Medical Staff Bylaws - Arkansas Children's Hospital

More documents

Recommendations

Info

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
Page 2: Approved: August 2011
Page 6 and 7: 10.13 Release .....................
Page 8: PREAMBLEWHEREAS, Arkansas Children'
Page 11 and 12: 3.1 Nature of Medical Staff Members
Page 13 and 14: ARTICLE 4: CATEGORIES OF THE MEDICA
Page 15 and 16: 4.2.6.4 If the H&P has been written
Page 17 and 18: ARTICLE 5. HOUSE STAFF AND MEDICAL
Page 19 and 20: ARTICLE 6: AFFILIATED HEALTH PROFES
Page 21 and 22: 7.1 General ConditionsARTICLE 7: AP
Page 23 and 24: A. To abide by the Bylaws, Rules an
Page 25 and 26: 7.4 Reapplication After Adverse Dec
Page 27 and 28: and for the granting of clinical pr
Page 29 and 30: ARTICLE 8: CLINICAL PRIVILEGES8.1 C
Page 31 and 32: date such action becomes effective
Page 33 and 34: E. Ability to perform the privilege
Page 35 and 36: A. if no other physician currently
Page 37 and 38: B. A current license to practice.C.
Page 39: 9.2.2.1 In conducting such evaluati
Page 43 and 44: 9.4.3 A summary suspension becomes
Page 45 and 46: 9.6 Temporary Suspension9.6.1 A tem
Page 47 and 48: D. automatic suspensions;E. a suspe
Page 49 and 50: B. A hearing occasioned by an adver
Page 51 and 52: 10.6.6 Utilization of Attorneys. At
Page 53 and 54: D. Upon conclusion of the affected
Page 55 and 56: 10.5.3(a) involving actions other t
Page 57 and 58: C. Whether or not the hearing commi
Page 59 and 60: 10.14 Exceptions To Hearing And App
Page 61 and 62: ARTICLE 11: OFFICERS11.1 Officers o
Page 63 and 64: 11.6.1.8 Receive and interpret the
Page 65 and 66: ARTICLE 12: SERVICES12.1 Organizati
Page 67 and 68: D. Determining the qualifications a
Page 69 and 70: 13.3 Notice of Meetings13.3.1 Writt
Page 71 and 72: written notification of any further
Page 73 and 74: K. Make recommendations regarding t
Page 75 and 76: G. Provide for development of medic
Page 77 and 78: 13.9.5.1 Composition: The Patient C
Page 80 and 81: ACH commitment to patient care qual
Page 82 and 83: 14.5 Removal of Delegated Authority
Page 84 and 85: 16.1 Confidentiality of Information
Page 86 and 87: ARTICLE 17: RULES AND REGULATIONS17
Page 88 and 89: ARTICLE 19: POLICIESWhen the MSEC a
Page 90 and 91:
DEFINITIONSAdmitting Physician - Th
Page 92 and 93:
REVISIONS TO MEDICAL STAFF BYLAWSAD
Page 94 and 95:
functions of the ACH clinical enter
Page 96 and 97:
per year.3. Meetings: The Quality a
Page 98:
6.5 Violations of AppointmentAny vi
show all

Medical Staff Bylaws - Arkansas Children's Hospital

Create successful ePaper yourself

Delete template?

Save as template?