is used, a legible copy of the H&P must be placed in the patient's hospital medical record.5

4.2.6.4 If the H&P has been written by a physician who is not a member of the ACHmedical staff, the update at the time of admission must be by a member of the Medical Staff or otherpractitioner who has the privilege to do so.4.2.6.5 When the H&P is not recorded before an operation or any potentiallyhazardous diagnostic procedure, the procedure shall be canceled, unless the primary physician states thatsuch delay would be life threatening to the patient. The reason for the decision shall be documented.4.2.6.6 If a patient is initially admitted as observation status but remains in thehospital for greater than 24 hours and if a limited H&P was performed at the time of admission toobservation status, the physician should note the change of status in the progress notes and documentadditional information or findings necessary for a complete inpatient H&P.4.2.6.7 The clinical attending physician will countersign the inpatient H&P whenrecorded by a member of the house staff or by affiliated staff with appropriate privileges.4.3 Courtesy Medical Staff Membership4.3.1 Courtesy Medical Staff members may not admit, treat, or write orders for patients at anACH site. They may visit patients and document data from their own patients in the ACH progressnotes.4.3.2 Courtesy Medical Staff members may order outpatient diagnostic testing. The orderingphysician retains responsibility for care, management, and follow-up of the patient.4.3.3 Courtesy Medical Staff Members may have access to ACH data for patients for whomthey provide treatment in their own practice.4.3.4 Courtesy Medical Staff members are eligible for membership on the MSEC.4.3.5 Courtesy Medical Staff members are not required to serve on Medical Staff committeesor to attend the annual meeting of the Medical Staff.4.3.6 Courtesy Medical Staff members who meet the criteria for active status will be changedto active.4.4 The Honorary/Emeritus Medical Staff4.4.1 The Honorary/Emeritus Medical Staff shall consist of Physicians and Dentists who arenot active in the Hospital but are honored by emeritus positions. These may be Physicians, Dentists, andothers who have retired from active hospital practice or who are of outstanding reputation, notnecessarily residing in the community.4.4.2 Honorary/Emeritus Medical Staff are nominated to this emeritus position by an ActiveMedical Staff member and approved by the MSEC and approved by the Board of Directors.6

4.4.3. Honorary/Emeritus Medical Staff do not have admitting or clinical privileges and will nottreat patients at the Hospital but may continue to participate in educational activities.4.4.4 Honorary/Emeritus Staff members shall not be eligible to vote, to hold office, or to serveon standing Medical Staff committees.4.4.5 The Honorary/Emeritus Medical Staff are not required to seek reappointment.7

ARTICLE 5. HOUSE STAFF AND MEDICAL STUDENTS5.1 Nature of the House Staff5.1.1 The House Staff shall consist of practitioners who have been assigned clinical rotations atArkansas Children's Hospital by virtue of their appointment in a University of Arkansas College ofMedicine medical training program or fellowship.5.1.2 Members of the House Staff are not eligible to admit patients or to hold office but mayfunction in the clinical areas of the Hospital within the limitations of their appointment. They may beasked to serve on a Professional Partnership Committees and may vote as a member of the committee.One General Pediatric Chief Resident may be asked to serve on the Medical Staff Health Committee andwill have voting rights.5.2 Supervision of House Staff5.2.1 Members of the House Staff are directly responsible to respective Chiefs of Service andto the Medical Director for clinical aspects of patient care.5.2.2 Members of the House Staff must comply with pertinent Medical Staff Rules andRegulations and hospital policies/procedures.5.2.3 During their rotation at ACH, members of the house staff are supervised by members ofthe Active Medical Staff who serve as teaching attending Physicians. Consistent with the privileges ofthe teaching attending, certain duties and responsibilities may be delegated by a member of the MedicalStaff according to the house officer's capabilities and experience.5.2.4 Examples of supervision include review by the teaching attending of all admissions, cosigningof history and physical examinations and operative and procedure reports, clinical rounds,availability for consultation, and co-signing of discharge summaries.5.3 Role, Responsibilities, and Patient Care ActivitiesWritten descriptions of the role, responsibilities, and patient care activities of house staff are establishedby the Chief of each respective service and the Residency and Fellowship Director, (consistent with theAccreditation Council Graduate Medical Education Guidelines). These descriptions are submitted to theMSEC for approval.5.4 Graduate Medical Education Committee (UAMS)5.4.1 The Medical Director or his/her designee will be a standing member of the UAMSGraduate Medical Education Committee (GMEC) and serve as a liaison for communication between theGMEC and ACH Medical Staff and Board of Directors.8

5.4.2 The Medical Director or his/her designee will communicate to the Medical Staff and theBoard of Directors about the patient care, treatment, and services provided by, and the relatededucational and supervisory needs of, its participants in the professional graduate education programs.5.4.3 The Medical Director shall communicate information to the GMEC about the quality ofcare, treatment, and services and educational needs of the house staff.5.5 Medical Students5.5.1 UAMS medical students or students visiting from other LCME accredited Colleges ofMedicine taking part in student electives are allowed to provide supervised care at Arkansas Children’sHospital under the direction of active members of the ACH Medical Staff.5.5.2 Students must be appropriately certified as having completed training inpatientconfidentiality issues, such as HIPAA.5.5.3 Students are allowed to perform history and physical examinations, take part in thegeneral care of the patients, and perform procedures commensurate with their level of training as judgedappropriate by their supervisor.5.5.4 Students may make notes in official patient records. Orders must be cosigned by amember of the Medical Staff or house staff as specified in the Rules and Regulations of the MedicalStaff.9

ARTICLE 6: AFFILIATED HEALTH PROFESSIONAL STAFF6.1 Nature of Affiliated Health Professional Staff6.1.1 Affiliated Health Professional Staff are non-Physicians who hold advanced degrees andprovide patient services independently.6.1.2 This non-Physician category includes, but is not limited to: Advanced Practice Nurses,Physician’s Assistants, and Licensed Clinical Psychologists, Doctoral Pharmacologists and Optometrists.6.1.3 Affiliated Health Personnel may render patient services within the confines of ACH andits clinics in accordance with the clinical privileges they have been granted. While carrying out activitiesat ACH, Affiliated Health Personnel will follow the Bylaws/Rules and Regulations of the Medical Staffand policies and procedures of the hospital.6.2 Conditions of Appointment6.2.1 Conditions of appointment and membership for the Affiliated Health Professional Staffshall be as outlined in Bylaws of the Medical Staff.6.2.2 Appointments to the Affiliated Health Professional staff confer on the appointee onlysuch clinical privileges as have been granted by the Board of Directors. Members of the AffiliatedHealth Professional Staff do not have admitting privileges, cannot serve as clinical attending forinpatients, nor can they be granted privileges outside the scope of their license.6.2.3 Affiliated Staff may practice independently in clinic settings consistent with theirprivileges and within the scope of their licenses. A member of the medical staff is required to beavailable (although not required to be physically present in the clinic). Documentation of clinic notesand orders do not require co-signature.6.2.4 Acceptance of membership in the Affiliated Health Professional Staff shall constitute thestaff member’s agreement that he/she will abide by the Medical Staff Bylaws, Rules and Regulations, theapplicable policies and procedures of Arkansas Children's Hospital, and the Code of Conduct ofArkansas Children's Hospital.6.2.5 Members of the Affiliated Health Professional Staff may attend meetings of the generalMedical Staff, but without vote.6.2.6 The member may be appointed by the Chief of Staff to serve on committees of theMedical Staff. Such appointment by the Chief of Staff confers the right to vote on such matterspresented to that committee.10

6.3 Appointment, ReappointmentProcedures for appointment and reappointment of Affiliated Health Professional Staff shall be consistentwith the Bylaws of the Medical Staff and in accordance with hospital policy.6.4 Clinical Privileges6.4.1 Clinical privileges for Affiliated Health Professional Staff shall be granted as outlined inthe Medical Staff Bylaws and/or Medical Staff policy, as appropriate to the privileges being granted.6.4.2 Members of the Affiliated Health Professional staff shall be assigned to the ClinicalService in which most of the privileges are performed.6.4.3 Advanced practice nurses may be granted privileges for prescriptive authority if the nurseholds the appropriate license, if recommended by the MSEC, and if approved by the Board of Directors.(Refer to Medical Staff Rules and Regulations re: orders and entries into the medical record.)6.5 Violations of AppointmentAny violation of the standards set forth within these Bylaws, Rules and Regulations will be reported tothe MSEC through the Medical Director for appropriate action.6.6 Allied Health Personnel6.6.1 Allied Health Personnel are health practitioners (1) functioning under the supervision of amember of the Active Medical Staff and (2) are NOT employees of Arkansas Children's Hospital. Thiscategory includes, but is not limited to, registered nurses, registered nurse practitioners (RNP), orthotists,dental assistants, and surgical assistants.6.6.2 Allied Health Personnel may render patient services in accordance with their jobdescription and/or clinical practice agreements.6.6.3 While carrying out activities at ACH, Allied Health Personnel will follow theBylaws/Rules and Regulations of the Medical Staff and policies and procedures of the Hospital.6.6.4 Individuals in this category follow procedures consistent with human resourcerequirements for employees. Refer to Medical Staff Policy/Procedure: In-Processing and Verification ofCompetency of Allied Health Personnel.6.6.5 Allied Health Professional Staff are NOT entitled to the procedural right of reviewafforded by the Medical Staff Bylaws to Medical Staff Members.11

7.1 General ConditionsARTICLE 7: APPOINTMENT AND REAPPOINTMENT7.1.1 Initial appointments and reappointments to the Medical Staff shall be made by the Boardof Directors. The Board of Directors shall act on appointments, reappointments, or the revocation ofappointments only after there has been a recommendation from the Medical Staff as provided in theBylaws. In the event of an extended delay (defined as 70 business days between the dates when theapplication is presented to the MSEC and the date that the MSEC makes a recommendation on theapplication), the Board of Directors may act without such recommendation on the basis of documentedevidence of the Applicant’s or staff member’s professional and ethical qualifications obtained fromreliable sources other than the Medical Staff.7.1.2 All appointments and reappointments are for a period not to exceed two (2) years.7.1.3 Time periods specified in these bylaws are intended to provide a guideline for theprocessing of applications for initial staff appointment and reappointment. Deviations from the timeperiods herein shall not be grounds for invalidating the action taken.7.1.4 The Practitioner applying for staff appointment or reappointment must continuouslyupdate his/her application with the most current information available. Failure to do so may constitutegrounds for denial or revocation of Medical Staff appointment and/or privileges.7.1.5 Withholding requested information, providing false or misleading information or failureto adequately complete documents used for the purpose of credentialing and privileging, shall, in and ofitself, constitute a basis for investigation and possible disciplinary action, up to and including denial orrevocation of Medical Staff appointment and/or privileges. (Refer to Section 9.2 Investigation ofAllegations of Conduct or Performance of Practitioner).7.1.6 As required by Arkansas law, the Arkansas State Medical Board CentralizedCredentialing Verification Service (CCVS) must be used for primary source verifications. ArkansasChildren’s Hospital may request information not provided by the CCVS.7.1.7 By applying for appointment to the Medical Staff, each Applicant therebyA. Signifies his/her willingness to appear for interviews in regard to his/herapplication,B. Authorizes the Hospital to consult with members of hospital Medical Staffs withwhom he/she has been associated and with other people or agencies who may haveinformation bearing on his/her competence, character, and ethical qualifications,consents to the hospital's inspection of all records and documents that may bematerial to an evaluation of his/her professional qualifications and competence tocarry out the clinical privileges requested as well as of his/her moral and ethicalqualifications for staff membership.12

C. Agrees to be bound by the provisions of these Bylaws and the Medical Staff Rulesand Regulations, regardless of whether the application is approved;D. Represents and warrants that all information provided is true, correct and completein all material respects and agrees to notify ACH of any change in any of theinformation furnished; andE. Pledges to provide continuous care for his/her patients.7.1.8 The Applicant releases from liability all representatives of the hospital and its MedicalStaff for acts performed in good faith and without malice in connection with evaluating him/her andhis/her credentials, and releases from any liability all individuals and organizations who provideinformation to the Hospital in good faith and without malice concerning his/her competence, ethics,character, and other qualifications for staff appointment and clinical privileges, including otherwiseprivileged or confidential information.7.1.9 Upon recommendation by an ACH Service Chief, exceptions to requirements formembership or privileges may be made with approval by two-thirds (2/3) of voting members of theMSEC and two-thirds (2/3) of the voting members of the Board of Directors.7.2 Application for Appointment7.2.1 All applications for Medical Staff membership and for clinical privileges shall be inwriting, submitted on a form approved by the Board of Directors after consultation with MSEC, andshall be signed by the Applicant. The application shall contain consent to the release of information.Applications must be returned within three (3) months of the date sent or the application will not beprocessed.7.2.2 The Applicant shall have the burden of producing adequate information to properlyevaluate his/her competence, moral and ethical character, and other qualifications, and to resolve anydoubts about such qualifications.7.2.3 Information requested on the application shall be completed by the Applicant and verifiedby the Hospital or the CCVS. An application will be considered complete when all documents requestedand verifications are received by Medical Staff Services.7.2.4 If a history of practice-limiting health problems is identified, the practitioner mustprovide documentation as evidence of his/her current health status and receive a positiverecommendation from the Medical Staff Health Committee Chairperson (or designee).7.2.5 The application form will include a statement that the Applicant has received, read, andagreed to the following:13

A. To abide by the Bylaws, Rules and Regulations/Policies and Procedures ofArkansas Children’s Hospital and its Medical Staff and to be bound by the termsthereof, if granted membership on the Medical Staff and/or clinical privileges.B. To abide by the ACH Code of Conduct and to conduct professional staff medicalservices in a manner compliant with all relevant governmental statutes, rules andregulations.7.3 Appointment Process7.3.1 The MSEC will make a written recommendation of its evaluation/assessment to theCredentialing Committee of the Board of Directors (see Hospital Bylaws), including a recommendationthatA. the practitioner be appointed to the Medical Staff (including the clinical privilegesto be granted and a focused professional practice evaluation),B. he/she be granted limited membership and privileges and the conditions of thelimitation,C. that he/she be denied for Medical Staff membership and/or privileges, orD. that his/her application be deferred for further consideration.7.3.2 Prior to making this report and recommendation to the Credentialing Committee of theBoard of Directors, the MSEC will examine the evidence of the moral and ethical character, professionalcompetence, qualifications of the practitioner and will determine from information contained in theapplication,, whether the practitioner has established and meets all of the necessary qualifications for thecategory of staff membership and the clinical privileges requested. The MSEC may, but is not requiredto conduct an interview with the Applicant. If so conducted, this interview shall not constitute a hearingand none of the procedural rules provided in these Bylaws with respect to a hearing shall apply.7.3.3 When the recommendation of the MSEC is to defer the application for furtherconsideration, it must be followed up at the next scheduled meeting with a subsequent recommendationfor an enhanced Focused Professional Practice Evaluation (FPPE) monitoring plan or for denial ofMedical Staff membership and privileges. The affected practitioner will be notified by the Chief of Staffof the decision of the MSEC to defer his or her application.7.3.4 When the recommendation of the MSEC is to recommend the practitioner forappointment and requested privileges, the Chief of Staff will promptly forward it, together with allsupporting documentation, to the Credentialing Committee of the Board of Directors.7.3.5 When the recommendation of the MSEC is to deny the Practitioner appointment orclinical privileges, the Chief Executive Officer, Chief of Staff, or Medical Director will notify thePractitioner by certified mail, return receipt requested within 3 business days.14

7.3.5.1 The notice will include a brief general description of the credentialing or peerreview considerations that led to the negative recommendation, as well as the right to a fair hearing andappeal process, and the deadline for requesting a hearing.7.3.5.2 No adverse recommendation need be forwarded to the Board of Directors untilafter the Practitioner has exercised or has been deemed to have waived his or her right to a hearing asprovided in these Bylaws.7.3.5.3 If, after the MSEC has considered the report and recommendation of thehearing committee and the hearing record, the Committee's reconsidered recommendation is favorable tothe Practitioner, it will be processed in accordance with the Bylaws by the Board of Directors. If therecommendation remains adverse, the Chief Executive Officer will promptly so notify the Practitioner,by certified mail, return receipt requested. The Chief Executive Officer will also forward suchrecommendation and documentation to the Board of Directors. The Board of Directors will take noaction on the recommendation until after the Practitioner has exercised or has been deemed to havewaived his/her right to an appellate review as provided in these Bylaws.7.3.5.4 At its next regular meeting after receipt of a favorable recommendation, theBoard of Directors or its Executive Committee will act in the matter. If the Board of Director’s decisionis adverse to the Practitioner with respect to either appointment or clinical privileges, the ChiefExecutive Officer will promptly notify him/her of the adverse decision by certified mail, return receiptrequested, and the adverse decision will be held in abeyance until the Practitioner has exercised or hasbeen deemed to have waived his/her rights under these Bylaws.7.3.5.5 At its next regular meeting after all of the Practitioner's rights have beenexhausted or waived, the Board of Directors or its duly authorized committee will act in the matter. TheBoard of Director’s decision will be conclusive, except that the Board of Directors may defer finaldetermination by referring the matter back for further reconsideration. Any referral back will state thereasons, will set a time limit within which a subsequent recommendation to the Board of Directors willbe made, and may include a directive that an additional hearing be conducted to clarify issues which arein doubt. At its next regular meeting after receipt of subsequent recommendation, and new evidence inthe matter, if any, the Board of Directors will make a decision either to appoint the Practitioner to thestaff or to reject him/her for staff membership. All decisions to appoint will include a delineation of theclinical privileges which the Practitioner may exercise.7.3.5.6 Whenever the Board of Director’s decision is contrary to the recommendationof the MSEC, the Board of Directors will submit the matter to the Chief of Staff for review andrecommendation and will consider this recommendation before making its decision final.7.3.5.7 When the Board of Director’s decision is final, it will send notice of thedecision through the Chief Executive Officer to the Chief of Staff, to the Chief of Service concerned,and by certified mail, return receipt requested, to the Practitioner.15

