Preamble

WHEREAS, Good Samaritan Hospital Medical Center is a non-profit corporation recognized under the laws of the State of New York; and

WHEREAS, its purpose is to serve as a general hospital providing patient care, education and research; and

WHEREAS, it is recognized that the Medical Staff is delegated responsibility for the quality of medical care in the Hospital and must accept and discharge this responsibility, subject to the ultimate authority of the hospital Governing Body, and that the cooperative efforts of the Medical Staff, the Chief Executive Officer and the Governing Body are necessary to fulfill the Hospital's obligations to its patients;

THEREFORE, the physicians, dentists and podiatrists practicing in this Hospital hereby organize themselves into a Medical Staff in conformity with these Bylaws.

Preamble...................................................................................................... 1

Definitions ....................................................................................................4

ARTICLE I - Name ......................................................................................5

ARTICLE II - Purposes ..............................................................................5

ARTICLE III - Medical Staff Membership ................................................5

1. Nature of Membership .....................................................................5

2. Qualifications for Membership .......................................................5

3. Conditions & Duration of Appointment

and Reappointment ……………………………………...………..6

ARTICLE IV- Categories of the Medical Staff…………………………..8

1. The Medical Staff ................................................................................8

2. Honorary Medical Staff ......................................................................8

3. Active Medical Staff .......................................................................... . 8

4. Consulting Staff ................................................................................. 8

5. Teaching Adjunct ............................................................................... 9

6. Residents ........................................................................................... 9

ARTICLE V- Procedure for Appointment

and Reappointment ............................................................................... 9

1. Application for Appointment ............................................................. 9

2. Appointment Process ..................................................................... 10

3. Reappointment Process ................................................................ 11

4. Medical Malpractice Coverage Requirements ........................... 12

ARTICLE VI- Clinical Privileges ..........................................................12

1. Clinical Privileges Restricted ......................................................... 12

2. Temporary Privileges ....................................................................... 13

3. Emergency and Disaster Privileges ............................................. 13

4. Monitoring of Clinical Privileges .................................................... 14

5. Credentials Files .............................................................................. 14

ARTICLE VII- Corrective Action ........................................................... 14

1. Procedure ........................................................................................... 14

2. Summary Suspension ..................................................................... 15

3. Automatic Suspension ..................................................................... 16

4. Automatic Termination ...................................................................... 17

5. Leave of Absence ............................................................................... 17

ARTICLE VIII- Hearing & Appellate Review Procedure ................... 17

1. Right to Hearing & to Appellate Review .. ..................................... 17

2. Request for Hearing ......................................................................... 18

3. Notice of Hearing .............................................................................. 18

4. Composition of Hearing Committee ............................................. 19

5. Conduct of Hearing ........................................................................... 19

6. Appellate Review ............................................................................... 20

7. Final Decision by the Governing Body ............................................ 22

ARTICLE IX Officers ................................................................................ 22

1. Officers of the Medical Staff ............................................................... 22

2. Qualifications of Officers .................................................................... 23

3. Election of Officers .............................................................................. 23

4. Term of office ....................................................................................... 23

5. Vacancies in Office ............................................................................. 23

6. Removal of Elected Officers ............................................................. 23

7. Duties of Officers................................................................................. 23

8. Liaison Committee of the Medical Staff...........................................24

ARTICLE X- Clinical Departments …………………….......….....……24

1. Organization of Clinical Departments ………………………….....24

2. Qualifications, Selection

and Tenure of Department Chairmen ................................................ 25

3. Functions of Department Chairmen... ............................................ 26

4. Functions of Departments ................................................................ 27

5. Assignments to Departments .......................................................... 28

6. Allied Health Professionals .............................................................. 28

ARTICLE XI- Committees ...................................................................... 29

1. Medical Board ...................................................................................... 29

2. Standing Committees ........................................................................ 31

3. Specific Function Committees.......................................................... 36

4. Overall Quality Assurance Program

and Monitoring ......................................................................................... 37

ARTICLE XII- Medical Staff Meetings................................................... 38

1. Regular Meetings ............................................................................... 38

2. Special Meetings ................................................................................ 38

3. Quorum ................................................................................................ 38

4. Attendance Requirements ............................................................... 39

5. Agenda ................................................................................................. 39

ARTICLE XIII- Department Meetings ................................................... 39

