BYLAWS OF THE MEDICAL/DENTAL STAFF OF ST. JOSEPH HOSPITAL
Page
Forward . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Preamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Definitions and General Provisions . . . . . . . . . . . . . . . . . . . . . . 2-3
ARTICLE I: NAME . . . . . . . . . . . . . . . . . . . . . . . . . . 4
ARTICLE II: PURPOSE . . . . . . . . . . . . . . . . . . . . . . . . 4
ARTICLE III: MEDICAL/DENTAL STAFF MEMBERSHIP . . . . . . . . . . . . . . 4
ARTICLE IV: CATEGORIES OF MEMBERSHIP . . . . . . . . . . . . . . . . 9
Page
Page
BYLAWS OF THE MEDICAL/DENTAL STAFF OF
ST. JOSEPH HOSPITAL, FORT WAYNE, INDIANA
FORWARD
St. Joseph Health System, LLC d/b/a/ St. Joseph Hospital, is located at 700 Broadway, Fort Wayne, Indiana 46802, and is organized under the laws of the State of Delaware. St. Joseph Hospital is an affiliate of Triad Hospitals, Inc., headquartered in Plano, Texas.
In this document the masculine nomenclature shall be used throughout as a matter of convenience. It is not to be used as discrimination in as much as it is a precept of the Medical/Dental Staff of St. Joseph Hospital that there be no discrimination on the basis of gender, religion, creed, race, national origin, age, color, political affiliation, or any other possibility based on association with some specific human category.
PREAMBLE
WHEREAS, St. Joseph Hospital is a limited liability company organized under the laws of the State of Delaware; and
WHEREAS, in recognition that the quality of professional performance, medical care, education and research in the Hospital is the ultimate responsibility of the Board of Trustees, and that the Medical/Dental Staff needs to provide advice and recommendations and that the best interest of the patients cared for within the Hospital are met by cooperative efforts;
THEREFORE, the practitioners and non-physicians practicing at St. Joseph Hospital are hereby organized, in conformity with these Bylaws formulated by the Medical/Dental Staff to aid the Staff in self-governance, to advise the Board of Trustees that it may most wisely make decisions reflecting its responsibilities in all matters pertaining to patient care; and, to maintain harmonious and cooperative relationships between the Medical/Dental Staff and the governance of the Hospital.
THEREFORE, these Bylaws, which originate with the Medical/Dental Staff, are adopted in order to provide for the organization of the Medical/Dental Staff of St. Joseph Hospital and to provide a framework for self‑governance in order to permit the Medical/Dental Staff to discharge its responsibilities in matters involving the quality of medical care and to govern the orderly resolution of those purposes. These Bylaws provide the professional and legal structure for Medical/Dental Staff operations, organized Medical/Dental Staff relations with the Board of Trustees, and relations with applicants to and members of the Medical/Dental Staff. These Bylaws, when adopted by the Medical/Dental Staff and accepted by the Board of Trustees, create a framework for the efficient and effective delivery of quality patient care services consistent with the mission of the Hospital and its Medical/Dental Staff.
DEFINITIONS AND GENERAL
PROVISIONS
DEFINITIONS:
1. The term Allied Health Professional or AHP means an individual other than a licensed physician, podiatrist, or dentist, who is qualified by academic and/or clinical training and by experience and current competence to function in a medical support role to and under the direction of a Medical/Dental Staff member. Allied Health Professionals are not considered members of the Medical/Dental Staff but may be granted a scope of practice and prerogatives in conformance with the applicable state practice act and these Bylaws.
2. The term Board of Trustees or Board means the Hospital's governing body. As appropriate to the context and consistent with the Hospital's Bylaws, it may also mean any Board committee or any individual authorized by the Board to act on its behalf.
3. The term Chief Executive Officer means the individual appointed by the Triad Hospitals Inc. as the Chief Executive Officer of the Hospital to manage the Hospital's affairs. The Chief Executive Officer may designate a representative to perform the responsibilities specified in the Medical/Dental Staff Bylaws.
4. The term Clinical Privileges or Privileges mean the permission the Board grants to a physician, podiatrist, or dentist to provide delineated diagnostic, therapeutic, medical, dental, podiatric, surgical, consultative or psychological services, and to use Hospital equipment.
5. The term Executive Committee or Medical Executive Committee means the Executive Committee of the Medical/Dental Staff unless otherwise stated.
6. The term Ex-Officio means service by virtue of office or position held. An ex-officio membership is, without vote unless indicated otherwise.
7. The term Hospital means St. Joseph Health System LLC d/b/a St. Joseph Hospital of Fort Wayne.
8. The term Medical/Dental Staff or Staff is the organizational component of the Hospital that includes all practitioners who are appointed to it and have privileges to attend patients or to provide other diagnostic, therapeutic, teaching or research services at the Hospital.
9. The term Medical/Dental Staff Year means the 12-month period commencing on January 1 of each year and ending on December 31.
10. The term Medical Administrative Officer means a practitioner employed by or otherwise serving the Hospital on a full or part time basis, whose duties include certain responsibilities, which is both administrative and clinical in nature. Clinical responsibilities as used herein are those responsibilities, which require a practitioner to exercise clinical judgement with respect to patient care, and it includes the supervision of professional activities of practitioners under his direction.
11. The term Physician means an individual with an M.D. or D.O. degree who is fully licensed to practice medicine in the State of Indiana.
12. The term Scope of Practice means the permission granted to an Allied Health Professional to participate in the provision of certain patient care services.
13. The term Practitioner means, unless otherwise expressly limited, any licensed physician, dentist or podiatrist who is applying for Medical/Dental Staff membership and/or clinical privileges, or who is a Medical/Dental Staff member and/or who exercises clinical privileges in this Hospital.
14. The term Prerogative means a right granted to a Staff member or Allied Health Professional to participate in Medical/Dental Staff organization activities and provide patient care service subject to the conditions and limitations imposed in these Bylaws, and by Hospital Medical/Dental Staff policies.
15. The term President means the President of the Medical/Dental Staff unless otherwise stated.
16. The term Special Notice means written notification sent by certified mail return receipt requested, or by personal delivery service with signed acknowledgement of receipt.
17. The term Qualified Health Care Provider means a health care provider as defined by the Indiana Medical Malpractice Act who is qualified under I.C. 34-18-3 et seq. of the Act, as amended from time to time.