7.4 Reapplication After Adverse Decision Denying Application, Adverse Corrective ActionDecision, or Resignation in Lieu of Disciplinary Action7.4.1 A present or former Applicant or Practitioner shall not be eligible to apply or reapply forStaff Appointment and/or Clinical Privileges affected by a previous action for a period of at least thirtysix(36) months who has:A. received a final adverse decision regarding application or reapplication for StaffAppointment or Clinical PrivilegesB. withdrawn his/her application or reapplication for Staff Appointment or clinicalPrivileges following an adverse recommendation by the MSEC, CredentialingCommittee of the Board of Directors, or the Board of Directors; orC. received a final adverse decision resulting in suspension or termination, limitationor restriction of Staff Appointment or Clinical Privileges; orD. resigned, surrendered, failed to reapply, or failed to pursue a hearing and other dueprocess rights under these Bylaws for Appointment or Clinical Privileges followingan automatic suspension or an adverse recommendation by the MSEC,Credentialing Committee of the Board of Directors, or the Board of Directors. Suchineligibility shall extend for a period of at least thirty-six (36) months from the datethe adverse decision became final, the date the application or request waswithdrawn, the date on which the procedural rights were deemed to be waived, orthe date resignation became effective, whichever is applicable.7.4.2 For the purpose of this Section, a decision shall be considered adverse if it is based on thetype of occurrence directly pertaining to medical or ethical conduct which might give rise to a correctiveaction. Examples of actions that are not considered adverse are failure to maintain a practice in the area(which could be cured by a move), failure to maintain malpractice insurance coverage (which could becured by securing such insurance) or failure to renew a license in a timely manner (which could be curedby renewing).7.4.3 After the thirty-six (36) month period, the former Applicant or Practitioner may submit anapplication for Staff Appointment and/or Clinical Privileges which shall be processed as an initialapplication. The former Applicant, Practitioner or former Practitioner shall also furnish evidence thatthe basis for the earlier adverse recommendation or action no longer exists and/or of reasonablerehabilitation in those areas which formed the basis for the previous adverse recommendation or action,whichever is applicable. In addition, such applications shall not be processed unless the Applicant,Practitioner or former Practitioner submits satisfactory evidence to the MSEC that he/she has compliedwith all of the specific requirements any such adverse decision may have included, such as completion oftraining or proctoring conditions.16

7.5 Reappointment Process7.5.1 Formal application for membership reappointment and/or privileges must be made atleast every two years.7.5.2 A reappointment application will be considered complete when all documents requestedand verifications are received by Medical Staff Services.7.5.3 Reappointment of a Medical Staff member and the clinical privileges to be granted uponreappointment will be based upon at least the following:A. the member's professional competence and clinical judgment in the treatment ofpatients,B. if the Practitioner has exercised the requested privileges with sufficient frequency toindicate current competence,C. his/her ethical practice and conduct,D. current Arkansas licensure,E. a statement from the Applicant that no health problems exist that could affecthis/her ability to perform the privileges requested,F. attendance at Medical Staff meetings and participation in staff affairs,G. evidence of participation in continuing medical education that relate, in part, toindividual clinical privileges,H. compliance with Bylaws, Rules and Regulations and policies/procedures of MedicalStaff and Arkansas Children's Hospital,I. cooperation with hospital personnel,J. relations with other practitioners, andK. general attitude toward patients, the hospital, and the public.This information will become a part of the permanent files of the hospital.7.5.4 Thereafter, the procedure provided in these Bylaws relating to requirements onapplications for initial appointment will be followed.7.5.5 Prior to scheduled meetings of the Credentialing Committee of the Board of Directors,the MSEC will review all pertinent information available on each practitioner scheduled for periodicappraisal, for the purpose of determining its recommendations for reappointment to the Medical Staff17

and for the granting of clinical privileges for the ensuing period, and will transmit its recommendations,in writing, to the Credentialing Committee. Where non-reappointment or a change in requested clinicalprivileges is recommended, the reason for the recommendation will be documented and therecommendation presented to the Board of Directors or its Executive Committee. (Refer to the Role ofthe Credentialing Committee of the Board of Directors for reappointment applications which must betaken to the Board of Directors or its Executive Committee.)7.6 Leave of AbsenceA member of the Medical Staff, who has been granted membership and privileges, must obtain avoluntary leave of absence (not to exceed one year) for reasons such as medical (See LicensedIndependent Practitioner Medical Leave of Absence Policy) or non-medical reasons such as study,military service, locum tenens status, or other valid causes, by submitting written notice, approved by therespective service chief, to the MSEC. Non-medical leaves of absence must be obtained if the leaveexceeds 90 days. A leave of absence will be reported to the Board of Directors upon receipt of suchrequest and recommendation of the MSEC.If there is a temporary interruption in the ability of the physician to carry out his/her privileges (e.g.extended acute illness, critical medical event, change in medical status) not requiring a Medical Leave ofAbsence, refer to Licensed Independent Practitioner Medical Leave of Absence Policy.7.6.1 While on a leave of absence, Medical Staff membership and privileges are suspended.7.6.2 If, during the Leave of Absence, the Medical Staff member’s 2-year reappointment is due,the Medical Staff member shall complete the reappointment process or be considered to have voluntarilyresigned.7.6.3 Termination of Leave of Absence: At the end of the leave of absence, or at any earliertime, the staff member may request reinstatement of his/her privileges and prerogatives by submitting awritten request to the MSEC.A. If the Medical Staff member has completed/maintained the reappointment process,the Medical Director or Chief of Staff may approve immediate reinstatement onbehalf of the MSEC.B. Failure to request reinstatement or provide the requested summary of activities,without sufficient cause, shall be considered a voluntary resignation of MedicalStaff membership and clinical privileges upon expiration of the leave of absenceexpired and the lapse of reappointment.C. If the leave of absence was for medical reasons, see Licensed IndependentPractitioner Medical Leave of Absence Policy.7.7 Resignations: Resignation from the Medical Staff, and the reason for such, shall be submitted inwriting to the respective service chief and the MSEC. The MSEC will forward a communication to theBoard of Directors in relationship to the resignation.18

7.7.1 In cases where a Medical Staff member moves away from the area without submitting inwriting his/her intentions regarding staff appointment, the practitioner shall be terminated from theMedical Staff after notification by the respective service chief to the Medical Director or Chief of Staff.The MSEC and the Board of Directors will be informed of the change of status.7.7.2 The failure of a Medical Staff member to return a completed reappointment form, as wellas inclusion of all necessary attachments, within 60 days of mailing of the reappointment forms shall bedeemed a voluntary resignation of Medical Staff membership and privileges, without right of hearing orappellate review.7.8 Reinstatement: A Practitioner, who has voluntarily resigned while in good standing, mayqualify for reinstatement if no more than 12 months have elapsed and if their scheduled reappointmentdid not occur during this 12-month period.7.8.1 The Practitioner must submit a written request for reinstatement, along with a writtensummary of his/her relevant activities during the previous period. All information within the member’sfile will be updated and evidence of current competence must be provided, as requested. .7.8.2 Unless the practitioner meets the exception in 7.8.3, the request for reinstatement will beforwarded to the Chief of Service and/or Section Chief for approval and then to the MSEC andCredentialing Committee of the Board of Directors.7.8.3 Practitioners suspended for failure to renew their license or because of lack of malpracticecoverage, may be immediately reinstated upon proof of compliance if the Practitioner is in compliancewith all other requirements of Medical Staff membership, was in good standing at the time that the noncompliantissue occurred, and the suspension was five working days or less.19

ARTICLE 8: CLINICAL PRIVILEGES8.1 Clinical Privileges8.1.1 Every Practitioner practicing at this Hospital by virtue of Medical Staff membership orotherwise, will, in connection with such practice, be entitled to exercise only those clinical privilegesspecifically granted to him/her by the Board of Directors.8.1.2 The Hospital may grant privileges only for clinical care that is supported by Hospitaldepartments and services.8.2 Application for Privileges and Renewal of Clinical Privileges (Refer to Medical Staff PeerReview Program Policy)8.2.1 Applications for appointment and reappointment to the Active Medical Staff and ActiveAffiliated Staff must contain a request for the specific clinical privileges desired by the Applicant. TheApplicant has the burden of providing reasonable evidence to establish his/her qualifications andcompetency to perform the clinical privileges requested.8.2.2 The evaluation of the requests for privileges shall be based upon the Applicant'seducation, training, experience, demonstrated competence, peer recommendations, and other relevantinformation, including an appraisal by the service in which privileges are sought. Peer recommendationswill include written information regarding the Applicant’s medical/clinical knowledge, technical andclinical skills, clinical judgment, interpersonal skills, communication skills, and professionalism.8.2.3 A Focused Professional Practice Evaluation (FPPE) is required for all initially requestedprivileges.A. Criteria and methods for conducting this evaluation are established by the ServiceChief and approved by the Credentials Committee of the Medical Staff.B. Unless otherwise stated in the FPPE Plan, the duration of monitoring will be for adefined period of time, as described within the policy. Any modifications orextensions of the FPPE period will be reported by the Chief of Service (or SectionChief designee) to the Credentials Committee.8.2.4 Reassessment for clinical privileges requires demonstration of clinical competence asshown through Ongoing Professional Practice Evaluation (OPPE), monitoring and evaluation, peerrecommendations, and/or consideration of participation in continuing education activities that relate, inpart, to the privileges sought.A. If the Applicant has little or no activity at ACH identified in OPPE reports duringthe two (2) year appointment period, the Credentials Committee of the MedicalStaff will decide what, if any, evidence beyond peer recommendations is required.20

Applicant may be considered ineligible for reappointment if he/she is unable toprovide evidence of activity.B. If the Applicant fails to meet the requirements for renewal of privileges, theapplicant may withdraw his/her request for the privilege or with the approval of theChief of Service (or Section Chief designee) enter into a modified FPPE plan thatshould reasonably allow the Applicant to successfully complete the renewal ofprivileges requirement.8.2.5 The Applicant may withdraw or revise a request for specific clinical privileges during theFPPE period or at renewal of privileges. Withdrawal or revision of a request for clinical privileges madeby the Applicant is not reportable to the National Practitioner Data Bank.8.3 Applications for Additional PrivilegesApplications for additional clinical privileges must be in writing and will be processed and evaluated inthe same manner as the original application. A FPPE is required for additional privileges.8.4 Notification of Privilege StatusWhen the Board of Directors has made the decision to grant, deny, revise or revoke privilege(s), thisinformation is disseminated and made available to all appropriate internal and/or external persons orentities, as defined by the Hospital, Medical Staff, and applicable law.8.5 Dental Privileges8.5.1 Privileges granted to Dentists will be based on their license, training, experience, anddemonstrated competence and judgment.8.5.2 The scope and extent of surgical procedures that each Dentist may perform will bespecifically delineated and granted in the same manner as all other surgical privileges.8.5.3 Surgical procedures performed by Dentists will be under the overall supervision of theChief of Dentistry. Dentists with expanded privileges for Oral and Maxillofacial surgery will also beunder the overall supervision of the Chief of Otolaryngology.8.5.4 All dental patients will receive the same medical assessment as patients admitted to othersurgical services. A Physician member of the Medical Staff will be responsible for the care of anymedical problem that is present at the time of admission or that may arise during hospitalization.8.6 DEA8.6.1 If Clinical Privileges are requested which include the prescribing of controlledsubstances, the practitioner must maintain current DEA certification Whenever a practitioner’s DEAcertificate expires, is revoked, limited, or suspended, the practitioner shall automatically andcorrespondingly be divested of the right to prescribe medications covered by the certificate, as of the21

date such action becomes effective and throughout its term. If the Practitioner allows his/her DEA toexpire, the Practitioner will immediately notify the Service Chief and, if applicable, the Section Chief.Restrictions for failure to renew a DEA certificate will be removed as soon as the renewed DEAcertificate is received.8.7 Liability Insurance/Actions8.7.1 Each member of the Medical Staff is required to have a minimum of $1,000,000 (peroccurrence) liability insurance for practice at an ACH site with a company licensed or approved by thisstate. Members will provide documentation that he or she possesses continuous malpractice insurancecoverage (See Automatic Suspension). Such certification shall include the name of the carrier, theperiod of coverage, and a copy of the certificate of insurance that verifies compliance with thisrequirement.8.7.2 Physicians, Dentists, and Affiliated Health Practitioners who apply for privileges in thisHospital or who reapply for continuation of privileges must specify if any professional liability actionsagainst them have reached final judgment or settlement and, if so, the results.8.8 Temporary Clinical Privileges8.8.1 Temporary clinical privileges may be granted under the following circumstances:A. to fulfill an important patient care need by a physician or dentist who is not amember of the Medical Staff orB. when an Applicant with a completed application without any area of concern isawaiting review and approval of the MSEC and the Board of Directors.8.8.2 Temporary clinical privileges can be granted on a case by case basis when there is animportant patient care need. Examples may include when existing Medical Staff with appropriateprivileges cannot provide adequate coverage to support patient care or when the appropriate skills orneeded privilege is not available from a member of the Medical Staff8.8.2.1 The request for temporary clinical privileges for important patient care needwill be made in writing by the applicable Chief of Service (or Section Chief designee) with arecommendation from the Chief of Staff (or designee) and approved by the Chief Executive Officer (ordesignee). The request made by the Chief should include identification of the Physician for whom theprivileges are requested, the patient or circumstance for which temporary clinical privileges are beingsought and the scope of privileges being requested.8.8.2.2 Information which must be verified prior to granting temporary clinicalprivileges in order to meet an important patient care need includes, at a minimum, current Arkansasmedical/dental/professional license, malpractice, and current competence as assessed by the Chief ofStaff (or designee).22

8.8.2.3 The applicant shall present at least one of the following for review by thesenior administrative or Medical Staff leader present:A. A current hospital picture ID card.B. A current license to practice with a valid photo ID issued by a state,federal, or regulatory agency.C. Presentation by current hospital or Medical Staff member with personalknowledge of the practitioner's identity.8.8.2.4 When requesting temporary privileges in order to meet an important patientcare need, the applicant must complete the emergency/temporary privilege form as soon as possible.8.8.2.5 Once the important patient need has been satisfied, the temporary privilegesare terminated, and the patient shall be assigned to an appropriate member of the Medical Staff.Termination of privileges exercised to satisfy an important patient care need does not entitle thePhysician/Dentist to a fair hearing or appeal process.8.8.2.6 The Chief of Staff or Medical Director shall inform the MSEC and Board ofDirectors when temporary privileges for an important patient care need have been extended.8.8.3 A Practitioner with a completed application for Medical Staff membership or privilegesmay be granted temporary clinical privileges while waiting for review of the MSEC under the followingcircumstances.A. The application must be complete and verified as described in these Bylaws.B. There are no areas of concern in the initial review of the application.8.8.3.1 The request for temporary clinical privileges while awaiting review andapproval by the Medical Staff will be made in writing by the applicable Chief of Service (or SectionChief designee) with a recommendation from the Chief of Staff (or designee) and approved by the ChiefExecutive Officer (or designee).8.8.3.2 Information which must be verified prior to granting temporary clinicalprivileges while awaiting review and approval by the Medical Staff Executive Committee and Board ofDirectors includes, at a minimum,A. Current Arkansas medical/dental/professional license,B. Current malpractice insurance coverage,C. Relevant training and experience,D. Current competence,23

E. Ability to perform the privileges requested,F. Other criteria required by these bylaws and hospital policy,G. A query and evaluation of the National Practitioner Data Bank (NPDB) informationH. A complete application,I. No current or previously successful challenge to licensure or registration,J. No subjection to involuntary termination of medical staff membership at anotherorganization,K. No subjection to involuntary limitation, reduction, denial, or loss of clinicalprivileges.L. Query of the Arkansas State Medical Board CCVS.8.8.4 Temporary clinical privileges shall be for a limited period of time not to exceed sixty (60)days. Any Practitioner anticipated to practice at ACH for more than 60 days must have active MedicalStaff privileges.8.8.5 The Applicant Practitioner must sign an acknowledgment that he/she has received andread copies of the Medical Staff's Bylaws and Rules and Regulations and that he/she agrees to be boundby the terms thereof in all matters relating to his/her temporary clinical privileges.8.8.6 An active Medical Staff member will provide oversight for Practitioners holdingtemporary clinical privileges.8.8.7 Special requirements of supervision and reporting may be imposed by the Chief ofService (or Section Chief designee), Chief of Staff, or Medical Director on any Practitioner grantedtemporary clinical privileges. Temporary clinical privileges will be immediately terminated by the ChiefExecutive Officer, Medical Director, or the Chief of Staff upon notice of any failure by the Practitionerto comply with any of the special requirements.8.8.8 The Chief Executive Officer, Medical Director, or the Chief of Staff may at any time withor without cause, terminate a Practitioner's temporary privileges.8.8.9 Temporary clinical privileges granted by these Bylaws are for the special purpose ofaccommodating special temporary needs of Applicants, Medical Staff members, or patients.Accordingly, neither the refusal to grant temporary clinical privileges nor the modification ortermination of the temporary clinical privileges shall entitle an affected Applicant to any proceduralprocess rights afforded by the corrective action, fair hearing, and appeal procedures except for reasons ofcompetence or conduct for which the fair hearing and appeal process would be initiated.24

8.9 TelemedicineDefinitionsTelemedicine is defined as the use of medical information exchanged from one site to another viaelectronic communications.Originating site: The site where the patient is located at the time the service is provided.Distant site: The site where the Practitioner providing the service is located.8.9.1 If the Telemedicine Practitioner at the distant site prescribes, diagnoses, provides clinicaltreatment, or consults for patients at ACH, he/she must be credentialed and privileged to do so at theoriginating site through one of the following mechanisms:A. The originating site may fully privilege and credential the Practitioner according tothat Hospitals’ Bylaws.B. The originating site may use the credentialing and privileging information from thedistant site if all the following requirements are met:1. The distant site is a Medicare-participating hospital.2. The Practitioner is privileged at the distant site providing thetelemedicine services, which provides a current list of the distant-sitephysician’s or practitioner’s privileges at the distant-site hospital.3. The individual distant-site physician or practitioner holds a licenseissued or recognized by the State in which the hospital whose patientsare receiving the telemedicine services is located.4. The originating site has evidence of an internal review of thePractitioner’s performance of those privileges and sends to the distantsite information that is necessary to assess the Practitioner’s quality ofcare, treatment, and services for use in privileging and performanceimprovement. At a minimum, this information must include alladverse events that result from the telemedicine services provided bythe distant-site physician or practitioner and all complaints thehospital has received about the distant-site physician or practitioner.C. The originating site retains the responsibility for overseeing the safety and quality ofservices offered to its patients.8.10 Visiting Faculty/Physician8.10.1 Visiting Faculty/Physicians include Physicians who wish to participate in the care ofspecific ACH patients. Temporary privileges may be granted to a Visiting Faculty/Physician only:25

