Medical Staff Bylaws - Arkansas Children's Hospital

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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
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 and 40: 9.2.2.1 In conducting such evaluati
Page 41: 9.3.2 Whenever the corrective actio
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
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Medical Staff Bylaws - Arkansas Children's Hospital

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