GENERAL PROVISIONS:
1. Each member of the Medical/Dental Staff shall conduct himself in the highest ethical manner. By accepting membership on the Medical/Dental Staff a member specifically, agrees as a condition of continuing membership, to abide by the current Ethical and Religious Directives of Catholic Health Facilities. Each practitioner further agrees as a condition of continuing membership on the Hospital's Medical/Dental Staff to abide by the principles of Medical Ethics currently adopted by the American Medical Association, Standards of Professional Conduct promulgated by the Medical Licensing Board of Indiana, or as applicable, to any existing and currently adopted Code of Ethics of those state and national professional societies representing other practitioners not doctors of medicine. Each member agrees to abide to practice only within the scope or privileges granted to him.
2. Hospital Administration shall cause to be printed a sufficient number of copies of the current Medical/Dental Staff Bylaws and Rules and Regulations, dated as to year of publication and incorporating all finalized Bylaws and or Rules and Regulations changed since their last printing. Copies shall be maintained in the Medical Staff Office and available to individual physicians as requested.
ARTICLE I
NAME
The name of this organization shall be "THE MEDICAL/DENTAL STAFF OF ST. JOSEPH HOSPITAL OF FORT WAYNE, INDIANA"
ARTICLE II
PURPOSE
The purposes of this organization are:
2.1 To provide a single organized body with overall responsibilities for the quality of the care, treatment, patient safety and professional services provided by individuals with clinical privileges, as well as the responsibility for reporting same to the governing body.
2.2 To pursue a level of professional performance consistent with quality patient care by all practitioners authorized to practice in the Hospital through the appropriate delineation of the clinical privileges that each practitioner may exercise in the Hospital, and through a periodic review and evaluation of each practitioner's performance in the Hospital.
2.3 To establish educational standards which will lead to advancement in professional knowledge and skill and will result in the provision of high quality care.
2.4 To initiate, maintain, review and revise Rules and Regulations for self-governance of the Medical/Dental Staff.
ARTICLE III
MEDICAL/DENTAL STAFF MEMBERSHIP
3.1 NATURE OF MEMBERSHIP
Membership on the Medical/Dental Staff and/or for clinical privileges shall be extended only to practitioners who are professionally competent and who continually meet the qualifications, standards, and requirements set forth in these Bylaws and the adopted Rules and Regulations and Medical Staff policies. Gender, Race, Creed or National Origin are not used in making decisions regarding granting or denying medical staff membership or clinical privileges. Appointment to and membership on the Medical/Dental Staff shall confer on the member only such clinical privileges and prerogatives as have been granted by the Board of Trustees in accordance with these Bylaws.
No practitioner, including those in a medical administrative position by virtue of a contract or employment with the Hospital and excepting those Staff members already granted clinical privileges, shall admit or provide services to patients in the Hospital until or unless he is a member of the Medical/Dental Staff or has been granted temporary privileges in accordance with the procedures set forth in these Bylaws.
3.2 QUALIFICATION FOR MEMBERSHIP
3.2-1 GENERAL QUALIFICATIONS
Membership shall be awarded only to appropriately licensed practitioners who possess and maintain the basic qualifications for membership on the Medical/Dental Staff, except for the Honorary, Emeritus and/or Retired Staff categories in which case these criteria shall only apply as deemed individually applicable by the Medical/Dental Staff and each of whom:
(a) Documents current licensure, including temporary if applicable,Federal DEA number, experience, background, education, training, demonstrated ability, professional competence, and physical and mental health status with sufficient adequacy to demonstrate qualification to exercise clinical privileges and that patient care provided will meet the current standard of care recognized in the hospital and community.
(b) On the basis of verified references, demonstrate a willingness to strictly adhere to the lawful ethics of his respective profession, work cooperatively with others in the Hospital setting, participate in and properly discharge Staff responsibilities, and commit to and regularly assist the Hospital in fulfilling its obligations related to patient care, within the scope of his professional competence and credentials.
(c) Has offices and residences located close enough to the Hospital to provide continuity of quality care.
(d) Maintains professional liability insurance coverage in the amount required by the Hospital and the Indiana State Department of Insurance and provides adequate proof that he is a Qualified Health Care Provider under the Indiana Malpractice Act. THE INSURANCE MUST COVER ALL PRIVILEGES THE PRACTITIONER IS GRANTED.
3.2-2 PARTICULAR QUALIFICATIONS
(a) Physicians:An applicant for Physician Staff membership must (1) hold an M.D. or D.O. degree issued by the medical or osteopathic school approved at the time of the issuance of such degree by the Medical Licensing Board of Indiana; (2) hold a valid and unsuspended license to practice medicine issued by the Medical Licensing Board of Indiana; and, (3) be "Board Certified" or "Board Qualified" or possess outstanding and exceptional qualifications and recommendations in the specialty or specialties in which the physician seeks clinical privileges. The term "Board Certified" shall mean a certification issued by a specialty board ("Specialty Board") that is approved by the American Board of Medical Specialties ("ABMS"), the American Osteopathic Association ("AOA"), or the equivalent organization in a foreign country, to certify the physician in a specific medical specialty. The equivalent organization in a foreign country must be recognized as equivalent by the ABMS if the practitioner is an M.D. or the AOA if the practitioner is a D.O. The term "Board Qualified" shall mean that the physician is eligible to take the examination to become Board Certified in the medical specialty in which the physician seeks clinical privileges, as established by the appropriate Specialty Board. Provided, however, if a physician is not eligible to take the examination solely because the physician has not practiced medicine the number of
Years required by the appropriate Specialty Board as a prerequisite to taking the examination, then the physician shall nonetheless be Board Qualified. A physician may hold Board Qualified status for no longer than five (5) years from the date on which the physician first became eligible to take the appropriate Specialty Board examination. If a physician fails to become Board Certified during the period of time that the physician was Board Qualified, then when the physician is next reviewed for reappointment, the physician shall no longer satisfy the requirements of this Section 3.2‑2 and the physician shall not be reappointed as a member of the Medical/Dental Staff. Provided, however, if the physician holds privileges in more than one specialty, only the clinical privileges in the affected specialty shall be terminated and the physician's membership and other clinical privileges shall not be terminated. A physician who is neither Board Certified nor Board Qualified at the time the initial application is submitted shall be presumed to be ineligible for membership and/or clinical privileges and only upon a showing of outstanding qualifications and recommendation, and otherwise satisfying his or her burden of proof (as set forth in Section 6.2) shall such a physician be qualified to obtain membership and/or clinical privileges. This paragraph creates an obligation for a physician to be Board Certified, Board Qualified or possess exceptional qualifications and recommendations, at the time the physician submits an initial application for membership and privileges. In addition, in the case of a physician who is Board Qualified at the time the initial application is submitted, the physician is obligated to become Board Certified within five (5) years of becoming eligible to take the examination or the physician will thereafter become ineligible to retain his membership. This paragraph creates no ongoing obligation for a physician to maintain his Board Certified status after becoming a member of the Medical/Dental Staff.