A. if no other physician currently on staff has the expertise/privilegesB. for instructional/educational purposes that constitutes an important patient careneed.Physicians requesting these privileges must be licensed to practice in Arkansas or in another state andare under the direct supervision of an Active Staff member.8.10.2 Visiting Faculty/Physicians may be granted privileges for a period not to exceed a total offive (5) days in a six (6) month period. If this time limitation is to be exceeded, the physician must applyfor privileges as established in these Bylaws.8.10.3 Consistent with Arkansas Medical Practices Act, a physician must possess a license topractice medicine in Arkansas if any one of the following is met. The physicianA. provides services for more than an occasional case,B. establishes any regular connection with a hospital, orC. is provided an office or any other place for regular use to render services.8.10.4 The request for Visiting Faculty/Physician will be made in writing by the applicable Chiefof Service (or Section Chief designee) and Chief of Staff (or designee) and approved by the ChiefExecutive Officer (or designee). This request should include identification of the physician for whomthe privileges are requested, the patient or circumstance for requesting privileges as VisitingFaculty/Physician, the scope of privileges being requested, and the dates the physician will be visitingACH.8.10.5 Approval of Visiting Faculty/Physician privileges is contingent upon:A. Completion of a Visiting Faculty Application.B. Completion of delineation of clinical privilegesC. Verification of Medical Staff membership and like privileges at another facility.D. Completion of the Practitioner health questionnaire.E. Primary source verification of licensure in the state in which he/she resides.F. Evidence of active malpractice insurance which includes coverage for the Physicianwhile practicing at ACH.G. Query of the National Practitioner Data Bank.H. OIG sanction check26

I. CCVS attestation,J. CVK. DEA certification.8.11 Emergency PrivilegesDefinition:For the purpose of this section, an "emergency" is defined as a condition in which serious permanentharm would result to a patient or in which the life of a patient is in immediate danger and any delay inadministering treatment would add to that danger.8.11.1 In an emergency, any Practitioner, who is a member of the Medical Staff or AffiliatedStaff, to the degree permitted by his/her license and regardless of service or staff status or lack of it, willbe permitted and assisted to do everything possible to save the life of a patient, using every facility of thehospital necessary, including calling for any consultation necessary or desirable.8.12 Disaster Privileges (Refer to Safety & Emergency Manual: Emergency Operations Plan8.12.1 Disaster privileges may be granted to Licensed Independent practitioners who are notmembers of the Medical Staff or Affiliated Health Staffat Arkansas Children's Hospital and who do notpossess Medical Staff privileges once the Emergency Management Plan is activated and if availableACH staff are unable to handle immediate patient care needs.8.12.2 The Chief Executive Officer, Chief of Staff, Medical Director, or their designee(s) areresponsible for granting disaster privileges to volunteer licensed independent practitioners.8.12.3 ACH is not required to grant disaster privileges to any individual and such decisionsshould be made on a case-by-case basis.8.12.4 The Medical Staff is responsible for overseeing the performance of each volunteerlicensed independent practitioner during a disaster. It is highly desirable, but not required, thatmonitoring of individuals granted disaster privileges will be by direct observation by a credentialedpractitioner. If direct observation is not conducive to the situation, Medical Record review or mentoringmay also be sources of monitoring.8.12.5 Before thePractitioner is considered eligible to function as a volunteer licensedindependent practitioner, they must present a valid government-issued photo identification; e.g., driver’slicense or passport and at least one of the following:A. A current picture ID card from a health care organization that clearly identifiesprofessional designation.27

B. A current license to practice.C. Primary source verification of licensure.D. Identification indicating that the Practitioner is a member of a state or federalDisaster Medical Assistance Team (DMAT), Metropolitan Medical Response Team(MMRS), the Medical Reserve Corps (MRC), the Emergency System for AdvanceRegistration of Volunteer Health Professionals (ESAR-VHP), or other recognizedstate or federal response organization or group.E. Identification indicating that the Practitioner has been granted authority to renderpatient care in disaster circumstances, such authority having been granted by afederal, state, or municipal entity.F. Confirmation by current Hospital or Medical Staff member with personalknowledge of the Practitioner's identity and ability to act as a licensed independentpractitioner during a disaster.8.12.6 The Practitioner granted disaster privileges must complete the Disaster Privilege Form.This form includes the Practitioner’s statement that he/she is licensed, the license number, the stateissuing the license, and his/her area of specialty.8.12.6.1 The Disaster Privilege Form shall be forwarded as soon as possible to theMedical Staff Office to immediately verify as much as information as possible, including verification oflicensure and hospital affiliation, and query of the National Practitioner Data Bank.8.12.6.2 If the Practitioner has exercised the disaster privileges, primary sourceverification of licensure will begin as soon as the immediate situation is under control and is completedwithin 72 hours from the time the volunteer Practitioner presents to the hospital. If circumstancesprevent verifications within 72 hours, the reason for delay should be documented and the verificationscompleted as soon as possible.8.12.7 The volunteer licensed independent practitioners must wear a valid picture ID at all timesthat identifies them as a volunteer practitioner and that distinguishes them from the ACH staff.8.12.8 Medical Staff coordination of disaster privileges is accomplished by the Chief of Staff orMedical Director or his/her designee who will assign Physicians to appropriate areas.8.12.9 Once the immediate situation is under control, the disaster privileges are terminated.Termination of privileges granted in a disaster does not entitle the Practitioner to a fair hearing or appealprocess.8.12.10 Any information gathered that is not consistent with that provided by thePractitioner will be referred to the Medical Director immediately to determine any additional action.28

ARTICLE 9: INVESTIGATIVE REVIEW MEASURES AND CORRECTIVE ACTION9.1 Policy9.1.1 Whenever the activities, clinical performance, or professional conduct of any Practitionerwith clinical privileges are considered to be lower than the standards or aims of the Medical Staff, or thequalifications, obligations or responsibilities of Practitioners, are disruptive to the operations of theHospital, detrimental to patient safety or delivery of appropriate patient care in the Hospital, in disregardof or contrary to the Medical Staff Bylaws, Rules and Regulations, or Hospital policies, or animpairment to the community's confidence in the Hospital, such activity shall be reported to an officer ofthe Medical Staff, a Chief of any service, the Medical Director, Associate Medical Directors, or theChief Executive Officer.Disruptive behavior involving patients, employees, visitors or members of the Medical Staff will not betolerated as such activity impairs the effective functioning of the Hospital and has an adverse impact onpatient care. “Disruptive Behavior” may involve, but is not limited to, tirades, abusive treatment orsexual harassment involving patients, employees, visitors or other Medical Staff members. (Refer toACH Personnel Policy 400500)9.1.2 The MSEC maintains its authority to evaluate/assess issues, concerns and complaintsregarding activities, clinical performance and/or professional conduct of any Practitioner with clinicalprivileges.9.1.3 In conducting such evaluation/assessment, any actions, reports and records of writtendocumentation generated thereby are absolutely privileged communications pursuant to Ark Code Ann.§16-46-105.9.1.4 The member of the Medical Staff who is accused will be informed that retaliation orintimidation against the individual who has registered a concern can be considered an independent basisfor disciplinary action regardless of the outcome of the original concern.9.2 Investigation of Allegations of Conduct or Performance of Practitioner9.2.1 All allegations regarding conduct or performance of a Practitioner reported to any officerof the Medical Staff, a Chief of any Service, the Associate Medical Directors, or the Chief ExecutiveOfficer, may be reported to the MSEC through the Medical Director. Allegations regarding conduct ofPractitioners who are UAMS physician employees or residents may be reported to the MSEC throughthe UAMS ILLUMINE system.9.2.2 The MSEC may delegate its authority to evaluate/assess allegations, regarding theconduct or performance of a Practitioner, to the Medical Director or the UAMS Senior Advisory Council(“SAC”) pursuant to the UAMS ILLUMINE system, as applicable.29

9.2.2.1 In conducting such evaluation/assessment on behalf of the MSEC, the MedicalDirector’s and/or SAC’s actions and any reports, records of written documentation generated thereby areabsolutely privileged communication pursuant to Ark. Code. Ann. §16-46-105.9.2.2.2 Allegations involving the Medical Director shall be evaluated/assessed solelyby the Medical Staff Leadership Committee or SAC with the affected Practitioner refraining fromparticipation as a Committee member in any phase of the procedure.9.2.2.3 The Medical Director will notify the involved Practitioner of an allegation aswell as the Chief of Staff and Chief of Service.9.2.2.4 Evaluation/assessment of the concern will be conducted by the MedicalDirector, SAC, and others as needed. The Medical Director may obtain and utilize clinical andprofessional performance data in the evaluation/assessment. Interviews may also be conducted asneeded.9.2.2.5 Confidentiality will be maintained to the extent possible.9.2.3 Documentation of the alleged conduct or performance will include the following ifavailable:9.2.3.1 the date and time of the questionable behavior, conduct or performance;patient;9.2.3.2 if the incident affected or involved a patient in any way, the name of the9.2.3.3 the circumstances which preceded the situation;performance;9.2.3.4 a factual and objective description of the questionable behavior, conduct or9.2.3.5 the consequences, if any, of the behavior, conduct or performance as it relatesto patient care or hospital operations; and9.2.3.6 a record of action taken to remedy the situation including date, time, place,action and names of those who are interviewed.9.2.4 The documentation will be submitted to the Medical Director, who will submit a writtenreport of the evaluation/assessment, including recommendations, if any, for further action to the MedicalStaff Leadership and Chief of Staff.9.2.5 The Medical Staff Leadership will decide if further action is required. Actions whichmay be taken by the Medical Staff Leadership include, but are not limited to, counseling, requiringreferral to the MSHC, further information gathering by the Medical Director or SAC, or recommendingto the MSEC that an Ad Hoc Committee be appointed to formally investigate the matter.30

9.2.5.1 Any action of Medical Staff Leadership, other than a summary suspension(Paragraph 9.4), which may result in a revision, reduction or revocation of privileges must be made as arecommendation to MSEC.9.2.5.2 Repeated incidents or a single event of significant severity may warrantsubmission to the MSEC and/or SAC for consideration of corrective action.9.2.5.3 The Practitioner will be afforded an opportunity to respond to the allegationsin writing. If the Practitioner desires to respond in writing, the Practitioner will be allowed seven (7)business days from receipt of the allegations in which to submit the written response to the MedicalDirector. The Medical Director may conduct an additional evaluation/assessment if deemed appropriateupon receipt of the Practitioner’s response.9.2.6 When the recommendation of Medical Staff Leadership is to trigger a formalinvestigation or for corrective action, the Chief of Staff or Medical Director will inform the affectedPractitioner, SAC (as appropriate), the Chief Executive Officer and the Chief of Service.9.2.7 If corrective action is determined by the MSEC to be appropriate, the procedure outlinedin these Bylaws will be followed.9.2.8 Documentation of any substantiated complaint will be placed in the Practitioner’sconfidential QI file, including recommendations of the Medical Staff Leadership.9.3 Corrective Action9.3.1 Whenever there are grounds to suspect that a Practitioner with clinical privileges hasengaged in, made or exhibited acts, statements, demeanor, or engaged in personal or professionalconduct or performance, either within or outside the hospital, which is, or is reasonably likely to be:A. Lower than the standards or aims of the Medical Staff or the qualifications,obligation or responsibilities of Practitioners;B. Disruptive to the operations of the hospital;C. Detrimental to patient safety or delivery of appropriate patient care;D. Contrary to or in disregard of the Medical Staff Bylaws, Rules and Regulations, orhospital policies; orE. An impairment to the community's confidence in the hospitalCorrective action against the Practitioner may be instituted and requested by any officer of the MedicalStaff, a Chief of any Service, the Chief Executive Officer, or the Board of Directors. All requests forcorrective action will be in writing, will be made to the MSEC, and shall be supported by reference tothe specific activities or conduct which constitutes the grounds for the request.31

9.3.2 Whenever the corrective action could result in a reduction or suspension of clinicalprivileges, the MSEC will forward a request to the Chief of Staff. Upon receipt of the request, the Chiefof the Staff will appoint an Ad Hoc Committee to investigate the matter.9.3.3. If the corrective action involves the Chief of Staff, the Vice Chief shall perform allresponsibilities of the Chief of Staff.9.3.4 As soon as is reasonably practical, but no later than sixty (60) business days after the dateof the request for corrective action, the Ad Hoc Committee will make a report of its investigation to theMSEC.9.3.5 As soon as is reasonably practical, but no later than sixty (60) business days afterreceiving the report of the Ad Hoc Committee's investigation, the MSEC will take action upon therequest.9.3.5.1 If the corrective action could involve a reduction or suspension of clinicalprivileges, or a suspension or expulsion from the Medical Staff,, the affected Practitioner will bepermitted to appear before the MSEC. for an interview. Within a reasonable time period prior to theinterview, the Practitioner will be presented with the request for corrective action and the report of theinvestigation of the Ad Hoc Committee and at the interview, be invited to discuss, explain or refute theissues.9.3.5.2 The interview shall not constitute a hearing, will be preliminary in nature, andnone of the procedural rules provided in these Bylaws with respect to hearings and appeals will apply.Legal counsel is not permitted to be present for the interview.9.3.5.3 A record of the interview will be made by the MSEC.9.3.6 The action of the MSEC on a request for corrective action may be to:A. Make a finding clearing the Practitioner of the charges against him;B. Issue a warning, a letter of admonition, or a letter of reprimand to the Practitioner;C. Impose terms of probation or requirements of prior or concurrent consultation ordirect supervision;D. If a summary suspension is in effect, terminate, modify or sustain the summarysuspension;E. Suspend, reduce, limit or terminate staff membership and/or clinical privileges;F. Refer the matter to the MSHS; orG. Direct that all or part of the Practitioner's clinical privileges be suspended pendingfurther proceedings pursuant to these Bylaws.32

The written report of the MSEC shall include a statement of the facts and reasons supporting the actionof the committee. Any minority views shall also be reduced to writing along with the facts and reasonssupporting such minority views. If additional time is needed by the MSEC to complete its report, it maydefer issuing its report for up to an additional sixty (60) business days.9.3.7 Any recommendation by the MSEC for reduction, suspension or revocation of clinicalprivileges, or for suspension or expulsion from the Medical Staff will entitle the affected practitioner tothe procedural rights provided in these Bylaws.9.3.8 The Chief of Staff will promptly notify the Chief Executive Officer in writing of allrequests for corrective action received by the MSEC and will keep the Chief Executive Officer fullyinformed of all action taken in connection with this. If a recommendation for corrective action involves aUAMS physician employee or resident, the SAC will also be notified, as appropriate. After the MSEChas made its recommendation in the matter, the procedure to be followed will be as provided in theseBylaws.9.3.9 Corrective action, when instituted against any Medical Staff officer, automaticallysuspends the officer from office.9.3.10 The MSEC's report containing its recommendation shall be forwarded to the Board ofDirectors and/or SAC, if applicable, in situations where its action involves clearing the Practitioner,issuing a letter of warning or letter of admonition or reprimand, or imposing terms of probation,consultation or supervision, as these actions do not entitle the Practitioner to hearing and appeal rightsunder these Bylaws. The Board of Directors may affirm or modify the action of the MSEC, or may takeaction involving suspension, reduction or revocation of Staff membership and/or clinical privilegessubject to any applicable hearing and appellate review pursuant to these Bylaws.9.3.11 When the recommendation of the MSEC or Board of Directors involves actions deemedadverse under these Bylaws, the provisions of Article 10 shall apply, provided however that any actionof the MSEC or Board of Directors shall remain in full force unless and until modified by the hearingcommittee or the Board of Directors on appellate review.9.4 Summary Suspension9.41 Initiation of Summary Suspension or Termination - Whenever there are reasonablegrounds to believe that the conduct or activities of a Practitioner pose a threat to the life, health or safetyof any patient, employee, or other person and that the failure to take prompt action may result inimminent danger to the life, health or safety of that person, the Chief of the Medical Staff, a Chief ofService, the Chief Executive Officer, or the Executive Committee of either the Medical Staff or theBoard of Directors shall each have the authority to summarily terminate the appointment of suchPractitioner and/or to summarily suspend or restrict all or any portion of his or her clinical privileges.9.4.2. If the summary suspension affects a Practitioner who is a member of the faculty ofUAMS, the Dean of the UAMS College of Medicine shall serve on the MSEC as an ex-officio memberwithout vote so as to be informed of the proceedings.33

9.4.3 A summary suspension becomes effective immediately.9.4.4 The Chief of Staff will appoint an Ad Hoc Committee of at least three (3) members of theMSEC to investigate the summary suspension as soon as is reasonably practical. As a part of itsinvestigation, the Ad Hoc Committee may, in its discretion, afford the affected Practitioner anopportunity for an interview. At such interview, he/she shall be informed of the general nature of thecause for the summary suspension, and shall be invited to discuss, explain or refute the allegations. Thisinterview shall not constitute a hearing, shall be preliminary in nature, and none of the procedural rulesprovided in these Bylaws with respect to hearing and appeal shall apply. No legal counsel shall bepermitted to appear. A record of such interview shall be made by the Ad Hoc Committee and includedwith its report to the Chief of Staff.9.4.5 In addition to investigating the summary suspension, the Ad Hoc Committee mayconsider whether further corrective action with respect to the Practitioner is warranted.9.4.6 As soon as is reasonably practical, but no later than fourteen (14) business days after thedate of summary suspension, the Ad Hoc Committee shall report to the MSEC the results of itsinvestigation and the MSEC shall take one or more of the following actions with regard to the summarysuspension:A. make a finding clearing the Practitioner of the charges against him;B. direct that the summary suspension be terminated;C. direct that the summary suspension be continued pending further proceedings underthese Bylaws;D. issue a warning, a letter of admonition, or a letter of reprimand to the Practitioner;E. impose terms of probation or requirements of prior or concurrent consultation ordirect supervisions;F. refer the matter to the MSHS; orG. make a finding that there is sufficient evidence to warrant, and a recommendation ofsuspension, reduction, limitation or termination of staff membership and/or clinicalprivileges.9.4.7 If additional time is needed to complete the investigative process, the MSEC may deferaction on the matter but only with written consent of the affected Practitioner. A recommendation forone or more of the actions listed in Section 9.4.6 above must be made within the time specified in theconsent, and if no time is specified, within thirty (30) business days of the deferral.9.4.8 The report of the MSEC to the Executive Committee of the Board of Directors shall beaccompanied by a written statement of the facts and reasons supporting the action of the committee.34

