Mount Carmel Health System Medical Staff

Bylaws Mount Carmel Health (MCE/MCW)

Mount Carmel St. Anns Mount Carmel New Albany

A Medical Staff Document

C:\Documents and Settings\pdfgen\Local Settings\Temp\pdfg-pdfgen\02\02f8-82c916-38ee6e-5e5461-052b99-aa318f\MCHS Medical Staff Bylaws.DOC Document Manager: Mary Harger, System Director, Medical Staff Services

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TABLE OF CONTENTS Page

TABLE OF CONTENTS................................................................................................... i

PREAMBLE .................................................................................................................... 1

DEFINITIONS ................................................................................................................. 2

OTHER............................................................................................................................ 5

ARTICLE I NAME ........................................................................................................... 7

ARTICLE II PURPOSES AND RESPONSIBILITIES ...................................................... 8

2.1 Purposes.................................................................................................... 8 2.2 Responsibilities. ......................................................................................... 8

ARTICLE III APPOINTMENT AND PRIVILEGES ........................................................ 10

3.1 Nature of Appointment and Privileges. .................................................... 10 3.2 Non-Discrimination................................................................................... 10 3.3 No Entitlement to Appointment and/or Privileges..................................... 10 3.4 Additional Considerations. ....................................................................... 10 3.5 Exclusive Contract/Closed Specialty. ...................................................... 11 3.6 Contract Practitioners. ............................................................................. 12 3.7 Qualifications for Appointment and Privileges or for Privileges Only. ...... 12 3.8 Qualifications for Appointment Only......................................................... 17 3.9 Obligations of Appointment and/or Privileges. ......................................... 17 3.10 Obligations of Practitioners Appointed to Medical Staff Categories

without Privileges. .................................................................................... 18 3.11 Duration of Appointment/Privileges.......................................................... 18 3.12 Medical History and Physical Examination Requirements. ...................... 19 3.13 Medico-Administrative Positions. ............................................................. 19

ARTICLE IV MEDICAL STAFF CATEGORIES ............................................................ 20

4.1 Categories. .............................................................................................. 20

ARTICLE V CREDENTIALING, APPOINTMENT/ REAPPOINTMENT AND PRIVILEGING PROCEDURES ............................................................... 30

5.1 Process.................................................................................................... 30 5.2 Focused Professional Practice Evaluation and Ongoing

Professional Practice Evaluation. ............................................................ 30 5.3 Details...................................................................................................... 30

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ARTICLE VI MEDICAL STAFF OFFICERS AND MEC MEMBERS AT LARGE ......... 31

6.1 Officers of the Medical Staff..................................................................... 31 6.2 Qualifications. .......................................................................................... 31 6.3 Nominations and Election. ....................................................................... 31 6.4 Succession .............................................................................................. 32 6.5 Term. ....................................................................................................... 32 6.6 Vacancies. ............................................................................................... 33 6.7 Resignation and Removal........................................................................ 33 6.8 Duties of Officers. .................................................................................... 34

ARTICLE VII CLINICAL DEPARTMENTS ................................................................... 35

7.1 Current Departments; Affiliation. .............................................................. 35 7.2 Department Chair: Qualifications, Election, and Term. ........................... 36 7.3 Department Chair: Responsibilities and Authority.................................... 36 7.4 Department Chair: Resignation or Removal from Position....................... 38 7.5 Department Vice-Chairs........................................................................... 38

ARTICLE VIII COMMITTEES ....................................................................................... 39

8.1 Peer Review Committees ........................................................................ 39 8.2 Medical Executive Committee.................................................................. 39 8.3 Other Medical Staff Committees. ............................................................. 41

ARTICLE IX MEDICAL STAFF, DEPARTMENT, SECTION, AND COMMITTEE MEETINGS .............................................................................................. 42

ARTICLE X CORRECTIVE ACTION, SUMMARY SUSPENSION, AUTOMATIC SUSPENSION/TERMINATION ............................................................... 43

10.1 Collegial Intervention. .............................................................................. 43 10.2 Corrective Action. .................................................................................... 43 10.3 Summary Suspension.............................................................................. 46 10.4 Automatic Suspension. ............................................................................ 47 10.5 Automatic Termination. ............................................................................ 49 10.6 Continuity of Patient Care. ....................................................................... 50 10.7 Sharing of Information.............................................................................. 50 10.8 Fair Hearing/Appeal Process. .................................................................. 51

ARTICLE XI CONFIDENTIALITY, AUTHORIZATIONS, IMMUNITY AND RELEASES ............................................................................................. 53

11.1 Special Definitions. .................................................................................. 53 11.2 Authorizations and Conditions. ................................................................ 53 11.3 Confidentiality of Information. .................................................................. 54 11.4 Immunity from Liability. ............................................................................ 54 11.5 Activities and Information Covered. ......................................................... 54

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11.6 Releases.................................................................................................. 55 11.7 Cumulative Effect..................................................................................... 55

ARTICLE XII INTERNAL CONFLICT OF INTEREST................................................... 56

12.1 In General. ............................................................................................... 56 12.2 Department Chair. ................................................................................... 56

ARTICLE XIII ADOPTION AND AMENDMENT ........................................................... 57

13.1 Medical Staff Authority. ............................................................................ 57 13.2 Adoption/Amendment of Medical Staff Bylaws. ....................................... 57 13.3 Adoption and Amendment of Medical Staff Policies and Rules and

Regulations.............................................................................................. 58 13.4 Department Rules & Regulations............................................................. 59 13.5 Conflict Between Documents................................................................... 59 13.6 Member Action......................................................................................... 59 13.7 Medical Staff/MEC Conflict Resolution. ................................................... 60

ARTICLE XIV CERTIFICATION OF ADOPTION & APPROVAL ................................. 61

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PREAMBLE

Mount Carmel Health System is a non-profit corporation organized under the laws of the State of Ohio for the purpose of providing health care and medical services for inpatients and outpatients and promoting the well-being of the citizens of Columbus, Ohio and the surrounding area.

The System owns and operates three (3) acute care hospitals in central Ohio: Mount Carmel St. Anns, Mount Carmel New Albany Surgical Hospital, and Mount Carmel Health (consisting of two (2) campusesMount Carmel East and Mount Carmel West). Mount Carmel St. Anns and Mount Carmel New Albany Surgical Hospital each has its own Medical Staff. Mount Carmel East and Mount Carmel