(b) Dental Staff:Applicants for Dental Staff membership must (1) meet the general qualifications for membership set forth in section 3.2-1; (2) be graduates of a dental school approved at the time of graduation by the Indiana State Board of Dental Examiners and have a valid, unrevoked and unsuspended license to practice dentistry in the State of Indiana; and (3) pay dues.
Appointment to the Dental Staff and the granting of applicable privileges shall be pursuant to the same terms and procedures governing the Medical/Dental Staff as set forth in these Bylaws and particularly section 3.4, except as may be specifically limited.
The prerogatives of a Dental Staff member shall be to: (1) co-admit patients under the name of a Physician Staff member who shall assume the overall responsibility for the care and medical welfare of the patient; (2) be responsible for the dental care of the patient; (3) share joint responsibility with the admitting Physician Staff member for all medication, preoperative preparation and medical aftercare of the patient, within the scope of his license to practice dentistry; and (4) act as advisors on dental problems to members of the Medical/Dental Staff.
(c) Podiatry Staff:Applicants for Podiatric Staff membership must (1) meet the general qualifications for membership set forth in section 3.2-1; (2) be graduates of a certified school of podiatric medicine; (3) have completed a residency (approved by American Board of Podiatric Surgery/ or the American Board of Podiatric Orthopedics and Primary Podiatric Medicine); (4) be Board Eligible or Board Certified by the American Board of Podiatric Surgery/American Board of Podiatric Orthopedics and Primary Podiatric Medicine. A Podiatrist may hold Board Qualified status for no longer than five (5) years from the date on which first becoming eligible to take the appropriate
Specialty Board examination. If a physician fails to become Board Certified during the period of time that the physician was Board Qualified, then when the Podiatrist is next reviewed for reappointment, shall no longer satisfy the requiremens of this section and shall not be reappointed as a member of the Podiatry Staff; and (5) pay dues.
The prerogatives of a Podiatric Staff member shall be to: (1) co-admit patients under the name of a Physician Staff member who shall assume the overall responsibility for the care and medical welfare of the patient; (2) be responsible for the podiatric care of the patient; (3) share joint responsibility with the admitting Physician Staff member for all medication, preoperative preparation and postoperative care of the patient, completion of discharge summary and face sheet, within the scope of the license to practice podiatry; (4) act under the direct supervision of the Department of Surgery; and (5) act as advisors on podiatric problems to members of the Medical/Dental Staff.
(d) Residents:Residents are physicians in training who act under the approved residency program directives. Residents may take histories, perform examinations, and treat patients in accordance with the stage of their training as determined by program directives and mentors, who shall be responsible for the actions of the Residents. Residents are not eligible for Medical/Dental Staff membership.
3.3 EFFECT OF OTHER AFFILIATIONS
No person shall be entitled to membership on the Medical/Dental Staff merely because he holds a certain degree, is licensed to practice in this or in any other state, is a member of any professional organization, is certified by a clinical board, or because such person had, or presently has, staff membership or privileges at another health care facility.
3.4 BASIC RESPONSIBILITIES OF MEDICAL/DENTAL STAFF MEMBERSHIP
The ongoing responsibilities of each member of the Medical/Dental Staff shall include:
3.4-1 Providing patients with the quality of care meeting the professional standards of the Medical/Dental Staff of this Hospital.
3.4-2 Abiding by the Medical/Dental Staff Bylaws and Medical/Dental Staff Rules and Regulations.
3.4-3 Discharging in a responsible and cooperative manner such reasonable responsibilities and assignments imposed upon the member by virtue of Medical/Dental Staff membership, including committee assignments.
3.4-4 Preparing and completing in timely fashion medical records for all the patients to whom the member provides care in the Hospital.
3.4-5 Abiding by the lawful and ethical principles of the Indiana State Medical Association or the Indiana Osteopathic Association.
3.4-6 Aiding in any Medical/Dental Staff approved education programs for medical students, interns, resident physicians, and non-physician practitioners.
3.4-7 Working cooperatively with members, nurses, Hospital Administration and others so as not to affect patient care adversely.
3.4-8 Making appropriate arrangements for coverage for his patients as determined by the Medical/Dental Staff.
3.4-9 Refusing to engage in improper inducements for patient referral.
3.4-10 Participating in continuing education programs as determined by the Medical/Dental Staff. A total of 40 Category 1 hours for two years.
3.4-11 Participating in such emergency service coverage or consultation panels as may be determined by the Medical/Dental Staff.
3.4-12 Notifying the Medical Executive Committee and the Hospital Administration of any challenges/relinquishments/adverse actions taken against the practitioner by any health care entity, any state licensure board, Drug Enforcement Administration, state pharmacy board, the Department of Health and Human Services (Office of Inspector General) or court of law in a malpractice action. Failure to report above may result in disciplinary action.
3.4-13 Discharging such other Staff obligations as may be lawfully established from time to time by the Medical/Dental Staff.
3.4-14 Abiding by applicable Hospital policies and procedures, as they now exist or are from time-to-time amended or adopted.
3.4-15Maintains appropriate work relationships and avoiding disruptive, intimidating and/or harassing behaviors.
ARTICLE IV
CATEGORIES OF MEMBERSHIP
4.1 CATEGORIES
The categories of the Medical/Dental Staff shall include the following: Active, Courtesy, Provisional, Honorary, Emeritus, Specified Professional Personnel, and Retired. At each time of reappointment, the member's Staff category shall be determined.
4.2 ACTIVE STAFF
4.2-1 QUALIFICATIONS
The Active Medical/Dental Staff shall consist of members who:
(a) Meet the general qualifications for membership set forth in Section 3.2.
(b) Regularly care for patients in this Hospital or are regularly involved in Medical/Dental Staff functions, as determined by the Medical/Dental Staff.
(d) Successfully complete the provisional period described in Section 4.4.
(e) Pay dues.
4.2-2 PREROGATIVES
Except as otherwise provided, the prerogatives of an Active Medical/Dental Staff member shall be to:
(a) Admit patients and/or exercise clinical privileges as granted.
(b) Attend and vote on matters presented at general and special meetings of the Medical/Dental Staff and of the department and committees of which he is a member.