Any minority views shall also be reduced to writing, referencing facts and reasons supporting suchminority views, and transmitted with the majority report. The MSEC's report shall be forwarded to theExecutive Committee of the Board of Directors in situations where the committee's action involvesclearing the Practitioner, issuing a letter of warning or letter of admonition or reprimand, or imposingterms of probation, consultation, or supervision. The foregoing actions do not entitle the Practitioner tohearing and appeal rights under Article 10 of these Bylaws. The Board of Directors may affirm ormodify the action of the MSEC or may take action involving suspension, reduction or revocation of staffmembership and/or clinical privileges subject to any applicable hearing and appellate review pursuant toArticle 10.9.4.9 When the recommendation of the MSEC involves a continuation of summary suspensionor other actions deemed adverse under Article 10, the MSEC's report shall not be forwarded to the Boardof Directors, but instead, the provisions of Article 10 shall apply. The action of the MSEC as reflectedin its report shall remain in full force unless and until modified by the Board of Directors on appellatereview.9.4.10 Immediately upon the imposition of a summary suspension, the Medical Director, Chiefof Staff or responsible Chief of Service will have authority to provide for alternative medical coveragefor the patients of the suspended Practitioner.9.5 Automatic Suspension9.5.1 A Practitioner’s privileges will be automatically suspended if the Practitioner’s license isrevoked or suspended by the Arkansas State Medical Board, Arkansas Board of Dental Examiners,Board of Nursing, or any agency charged with granting a license to any Practitioner, who may be grantedappointment or privileges under the Medical Staff Bylaws.9.5.1.1 If the Practitioner is placed on probation by the licensing agency, all hospitalprivileges are suspended until an investigation has been completed.9.5.1.2 It is the responsibility of the practitioner to immediately notify the Chief ofStaff, the Medical Director, and the appropriate Chief of Service if an adverse action by a licensingagency is anticipated or has been taken.9.5.2 Failure of a Practitioner to renew his/her license, to maintain continuous, adequatemalpractice insurance, or to meet any of the requirements for medical staff membership willautomatically suspend all of his/her hospital privileges until the requirements have been met.9.5.3 Consistent with the regulations of the Office of Inspector General (OIG), the privileges ofan individual who is excluded from participation in Federal Health Care Programs will be automaticallysuspended.9.5.4 If applicable, failure of a Practitioner to hold a current and valid work/employmentauthorization will result in automatic suspension of all hospital privileges.9.5.5 It will be the duty of the Chief of Staff or designee to enforce all automatic suspensions.35

9.6 Temporary Suspension9.6.1 A temporary suspension in the form of withdrawal of a Practitioner's admitting privilegesmay be imposed by the MSEC for non-clinical reasons such as failure to complete medical records orbilling forms.9.6.2 Operating privileges may be temporarily suspended for failure to dictate operative reportsconsistent with requirements of Medical Staff Rules and Regulations.9.6.3 Repeated temporary suspensions shall be considered at reappointment.9.6.4 Temporary suspensions for non-clinical reasons are not reported to the NationalPractitioner Databank.9.7 Informal Action9.7.1 In certain circumstances where no summary suspension has been invoked and the MSEChas not received a request for corrective action and the nature of the issue is such that it mayappropriately be resolved through informal, person-to-person contact, the MSEC may exercise itspowers regarding review and evaluation of the quality of medical and hospital care through suchinformal means. Recognizing that such informal action may be more effective if performed by a personrather than a committee, the MSEC delegates its powers to take informal action in such instances to anyof the following: the Chief of Staff, the Medical Director, and the Chief Executive Officer.36

ARTICLE 10: HEARING AND APPELLATE REVIEW PROCEDURE10.1 Right To Hearing And Appellate Review10.1.1 Right To Hearing Generally. Except as provided herein, when any Applicant orPractitioner receives notice of any final adverse action under circumstances as defined in Sections 10.1.2and 10.1.3, he/she shall be entitled, upon timely and proper request, to the hearing and other proceduresprovided for in this Article.10.1.2 Adverse Actions. The following recommendations or actions, if deemed final underSection 10.1.3 below, shall entitle the Practitioner to the rights provided for in this Article 10:A. denial of initial Staff Appointment;B. denial of reappointment to the Staff;C. revocation of Staff Appointment and/or Clinical Privileges;D. denial of requested Clinical Privileges;E. reduction, revocation or suspension of Clinical Privileges which lastsgreater than 14 days for reasons of competence or conduct; andF. summary suspension of Staff appointment and/or Clinical Privileges whichlasts greater than 14 days for reasons of competence or conduct.10.1.3 Final Action. A recommendation or action listed in Section 10.1.2 above is final onlywhen it has been:A. recommended by the MSEC pursuant to Sections 9.3.6 or 9.4.6, orB. taken by the Board of Directors under circumstances where no prior right to requesta hearing existed.10.1.4 Actions Not Deemed Adverse. None of the following actions shall entitle an affectedApplicant or Practitioner to any hearing, appellate review or other rights under this Article 10:A. the issuance of a warning, a letter of admonition, or a letter of reprimand;B. the imposition of terms of probation, or requirements of prior or concurrentconsultation or direct supervision that do not affect the Practitioner’s ability topractice independently;C. the termination of any temporary Clinical Privileges if not for reasons ofcompetence or conduct;37

D. automatic suspensions;E. a suspension or restriction of Clinical Privileges for a period of not longer thanfourteen (14) business days during which an investigation is being conducted todetermine the need for professional review action;F. change in, or denial of change in, Staff category;G. other situations which are specifically covered in these Bylaws which specificallyexclude hearing and appeal rights.10.2 Notice Of Adverse ActionThe Chief Executive Officer shall be responsible for giving prompt written notice of adverse actiondescribed in Section 10.1.2 by delivery to the affected Applicant or Practitioner either in person or bycertified mail, return receipt requested. This notice shall:10.3 Request For HearingA. advise the Applicant or Practitioner of the action and of his/her right to request ahearing pursuant to the provisions of these Bylaws;B. specify that the Applicant or Practitioner has thirty (30) calendar days afterreceiving the notice within which to submit a request for a hearing and that therequest must satisfy the conditions of Section 10.3 hereof;C. state that the failure to request a hearing within the time period and in the propermanner shall constitute a waiver of rights to any hearing or appellate review on thematter which is the subject of the notice;D. state that the Board of Directors is not bound by the adverse action that theApplicant or Practitioner accepts by virtue of his/her waiver, but may take anyaction, whether more or less severe it deems warranted by the circumstances;E. state the grounds upon which the adverse recommendations or actions are based;F. state that upon receipt of his/her hearing request, the Applicant or Practitioner willbe notified of the date, time and place of the hearing; andG. provide a summary of the Applicant's or Practitioner's rights at the hearing.The Applicant or Practitioner shall have thirty (30) business days after receiving a notice under Section10.2 to file a written request for a hearing. The request must be delivered to the Chief Executive Officereither in person or by certified mail, return receipt requested. In addition to requesting a hearing, suchrequest must respond, point by point, to each finding or ground relied upon by the MSEC in support of38

its action or recommendation. This response must clearly detail all reasons that, from the affectedApplicant's or Practitioner's point of view, each finding or ground of the MSEC and the action orrecommendation itself, is in error.10.4 Waiver10.4.1 Failure to Request Hearing. Failure of an Applicant or Practitioner to request a hearingwithin the time and in the manner specified in Section 10.3 above shall be deemed to be a waiver ofhis/her right to any hearing or appellate review to which he/she might otherwise have been entitled.10.4.2 Incomplete Request. In the event the affected Applicant's or Practitioner's request isincomplete, the Chief Executive Officer shall so notify him. Failure to furnish a complete request withinfive (5) business days after notice from the Chief Executive Officer shall be deemed to be a waiver ofthe Applicant's or Practitioner's right to any hearing or appellate review to which he otherwise may havebeen entitled, notwithstanding the earlier incomplete request.10.4.3 Effect of Waiver. Any waiver shall apply only to the matters which were the bases forthe adverse action triggering the Section 10.2 notice. Upon waiver, the adverse action taken against theApplicant or Practitioner shall remain in effect pending the Board of Directors's final action in thematter. The Board of Directors is not bound by the previous adverse action that the Applicant orPractitioner has accepted by virtue of his/her waiver, but may take any action, whether more or lesssevere, it deems warranted by the circumstances. The Chief Executive Officer shall promptly notify theaffected Applicant or Practitioner of his/her status and of the final action of the Board of Directors.10.5 Hearing Prerequisites10.5.1 Notice of Time and Place of Hearing. Within ten (10) business days after receipt of arequest for hearing from an Applicant or Practitioner entitled to the same, the Chief Executive Officershall schedule and arrange for a hearing and shall notify the Applicant or Practitioner of the time, placeand date of the hearing by written notice delivered either in person or by certified mail, return receiptrequested. Ordinarily, the hearing date shall not be less than thirty (30) business days from the date of thenotice of the hearing by the Chief Executive Officer; provided, however, that the Applicant orPractitioner may request an earlier hearing date and, in such case, the hearing shall be held as soon asarrangements therefore may reasonably be made.10.5.2 Statement of Issues. The notice of hearing shall contain a concise statement of the factualbases for the adverse action, a list by number of the specific or representative patient records in question,a list of witnesses (if any) expected to testify at the hearing and/or the other reasons or subject matterforming the basis for the adverse action or recommendation which is to be the subject of the hearing.10.5.3 Composition of Hearing Committee.A. A hearing occasioned by an adverse action or recommendation of the MSEC shall,subject to Section 10.5.4, be conducted by an Ad Hoc Hearing Committeecomprised of not less than three (3) members of the Active Staff appointed by theChief of Staff39

B. A hearing occasioned by an adverse action of the Board of Directors undercircumstances where the Applicant or Practitioner had no previous right to request ahearing shall be conducted by a hearing committee appointed by the Chairman ofthe Board of Directors and composed of not less than three persons. The hearingcommittee may name such non-voting, advisory members to assist it as it deemsnecessary.10.5.4 Service on Hearing Committee Composed Under Section 10.5.3(a). The followingprovisions of this Section 10.5.4 apply only to hearing committees composed under Section 10.5.3(a):A. Prior involvement of a Medical Staff member in formulation of the adverse actionwhich occasioned the hearing bars participation as a hearing committee member.B. The hearing committee shall exclude as members persons who are in directeconomic competition with the affected Applicant or Practitioner. Such exclusionmay initially be effected by the determination of the Chief Executive Officer or theperson himself/herself. The affected Applicant or Practitioner shall be notified ofthe names of the hearing committee members and may object to any committeemember on the basis of such committee member being in direct economiccompetition with him. The remaining hearing committee members shall rule on anysuch objection. Failure of the affected Applicant or Practitioner to so object as toany committee member shall be deemed a waiver of his/her right to do so.C. If one or more persons are excluded from the hearing committee, the ChiefExecutive Officer shall, in his/her discretion, determine whether a sufficient numberof hearing committee members remain to conduct the hearing. If this determinationis in the negative, the Chief Executive Officer may, in his/her discretion, nameadditional hearing committee members or an arbitrator to serve as the trier of fact atthe hearing. Any determination by the Chief Executive Officer to name additionalhearing committee members or not, or to name an arbitrator or not, shall be finaland binding on all parties.10.5.5 Authority of Hearing Committee. The hearing committee shall have the authority to:A. Establish the time, place, manner and procedure for conducting the hearing,consistent with these Bylaws;B. Clarify and narrow the issues to the extent possible;C. Hold a preliminary meeting with the parties for the purpose of clarifying issues,establishing procedures, or otherwise aiding the committee;D. Conduct a hearing, consider and receive evidence, and deliberate and reach adetermination in the form of a final recommendation;40

10.6 Hearing ProcedureE. Request that other Practitioners or outside experts examine questions within theirrespective specialties or questions where a dispute exists between the position of theaffected Practitioner and the adversary representative, and report to the hearingcommittee their opinions and the basis for those opinions;F. Direct the attendance and participation of witnesses, and the submission andintroduction of documentary evidence, whether or not proffered by the adversaryrepresentative or the affected Applicant or Practitioner;G. Rule on the admissibility of evidence and determine the weight to be accorded toevidence which is admitted; andH. Take such other actions as will facilitate its business.10.6.1 Personal Presence. The personal presence of the Applicant or Practitioner is required. AnApplicant or Practitioner who fails without good cause to appear and proceed at the hearing shall bedeemed to waive his/her rights in the same manner and with the same consequences as provided inSection 10.4.1 and 10.4.3.10.6.2 Presiding Officer. The Chief Executive Officer may appoint a Presiding Officer. Eitherthe Presiding Officer, if one is appointed, or the chairman of the hearing committee or his/her designeeshall preside over the hearing to assure that all participants in the hearing have a reasonable opportunityto present relevant oral and documentary evidence and to maintain decorum. If a Presiding Officer isutilized, he/she may be an attorney at law. An attorney may not serve as Presiding Officer andsimultaneously represent the adverse recommendation.10.6.3 Committee Members. Members of the hearing committee are actively encouraged to takea participatory role in the proceedings, to question witnesses, to call upon witnesses for informationwithin their possession, to direct the submission of additional evidence and documentation, to questionthe adversary representative and the affected Applicant or Practitioner, and to see that the recordcontains all information which the committee considers necessary in order to reach a decision.10.6.4 Representation of the Adverse Recommendation. If the action which prompted thehearing was taken by a committee of the Staff, it shall appoint one or more of its members orPractitioners to represent it at the hearing. If the action which promoted the hearing was taken by theBoard of Directors, it shall appoint one or more of its members to represent it at the hearing. Suchadversary representatives shall have the obligation to present the facts in support of the adverse action,and to otherwise participate fully in the hearing.10.6.5 Representation of the Practitioner. The affected Applicant or Practitioner is entitled tohave an attorney or other representative of his/her choice at the hearing within the parameters of Section10.6.6.41

10.6.6 Utilization of Attorneys. Attorneys representing the adversary representative and theattorney or representative of the affected Applicant or Practitioner who has requested the hearing may bepresent at the hearing, advise their client, and participate in resolving procedural matters. Attorneys maynot introduce evidence, including, but not limited to, examining or cross-examining witnesses with theunderstanding that the hearings provided for in these Bylaws are for the purpose of resolving, on anintra-professional basis, matters bearing on professional competency and conduct and are not a judicialforum. If attorneys are utilized by either the Applicant or Practitioner or adversary representative, theyshould strive to facilitate, and not hinder, the hearing process in order that a prompt and fair decisionmay be made by the hearing committee.10.6.7 Clarification of Issues.A. Outline of Case. At least fifteen (15) business days prior to the scheduled date of ahearing, the affected Applicant or Practitioner and the adversary representative shalleach submit an outline and written documentation to the Chief Executive Officer fortransmittal to the committee and to the other party setting forth, so far as is thenreasonably known:1. Issues which each party proposes to raise at the hearing.2. Witnesses whom each party proposes to call at the hearing and the subject orsubjects on which such witnesses will testify.3. A description of all written or documentary evidence that each partyanticipates introducing as evidence at the hearing.4. A short summary of what the party expects to demonstrate at the hearing insupport of its position.5. The specific result or results requested from the hearing committee.B. Pre-hearing Conference. Prior to the scheduled commencement of the hearing, thecommittee or its chairman or Presiding Officer shall meet with the parties for thepurpose of conducting a prehearing conference to discuss possible stipulations offacts, amendments to the grounds for action or the issues in dispute, and changes inthe witness or evidence list of each party. Any further procedures established for theconduct of the hearing shall be explained at such time. No attorneys for the partiesmay be present at the pre-hearing conference.C. Discovery. Except as expressly provided for in Section 10.6.7(a), no pre-hearingdiscovery, including but not limited to, requests for production of documents ordepositions, is allowed.10.6.8 Issues. Once a hearing has been requested, the hearing committee shall not be bound bythe statement of grounds on which the prior action or recommendation of the MSEC was based. Instead,42

the committee may, upon advising the parties, broaden the issues under examination and may base itsdecision, wholly or in part, upon the resolution of issues not originally considered or listed.10.6.9 Rights of Parties. During a hearing, each party may:A. Call and examine witnesses;B. Introduce exhibits;C. Cross-examine any witness on any matter relevant to the issues;D. Impeach any witness;E. Rebut any evidence;F. Request that the record of the hearing be made by use of a court reporter orelectronic recording unit pursuant to the provisions of Section 10.6.14 hereof; andG. Submit a written statement at the close of the hearing.10.6.10 Procedure and Evidence. The hearing need not be conducted strictly according to therules of law relating to the examination of witnesses or the presentation of evidence. Any relevant matterupon which responsible persons customarily rely in the conduct of serious affairs may be considered,regardless of the existence of any common law or statutory rule which might make the evidenceinadmissible over objection in civil or criminal actions. Each party is entitled, prior to or during thehearing, to submit memoranda concerning any issue of law or fact, and to have such memoranda becomepart of the hearing record. The presiding officer may, but is not required to, order that oral evidence betaken only on oath or affirmation administered by any person designated by him and entitled to notarizedocuments.10.6.11 Order of Procedure. The basic order of procedure for the hearing shall be as follows:A. First, the adversary representative shall present the facts in support of the adverseaction, whether through testimony, written evidence or otherwise.B. Immediately following conclusion of the adversary representative's presentation(and any cross-examination by the affected Applicant or Practitioner), the affectedApplicant or Practitioner shall testify in response to the facts and issues raised bythe adversary representative, and shall be subject to cross-examination by theadversary representative. If the affected Applicant or Practitioner does not testify onhis/her own behalf, he/she may be called to testify and examined as if under crossexamination.C. Upon conclusion of the affected Applicant or Practitioner's testimony, the affectedApplicant or Practitioner may then call such other witnesses to testify as to matterswhich are relevant to the issues before the hearing committee.43

