Medical Staff Bylaws Table of Contents 2008 - North Florida ...

North Florida Regional Medical CenterMedical Staff Bylaws – July 28, 2008_____________________________________________________________________________________________________________________TABLE OF CONTENTS1. ARTICLE ONE: DEFINITIONS/CONSTRUCTION OF TERMS AND HEADINGS ................ 11.1 DEFINITIONS.......................................................................................................................... 11.2 CONSTRUCTION OF TERMS AND HEADINGS................................................................. 72. ARTICLE TWO: NAME, PURPOSES AND RESPONSIBILITIES .............................................. 82.1 NAME....................................................................................................................................... 82.2 PURPOSES AND RESPONSIBILITIES ................................................................................. 83. ARTICLE THREE: APPOINTMENT/REAPPOINTMENT ........................................................ 103.1 NATURE OF MEMBERSHIP AND GENERAL QUALIFICATION................................... 103.2 HOSPITAL NEED AND ABILITY TO ACCOMMODATE ................................................ 133.3 EFFECTS OF OTHER AFFILIATIONS................................................................................ 143.4 NONDISCRIMINATION....................................................................................................... 143.5 BASIC OBLIGATIONS ......................................................................................................... 143.6 TERMS OF APPOINTMENT ................................................................................................ 153.7 CREDENTIALS VERIFICATION AND APPLICATION PROCESSING PROCEDURES 163.8 CREDENTIALS SUBJECT TO ONGOING VERIFICATION ............................................. 253.9 ASSISTANCE WITH EVALUATION .................................................................................. 253.10 PERFORMANCE PROFILING ............................................................................................. 263.11 PROVISIONAL STATUS/PROCTORING............................................................................ 273.12 PREVIOUSLY DENIED OR TERMINATED APPLICANTS.............................................. 283.13 MEDICO ADMINISTRATIVE OFFICERS .......................................................................... 293.14 INDIVIDUALS PROVIDING PROFESSIONAL SERVICES BY CONTRACT OREMPLOYMENT..................................................................................................................... 293.15 LEAVE OF ABSENCE .......................................................................................................... 303.16 RESIGNATION...................................................................................................................... 323.17 ACTIONS INVOLVING AN IMPAIRED PRACTITIONER................................................ 323.18 ACTIONS IN RESPONSE TO DISRUPTIVE CONDUCT................................................... 374. ARTICLE FOUR: CATEGORIES OF THE MEDICAL STAFF ................................................. 424.1 CATEGORIES........................................................................................................................ 424.2 LIMITATIONS ON PREROGATIVES ................................................................................ 424.3 ACTIVE STAFF ..................................................................................................................... 42C:\Documents and Settings\poa9885\Desktop\MEDICAL STAFF BYLAWS TABLE OF CONTENTS 072808.doc 8/7/2008 10:14 AMi

North Florida Regional Medical CenterMedical Staff Bylaws – July 28, 2008_____________________________________________________________________________________________________________________4.4 ASSOCIATE STAFF.............................................................................................................. 434.5 COURTESY-A STAFF .......................................................................................................... 444.6 COURTESY-B STAFF........................................................................................................... 444.7 HONORARY RECOGNITION.............................................................................................. 454.8 CHANGE IN STAFF CATEGORY ....................................................................................... 454.9 ALLIED HEALTH PROFESSIONALS................................................................................. 455. ARTICLE FIVE: CLINICAL PRIVILEGES.................................................................................. 485.1 EXERCISE OF PRIVILEGES................................................................................................ 485.2 DELINEATION OF PRIVILEGES ........................................................................................ 485.3 TEMPORARY PRIVILEGES ................................................................................................ 545.4 EMERGENCY PRIVILEGES ................................................................................................ 586. ARTICLE SIX: CORRECTIVE ACTIONS.................................................................................... 596.1 CRITERIA FOR INITIATION............................................................................................... 596.2 ALTERNATIVE TO CORRECTIVE ACTION..................................................................... 596.3 SUMARY SUSPENSION OR RESTRICTION ..................................................................... 606.4 INVESTIGATION/PEER REVIEW PROCESS .................................................................... 606.5 ACTION ON INVESTIGATION REPORT........................................................................... 616.6 AUTOMATIC SUSPENSION OR TERMINATION............................................................. 616.7 CRIMINAL ARREST............................................................................................................. 626.8 AUTOMATIC RESIGNATION ............................................................................................. 627. ARTICLE SEVEN: HEARING AND APPELLATE REVIEW PROCEDURES........................ 637.1 OVERVIEW ........................................................................................................................... 637.2 EXCEPTIONS TO HEARING AND APPEAL RIGHTS ...................................................... 637.3 HEARING RIGHTS ............................................................................................................... 647.4 HEARING PREREQUISITES................................................................................................ 657.5 HEARING PROCEDURE ...................................................................................................... 677.6 HEARING COMMITTEE REPORT AND FURTHER ACTION ......................................... 687.7 INITIATION AND PREREQUISITES OF APPELLATE REVIEW..................................... 697.8 APPELLATE REVIEW PROCEDURE ................................................................................. 707.9 FINAL DECISION OF THE BOARD.................................................................................... 717.10 GENERAL PROVISIONS...................................................................................................... 718. ARTICLE EIGHT: MEDICAL STAFF OFFICERS...................................................................... 748.1 ELECTED OFFICERS OF THE STAFF................................................................................ 74C:\Documents and Settings\poa9885\Desktop\MEDICAL STAFF BYLAWS TABLE OF CONTENTS 072808.doc 8/7/2008 10:14 AMii