(c) Hold Staff, division, committee, or department office and serve as a voting member of committees to which he is duly appointed or elected by the Medical/Dental Staff or duly authorized representative thereof.
4.3 THE COURTESY STAFF
4.3-1 QUALIFICATIONS
The Courtesy Medical/Dental Staff shall consist of members who:
(a) Meet the general qualifications set forth in Section 3.2.
(b) Do not regularly care for patients or are not regularly involved in the Medical/Dental Staff functions.
(c) Are members in good standing of the Active or Provisional Medical/Dental Staff of another Indiana licensed hospital, although exceptions to this requirement may be made by the Medical Executive Committee for good cause. Dentists may be granted courtesy staff status without being on the active staff of another hospital.
(d) Successfully complete the provisional period described in Section 4.4.
(e) Pay Dues.
4.3-2 PREROGATIVES
Except as otherwise provided, the Courtesy Medical/Dental Staff member shall be entitled to:
(a) Admit patients and/or exercise clinical privileges as granted.
(b) Attend in a non-voting capacity meetings of the Medical/Dental Staff and the department of which he is a member, including open committee meetings and educational programs, but shall have no right to vote at such meetings, except within committees when the right to vote is specified at the time of appointment. Courtesy Staff members shall not be eligible to hold office in the Medical/Dental Staff.
c) Courtesy Medical/Dental Staff members who admit patients or regularly care for
patients at the Hospital shall, upon review of the Medical Executive Committee, be encouraged to seek appointment to the appropriate Staff category.
4.4 PROVISIONAL STAFF
4.4-1 QUALIFICATIONS
The Provisional Medical/Dental Staff shall consist of all new members for at least a period of one year who:
(a) Meet the general qualifications for membership set forth in Section 3.2.
(b) Immediately prior to their application and appointment were not members (or were no longer members) in good standing of this Medical/Dental Staff.
(c) Pay dues
4.4-2 PREROGATIVES
The Provisional Medical/Dental Staff member shall be entitled to:
(a) Admit patients and/or exercise clinical privileges as granted.
(b) May serve on committees and attend and exercise vote at meetings of the Medical/Dental Staff and the department or committee of which physician is a member, including open meeting and educational programs. Provisional Medical/Dental Staff members shall not be eligible to hold office in the Medical/Dental Staff organization.
4.4-3 OBSERVATION OF PROVISIONAL STAFF MEMBER
Each Provisional Staff member shall undergo a period of observation by the Department Chairman or assigned service member. The observation shall be to evaluate the member's proficiency in the exercise of clinical privileges granted. Observation of Provisional Staff members may include but not be limited to, concurrent or retrospective chart review, mandatory consultation, and/or direct observation. Appropriate records shall be maintained. The results of the observation shall be communicated by the department chairman to the Credentials Committee.
4.4-4 TERM OF PROVISIONAL STAFF STATUS
A member shall remain on the Provisional Staff for a period of one year. Provisional status may be extended for an additional period of up to two years upon determination of good cause.
4.4-5 ACTION AT CONCLUSION OF PROVISIONAL STAFF STATUS
(a) If the Provisional Staff member has satisfactorily demonstrated his ability to exercise the clinical privileges initially granted and otherwise appears qualified for continued Staff membership, the member shall be appointed to the Active or Courtesy Staff, as appropriate, upon recommendation of the Medical Executive Committee, and approval by the Board of Trustees.
(b) In all other cases, the appropriate Service Department Chairman shall advise the Credentials Committee which shall make its report to the Medical Executive Committee, which in turn shall make its recommendation to the Board regarding a modification or termination of clinical privileges.
4.5 SPECIFIED PROFESSIONAL PERSONNEL
4.5-1 Definition
Specified Professional Personnel (“Specified Professionals”) provide certain professional services to patients at the Hospital or one of its affiliate sites. These individuals must be licensed by the appropriate state licensing authorities. Privileges for Specified Professional Personnel shall be based upon the individual’s professional training, experience, and demonstrated competency.
4.5-2 Scope of Practice
(a) Specified professionals generally can bill independently for the services they provide and they require no direct supervision by a member of the Medical / Dental staff.
(b) The Medical / Dental Staff will establish and obtain Board approval for clinical privileges to be granted to each Specified Professional Personnel.
(c) Categories of Specified Professionals may be added or deleted by action of the St. Joseph Hospital Board of Trustees upon recommendations by the Medical Executive Committee.
4.5.3 Qualifications of Specified Professional Personnel
Only those Specified Professionals who hold a license, certificate, or other credentials required by applicable state law and satisfy the requirements of the Specified Professional Personnel Category(s) established in 4.5-2 above are eligible to provide such services in the Hospital or one of its affiliated sites. The Credentials Committee may, in consultation with the Chief Executive Officer and the Medical Executive Committee, establish such additional qualifications required of Specified Professional Personnel as are deemed appropriate for patient care purposes.
4.5.4 Procedure for Specification of Services
Written guidelines for the performance of specified services by Specified Professional Personnel will be developed by the Chief Executive Officer and the Medical Executive Committee with input, when applicable, from the practitioner chairman of the clinical service involved. For each category of Specified Professional Personnel, such guidelines must include, without limitation:
(a) Specification of classes of patients who may be seen;
(b) Description of the services to be provided, procedures to be performed, and responsibility for medical record completion and ordering of drugs;
(c) Definition of the degree of assistance that may be provided to Specified Professional Personnel in the treating of patients on Hospital premises and any limitation thereof, including the degree of Specified Professional Personnel or physician supervision required for each service;
(d) Procedure for admission and discharge of patients for whom Specified Professional Personnel are to provide services.
4.5.5 Prerogatives of Specified Professional Personnel
Specified Professional Personnel have the following prerogatives:
(a) Provide Specifically Designated Patient Care Services
Provide specifically designated patient care services as deemed appropriate by the Chief Executive Officer and the Medical Executive Committee.
(b) Write Orders to Extent Specified
Write orders only to the extent specified in the position description required under 4.5-4, but not beyond the scope to the Specified Professional’s license, certificate, or other legal credential.
(c) Attend Clinical Services, Hospital, Staff Education Programs
Attend, upon request and without vote, Staff, Hospital, and clinical service education programs and clinical meetings related to their disciplines or where their special training and knowledge are desirable.
(d) Other Prerogatives
Exercise such other prerogatives as the Credentials Committee, with the approval of the Medical Executive Committee, may accord them in general or as a specific category of Specified Professional Personnel.