D. Upon conclusion of the affected Applicant or Practitioner's presentation (and anycross-examination by the adversary representative), the adversary representativemay introduce rebuttal evidence.E. At any time during the procedure, the hearing committee members may questionwitnesses.10.6.12 Official Notice. In reaching a decision, the hearing committee may take official notice,either before or after submission of the matter for decision, of any generally accepted technical orscientific matter relating to the issues under consideration and of any facts that may be judicially noticedby the courts of this state. Parties present at the hearing must be informed of the matters to be noticed,and those matters must be noted in the hearing record. Any party shall be given opportunity, on timelyrequest, to request that a matter be officially noticed and to refute any officially noticed matter byevidence or by written or oral presentation of authority, in a manner to be determined by the hearingcommittee. The committee is also entitled to consider all other information that can be considered underthese Bylaws in connection with credentials matters.10.6.13 Burden of Proof. When a hearing relates to Section 10.1.2 (a), (b) or (d), the Applicantor Practitioner shall have the burden of proving, by clear and convincing evidence, that the adverseaction lacks any substantial factual basis or that such basis (or the action based thereon) is eitherarbitrary, unreasonable or capricious. When a hearing relates to Section 10.1.2 (c), (e), or (f), theadversary representative shall have the initial obligation to present evidence in support of the adverseaction, but the Applicant or Practitioner thereafter is responsible for supporting (by a preponderance ofthe evidence) his/her challenge that the adverse action lacks any substantial factual basis, or that suchbasis (or the action based thereon) is either arbitrary, unreasonable, or capricious.10.6.14 Hearing Record. A record of the hearing must be kept that is of sufficient accuracy topermit an informed and valid judgment to be made by any group that may be later called upon to reviewthe record and render a recommendation or decision in the matter. The hearing committee may select themethod to be used for making the record, such as court reporter, electronic recording unit, detailedtranscription, or minutes of the proceeding. The affected Applicant or Practitioner shall be entitled to acopy of the record upon request accompanied with payment of any reasonable charges associated withthe preparation thereof.10.6.15 Postponement. Postponement of a hearing shall be granted only by the hearingcommittee, in its sole discretion, upon a showing of good cause therefor.10.6.16 Presence of Committee Members and Vote. A majority of the hearing committeemembers must be present throughout the hearing and deliberations. If a committee member is absentfrom any part of the hearing, he/she may not participate in the final hearing committee vote until he/shecertifies that he/she has reviewed the portion of the hearing record covering the portion of the hearingwhich took place during his/her absence. No committee member may vote by proxy. The ChiefExecutive Officer and the Senior Vice President for Medical Affairs/Medical Director, while notcommittee members, are entitled to and may be present during all proceedings, deliberations and vote ofthe hearing committee as the duly authorized representatives of the Board of Directors.44

10.6.17 Recesses And Adjournment. The hearing committee may recess and reconvene thehearing without additional notice for the convenience of the participants or for the purpose of obtainingnew or additional evidence or consultation. Upon conclusion of the presentation of oral and writtenevidence, the hearing shall be closed. The hearing committee shall, at a time convenient to itself,conduct its deliberations outside the presence of the parties.10.6.18 Proposed Findings. The hearing committee may direct the parties to submit proposedfindings, referencing the hearing record, prior to conducting its deliberations. The presiding officer shallset the schedule for the submission of such proposed findings to the hearing committee.10.7 Hearing Committee Report And Further Action10.7.1 Hearing Committee Report. As soon as is reasonably practical, but no later than sixty(60) business days following adjournment of the hearing, the hearing committee shall make a writtenreport of its findings and shall affirm, modify, or reject the original adverse action. Such report shallinclude a statement of the basis for the action of the hearing committee. Such action by the hearingcommittee shall remain in full force and effect unless and until modified by the Board of Directors in theappellate review process, or otherwise as provided in these Bylaws. The hearing committee report, alongwith the hearing record and all other documentation considered, shall be forwarded to the ExecutiveCommittee of the Board of Directors.10.7.2 Notice. The Chief Executive Officer shall be responsible for giving the affectedApplicant or Practitioner prompt notice of the hearing committee's action either by certified mail, returnreceipt requested, or personal delivery. This notice shall:A. Include a copy of the hearing committee report;B. Advise the affected Applicant or Practitioner of his/her right to request appellatereview pursuant to these Bylaws and of the waiver provisions contained herein; andC. Be copied to the Chief of Staff, and to the Executive Committee of the Board ofDirectors.10.7.3 Effect Of Report.A. Appellate Review From Action of Hearing Committee Composed Under Section10.5.3(a). Action by a hearing committee composed under Section 10.5.3(a)involving any of the adverse actions described in Section 10.1.2 shall entitle theaffected Applicant or Practitioner to appellate review. Any action of such hearingcommittee involving an adverse action described in Section 10.1.2 shall remain ineffect unless and until modified by the Board of Directors in the appellate reviewprocess or otherwise as provided in these Bylaws.B. Report to Board of Directors From Other Action of Hearing Committee ComposedUnder Section 10.5.3(a). Action by a hearing committee composed under Section45

10.5.3(a) involving actions other than specified in Section 10.1.2, shall not entitlethe affected Applicant or Practitioner to appellate review. The hearing committeereport shall be forwarded to the Board of Directors for final action. The Board ofDirectors may affirm, reject or modify the action of the hearing committee and itselftake any action, whether more or less severe than the action of the hearingcommittee it deems warranted by the circumstances. In the event such action by theBoard of Directors results in an action specified in Section 10.1.2 hereof, theaffected Applicant or Practitioner shall then be entitled to appellate review.C. Report to Board of Directors From Action of Hearing Committee Composed UnderSection 10.5.3(b). The affected Applicant or Practitioner is not entitled to appellatereview hereof from any action by a hearing committee composed under Section10.5.3(b). The hearing committee report shall be forwarded to the Board ofDirectors for final action. The Board of Directors may affirm, reject or modify theaction of the hearing committee and itself take any action, whether more or lesssevere than the action of the hearing committee it deems warranted by thecircumstances.10.8 Initiation And Prerequisites Of Appellate Review10.8.1 Request for Appellate Review. The affected Applicant or Practitioner shall have ten (10)business days after receiving a notice of adverse action under Section 10.7.2 that entitles him to appellatereview to file a written request for appellate review. The request must be delivered to the ChiefExecutive Officer either in person or by certified mail, return receipt requested, and may, in the affectedApplicant's or Practitioner's discretion, include requests for:A. A copy of the hearing committee report and record and all other material, favorableor unfavorable, if not previously forwarded, that was considered in taking theadverse action;B. The right to submit a written statement pursuant to Section 10.9.2;C. The right to make an oral statement pursuant to Section 10.9.3; orD. Consideration of new or additional matters pursuant to Section 10.9.4.10.8.2 Waiver.A. An affected Applicant or Practitioner who fails to request an appellate reviewwithin the time and manner specified in Section 10.8.1 shall be deemed to havewaived any right to appellate review. Such waiver shall have the same force andeffect as provided in Section 10.4.B. An affected Applicant or Practitioner who fails to request the right to submit awritten statement, or who fails to request the right to make an oral statement shallbe deemed to have waived any right to make such request or submit such written or46

oral statement. Any subsequent request or submission shall not be considered as apart of appellate review.C. The failure of the affected Applicant or Practitioner to include in his/her request forappellate review a request for consideration of specifically identified new oradditional matters shall be deemed a waiver of any right he/she would otherwisehave to request the same.D. The failure of the affected Applicant or Practitioner to submit a written statementwithin the time specified herein shall be deemed to be a waiver of any right he/shemay otherwise have had to submit such statement.E. The failure of the affected Applicant or Practitioner to appear at the time and placedesignated for oral statements shall be deemed to be a waiver of any right he/shemay otherwise have had to submit such statement.10.8.3 Notice of Time and Place for Appellate Review. Within ten (10) business days afterreceipt of a request for appellate review pursuant to Section 10.8.1, the Chief Executive Officer shallschedule a date for appellate review, including the time and place for oral statements if such have beenrequested, and the Chief Executive Officer, either by personal delivery or by certified mail, return receiptrequested, shall notify the affected Applicant or Practitioner of the same. The date of appellate reviewshall ordinarily not be less than twenty-five (25) business days, nor more than forty-five (45) businessdays, from the date of receipt of the notice of request for appellate review, except that when thePractitioner requesting a review is under a suspension which is then in effect, such review shall bescheduled as soon as the arrangements for it may reasonably be made. These time periods are merelyguidelines and are designed to assist the Chief Executive Officer and the Board of Directors inaccomplishing their tasks. Consequently, they shall not be deemed to create any right for the affectedApplicant or Practitioner to have appellate review scheduled within these precise periods.10.8.4 Appellate Review Body. The appellate review shall be conducted by the Board ofDirectors or a duly appointed subcommittee of the Board of Directors together with such other advisorynon-voting members as the Board of Directors or such committee may designate. If any member of theappellate review body has participated in any of the prior proceedings involving the Applicant orPractitioner, such member may only participate as a non-voting member of the appellate review body.10.9 Appellate Review Procedure10.9.1 Nature of the Proceedings. The appellate review proceedings are a review based upon thehearing record, the hearing committee's report, all subsequent results and actions, the written or oralstatements, if any, provided below and any other material that may be presented and accepted underSection 10.9.4 below. In reaching its decision, the appellate review body is limited to consideration of:A. Whether or not the Staff Bylaws have been followed;B. Whether or not the decision of the hearing committee was based upon substantialevidence of record; and47

C. Whether or not the hearing committee's decision was a reasonable one in light of theHospital's duty to the public.10.9.2 Written Statements. If the Applicant or Practitioner has requested the right to submit awritten statement pursuant to Section 10.8.1 (b), he/she shall have ten (10) business days from the dateof his/her request for appellate review in which to submit to the Chief Executive Officer, either in personor by certified mail, return receipt requested, a written statement detailing the factual and proceduralmatters with which he/she disagrees, specifying the particular reasons for such disagreement. In order toassist the appellate review body in its review, the written statement should specifically referenceapplicable portions of the hearing record. This written statement may cover any matters raised at anystep in the procedure to which the appeal is related and legal counsel may assist in its preparation. Asimilar statement supporting the action of the hearing committee and replying to the statement of theaffected Applicant or Practitioner shall be submitted on behalf of the hearing committee within twenty(20) business days from the date of receipt of the request for appellate review by the Chief ExecutiveOfficer. Such written statements shall be submitted to the appellate review body by the Chief ExecutiveOfficer, and the Chief Executive Officer shall provide copies thereof to the affected Applicant orPractitioner or the hearing committee representative, as appropriate.10.9.3 Oral Statements. If the right to make an oral statement pursuant to Section 10.8.1(c) hasbeen requested by the affected Applicant or Practitioner, he/she shall be present at the appellate reviewproceedings and shall be permitted to speak for himself/herself or his/her representative make speak forthe Applicant or Practitioner against the adverse action. The affected Applicant or Practitioner shall besubject to examination by any member of the appellate review body. The hearing committee shall also berepresented by an individual who shall be permitted to speak in favor of the adverse action and who shallanswer questions put to him by any member of the appellate review body. Both the affected Applicant orPractitioner and the representative of the hearing committee, in their own discretion, may utilize theservices of an attorney-at-law as an advocate at such oral presentations.10.9.4 Consideration of New or Additional Matters. New or additional matters or evidence notraised or presented during the original hearing or in the hearing committee report and not otherwisereflected in the record may be introduced at appellate review only:A. If specifically identified in the request for appellate review; orB. If the party requesting consideration of the matter or evidence shows that it couldnot have been discovered in time for the initial hearing; orC. In the discretion of the appellate review body and as the appellate review bodydeems appropriate.Failure to request consideration of specifically identified new or additional matters by the affectedApplicant or Practitioner as a part of his/her request for appellate review shall, pursuant to Section10.8.2(c) result in a waiver of his/her right to make such request.48

10.9.5 Presiding Officer. The chairman of the appellate review body shall serve as the presidingofficer and shall determine the order of procedure during the review, make all required rulings, andmaintain decorum.10.9.6 Presence of Members. A majority of the appellate review body must be presentthroughout the review and deliberations.10.9.7 Recesses and Adjournment. The appellate review body may recess and reconvene theproceedings without additional notice for the convenience of the participants or for the purpose ofobtaining new or additional evidence or consultation. At the conclusion of the oral statements, if any, theappellate review shall be closed. The appellate review body shall then, at a time convenient to itself,conduct its deliberations.10.9.8 Action Taken. The appellate review body may affirm, modify or reverse the adverseresult or action, or in its discretion, may refer the matter back to the hearing committee for further reviewand recommendation within a time period set by the appellate review body. Within a reasonable timefollowing completion of appellate review, the Board of Directors shall take action and the Board ofDirectors's action shall be immediately effective and final, and shall not be subject to further hearing orappellate review.10.9.9 Notice of Final Action. The Chief Executive Officer shall promptly send written notice ofthe final action of the Board of Directors to the affected Applicant or Practitioner either by personaldelivery or by certified mail, return receipt requested. Such notice shall include a statement of the basisof the Board of Directors's action.10.10 Completion Of Hearing And Appellate Review ProcessThe hearing and appellate review process provided herein shall not be deemed to have been concludeduntil all of the procedural steps provided in this Article have either been completed or waived.10.11 Number of Hearings and ReviewsNotwithstanding any other provision of these Bylaws, no Applicant or Practitioner shall be entitled as aright to request more than one evidentiary hearing and appellate review with respect to the subject matterthat is the basis of an adverse action taken against him.10.12 Board of Directors Committee ActionWhere permitted by the ACH Board of Directors, all action required of the Board may be taken by acommittee of the Board of Directors duly authorized to act.10.13 ReleaseBy requesting a hearing or appellate review under this Article, an Applicant or Practitioner reaffirmshis/her prior agreements to be bound by the provisions of the Staff Bylaws relating to immunity fromliability.49

10.14 Exceptions To Hearing And Appellate Review ProceduresThe hearing and appellate review provisions of this Article 10 do not apply to:10.14.1 Resignation Or Failure To Reapply. The expiration or other termination ofAppointment or Clinical Privileges due to the Practitioner's resignation, failure to reapply, or failure torequest reinstatement following a leave of absence.10.14.2 Medicoadministrative Positions. Any automatic termination of Appointment orClinical Privileges for any medicoadministrative positions. (See Section 3.4)10.14.3 Failure To Meet Preliminary Eligibility Requirements. The failure of a person toestablish that he/she meets the preliminary eligibility criteria set forth in these Bylaws.10.14.4 Ineligibility Following Adverse Action. Ineligibility for Appointment or ClinicalPrivileges pursuant to these Bylaws.10.14.5 Temporary Clinical Privileges. Denial, non-renewal, limitation or termination oftemporary Clinical Privileges if not for reasons of competence or conduct.10.14.6 Automatic Suspension. Automatic suspension of Clinical Privileges as set forth inthese Bylaws.10.14.7 Suspension or Restriction of Clinical Privileges During Investigation. Suspension orrestriction of Clinical Privileges during an investigation under these Bylaws which lasts greater than 14days for reasons of competence or conduct.10.14.8 Interviews. Interviews of the affected Applicant or Practitioner provided for in theseBylaws.10.14.9 Termination of Employment or Contract. The termination of any employmentrelationship with ACH or the termination of any contract with ACH.10.14.10 Other Circumstances. The hearing and appellate review provisions of these Bylaws donot apply or are limited, under other circumstances where specified in these Bylaws.10.14.11 Affiliated Health Professional Staff. Nothing contained in these Bylaws shall beinterpreted to entitle a member of the Affiliated Health Professional Staff ("Affiliated Staff") to thecorrective action, hearing or appellate rights set forth in these Bylaws. However, an Affiliated Staffmember shall have the right to challenge any action that would constitute grounds for a hearing underSection 10.1.1, by filing a written grievance with the chief of service to which the Affiliated Staffmember has been assigned and in which he/she has the Clinical Privileges in question, within fifteen(15) business days of such action. Upon receipt of such a grievance, the chief shall initiate aninvestigation and afford the affected Affiliated Staff member an opportunity for a hearing before an adhoc committee appointed by said chief. This hearing shall not constitute the same type of "hearing" as is50

otherwise established by these Bylaws and need not be conducted according to procedures applicablewith respect to such hearings; rather, this hearing will be conducted solely pursuant to the procedures setout in this Section 10.14.11. Before the hearing, the Affiliated Staff member shall be informed of thegeneral nature of the circumstances giving rise to the proposed action, and at the hearing, the AffiliatedStaff member may present information relevant thereto. A record of the findings of such hearing shallbe made. A report of the findings and recommendations shall be made by the chief to the AffiliatedStaff member and the MSEC. Within ten (10) business days of receipt of the report, the Affiliated Staffmember may appeal the findings and recommendations by submitting to the Board of Directors a writtenstatement detailing the factual and procedural matters with which the Affiliated Staff member disagrees.This appeal shall not constitute the same type of "appeal" as is otherwise established by these Bylawsand need not be conducted according to the procedures applicable with respect to such appeals; rather,this appeal will be conducted solely pursuant to the procedures set out in this Section 10.14.11. TheBoard of Directors shall consider the report and the Affiliated Staff member's written statement, if any,and act thereon. The action of the Board of Directors shall be final.51

ARTICLE 11: OFFICERS11.1 Officers of the Medical StaffThe officers of the Medical Staff shall be:A. Chief of StaffB. Vice-Chief of StaffC. Secretary/Treasurer (Parliamentarian)D. Immediate Past Chief of Staff11.2 Qualifications of OfficersOfficers must be members of the Active Medical Staff at the time of nomination and election and mustremain members in good standing during their term of office. Failure to maintain this status willimmediately create a vacancy in the office involved.11.3 Election of Officers11.3.1 Officers will be elected at the annual meeting of the Medical Staff. Only members of theActive Medical Staff are eligible to vote.11.3.1.1 Non-contested elections may be by voice vote.11.3.1.2 In contested elections, voting will be by written ballot, with the voter selectingone individual for each position from among the nominees.11.3.1.3 A simple majority vote of those in attendance will determine the winners.11.3.1.4 If no candidate receives a majority, the name of the candidate receiving thefewest votes is omitted from each successive slate until a majority vote is obtained by one candidate.11.3.2. The Nominating Committee will be comprised of five (5) members of the Active MedicalStaff appointed by the Chief of the Medical Staff annually. The immediate Past Chief of Staff serves asChair of the Committee.11.3.2.1 Members of this committee will be selected so that no service or specialtyshall constitute more than two-fifths of the committee membership.11.3.2.2 In addition, members will have been on the Active staff for at least one yearprior to appointment to the Nominating Committee.52

11.3.2.3 The Committee will offer one or more nominees for each office.11.3.3 Nominations may be made from the floor at the time of the annual meeting.11.4 Term of Office11.4.1 Officers will serve a two (2) year term from their election date or until a successor iselected. Officers will take office on the first day of the Medical Staff year.11.4.2 The Vice-Chief of Staff will succeed as Chief of Staff at the end of the incumbent Chiefof Staff's term.11.4.3 Officers may serve an additional term by approval by the MSEC.11.5 Vacancies of Office11.5.1 Vacancies in office during the Medical Staff year, except for that of Chief of Staff, shallbe filled by a vote of the MSEC.11.5.2 If there is a vacancy in the office of Chief of Staff, the Vice-Chief of Staff will serve outthe remaining term.11.6 Duties of Officers11.6.1 Chief of Staff: The Chief of Staff will serve as the chief administrative officer of theMedical Staff to:11.6.1.1 Act in coordination and cooperation with the Chief Executive Officer and theMedical Director in all matters of mutual concern within the hospital;11.6.1.2 Call, preside at, and be responsible for the agenda of general meetings of theMedical Staff;11.6.1.3 Serve as Chair of the MSEC, Medical Staff General Meetings, and MedicalStaff Leadership Committee;11.6.1.4 Serve as ex officio member of all other Medical Staff Committees;Regulations;11.6.1.5 Be responsible for the enforcement of Medical Staff Bylaws, Rules and11.6.1.6 Appoint Committee members, including members of the House Staff, to allstanding, special, and multi-disciplinary Medical Staff Committees except the MSEC;11.6.1.7 Represent the views, policies, needs, and grievances of the Medical Staff tothe Board of Directors and to the Chief Executive Officer;53

