Medical Staff Bylaws - Arkansas Children's Hospital

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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
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Approved: August 2011
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10.13 Release .....................
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PREAMBLEWHEREAS, Arkansas Children'
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3.1 Nature of Medical Staff Members
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ARTICLE 4: CATEGORIES OF THE MEDICA
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4.2.6.4 If the H&P has been written
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ARTICLE 5. HOUSE STAFF AND MEDICAL
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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 and 42: 9.3.2 Whenever the corrective actio
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: written notification of any further
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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