4.5.6 Obligations of Specified Professional Personnel
(a) Basic Responsibilities
Specified Professional Personnel must meet the same basic qualifications and obligations as required for Medical Staff members, or as applicable to the Specified Professional Personnel’s field of practice.
(b) Appropriate Responsibility
Retain appropriate responsibility within their area of professional competence for the continuous care and supervision of each patient in the Hospital for whom they are providing services, or arrange a suitable alternate for such care and supervision.
(c) Quality Management Program
Participate as appropriate in the quality management program activities, supervise new appointees of the same profession during the provisional period, and discharge such other functions as may be requested by the Medical Executive Committee.
(d) Malpractice Insurance
Specified Professional Personnel shall carry in force malpractice insurance equal to that required of Medical Staff members or as deemed appropriate by the Medical Staff Executive Committee, and, if permitted by law, meet the requirements of I.C. 34-18-3, et seq, to be qualified health care providers.
4.5-7 Applications
Applications and credentials concerning specified professional privileges shall be submitted and
processed in the same manner as that prescribed for Medical Staff members in Article VI of
these Bylaws.
4.5-8 Granting Privileges for Specified Professionals
Requests for clinical privilege form Specified Professional Personnel are processed in the same manner specified in Article VII of these Bylaws.
4.5-9 Limitation of Prerogatives
The prerogatives set forth under each membership category are general in nature and may be
subject to limitation by special conditions attached to a particular membership, by other sections
of the Medical Staff Bylaws (the “Bylaws”) and by the Medical Staff Rules and Regulations.
Specified Professional Personnel are not entitled to the procedural rights provided to Medical
Staff Members in Article IX of the Bylaws. However, a Specified Professional may appeal the
suspension or termination of privileges or prerogatives pursuant to the following process:
(a) The Specified Professional must submit a written appeal of a suspension or termination of privileges or prerogatives to the President of the Hospital within 10 days of the Specified Professional’s receipt of notice of such a suspension or termination. Failure to provide a written appeal as herein described shall result in a waiver of the Specified Professional’s appeal rights.
(b) The written appeal shall contain a concise statement of the Specified Professional’s reasons for appealing the suspension or termination, and shall describe all material facts, which support the Specified Professional’s appeal.
(c ) The Specified Professional may retain an attorney or any other counsel to prepare or to assist in the preparation of the written appeal.
(d) Neither the Specified Professional nor his counsel, if any, shall have the unconditional right to make an oral presentation in support of the written appeal to the Chief Executive Officer of the Hospital. At his sole discretion, the Chief Executive Officer may agree to hear an oral presentation in support of the written appeal. In addition, and also at his sole discretion, the Chief Executive Officer may agree to hear an oral presentation in opposition to the written appeal by a member of the Credentials Committee or that Committee’s designee.
(e) The Chief Executive Officer shall render a decision on the written appeal within a reasonable time after his receipt of the written appeal and oral arguments in support thereof, if any.
(f)The Chief Executive Officer’s decision shall be final.
4.6 HONORARY, EMERITUS AND RETIRED
4.6-1 QUALIFICATIONS
(a) The Honorary Staff
The Honorary Staff shall consist of members who do not have clinical privileges at the Hospital but are deemed deserving of the membership by virtue of their outstanding reputation, noteworthy contributions to the health and medical sciences, or their previous long-standing service to the Hospital, and who continue to exemplify high standards of professional and ethical conduct. Honorary Staff members are not eligible to hold office in this Medical/Dental Staff organization, but they may serve on committees with voting privileges. They are not required to pay dues.
(b) The Emeritus Staff
A member must request Emeritus staff status. Emeritus Staff shall consist of members who have reached the age of 65, have clinical privileges, were members in good standing of the Active Medical/Dental Staff for at least ten years, and who continue to adhere to appropriate professional and ethical standards. Emeritus Staff members are not eligible to hold office in this Medical/Dental Staff organization, but they may serve on committees with voting privileges. They are not required to pay dues.
(c) The Retired Staff
The Retired Staff shall consist of members who have retired from active practice, may not maintain clinical privileges or admit patientsand were members in good standing at the time of retirement. They may attend department and educational meetings, but shall not have voting privileges. They are not required to pay dues.
4.7 LIMITATION OF PREROGATIVES
The prerogatives set forth under each membership category are general in nature and may be subject to limitation by special conditions attached to a particular membership, by other sections of these Bylaws and by the Medical/Dental Staff Rules and Regulations.
4.8 MODIFICATION OF MEMBERSHIP CATEGORY
On its own, upon recommendation of the Credentials Committee, or pursuant to a request by a member under Section 6.6-1, the Medical Executive Committee may recommend to the Board a change in the Medical/Dental Staff category of a member consistent with the requirements of the Bylaws.
4.9 PROCEDURAL RIGHTS FOR CHANGES IN CATEGORY
A practitioner may request a hearing and appellate review under Article IX to challenge an involuntary change to the Honorary category which results in termination of clinical privileges. A practitioner is not, however, entitled to any hearing or appeal to challenge any other Staff category change. A practitioner who believes that a change was based upon erroneous information concerning his activity may, however, submit a written description of his activities to the Executive Committee, which shall have the authority to reconsider any change in Staff category as a result of this further review. A written request for such reconsideration shall be a prerequisite to any further challenges to a change in Staff category.
ARTICLE V
ALLIED HEALTH PROFESSIONALS
5.1 QUALIFICATIONS
Allied Health Professionals (AHP) holding a license, certificate or such other legal credential, if any, as required by state law, which authorize the AHP’s to provide certain professional services, are not eligible for Medical/Dental Staff membership. Such AHP’s are eligible to be granted scope of practice in this Hospital only if they:
5.1-1 LICENSE
Hold a license, certificate, other legal credential, or experience in a category of AHP’s which the Board has identified as eligible to apply for scope of practice.
5.1-2 OTHER REQUIREMENTS
Document their experience, background, training, demonstrated ability, judgment, and physical and mental health status with sufficient adequacy to demonstrate that any patient treated by them will receive care of the professional level of quality and efficiency recognized by the Hospital and that they are qualified to exercise their scope of practice within the Hospital.
5.1-3 ETHICS
Adhere strictly to the lawful ethics of their respective professions, to work cooperatively with others in the Hospital setting, to be willing to participate in and properly discharge their responsibilities, and to be willing to commit to and regularly assist the Hospital in fulfilling its obligations related to patient care, within the areas of their professional competence and credentials.