11.6.1.8 Receive and interpret the policies of the Board of Directors to the MedicalStaff and report to the Board of Directors on the performance and maintenance of quality with respect tothe Medical Staff's delegated responsibility to provide medical care;11.6.1.9 Be responsible for the educational activities regarding Medical Staff affairs;11.6.1.10 Be the representative for the Medical Staff in its external professional andpublic relations; and11.6.1.11 Serve as a member of the Board of Directors.11.6.2 Vice-Chief of Staff: In the absence of the Chief of Staff, the Vice Chief will assume allthe duties and the authority of the Chief of Staff, be a member of the MSEC and Medical StaffLeadership, and succeed the Chief of Staff when the latter fails to serve for any reason.11.6.3 Secretary-Treasurer: The Secretary/Treasurer will be a member of the MSEC andMedical Staff Leadership Committee; serves as parliamentarian for the Medical Staff organization; willregularly communicate the activities and actions of the MSEC to members of the Medical Staff, willperform other duties as may be assigned by the Chief of Staff; and will serve as Chief of Staff if theChief of Staff and Vice Chief of Staff are unavailable..11.6.4 Immediate Past Chief of Staff: The Immediate Past Chief of Staff will be a member ofthe MSEC and Medical Staff Leadership Committee. serves as chair of the Nominating Committee, andmay chair the Medical Staff Executive Committee in the absence of one of the other officers.11.7 Removal of an Officer11.7.2 Failure of an officer to remain a member in-good-standing of the Arkansas Children'sHospital Medical Staff shall result in immediate and automatic suspension from office.11.7.1 Removal of an officer during his/her term of office may be initiated by a two-thirds voteof the voting members of MSEC.11.8 Medical Director11.8.1 The Medical Director will be a physician who is a member of the Active Medical Staff.11.8.2 The Medical Director will be appointed jointly by Arkansas Children's Hospital and theUniversity of Arkansas for Medical Sciences.11.8.2.1 The Medical Director carries additional responsibilities to UAMS as set forthin the Affiliation Agreement.54

11.8.2.2 The Medical Director will communicate to the Board of Directors about thesafety and quality of patient care, treatment, and services provided by, and the related educational andsupervisory needs of, the participants in professional graduate education programs.11.8.3 The Medical Director is responsible, through the Chief Executive Officer, to the ArkansasChildren's Hospital Board of Directors for administrative aspects of his/her position including quality ofpatient care, performance improvement, patient safety, Medical Staff credentialing, and the medicallibrary.11.8.4 The Medical Director serves as a liaison with the University of Arkansas for MedicalSciences.11.8.5 In cooperation with the Chief of the Medical Staff, the Medical Director is responsible forliaison with the various services regarding professional activities of the hospital. The Medical Director isan ex officio member of all Medical Staff Committees.by:11.8.6 The Medical Director shall provide coordination of professional aspects of patient care11.8.6.1 Assisting in implementation of policies and directives as approved by theBoard of Directors.11.8.6.2 Coordinating performance improvement and patient safety activitiesthroughout the organization and with Medical Staff.11.8.6.3 Coordinating the functions of the Medical Staff and committees inconjunction with the Chief of the Medical Staff.11.8.6.4 Advising and recommending guidance on Medical Staff problems, discipline,quality control, privileges, and obligations, including conducting informal or formal investigations asdelegated by the MSEC in accordance with the Medical Staff Bylaws.11.8.6.5 Directing the ACH Medical Staff credentialing process including primaryappointment, reappointment, and privileging.11.8.6.6 Maintaining professional administrative responsibility for the Chiefs ofService and serve as their representative to the Board of Directors through the Chief Executive Officer.11.8.6.7 Providing consultation and medical input to clinical departments and services.11.9 Associate Medical Director(s)The Associate Medical Director(s) may act on behalf of the Medical Director in his/her absence andperform such other duties as assigned.55

ARTICLE 12: SERVICES12.1 Organization of Services12.1.1 There shall be services of Anesthesiology, Cardiovascular Surgery, Dentistry,Neurosurgery, Ophthalmology, Orthopaedic Surgery, Otolaryngology, Pathology, Pediatric Medicine,Psychiatry, Radiology, Surgery, Urology, and Adult Medicine.12.1.2 Each Service shall be headed by a Chief of Service and shall function under the directionof the MSEC. Each service will also have a Vice-Chief, when possible.12.2 Assignment to Services12.2.1 The MSEC will, after consideration of the recommendations of the clinical services,recommend initial service assignments for all Medical Staff members and for all other approvedPractitioners with clinical privileges.12.2.2 Physicians assigned to the Adult Medicine Service are limited to adultspecialists/subspecialists who take call for the Burn Unit or are asked to treat adult patients who havebeen granted a treatment exception (over 21) by the Medical Director. Adult Medicine physicians mustfollow the requirements for admitting adult patients as specified in Paragraphs 1.1.2 & 1.1.3.12.3 Qualifications, Selection, and Tenure of Service Chiefs and Vice-Chiefs12.3.1 Each Chief and each Vice-Chief will be a member of the Active staff. Each Chief andService Chief will be Board Certified or determined to be comparably competent atappointment/reappointment.12.3.2 The Chiefs of the various professional services at the Hospital will be either full-time orvoluntary faculty members at UAMS and will be selected by the Chairman of their respectivedepartment at UAMS, subject to approval of the Dean of the College of Medicine, the MSEC, and theACH Board of Directors. An exception to this is the Dental Service of which the Chief will benominated by the ACH Chief Executive Officer, in concert with the Chief of Otolaryngology, andapproved by the MSEC and the Board of Directors.12.3.3 Vice-Chiefs of services will be nominated by the Chiefs of Services with subsequentapproval by the MSEC and the Board of Directors.12.3.4 Removal of a Chief may be initiated by the Chief Executive Officer uponrecommendation by the Chairman of the Department at UAMS and the Medical Director subject toapproval of the MSEC and the Board of Directors.12.3.5 Removal of a Vice-Chief may be initiated by a Chief of Service or Chief ExecutiveOfficer upon recommendation by the Chairman of the Department at UAMS and the Medical Directorsubject to approval of the MSEC and the Board of Directors.56

Examples of conditions that could result in removal of a Chief or Vice-Chief include loss of privilegesand failure to fulfill the responsibilities of the position.12.4 Functions of Service Chiefs12.4.1 Each Chief of Service is responsible forA. Clinical oversight of the Service,B. Administrative related activities of the Service unless otherwise provided by thehospital,C. Continuing surveillance of the professional performance of all individuals in theService who have delineated clinical privileges,D. Recommending criteria for clinical privileges that are relevant to the care providedby the Service, andE. Recommending clinical privileges for each member of the Service.12.4.2 The Chief will participate in development and implementation of the organizationalstrategic plan and policies and procedures with Hospital Administration and the Board of Directors. TheChief will integrate the service into the primary functions of the organization and with other clinicians,services and hospital departments on patient care issues.12.4.3 Duties and responsibilities of the Chief as delineated in the Chief of Service JobDescription will include:12.4.3.1 Planning and implementing a credentialing and privileging process for his /herService that includes the following:A. Establishing clinical privileges, determining qualifications andcompetencies necessary to hold such privilege(s); and designing andimplementing processes to confirm current competence at initialappointment and for focused and ongoing evaluation;B. Evaluating Applicant-specific information, including peerrecommendations, Practitioner-specific data from professional practiceevaluation and peer review, and other information that may be availableto demonstrate the Applicant’s ability to perform the requestedprivilege(s); andC. Submitting recommendations to the MSEC and to the CredentialingCommittee of the Board of Directors for Applicant-specific delineatedprivileges and/or Medical Staff membership.57

D. Determining the qualifications and competence of service personnel whoare not licensed independent practitioners and who provide care,treatment, and services.12.4.3.2 Based on an assessment of the patient population served, and in consultationwith Hospital and the Medical Staff, establish the type and scope of services, make recommendations fora sufficient number of qualified and competent persons assuring adequate coverage to provide care,treatment, and services; make recommendations for space and other resources needed by the service; anddevelop and institute policies and procedures for provision of care, treatment and services;12.4.3.3 Participate in the hospital's performance improvement and patient safetyprograms; and within his/her service, provide for continuous assessment and improvement of the qualityof care, treatment, and services, and, as appropriate, maintain quality control programs;12.4.3.4 Be responsible for the service’s teaching program, provide education asneeded, orientation and continuing education of all persons within the service, and establish servicespecific guidelines regarding House Officer scope and level of responsibility;12.4.3.5 Assess and recommend to the Hospital Administration off-site sources forneeded patient care, treatment, and services not provided by the Service or the Hospital.12.4.3.6 Serve as a member of the MSEC, make recommendations and suggestionsregarding his/her Service to assure quality patient care, communicate its recommendations andimplement its actions within his/her Service.12.5 Functions of Vice-ChiefsThe Vice-Chiefs will attend meetings and carry out the duties of the Chief when the Chief is absent.12.6 Appointment and Functions of Section ChiefsSection Chiefs within a Service will be appointed by the Chief of Service. Section Chiefs haveresponsibility for a group of practitioners within their subspeciality. With the approval of the Chief ofService, they may act as the Service Chief’s designee on matters pertaining to credentialing andprivileging within their subspecialty Section.12.6.1 Removal of a Section Chief will be initiated by the Chief of Service.12.7 Physician Directors of Specialized Patient Care Areas and ProgramsIn those specialized patient care areas and programs of the Hospital requiring professional medicalsupervision, a Physician Director may be appointed by the Hospital Chief Executive Officer followingthe recommendation of the Medical Director in concert with the Service Chief, and approval by theMSEC. A written job description of this physician director's duties and responsibilities will be developedand maintained by the Medical Director.58

ARTICLE 13: COMMITTEES13.1 Standing Committees13.1.1 Standing committees of the organized Medical Staff will be the Medical Staff ExecutiveCommittee (MSEC), Credentials Committee of the Medical Staff, Medical Staff Leadership Committee,Medical Staff Health Committee, Pharmacy & Therapeutics Committee, Quality and Safety Committee,Risk Management and Peer Review Committee, and Patient Care Committee. Other organizedcommittees of the Medical Staff, including those charged with the responsibility for reviewing andevaluating the quality of medical or hospital care, will be specified in Medical Staff Policies andProcedures. Although not designated as “standing” committees in these bylaws, they will, nonetheless,have the full protections afforded organized committees of the Medical Staff pursuant to Arkansas law.13.1.2 In performing the functions set forth in these Bylaws, each standing committee and theirappointed subcommittees are organized committees of the Medical Staff. These Medical Staffcommittees and subcommittees are responsible for reviewing and evaluating the quality of medical orhospital care. All proceedings, minutes, records, or reports of these committees or subcommittees areabsolutely privileged communications and are not subject to discovery or admissible in any legalproceeding.13.2 Appointment to Committees13.2.1 Chairpersons and Medical Staff members of standing committees, except the MSEC, willbe appointed annually by the Chief of the Medical Staff after consultation with the Medical Director, andnotification of the Chief Executive Officer or his/her designee. All standing committee chairs will bemembers in good standing of the Active Staff.13.2.2 Special committees may be appointed by the Chief of Staff or MSEC as need arises.13.2.3 The Chief Executive Officer, or designee, will assign Hospital representatives to serve onthe various committees.13.2.4 All committee members will have voting privileges in committee deliberations except exofficio status or otherwise stated within these Bylaws.13.2.5 Multidisciplinary committees of the organized Medical Staff, designated here as“Professional Partnership Committees”, may be formed to determine proposed actions, policies, andprocedures affecting quality of care, treatment, and services of ACH patients. Medical staff will beasked to serve on and chair Professional Partnership Committees. The Patient Care Committee will actas the oversight committee for the Professional Partnership Committees.59

13.3 Notice of Meetings13.3.1 Written, oral or electronic notification stating the date, time and location of any regularmeeting shall be given to committee members prior to each scheduled meeting.13.3.2 Committees may, by resolution, provide the time for holding regular meetings withoutnotice other than such resolution.13.3.3 Special meetings may be called by the chair, the Chief of the Medical Staff, or byone-third of the members. Members will be notified of special meetings as far in advance as timepermits.13.3.4 In special circumstances, the Chair of a committee may call an electronic meeting; i.e.,inability to form a quorum by those present.13.4 Manner of Action13.4.1 The action of a majority of members present at a meeting at which a quorum, as definedin these Bylaws, is present will be the action of committee or service.13.4.2 In the event that a quorum is not present, consent may be attained by polling of asufficient number of voting members to achieve a majority vote.13.5 Rights of Ex Officio Members13.5.1 Persons serving under these Bylaws as ex officio members of a committee will not havethe right to vote nor be counted in deciding the existence of a quorum except in the followingcircumstances:13.5.1.1 The ex officio member is serving as the representative of a member.13.5.1.2 The ex officio member is designated by the Chairman of the committee to becounted in deciding the existence of a quorum.13.6 Removal of MembersIf a Member of a committee including the MSEC ceases to be a Member-In-Good-Standing of theMedical Staff, suffers a loss or significant limitation of practice Privileges, or if any other good causeexists, that Member may be removed by a majority vote of the Medical Executive Committee13.7 Minutes13.7.1 Minutes of each regular and special meeting of a committee or service will be prepared asa permanent record and will include members and guests attending, findings, proceedings, andrecommendations.60

13.7.2 Minutes will be signed by the presiding officer and submitted to attendees at the nextregular meeting for approval.13.7.3 Minutes from the Professional Partnership Committees will be reviewed and reported tothe Patient Care Committee.13.7.4 A summary of Professional Partnership Committee minutes will be submitted to theMSEC for review and action upon recommendations of the committee.13.8 Scope and Authority of CommitteesSpecific composition, functions, responsibilities, limitations, and authority of the individual committeesare defined below. Revisions to the scope and authority of standing committees of the Medical Staff andPharmacy & Therapeutics committees must be approved by a majority vote of theMedical Staff.Changes that affect Medical Staff organization or policies within the hospital will be recommended bythe committee, approved by the MSEC, and reported at a regular meeting of the Medical Staff.13.9 Committees13.9.1 Medical Staff Executive Committee (MSEC)13.9.1.1. Scope/Delegation: By approving these Bylaws, represents the Medical Staff’sdelegation to the MSEC to act on their behalf.13.9.1.2 Composition: The MSEC will be a standing committee and will consist of theofficers of the Medical Staff, the chief of each clinical service, the Medical Director, the Chief QualityOfficer, the Outpatient Medical Director, the Trauma Medical Director, two members-at-large appointedby the Chief of Staff, and three members from the Pediatric Medicine Service. The Chief of Staff acts asthe chair.13.9.1.3 Any member of the Medical Staff has the right to come before and address theMSEC in accordance with Medical Staff procedure.13.9.1.4 Conflict Resolution: Each staff member on the Active Medical Staff maychallenge any rule or policy established by the MSEC through the following process:Submission of written notification to their Chief of Service (Chief of Service will forward to Chief ofStaff) or Chief of Staff of the challenge and the basis for the challenge, including any recommendedchanges to the rule or policy.A. At the next meeting of the MSEC, the MSEC shall discuss the challengeand determine if any changes will be made to the rule or policy.B. If changes are adopted, they will be communicated to the Medical Staff,at which time each Active member of the Medical Staff may submit61

written notification of any further challenge(s) to the rule or policy to theChief of Staff.C. The MSEC may appoint a task force to review any challenge andrecommend potential changes to address concerns raised by thechallenge.D. If a task force is appointed, following the recommendation of such taskforce, the MSEC will take final action on the rule or policy.E. Once the MSEC has taken final action in response to the challenge, withor without recommendations from a task force, any medical staffmember may submit a petition signed by twenty percent (20%) of themembers of the active category requesting review and possible change ofa rule, regulation, policy or procedure. Upon presentation of such apetition, the adoption procedure outlined in Paragraph 18.1 will befollowed.If the Medical Staff votes to recommend directly to the Board an amendment to the bylaws or rules andregulations or policy that is different from what has been recommended by the MSEC, the followingconflict resolution process should be followed:A. The MSEC shall have the option of appointing a task force to review thediffering recommendations of the MSEC and the Medical Staff andrecommend language to the bylaws, rules and regulations, or policy thatis agreeable to both the Medical Staff and the MSEC.B. Whether or not the MSEC adopts modified language, the Medical Staffshall still have the opportunity to recommend directly to the Board ofDirectors alternative language. If the Board of Directors receivesdiffering recommendations for bylaws, rules and regulations, or a policyform the MSEC and the Medical Staff, the Board of Directors shall alsohave the option of appointing a task force of the Board of Directors tostudy the basis of the differing recommendations and to recommendappropriate Board action. Whether or not the Board appoints such a taskforce, the Board of Directors shall have final authority to resolve thedifferences between the Medical Staff and the MSEC. (At any point inthe process, the Medical Staff, MSEC, or Board of Directors may utilizean outside source to assist in addressing the disagreement. The finaldecision whether or not to utilize an outside resource, and the processthat will be followed is the responsibility of the Board of Directors.)13.9.1.5 When a Service Chief is unable to attend the MSEC meetings, the Vice-Chiefor other designee should attend for him/her, in which case the Vice-Chief may vote for the Service.62