North Florida Regional Medical CenterMedical Staff Bylaws – July 28, 2008_____________________________________________________________________________________________________________________8.2 TERM OF OFFICE AND ELIGIBILITY FOR RE-ELECTIONS ......................................... 748.3 ATTAINMENT OF OFFICE.................................................................................................. 748.4 VACANCIES.......................................................................................................................... 758.5 RESIGNATION, REMOVAL, AND RECALL FROM OFFICE .......................................... 768.6 RESPONSIBILITIES AND AUTHORITY OF THE ELECTED OFFICERS ....................... 778.7 IMMEDIATE PAST CHIEF OF STAFF................................................................................ 789. ARTICLE NINE: CLINICAL DEPARTMENTS ........................................................................... 799.1 DESIGNATION...................................................................................................................... 799.2 CRITERIA TO QUALIFY AS A DEPARTMENT................................................................ 809.3 REQUIREMENTS FOR AFFILIATION WITH DEPARTMENTS ...................................... 809.4 FUNCTIONS OF DEPARTMENTS ...................................................................................... 809.5 OFFICERS OF DEPARTMENTS .......................................................................................... 8210. ARTICLE TEN: FUNCTIONS AND COMMITTEES................................................................... 8610.1 FUNCTIONS OF THE STAFF............................................................................................... 8610.2 PRINCIPLES GOVERNING COMMITTEES....................................................................... 9010.3 DESIGNATION...................................................................................................................... 9110.4 OPERATIONAL MATTERS RELATING TO COMMITTEES ........................................... 9110.5 MEDICAL EXECUTIVE COMMITTEE............................................................................... 9710.6 CREDENTIALS COMMITTEE............................................................................................. 9910.7 QUALITY COUNCIL .......................................................................................................... 10010.8 CONTINUING MEDICAL EDUCATION COMMITTEE.................................................. 10210.9 BYLAWS COMMITTEE ..................................................................................................... 10310.10 NOMINATING COMMITTEE ............................................................................................ 10411. ARTICLE ELEVEN: MEETINGS................................................................................................. 10511.1 MEDICAL STAFF YEAR.................................................................................................... 10511.2 MEDICAL STAFF MEETINGS .......................................................................................... 10511.3 DEPARTMENT MEETINGS............................................................................................... 10511.4 ATTENDANCE REQUIREMENTS .................................................................................... 10511.5 MEETING PROCEDURES.................................................................................................. 10511.6 QUORUM............................................................................................................................. 10611.7 MANNER OF ACTION ....................................................................................................... 10611.8 VOTING RIGHTS................................................................................................................ 10611.9 RIGHTS OF EX-OFFICIO MEMBERS............................................................................... 10611.10 MINUTES............................................................................................................................. 106C:\Documents and Settings\poa9885\Desktop\MEDICAL STAFF BYLAWS TABLE OF CONTENTS 072808.doc 8/7/2008 10:14 AMiii

North Florida Regional Medical CenterMedical Staff Bylaws – July 28, 2008_____________________________________________________________________________________________________________________11.11 PROCEDURAL RULES....................................................................................................... 10612. ARTICLE TWELVE: CONFIDENTIALITY, IMMUNITY AND RELEASE .......................... 10812.1 AUTHORIZATIONS AND CONDITIONS......................................................................... 10812.2 CONFIDENTIALITY OF INFORMATION........................................................................ 10812.3 BREACH OF CONFIDENTIALITY.................................................................................... 10812.4 IMMUNITY FROM LIABILITY......................................................................................... 10812.5 RELEASES........................................................................................................................... 10912.6 SEVERABILITY .................................................................................................................. 10912.7 NONEXCLUSIVITY............................................................................................................10913. ARTICLE THIRTEEN: ADOPTION AND AMENTMEND AND GENERAL PROVISIONS11013.1 MEDICAL STAFF AUTHORITY AND RESPONSIBILITY ............................................. 11013.2 EXCLUSIVE MECHANISM ............................................................................................... 11013.3 METHODOLOGY................................................................................................................ 11013.4 TECHNICAL AND EDITORIAL AMENDMENTS ........................................................... 11113.5 GENERAL PROVISIONS.................................................................................................... 11114. CERTIFICATION OF ADOPTION AND APPROVAL............................................................... 114C:\Documents and Settings\poa9885\Desktop\MEDICAL STAFF BYLAWS TABLE OF CONTENTS 072808.doc 8/7/2008 10:14 AMiv