5.1-4 COMMUNICATION
Can read and understand the English language, communicate verbally in the English language in an intelligible manner, and prepare medical record entries and other required documentation in a legible manner.
5.1-5 QUALIFIED HEALTH CARE PROVIDER
The Allied Health Professional or the sponsor, where applicable, with the application for scope of practice, shall furnish proof of qualification of the Allied Health Professional under the provisions of the Indiana Medical Malpractice Act (I.C.34-18 et seq.) and of insurance at least equal to or exceeding the minimum limits provided for thereunder and shall agree to maintain qualification and insurance thereunder as a condition of eligibility for scope of practice hereunder. The sponsor shall also be deemed to have agreed to be responsible for all of the acts of the Allied Health Professional employee while attending patients in the Hospital and to have agreed to hold harmless the Hospital, its officers, agents and employees from any loss, costs, claims or liability of any nature whatsoever arising out of the acts or omissions of the Allied Health Professional employee. If an Allied Health Professional is ineligible to qualify for coverage under the Indiana Medical Malpractice Act, he shall furnish proof of financial responsibility in the amount of at least one hundred thousand dollars ($100,000) per occurrence and three hundred thousand dollars ($300,000) in the annual aggregate, or in amounts the Board of Trustees may otherwise require.
5.1-6 DIRECTION
All AHPs are assigned to work under the direction of a physician sponsor with the appropriate clinical training.
5.1-7 COMPLY WITH RULES
Comply with all applicable Medical/Dental staff Rules and Regulations and Medical Staff policies.
5.1-8 RETAIN RESPONSIBILITY
Retain responsibility within his scope of professional competence for the care and supervision of each patient in the Hospital for whom he is providing service.
5.1-9 PATIENT CARE AUDITS
Participate as appropriate in patient care audits and other quality improvement and patient safety activities.
5.2 DELINEATION OF CATEGORIES OF AHP’s ELIGIBLE TO APPLY FOR SCOPE OF PRACTICE
The Board shall secure recommendations from the Medical Executive Committee as to which categories of AHP’s should be eligible to apply for scope of practice and as to what scope of practice, prerogatives, terms and conditions may be granted and apply to AHP’s in each category. The delineation of categories of AHP’s eligible to apply for scope of practice and the corresponding scope of practice are approved by the Executive Committee and the Board of Trustees.
5.3 PROCEDURE FOR GRANTING AND RENEWING SCOPE OF PRACTICE
An AHP must apply and be approved by the Board of Trustees for scope of practice. Applications for initial granting of scope of practice must be signed by the sponsoring physician. The application, along with the application fee (amount to be determined by the Medical Executive Committee) must be submitted.
The AHP sponsoring physician will be mailed an evaluation form and current scope of practice forms for their AHP. The sponsor attests to the AHPs health status and competence and reports any disciplinary action taken against the AHP by another healthcare facility and/or licensing agency. The AHP is requested to submit a copy of current license and proof of malpractice insurance.
The appropriate Department Chairman reviews the evaluation forms, scope of practice and other materials in the AHPs file biannually and approves the renewal of the scope of practice.
5.4 ADVERSE ACTIONS AND HEARING RIGHTS
5.4-1 AUTOMATIC TERMINATION
An AHP's privileges shall automatically terminate in the event:
(a) The Medical/Dental Staff membership of the sponsor is terminated, whether such termination is voluntary or involuntary.
(b) The sponsor no longer agrees to act as the supervising practitioner for any reason, or the relationship between the AHP and the sponsor is otherwise terminated, regardless of the reason therefore.
(c) AHP's license or certification expires, is revoked, or is suspended.
(d) Health status prevents AHP from safely and effectively performing scope of practice.
5.4-2 TERMINATION BY PRESIDENT OR CEO
An AHP's privileges may also be terminated by the President and the Chief Executive Officer, acting with or without cause.
5.4-3 NO HEARING RIGHTS
Nothing contained in these Bylaws or the Medical/Dental Staff Rules and Regulations shall be interpreted to entitle an AHP to the fair hearing rights set forth in Articles VIII and IX.
ARTICLE VI
APPOINTMENT AND REAPPOINTMENT
6.1 GENERAL
Except as otherwise specified herein, no licensed independent practitioner (including persons engaged by the Hospital in administratively responsible positions) shall exercise clinical privileges in the Hospital unless and until the individual applies for and receives appointment to the Medical/Dental Staff as set forth in these Bylaws. By applying to the Medical/Dental Staff for appointment or reappointment (or, in the case of members of the Honorary Staff, by accepting an appointment to that category), the applicant acknowledges responsibility to first review these Bylaws. He agrees that throughout any period of membership he will comply with the responsibilities of Medical/Dental Staff membership, the Bylaws, and Rules and Regulations of the Medical/Dental Staff as they exist, as they may exist, and as they may be modified from time to time. Appointment to the Medical/Dental Staff shall confer on the appointee only such clinical privileges as have been granted in accordance with these Bylaws.
6.2 BURDEN OF PRODUCING INFORMATION
In connection with all applications for appointment, reappointment, advancement or transfer, the applicant shall have the burden of securing and producing accurate information for an adequate evaluation of the applicant's qualifications and suitability for the clinical privileges and Staff category requested, of resolving any reasonable doubts about these matters, and of satisfying requests for information. The applicant's failure to sustain this burden shall be grounds for denial of the application. This burden may include submission to a medical or psychiatric examination, at the applicant's expense, if deemed appropriate by the Medical Executive Committee, which may select the examining physician.
6.3 APPOINTMENT AUTHORITY
The Board, upon recommendation from the Medical Executive Committee, has the final authority for the appointment, denial, and revocation of appointments to the Medical/Dental Staff.
6.4 DURATION OF APPOINTMENT AND REAPPOINTMENT
Except as otherwise provided in these Bylaws, all appointments to the Medical/Dental Staff, other than Provisional, shall be for a period of two years unless membership is terminated at or before the conclusion of Provisional status. Reappointments shall be for a period of two years from initial appointments and subsequent reappointments.
6.5 APPLICATIONS FOR AND PROCESS OF INITIAL APPOINTMENT AND REAPPOINTMENT
6.5-1 PRE-APPLICATION FORM
A pre-application for admission to the Medical/Dental Staff shall only be given to an eligible
practitioner. The pre-application will be sent to the applicant within 3 working days or less
following their request. A practitioner shall be considered eligible when he completes and
submits a pre‑application form and establishes on the form that he satisfies the General Qualifications described in 3.2-1 and 3.2-2.