13.9.1.6The Chief Executive Officer, the Chief Operating Officer, the Chief NursingOfficer, and, when needed, other Hospital administrative representatives will attend meetings of theMSEC without vote.13.9.1.7All members of the Medical Staff, of any discipline or specialty, are eligible formembership on the MSEC.13.9.1.8 Duties: The duties of the MSEC will be to:A. Represent and act for the Medical Staff in the intervals between MedicalStaff meetings, subject to such limitations as may be imposed by theseBylaws;B..C..Coordinate the activities and general policies of the various services;Receive and act upon reports and recommendations from medical staffcommittees, clinical services, and assigned group activities;D. Carry out policies of the Medical Staff not otherwise the responsibilityof the services;E. Provide liaison between Medical Staff and the Chief Executive Officerand the Board of Directors;F. Recommend action to the President/Chief Executive Officer on mattersof a medico-administrative nature;G. Make recommendations on Hospital management matters to the Boardof Directors through the President/Chief Executive Officer;H. Fulfill the Medical Staff's accountability to the Board of Directors formedical care rendered to patients through monthly evaluation ofmorbidity and mortality, of quality assessment and improvementactivities, and of any other patient care assessments and to distribute thefindings and recommendations to the Medical Staff and the Board ofDirectors;I. Assure that the Medical Staff is kept abreast of the accreditation programand informed of the accreditation status of the Hospital;J. Review the credentials of Applicants for Medical Staff membership anddelineated clinical privileges, and make recommendations to theCredentialing Committee of the Board of Directors (refer to Bylaws forexceptions and adverse recommendations);63

K. Make recommendations regarding the process to review credentials anddelineate clinical privileges to the Board of Directors through theCredentialing Committee of the Board of Directors;L. Make recommendations for medical staff membership and delineatedclinical privileges to the Credentialing Committee of the Board ofDirectors (refer to Board of Directors Bylaws for exceptions);M. Recommend revisions to the Medical Staff Bylaws, Rules andRegulations of the Medical Staff for approval of the Board of Directors;N. Take all reasonable steps to insure professionally ethical conduct andcompetent clinical performance of all members of the Medical Staff,including the initiation of corrective action or review measures whenwarranted;O. Report at each Medical Staff General meeting; andP. Review and approve statements for delineation of clinical privileges foreach service, as proposed by the Chiefs of Service, and recommendapproval to the Board of Directors.13.9.1.9 Removal of MSEC: Removal of the MSEC authority would be by two-thirdsvote of the Medical Staff and approval of the Board of Directors.13.9.1.10. Meetings: The MSEC will meet monthly (except December) and maintain apermanent record of its proceedings and actions.13.9.2 Credentials Committee of the Medical Staff13.9.2.1 Composition: The Credentials Committee of the Medical Staff shall consistof the immediate Past Chief of Staff, who serves as Chair, at least three (3) other Past Chiefs of Staffwho are currently on the Active Medical Staff, and the Medical Director (or designee). The Chief ofStaff may appoint other members of the Active Medical Staff to serve on the committee, as needed.Physician members appointed to the Credentials Committee shall have served at least one year on theMedical Staff Executive Committee. Current membership on the MSEC is not required.The Chief Nursing Officer shall be an ex officio member and may vote on applications for AffiliatedHealth Professionals. The Chief of Staff, the Chief Executive Officer and the Vice President of MedicalStaff Services are ex officio members without vote.For the Credentials Committee, a quorum is defined as at least 50% of the voting members.13.9.2.2 Functions: The Credentials Committee will be responsible to64

A. review and evaluate the qualifications of all Applicants for Medical Staffand Affiliated Health Staff appointment, reappointment, and clinicalprivileges;B. review all available information regarding the clinical competence andprofessional performance of individuals with privileges or applying forprivileges;C. conduct interviews and collect additional information, as may benecessary;D. make recommendations for membership and/or privileges to the MedicalStaff Executive Committee; andE. develop, oversee, and make recommendations for Medical Staff Bylawsfor appointment and reappointment, medical staff policies andprocedures related to credentialing, and delineation of clinical privileges.December.13.9.2.3 Meetings: The Credentials Committee will meet monthly except in13.9.3 Medical Staff Leadership Committee13.9.3.1 Composition: The Medical Staff Leadership Committee will be asubcommittee of the MSEC and will consist of a minimum of the following: the officers of the MedicalStaff, the Medical Director, the Outpatient Medical Director, and the Associate Medical Directors. Atleast one member shall be from a service other than Pediatrics. The Chief of Staff will be the chair.13.9.3.2 Duties: The duties of the Medical Staff Leadership Committee will be to:A. Create and maintain a structure in which the medical staff leadershipfunctions effectively and efficiently,B. Evaluate and discuss issues, concerns, and complaints relevant to qualityof care, the delivery of care, and medical staff performance,C. Address matters that impact on the Medical Staff organization,D. Maintain current Medical Staff Bylaws, Rules and Regulations,including comprehensive triennial review,E. Provide oversight of peer review process, including corrective action,hearing and review, and any other processes which may result inrestriction or loss of privileges,F. Review any challenging applications for appointment or reappointment,65

G. Provide for development of medical staff leaders through orientation,training, and mentoring.H. Maintain regulatory compliance through study of new standards andnon-compliant standards,I. Makes recommendations to the MSEC.13.9.3.3 Meetings: The Medical Staff Leadership Committee will meet monthly or asneeded, and report to the MSEC.13.9.4 Medical Staff Health Committee13.9.4.1 Composition: The Medical Staff Health Committee will be composed of aminimum of the following: five (5) or more members of the Medical Staff, a Chief Resident, and onemember of the UAMS Health Committee, who serves as a liaison to the ACH Committee.Meetings of the Medical Staff Health Committee are open to members of the Committee and invitedguests only.13.9.4.2 Functions: The Medical Staff Health Committee will be advisory to theMSEC. The Medical Staff Health Committee is established to maintain and improve quality of care andassist staff members in the maintenance of appropriate standards of personal performance.The Medical Staff Health Committee will maintain confidentiality of the practitioner seeking referral orreferred for assistance, except as limited by law, ethical obligation, or when the health and safety of apatient is threatened.Its functions will include, but not be limited to:A. Provide education for the Medical Staff regarding the following areas ofconcern: medical staff health, well-being and impairment; appropriateresponses to different levels and kinds of distress and impairment;treatment, recovery and monitoring; responsibilities of the Medical Staffin response to concerns about medical staff health, and resources forprevention, treatment, rehabilitation, monitoring and reentry.B. Be the identified point within the Medical Staff where information andconsultation is provided to the Medical Staff member if he or she has aconcern regarding a personal health problem or that of anotherpractitioner.C. Make recommendations as needed or requested to MSEC regarding theappointment/reappointment of members of the Medical Staff andAffiliated Staff.66

D. Report to the Medical Staff Leadership Committee when a member ofthe Medical Staff or the Affiliated Staff fails to complete a requiredprogram and/or contract with ACH Committee or with the Physicians’Health Committee of the Arkansas Medical Foundation or fails to appearbefore the ACH Committee as requested.E. Evaluate and review concerns related to the health, well-being, orimpairment of practitioners as delegated by the MSEC.1. Perform an evaluation of the credibility of a complaint, allegation,or concern.2. A practitioner may be referred for emergency evaluation when atleast two (2) members of the Committee have been consulted andare in agreement regarding the need for the evaluation.F. Provide advice, assistance, and recommendations to the Practitioner witha health problem and to the referring source.G. Provide recommendations and referral for treatment, education and/orassistance in obtaining treatment or education.H. Coordinate monitoring of Practitioners for compliance with the terms ofa monitoring agreement.I. Serve as an advocate for the Practitioner with a health problem, andproviding assistance with re-entry issues.J. Coordinate with the Physicians' Health Committee of the ArkansasMedical Foundation in evaluating and monitoring of members on theArkansas Children's Hospital Medical Staff with health problems.The Medical Staff Health Committee will focus on the needs of the Practitioners in question. TheCommittee will have no authority to take disciplinary action. The Committee will operate with strictestconfidentiality.13.9.4.3 Meetings: The Medical Staff Health Committee will meet at least four times ayear and on request. The Committee will make appropriate reports to the MSEC.Emergency Meetings of the Medical Staff Health Committee: An emergency meeting of the MedicalStaff Health Committee may be called by any member of the Committee. The presence of three (3)members of the Committee shall constitute a quorum.13.9.5 Patient Care Committee67

13.9.5.1 Composition: The Patient Care Committee will consist of at least thefollowing: the Chief Medical Officer, the Chief Quality Officer, the Chief Operating Officer, the Chiefof Staff, The Chief Nursing Officer, the Chief Medical Information Officer, the Chief NursingInformation Officer, the Vice Chair for Clinical Services for Pediatrics, ACH General Counsel, theChairs of the Surgical Affairs Committee, the Ethics Advisory Committee, the Outpatient CareCommittee, the Trauma committee, the Pharmacy & Therapeutics Committee, the Medical/Surgical(Inpatient) Committee, the Infection Control Committee, and the Intensive Care Committee. The ACHGeneral Counsel will be a non-voting member of this committee.13.9.5.2 Function: The Committee is chartered by the Medical Staff ExecutiveCommittee to oversee on its behalf the delivery of patient care throughout the ACH system.• Oversee and align the decision-making activities of the professionalpartnership committees with the ACH mission and service standards• Review of activities of professional partnership committees andrecommend approval of minutes to MSEC• Review and recommend approval of new programs that impact thedelivery of care in the ACH system• Periodic review of existing patient care activities and programs• Review metrics of clinical activities of patient care service lines• Recommend and refer performance improvement initiatives to the Qualityand Patient Safety committeeand/or revision• Review selected clinical policies and make recommendations for update13.9.5.3 Meetings: The Patient Care Committee will meet at least 10 times per year.13.9.6 Pharmacy and Therapeutics Committee13.9.6.1 Composition: The Pharmacy and Therapeutics Committee will consist of aminimum of the following: three (3) or more members of the Medical Staff, the Director of Pharmacy, aClinical Nutritionist, an Administrative representative, and a Nursing representative.13.9.6.2 Functions: The Pharmacy and Therapeutics Committee will be responsible fordevelopment and surveillance of all drug utilization policies and practices to assure optimum clinicalresults and minimum potential for hazard; shall assist in the formulation of broad professional policiesregarding the evaluation, appraisal, selection, procurement, storage, distribution, use, safety procedures,and all other matters relating to drugs in the hospital; provide a clinical focal point for nutritionalassessment, care, and guidelines, and shall also perform the following specific functions:68

A. Provide advice to the Medical Staff and hospital staff on matterspertaining to choice of available drugs;B. Develop the drug formulary and all drug lists annually and make interimrevisions as needed;C. Make recommendations concerning drugs to be stocked on the nursingunits and by other services and emergency drug stocks;D. Prevent unnecessary duplication in stocking drugs and in medicationshaving identical amounts of the same therapeutic ingredients;E. Develop and review procedures for evaluating drug usage in the hospital,medication errors, adverse drug reactions and other aspects ofpharmaceutical quality control;F. Develop procedures for handling and control of drugs brought into thehospital by patients;G. Evaluate clinical data concerning new drugs or pharmacy preparationsrequested for use in the hospital; andH. Establish standards for use and control of investigational drugs and ofresearch in use of recognized drugs.quarterly.13.9.6.3 Meetings: The Pharmacy and Therapeutics Committee will meet at least13.9.7 Risk Management/Peer Review Committee13.9.7.1 Composition: The Risk Management/Peer Review Committee will consist ofat least the following: the Chief Quality Officer, the Medical Director, the Chief Operating Officer, theChief of Staff, The Chief Nursing Officer, the Chief Finance Officer, the Vice Chief of Staff, theImmediate Past Chief of Staff, the Surgeon-in-Chief, The Pediatrician-in-Chief, a General Pediatricsrepresentative, a Pediatric Chief Resident, a Vice-President Patient Care Services, a Pharmacyrepresentative, the Vice President of Medical Administration, Safety, and Improvement, the ClinicalRisk Management Director, the Medical Staff Administration Director, a Quality ImprovementCoordinator, and a representative of the Office of General Counsel as a non-voting member (for advisoryonly) The Chief Quality Officer, or designee, will serve as chairperson. Department Chairs/Directors ofaffected service(s) or section(s) or others requested by the committee will attend meetings without vote,as requested by the committee chair.13.9.7.2 Function: The Risk Management/Peer Review Committee is chartered by theBoard Services and Quality Committee to oversee the peer review and clinical risk managementfunctions of the ACH clinical enterprise. As such, deliberations and findings of the Committee areprotected under Arkansas statues.69

ACH commitment to patient care quality and patient safety across the clinical enterprise. As such,deliberations and findings of the committee are protected under the appropriate Arkansas statutes.Through its deliberations and activities, the committee will:a. Set the quality and patient safety agenda for the ACH clinical enterprise.b. Promote quality and patient safety initiatives in patient care areas and across theclinical enterprise.c. Ensure that quality and safety standards are being met across the clinicalenterprise.This will be accomplished through:1) Compliance with The Joint Commission standards and National PatientSafety Goals2) Review of quality and safety activities, including but not limited toa) Infection Controlb) Transfusionc) Radiation Safetyd) Escalation of Caree) Multi-institutional collaboratives/initiatives3) Review of clinical policies and procedures relevant to quality and patientsafety.4) Review of quality and safety performance indicators and metrics forclinical practice.5) Oversight of all other clinical and administrative activities as they affectquality and patient safety. For example,a) Medical equipment and supply purchase and careb) Pharmacy and medical safetyc) In-hospital of transport of patients13.9.8.3 Meetings: The Quality and Patient Safety Committee will meet at least sixtimes per year.13.9.9 Other CommitteesThe MSEC may appoint other committees as necessary for effective and efficient operation of theHospital and proper discharge of the Medical Staff's responsibility for assuring high quality patient carein the hospital. It may also assign new functions to existing committees.71

ARTICLE 14: MEDICAL STAFF MEETINGS14.1 Regular Meetings14.1.1 Medical Staff General (MSG) meetings will be held at least twice a year to receivereports of MSEC actions, including revisions to the Medical Staff Bylaws and Rules and Regulations; toreview and evaluate the medical performance of the Medical Staff, including the activities of the PatientCare Committee; and to receive reports of administrative activities.14.1.2 The Spring/Summer meeting will be the annual Medical Staff meeting at which timeelection of officers will be conducted.14.1.3 The MSEC will, by standing resolution, designate the time and place for all meetings ofMedical Staff General. Notice of the original resolution and any changes will be given to members ofthe staff in the same manner as provided for notice of a special meeting.14.2 Special (Called) Meetings14.2.1 The Chief of Staff, the MSEC, or not less than one fourth of the members of the Activemedical staff may at any time file a written request with the Chief of Staff that within 14 days of thefiling of such a request, a special meeting of the Medical Staff is called. The MSEC will designate thetime and place of any special meeting.14.2.2 Written or printed notice stating the place, day, and hour of any special meeting of theMedical Staff will be delivered, either personally, by e-mail, or by mail, to each member of the ActiveStaff not less than three (3) nor more than ten (10) days before the date of the called meeting, by or at thedirection of the Chief of Staff. Notice also may be sent to members of other Medical Staff groups whohave so requested. The attendance of a member of the Medical Staff at a meeting will constitute awaiver of notice of such meeting. No business will be transacted at any special meeting except thatstated in the notice calling the meeting.14.3 Agenda14.3.1 The agenda at any regular Medical Staff meeting will be determined by the Chief of Staffand, at a minimum, will include a report from the MSEC, the Chief Executive Officer and MedicalDirector (or their designees).14.3.2 Any member of the Medical Staff may request to speak at a MSG meeting by givingnotice to the Chief of Staff prior to the next scheduled staff meeting.14.4 Delegation of AuthorityThrough these Bylaws, the Medical Staff directs and authorizes the MSEC to act on its behalf. At eachmeeting of the MSG, the Chief of Staff will provide a report of actions taken by the MSEC.72

14.5 Removal of Delegated Authority14.5.1 If the Medical Staff believe that the MSEC is not representing its views on issues ofpatient safety and quality of care, the Medical Staff at its regular MSG meeting or at a special (called)meeting may make a motion to remove or limit the authority of the MSEC to act on its behalf.14.5.2 Approval of the motion will require a 2/3 vote of the Medical Staff members present atsuch meeting. Members of MSEC may not vote and are not counted in determining the voting quorum.14.5.3 If the motion is approved, the following process will be followed:14.5.3.1 At the same meeting during which the motion was approved, the MedicalStaff will appoint or elect three (3) representatives to work with the Medical Staff Leadership Committeeto clarify and resolve areas of conflict.MSG.14.5.3.2 A plan for resolution will be presented for approval at the next meeting of the14.5.4 MSEC shall retain authority to act on behalf of the Medical Staff until any plan(s) forresolution has been implemented.73

ARTICLE 15: ATTENDANCE AND QUORUM REQUIREMENTS15.1 Medical Staff General (MSG)15.1.1 Attendance at regular MSG or special called staff meetings is encouraged although notmandatory.15.1.2 Those Medical Staff members present shall be a quorum for the purpose of conducting allbusiness.15.2 Medical Staff Executive Committee (MSEC)15.2.1 Members of the MSEC are expected to attend 75 percent of the MSEC meetings.Attendance of either the Chief or Vice Chief of a Service will be counted toward the required 75 percentparticipation level.15.2.2 The presence of 50 percent or more of the MSEC membership shall constitute a quorumfor the purpose of conducting all business.15.3 Medical Staff Committees15.3.1 Medical Staff members are expected to attend, or be excused from not less than 50percent of the standing committees of the Medical Staff and the Professional Partnership Committeemeetings to which they have been appointed. Members who do not meet this attendance requirementmay not be reappointed to the committee.15.3.2 Those present at any committee meeting shall be deemed a quorum for conducting allbusiness provided that at least one (1) of the attendees is a member of the Medical Staff.15.4 Special Requirements15.4.1 Medical Staff members who are requested to attend a meeting of either the MSEC or theMedical Staff Health Committee are required to do so.74

16.1 Confidentiality of InformationARTICLE 16: IMMUNITY FROM LIABILITYInformation with respect to any practitioner, submitted, collected or prepared by a Representative orThird Party for the purpose of reviewing credentials, utilization review, peer review, corrective action,achieving and maintaining quality patient care, reducing morbidity and mortality, contributing to clinicalresearch or other related purposes of the Hospital shall be confidential to the fullest extent permitted bylaw, shall not be disseminated to anyone other than a representative unless required by law or consentedto by such practitioner, and shall not be used in any way except as provided herein or except asotherwise required by law. This information shall become a part of the Medical Staff files and shall notbecome part of any particular patient’s file or of the general Hospital records.16.2 Release from LiabilityEach Practitioner by requesting privileges and/or Medical Staff membership at the Hospital, and /orexercising any privileges at the Hospital, hereby releases, indemnifies and holds harmlessrepresentatives, Third Parties, and any individual authorized by any of the foregoing to performinformation gathering or disseminating functions from any and all claims, demands or actions withrespect to all acts, including without limitation, communications, reports, recommendations, ordisclosures of information performed pursuant to these Bylaws including, without limitation, actsperformed in connection with:A. Applications and Nominations for Medical Staff membership;B. Applications for clinical and admitting privileges;C. Applications for advancement from proctoring status;D. Applications for renewal and reappointment of Medical Staff Membership, clinicalprivileges or admitting privileges;E. Corrective action;F. Summary or automatic suspension or termination of Medical Staff membership and/orprivileges;G. Hearings and appeals;H. Medical care evaluation studies;I. Peer review committees and activities;75