6.5-2 APPLICATION FORM
An application form shall be developed by the Medical Executive Committee and approved by the Board. The application will be sent to the applicant within 3 working days or less following approval of the pre-application. The form shall require detailed information which, shall include, but not be limited to, information concerning the following:
(a) The applicant's qualifications, including, but not limited to, professional training and experience, current licensure, current DEA registration, current Indiana Controlled Substance Registration, and continuing medical education information related to the clinical privileges to be exercised by the applicant.
(b) Appropriate references by persons familiar with the applicant's professional competence and ethical character.
(c) Requests for membership categories, departments, and clinical privileges.
(d) Past or pending professional disciplinary action, licensure limitations, malpractice suits, denials of applications at other facilities, professional sanctions, and adverse actions of other health facilities.
(e) Physical and mental health status.
(f) Professional liability insurance pursuant to Section 3.2-1(d) and proof of qualification under the Indiana Malpractice Act.
(g) Voluntary or involuntary resignations or dismissals from other hospital medical staffs.
(h) A personal photograph for identification purposes.
6.5-3 EFFECT OF APPLICATION
By applying for appointment to the Medical/Dental Staff each applicant thereby signifies his willingness to the following: 1) appear for interviews in regard to his application; 2) authorizes the Hospital's Medical/Dental Staff or its designee to consult with members of medical staffs of other hospitals with which the applicant has been associated, and with others who may have information bearing on his competence, character and ethical qualifications, and authorizes such persons to provide all such information; 3) consents to the Hospital's inspection of all records and documents that may be material to an evaluation of his professional qualifications, personality, ability to cooperate with others, moral and ethical qualifications for membership, and physical, mental, and professional competence to carry out the clinical privileges he requests and directs individuals who have custody of such records and documents to permit inspection and/or copying; 4) certifies that he will report any changes in the information submitted on the application form which may subsequently occur to the Credentials Committee and the Chief Executive Officer; 5) releases from any liability, to the fullest extent permitted by law, all individuals and organizations providing information to the Hospital concerning the applicant and all Hospital representatives for their acts performed in connection with evaluating the applicant and his credentials.
6.5-4 VERIFICATION OF INFORMATION
The applicant shall deliver a completed application together with the appropriate application fee to the Medical/Dental Staff Office, which shall, in timely fashion, seek to collect primary source verification of references, licensure, and other qualification evidence submitted. This process may take approximately 6 to 8 weeks for completion. The Medical/Dental Staff Office shall also request information concerning the applicant from the medical or other practitioner licensing board and the National Practitioner Data Bank. The Medical/Dental Staff Office shall promptly notify the applicant of any problems in obtaining the information required, and it shall then be the applicant's obligation to obtain the required information. The Medical/Dental Staff Office shall continue to inform the applicant of any problems in obtaining the information.
The Medical/Dental Staff Office may, but is not required to, submit the application to the Credentials Committee for review prior to verifying the information. Such "pre-review" is for the purpose of identifying and addressing any problems at the earliest stage. When the collection and verification of information is completed the Medical/Dental Staff Office shall transmit the application and all supporting materials to the chairman of each department in which the applicant seeks privileges and to the Credentials Committee.
6.5-5 CREDENTIALS COMMITTEE ACTION
The Credentials Committee shall review the application, evaluate and verify the supporting documentation, the department chairman's report and recommendations, and other relevant information. The Credentials Committee may elect to interview the applicant and seek additional information. As soon as practicable, but within 60 days following review and recommendation from the department chairman, the Credentials Committee shall transmit to the Medical Executive Committee its recommendations as to appointment and, if appointment is recommended, as to membership category, department affiliation, clinical privileges to be granted, and any special conditions to be attached to the appointment. The committee may also recommend that the Medical Executive Committee defer action on the application for a specific time period.
6.5-6 MEDICAL EXECUTIVE COMMITTEE ACTION
At its next scheduled meeting or within 60 days after receipt of the Credentials Committee report and recommendation, the Medical Executive Committee shall consider the recommendation(s) and any other relevant information. The Medical Executive Committee may request additional information, return the matter to the Credentials Committee for further investigation, and/or elect to interview the applicant. The committee may also defer action on the application. The reasons for each recommendation shall be stated.
6.5-7 EFFECT OF MEDICAL EXECUTIVE COMMITTEE ACTION
(a) Favorable Recommendation: When the recommendation of the Medical Executive Committee is favorable to the applicant, it shall be promptly forwarded, together with supporting documentation, to the Board of Trustees.
(b) Adverse Recommendation: When a final recommendation of the Medical Executive Committee is adverse to the applicant, the Board of Trustees and the applicant shall be promptly informed by written notice. The applicant shall then be entitled to the procedural rights as provided in Article IX.
6.5-8 ACTION ON THE APPLICATION
At its first meeting following the Medical Executive Committee meeting, the Board of Trustees may accept or reject their recommendation or may refer the matter back to the Medical Executive Committee for further considerations, stating the purpose for such referral. The following procedures shall apply with respect to the action on the application:
(a) If the Medical Executive Committee issues a favorable recommendation and:
The Board of Trustees concurs with that recommendation, the decision of the Board shall be deemed final action. Applicant will be notified of Board of Trustees decision in writing.
(b) In the event the recommendation of the Medical Executive Committee is an action that constitutes grounds for a hearing as set forth in Section 9.2-1 of these Bylaws, the procedural rights set forth in Article IX shall apply and:
(1) Final action shall not be taken until an applicant has exhausted or waived his procedural
rights.
(2) If a hearing is requested, the decision of the Judicial Hearing Committee will be final subject to the right of appeal to the Board of Trustees, pursuant to Article IX. The appellate decision of the Board shall be deemed final action.
6.5-9 NOTICE OF FINAL DECISION
(a) Notice of the final decision shall be given to the Medical Executive Committee, the Credentials Committee, the chairman of each department concerned, the applicant, and the Chief Executive Officer.
(b) A decision and notice to appoint or reappoint shall include, if applicable: (1) the Staff category to which the applicant is appointed; (2) the department to which he is assigned; (3) the clinical privileges granted; and (4) any special conditions attached to the appointment.
6.5-10 REAPPLICATION AFTER ADVERSE DECISION DENYING APPLICATION, ADVERSE CORRECTIVE ACTION DECISION, OR RESIGNATION RESULTING IN DISCIPLINARY ACTION.
A waiting period shall apply to the following practitioners:
(1) An applicant who (a) has received a final adverse decision regarding appointment; or (b) withdrew his application or request for membership or privileges following an adverse recommendation by the Executive Committee or Board of Trustee;
(2) A former Medical/Dental Staff member who has (a) received a final adverse decision resulting in termination of Medical/Dental Staff membership and clinical privileges; or (b) resigned from the Medical/Dental Staff following the issuance of a Medical/Dental Staff or Board of Trustee recommendation adverse to the member's Medical/Dental Staff membership or clinical privileges; or
(3) A Medical/Dental Staff member who has received a final adverse decision resulting in (a) termination or restriction of his clinical privileges; or (b) denial of his request for additional clinical privileges.
These practitioners subject to waiting periods shall not be eligible to reapply for Medical/Dental Staff membership and/or clinical privileges affected by the previous action for a period of at least thirty-six (36) months from the date the adverse decision became final, the date the application or request was withdrawn, or the date the former Medical/Dental Staff member's resignation became effective, whichever is applicable.
For the purpose of this section, a decision is considered to be adverse only if it is based on medical disciplinary cause, unethical conduct or conduct disruptive to the Hospital's operation, and not if it is based upon reasons that are not medical, ethical, or professional in nature.
Actions which are not considered adverse, for the purpose of this section, include actions based on a failure to maintain a practice in the area, which can be cured by a move; or to pay dues, which can be cured by paying dues; or to maintain professional liability insurance, which can be cured by securing such insurance. Further, for the purpose of this section, an adverse decision shall be considered final at the time of completion of: (1) all hearing, appellate review, and other quasi-judicial proceedings conducted by the Hospital bearing on the decision and (2) all judicial proceedings bearing upon the decision which refiled and served within thirty-six (36) months after the completion of the Hospital proceedings described above.
After the thirty-six (36) months, the practitioner may submit an application for Medical/Dental Staff membership and/or clinical privileges, which shall be processed as an initial application. The practitioner shall also furnish evidence that the basis for the earlier adverse recommendation or action no longer exists and/or of reasonable rehabilitation 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 practitioner submits satisfactory evidence to the Executive Committee that he has complied with all of the specific requirements any such adverse decision may have included, such as completion of training or proctoring conditions. The Executive Committee's decision as to whether satisfactory evidence has been submitted shall be final, subject only to further review by the Board of Trustees within sixty (60) days after the Executive Committee decision was rendered.
6.5-11 TIMELY PROCESSING OF APPLICATIONS
Applications for Medical/Dental Staff membership shall be considered in a timely manner by all persons and committees required by these Bylaws to act thereon (refer to Sections 6.5-1 through 6.5-8 for specific time frames). While special or unusual circumstances may constitute good cause and warrant exceptions, the following time periods provide a guideline for the routine processing of applications. These guidelines are set forth for the purpose of helping the Medical/Dental Staff to process applications and not for the purpose of giving the applicant rights with respect to delays beyond the specified time period.
(a) Review and recommendation by the department(s) chairman thirty (30) days after receipt of all necessary documentation.
(b) Review and recommendation by the Credentials Committee at its first meeting after receipt of all necessary documentation, and review and recommendation by the department(s) chairman within 60 days of receipt of complete application.
(c) Review and recommendation of the application by the Executive Committee shall be at its first meeting after the meeting of the Credentials Committee within 90 days from receipt of complete application.
(d) 1. Review and approval of the application by the Board of Trustees shall be at its
first meeting after the meeting of the MEC within 90 days from receipt of complete application.
2. The Board of Trustees concurs with that recommendation, the decision of the
Board shall be deemed final action. Applicant will be notified of the Board of
Trustee’s decision in writing.
6.6 REAPPOINTMENTS
6.6-1 SCHEDULE FOR APPOINTMENT REVIEW
At least one hundred twenty (120) days prior to the expiration date of a member's appointment, the Medical/Dental Staff Office shall mail a reappointment application to the Staff member.
A member may request a change in membership category or in privileges when he is not scheduled for a biennial review, and such request may be considered when it is received. Such member's appointment shall also be reviewed in accordance with the schedule set forth above.
At least sixty (60) days prior to the expiration date of his Staff appointment, each Medical/Dental Staff member shall submit to the Medical/Dental Staff Office a completed reappointment application form.
6.6-2 REAPPOINTMENT APPLICATION
The reappointment application shall be in writing, on a form prescribed by the Medical/Dental Staff and approved by the Advisory Board, and it shall require detailed information concerning the changes in the applicant’s qualifications since his last review. Specifically, the form shall request all of the information and certifications requested in the appointment application form, as described in Section 6.5-2, except for that information which cannot change over time, such
as information regarding the member's premedical and medical education, date of birth, and so forth. The form shall also require information as to whether the applicant requests any change in his Staff status and/or clinical privileges. A requested change in clinical privileges must be supported by the type and nature of evidence, which would be necessary for such privileges to be granted in an initial application for same.
If the Staff member's level of clinical activity at the Hospital is not sufficient to permit the Staff and Board to evaluate his competence to exercise the clinical privileges requested, the Staff member shall have the burden of providing evidence of clinical performance at his principal institution in such a form as may be required by said authorities.
6.6-3 VERIFICATION AND COLLECTION OF INFORMATION
The Medical/Dental Staff Office shall in a timely fashion seek to collect or verify the additional information made available on each reappointment application form and to collect any other material or information deemed pertinent. The information shall address, without limitation:
(a) Patterns of care and utilization as demonstrated in the findings of quality review, risk management and utilization management activities;
(b) Acceptable documentation for meeting CME Category 1 (40 hours for two years) requirements for reappointment to the medical/dental staff shall consist of the following:
1. Documentation of weekly attendance at CME luncheons at any Fort Wayne acute care hospital;
2. Documentation of CME programs offered by the Isaac Knapp District Dental Society.
3. Official certification of completion of CME courses attended for.
4. Official transcripts from accredited colleges or Academies.
5. Specialty certifications as applicable.
6. Documentation of any CME provided by Fort Wayne Medical Society or any specialty societies.
7. AMA Recognition Award (valid at time of reappointment)
8. Participation in relevant continuing education activities.
(c) Level/amount of clinical activity (patient care contracts) at the Hospital;
(d) Sanctions imposed or pending and other problems;
(e) Health status including completion of a physical examination or psychiatric evaluation to be completed by the affected practitioner when so requested by the Executive Committee;
(f) Timely and accurate completion and preparation of medical records.
(g) Cooperativeness in working with other practitioners and Hospital personnel and general attitude toward patients and the Hospital.
(h) Professional liability claim experience including being named as a part in any professional liability claims, the disposition of any pending claim.