J. Other Hospital Department, Division, Medical Staff, Committee or Subcommitteeactivities relating to quality assurance, utilization review, risk management, patient care, andprofessional conduct;K. Providing information to Third parties.76

ARTICLE 17: RULES AND REGULATIONS17.1 The Medical Staff will adopt such Rules and Regulations as may be necessary to carry out thegeneral principles found within these Bylaws, subject to the approval of the Board of Directors. Thesewill relate to the proper conduct of Medical Staff organizational activities as well as embody the level ofpractice that is to be required of each practitioner in the hospital.17.2 The Medical Staff delegates to MSEC with approval of the Board of Directors the authority toapprove Rules and Regulations and to recommend approval to the Board of Directors. All changes willbe reported to the Medical Staff at the next regular meeting of the Medical Staff General.17.3 These changes will become effective when approved by the Board of Directors.77

ARTICLE 18: AMENDMENTS TO BYLAWS AND RULES AND REGULATIONS18.1 Proposed adoption or amendments to these Medical Staff Bylaws and Rules and Regulations maybe originated by the MSEC or by a petition signed by twenty percent (20%) of the voting members of theMedical Staff.A. When proposed by the MSEC, there will be communication of the proposed adoption oramendment to the organized medical staff.B. When proposed by the Medical Staff, there will be communication of the proposedadoption or amendment to the MSEC before a vote is taken by the Medical Staff.18.2 The Board of Directors has final approval authority for all proposed amendments to bylaws andrules and regulations78

ARTICLE 19: POLICIESWhen the MSEC adopts a policy or amendment to a policy, there will be communication of the policy oramendment to the Medical Staff.79

ARTICLE 20: ADOPTION20.1 Bylaws ReviewThe Bylaws of the Medical Staff and the Rules and Regulations will be reviewed as separate documentsin their entirety every three (3) years.20.2 ApprovalThese Bylaws with the appended Rules and Regulations will be adopted at any regular or specialmeeting of the MSEC, shall replace any previous Bylaws, Rules and Regulations, and shall becomeeffective when approved by the Board of Directors of the Hospital.80

DEFINITIONSAdmitting Physician - The ACH staff physician who makes the decision to admit the patient to theHospital.Attending Physician- The ACH staff physician who is directly responsible for the clinical care of thepatient for a given interval during the hospital admission.Board Certification - Certification by an approved board of the American Board of Medical Specialties(ABMS)Chief Executive Officer/President- The individual appointed by the Board of Directors to act in itsbehalf in the overall management of the Hospital. The terms Chief Executive Officer, CEO, orPresident may be used interchangeably.Chief of Service- The Medical Staff member designated in accordance with these Bylaws to serve as thehead of a service.Completed Application – The information as described in these Bylaws has been obtained.Consulting physician - Any ACH staff physician who is requested by the attending physician to evaluatethe patient and make recommendations regarding further diagnostic work-up or treatment.Credentialing – The process of obtaining, verifying, and assessming the qualifications of a practitionerto provide care or services.Credentialing Committee of the Board of Directors - The Credentialing Committee of the Board ofDirectors as established in the Bylaws of the Board of Directors.Executive Committee- The Executive Committee of the Medical Staff unless specific reference is made tothe Executive Committee of the Board of Directors. The terms Medical Staff Executive Committee,MSEC, and Executive Committee may be used interchangeably.Governing Body- The Board of Directors of the Hospital.Health Care Entity - Any hospital, clinic, managed care organization, health care network, integrateddelivery system or professional association.Health Care Provider - Any ACH Medical Staff member, Affiliated Health Professional Staff member,Allied Health, or ACH employee (e.g. nurse, pharmacist, respiratory therapist) directly involved inpatient care at Arkansas Children's Hospital.House Staff and Residents - Participants in a professional graduate medical education program.81

In Good Standing - There are no restrictions or suspensions of licensure or membership, controlledsubstances registration, and/or privileges at this or any other health care entity.Medical Director – The individual appointed to the administrative position of Chief Medical Officer ofthe Hospital. The term Senior Vice President for Clinical Affairs/Medical Director may also be used.Medical Staff - All Physicians and Dentists, who have been appointed to the Medical Staff.Peer - A practitioner who holds the same or equivalent licensure; i.e., MD to MD, MD to DO, DO toMD, DDS to DDS and has similar clinical experience.Physician - A doctor of medicine, osteopathy, dental surgery or dental medicine who is legallyauthorized to practice by the State and who is acting within the scope of his or her licensePractitioner - A physician, dentist, or other licensed independent healthcare professional.Primary Care Physician- The physician named by the family as the one who most consistently providesprimary care for the patient.Privileging – The process whereby the specific scope and content of patient care services (privileges)are authorized by the hospital based on the individual’s credentials and performance.Referring Physician - The physician identified by the Admitting Physician as the one who referred thepatient for evaluation and/or treatment.Section Chief – The Medical Staff member designated by the Chief of Service to have responsibilities fora group of practitioners with specialized privileges within the service.Service - The group of practitioners who have clinical privileges in one of the general areas of medicineOriginal documents, revisions, and approvals can be found in Medical Staff Services.82

REVISIONS TO MEDICAL STAFF BYLAWSADDITION OF ADULT SERVICE12.1 Organization of Services12.1.1 There shall be services of Anesthesiology, Cardiovascular Surgery, Dentistry,Neurosurgery, Ophthalmology, Orthopaedic Surgery, Otolaryngology, Pathology, Pediatric Medicine,Psychiatry, Radiology, Surgery, Urology, and Adult Medicine.12.1.2 Each Service shall be headed by a Chief of Service and shall function under the directionof the MSEC. Each service will also have a Vice-Chief, when possible.12.2 Assignment to Services12.2.1 The MSEC will, after consideration of the recommendations of the clinical services,recommend initial service assignments for all Medical Staff members and for all other approvedPractitioners with clinical privileges.12.2.2 Physicians assigned to the Adult Medicine Service are limited to adultspecialists/subspecialists who take call for the Burn Unit or are asked to treat adult patients who havebeen granted a treatment exception (over 21) by the Medical Director. Adult Medicine physicians mustfollow the requirements for admitting adult patients as specified in Paragraphs 1.1.2 & 1.1.3.Approved by Medical Staff Executive Committee: June 12, 2012Approved by Medical Staff General Committee: July 26, 2012Approved by Board of Directors: August 29, 2012REVISIONS TO MEDICAL STAFF BYLAWSDESCRIPTION OF STANDING COMMITTEES13.9.6 Patient Care Committee1. Composition: The Patient Care Committee will consist of at least the following:the Chief Medical Officer, the Chief Quality Officer, the Chief Operating Officer, the Chief of Staff, TheChief Nursing Officer, the Chief Medical Information Officer, the Chief Nursing Information Officer,the Vice Chair for Clinical Services for Pediatrics, ACH General Counsel, the Chairs of the SurgicalAffairs Committee, the Ethics Advisory Committee, the Outpatient Care Committee, the Traumacommittee, the Pharmacy & Therapeutics Committee, the Medical/Surgical (Inpatient) Committee, theInfection Control Committee, and the Intensive Care Committee. The ACH General Counsel will be anon-voting member of this committee.83

2. Function: The Committee is chartered by the Medical Staff Executive Committeeto oversee on its behalf the delivery of patient care throughout the ACH system.• Oversee and align the decision-making activities of the professionalpartnership committees with the ACH mission and service standards• Review of activities of professional partnership committees andrecommend approval of minutes to MSEC• Review and recommend approval of new programs that impact thedelivery of care in the ACH system• Periodic review of existing patient care activities and programs• Review metrics of clinical activities of patient care service lines• Recommend and refer performance improvement initiatives to the Qualityand Patient Safety committeeand/or revision• Review selected clinical policies and make recommendations for update3. Meetings: The Patient Care Committee will meet at least 10 times per year.Approved by Medical Staff Executive Committee: July 10, 2012Approved by Medical Staff General Committee: July 26, 2012Approved by Board of Directors: August 29, 201213.9.7 Risk Management/Peer Review Committee1. Composition: The Risk Management/Peer Review Committee will consist of atleast the following: the Chief Quality Officer, the Medical Director, the Chief Operating Officer, theChief of Staff, The Chief Nursing Officer, the Chief Finance Officer, the Vice Chief of Staff, theImmediate Past Chief of Staff, the Surgeon-in-Chief, The Pediatrician-in-Chief, a General Pediatricsrepresentative, a Pediatric Chief Resident, a Vice-President Patient Care Services, a Pharmacyrepresentative, the Vice President of Medical Administration, Safety, and Improvement, the ClinicalRisk Management Director, the Medical Staff Administration Director, a Quality ImprovementCoordinator, and a representative of the Office of General Counsel as a non-voting member (for advisoryonly) The Chief Quality Officer, or designee, will serve as chairperson. Department Chairs/Directors ofaffected service(s) or section(s) or others requested by the committee will attend meetings without vote,as requested by the committee chair.2. Function: The Risk Management/Peer Review Committee is chartered by theBoard Services and Quality Committee to oversee the peer review and clinical risk management84

functions of the ACH clinical enterprise. As such, deliberations and findings of the Committee areprotected under Arkansas statues.Through its deliberations and activities, the committee will:e. Affirm proper service recovery was done in case of adverse events in patients.f. Provide enterprise-wide accountability for regular review and follow-up of:1) Opportunities for improvement or corrective actions identified throughservice- and section-based morbidity and mortality (M&M) conferences.2) Findings and action plans developed as a result of Root Cause Analyses(RCAs).3) Summary and relevant details of all adverse events.4) General Counsel open file issues related to patient care and safety.5) Other issues as identified by or referred to the Committee.g. Refer as appropriate issues for specific actions and follow up to the respectivesenior leader. For example,1) Quality improvement and risk management – Chief Quality Officer2) Credentialing of Physicians and other Independent Practitioners – Chief ofStaff3) Operations – Chief Operating Officer4) Medical Staff – Chief Medical Officer5) Patient Care Services and Nursing – Chief Nursing Officer6) Hospital information technology – Chief Medical Information Officerh. The Committee shall regularly report its findings to the Board Services andQuality Committee and the Medical Staff Executive Committee.3. Meetings: The Risk Management/Peer Review Committee will meet at least sixtimes per year.13.9.8 Quality and Patient Safety Committee1. Composition: The Quality and Patient Safety Committee will consist of at leastthe following: the Chief Quality Officer, the Chief of Staff, the Medical Director, the Chief OperatingOfficer, the Chief Nursing Officer, the Chief Finance Officer, Vice President, Ambulatory Services, theChief Medical Information Officer, the Chief Nursing Information Officer, the Chair of the IntensiveCare Committee, the Chair of the Escalation of Care Committee, a Pediatric Chief Resident, anEmergency Department physician representative, a Surgery physician representative, an Anesthesiaphysician representative, an Infection Control representative, a Safety Office representative, a QualityImprovement physician representative, an NICU Quality Improvement physician representative, the Vice85

President for Medical Administration, Safety, and Improvement, the Nursing QualityImprovement/Accreditation Director, the Chair of the organization-wide Quality and Safety Council, theVice President of Clinical Services, a Pharmacy representative, Vice President of Operations, QualityImprovement Director, a parent representative, the Radiation Safety Officer, the Chair of the TransfusionCommittee, and a representative of the Office of General Counsel as a non-voting member (for advisoryonly). The Chief Quality Officer, or designee, will serve as chairperson.2. Function: The Quality and Patient Safety Committee is chartered jointly by theBoard Services and Quality Committee and the Medical Staff Executive Committee to oversee the ACHcommitment to patient care quality and patient safety across the clinical enterprise. As such,deliberations and findings of the committee are protected under the appropriate Arkansas statutes.Through its deliberations and activities, the committee will:d. Set the quality and patient safety agenda for the ACH clinical enterprise.e. Promote quality and patient safety initiatives in patient care areas and across theclinical enterprise.f. Ensure that quality and safety standards are being met across the clinicalenterprise.This will be accomplished through:Safety Goals6) Compliance with The Joint Commission standards and National Patient7) Review of quality and safety activities, including but not limited toa) Infection Controlb) Transfusionc) Radiation Safetyd) Escalation of Caree) Multi-institutional collaboratives/initiatives8) Review of clinical policies and procedures relevant to quality and patientsafety.9) Review of quality and safety performance indicators and metrics forclinical practice.10) Oversight of all other clinical and administrative activities as they affectquality and patient safety. For example,a) Medical equipment and supply purchase and careb) Pharmacy and medical safetyc) In-hospital of transport of patients86

per year.3. Meetings: The Quality and Patient Safety Committee will meet at least six timesApproved by Medical Staff Executive Committee: June 12, 2012Approved by Medical Staff General Committee: July 26, 2012Approved by Board of Directors: August 29, 2012REVISIONS TO MEDICAL STAFF BYLAWSDENTAL H&P CLARIFICATIONParagraph 4.2.6.7: The clinical attending physician will countersign the inpatient H&P when recordedby a member of the house staff or by affiliated staff with appropriate privileges. A clinical attendingmust complete and sign the inpatient H&P for dentists who do not hold admitting privileges.Paragraph 8.5.4: All dental patients will receive the same medical assessment, including H&P by aclinical attending physician or Anesthesia H&P, as patients admitted to other surgical services. APhysician member of the Medical Staff will be responsible for the care of any medical problem that ispresent at the time of admission or that may arise during hospitalization.Approved by Medical Staff Executive Committee: September 11, 2012Approved by Medical Staff General Committee: October 25, 2012Approved by Board of Directors: November 28, 2012REVISIONS TO MEDICAL STAFF BYLAWSCLARIFICATION OF AFFILIATED AND ALLIED HEALTH PROFESSIONALSARTICLE 6: AFFILIATED/ALLIED HEALTH PROFESSIONAL STAFF6.1 Nature of Affiliated Health Professional Staff6.1.1 Affiliated Health Professional Staff are non-Physicians who hold advanced degrees andprovide patient services independently.6.1.2 This non-Physician category includes, but is not limited to: Advanced Practice Nurses,Licensed Clinical Psychologists, and Optometrists.6.1.3 Affiliated Health Personnel may render patient services within the confines of ACH andits clinics in accordance with the clinical privileges they have been granted. While carrying out activitiesat ACH, Affiliated Health Personnel will follow the Bylaws/Rules and Regulations of the Medical Staffand policies and procedures of the hospital.87

6.2 Conditions of Appointment6.2.1 Conditions of appointment and membership for the Affiliated Health Professional Staffshall be as outlined in Bylaws of the Medical Staff.6.2.2 Appointments to the Affiliated Health Professional staff confer on the appointee onlysuch clinical privileges as have been granted by the Board of Directors. Members of the AffiliatedHealth Professional Staff do not have admitting privileges, cannot serve as clinical attending forinpatients, nor can they be granted privileges outside the scope of their license.6.2.3 Affiliated Staff may practice independently in clinic settings consistent with theirprivileges and within the scope of their licenses. A member of the medical staff is required to beavailable (although not required to be physically present in the clinic). Documentation of clinic notesand orders do not require co-signature.6.2.4 Acceptance of membership in the Affiliated Health Professional Staff shall constitute thestaff member’s agreement that he/she will abide by the Medical Staff Bylaws, Rules and Regulations, theapplicable policies and procedures of Arkansas Children's Hospital, and the Code of Conduct ofArkansas Children's Hospital.6.2.5 Members of the Affiliated Health Professional Staff may attend meetings of the generalMedical Staff, but without vote.6.2.6 The member may be appointed by the Chief of Staff to serve on committees of theMedical Staff. Such appointment by the Chief of Staff confers the right to vote on such matterspresented to that committee.6.3 Appointment, ReappointmentProcedures for appointment and reappointment of Affiliated Health Professional Staff shall be consistentwith the Bylaws of the Medical Staff and in accordance with hospital policy.6.4 Clinical Privileges6.4.1 Clinical privileges for Affiliated Health Professional Staff shall be granted as outlined inthe Medical Staff Bylaws and/or Medical Staff policy, as appropriate to the privileges being granted.6.4.2 Members of the Affiliated Health Professional staff shall be assigned to the ClinicalService in which most of the privileges are performed.6.4.3 Advanced practice nurses may be granted privileges for prescriptive authority if the nurseholds the appropriate license, if recommended by the MSEC, and if approved by the Board of Directors.(Refer to Medical Staff Rules and Regulations re: orders and entries into the medical record.)88

6.5 Violations of AppointmentAny violation of the standards set forth within these Bylaws, Rules and Regulations will be reported tothe MSEC through the Medical Director for appropriate action.6.6 Allied Health Personnel6.6.1 Allied Health Personnel are health practitioners functioning under the supervision of amember of the Active Medical Staff.. All dependent practitioners who are NOT employees of ArkansasChildren’s Hospital are considered Allied Health Personnel. This category includes, but is not limited toRegistered Nurses, Registered Nurse Practitioners (RNP), Orthotists, Dental Assistants, GeneticCounselors, Psychological Examiners, Physician Assistants, Radiology Assistants, Licensed PracticalNurses, Doctor of Pharmacy, Surgical Assistants, Clinical Ethicist, Registered Nurse First Assistants,and Surgical Techs.6.6.2 Allied Health Personnel may render patient services in accordance with their jobdescription and/or clinical practice agreements.6.6.3 While carrying out activities at ACH, Allied Health Personnel will follow theBylaws/Rules and Regulations of the Medical Staff and policies and procedures of the Hospital.6.6.4 Individuals in this category are approved and follow procedures consistent with humanresource requirements for employees. Refer to Allied Health Policy. Additionally, Physician Assistants,Radiology Assistants, Registered Nurse First Assistants, and Surgical Assistants may be employed byArkansas Children's Hospital and must be credentialed and appointed by the Board of Directors.6.6.5 Allied Health Professional Staff are NOT entitled to the procedural right of reviewafforded by the Medical Staff Bylaws to Medical Staff Members.Approved by Medical Staff Executive Committee: October 9, 2012Approved by Medical Staff General Committee: October 25, 2012Approved by Board of Directors: November 28, 201289