1. Regular Meetings ............................................................................... 39

2. Special Meetings ................................................................................ 39

3. Notice of Meetings .............................................................................. 39

4. Quorum ................................................................................................. 39

5. Attendance Requirements ................................................................. 39

6. Manner of Action .................................................................................. 39

7. Minutes .................................................................................................. 40

ARTICLE XIV- Immunity from Liability.................................................... 40

ARTICLE XV- Medico-Administrative Staff............................................. 41

ARTICLE XVI- Medical Staff Rules and Regulations .......................... 41

ARTICLE XVII- Bylaws Amendments ..................................................... 42

1. Procedure for Amendment .................................................................. 42

2. Periodic Review of Bylaws .................................................................. 42

ARTICLE XVIII- Bylaws Precedence ....................................................... 42

ARTICLE XIX- Adoption.............................................................................. 42

Definitions

1. The term “Medical Staff” means all professionally licensed physicians, dentists and podiatrists who are privileged to attend patients in the Hospital.

2. The term “Governing Body” means the Board of Trustees of Good Samaritan Hospital Medical Center.

3. The term “Medical Board” means the standing committee as defined in Article XI, Section 1 of these Bylaws making up an Executive Committee of the Medical Staff.

4. The term “Chief Executive Officer” means the individual appointed by the Governing Body to act in its behalf in the overall management of the Hospital. His/her official title is President & CEO of the Hospital.

5. The term “Practitioner” means an appropriately licensed physician, dentist or podiatrist.

6. The “Clinical Departments” of Good Samaritan Hospital Medical Center consist of:

Anesthesiology

Pathology

Emergency Medicine & Community Medicine

Pediatrics

Psychiatry

Family Medicine

Radiology

Internal Medicine

Surgery

Medical Education

Obstetrics/Gynecology

7. Each Clinical Department shall be directed by a “Chairman” appointed by the Governing Body, who shall be responsible for the overall supervision of the Department as defined in Article X.

8. The term “Medical Staff Bylaws” shall include this document and the Rules and Regulations of the Medical Staff.

9. Whenever any document is deemed incorporated herein by reference, such reference shall be to such document as amended.

Medical Staff Bylaws

ARTICLE I– NAME

The name of this organization shall be the Medical Staff of Good Samaritan Hospital Medical Center. The Medical Staff is organized under Bylaws approved by the Governing Body, and responsible to the Governing Body of the Hospital for the quality of all medical care provided patients in the Hospital and for the ethical and professional practices of its members.

ARTICLE II – PURPOSES

* The purposes of this organization are:

1. To insure that all patients admitted to or treated in any of the facilities, departments or services of the Hospital shall receive appropriate care consistent with community standards;
2. To insure the professional performance of 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 an ongoing review and evaluation of each practitioner's performance in the Hospital;
3. To provide an appropriate educational setting that will maintain scientific standards and that will lead to continuous advancement in professional knowledge and skill;
4. To initiate and maintain rules and regulations for governance of the Medical Staff subject to the approval of the Governing Body; and

5. To provide a means whereby issues concerning the Medical Staff and the Hospital may be discussed by the Medical Staff with the Governing Body and the Chief Executive Officer.* A descriptive outline of the Medical Staff organization is found in Article X of these Bylaws.

ARTICLE III - MEDICAL STAFF MEMBERSHIP

Section 1. Nature of Medical Staff Membership

Membership on the Medical Staff of Good Samaritan Hospital Medical Center is a privilege which shall be extended only to professionally licensed and competent physicians, dentists and podiatrists who continuously meet the qualifications, standards and requirements set forth in these Bylaws.

Section 2. Qualifications for Membership

a. Membership on the Medical Staff shall be based on criteria related to standards of patient care, patient welfare, the objectives of the Hospital and the character and competency of the applicants. Only practitioners licensed to practice in the State of New York who can document their background, experience, training and demonstrated current competence, their meeting of geographic location requirements, their adherence to the ethics of their profession, their good reputation, evidence of adequate professional liability insurance coverage, and their ability to work with others, with sufficient adequacy to assure the Medical Staff and the Governing Body that any patient treated by them in the hospital will be given medical care consistent with community standards, shall be eligible for membership on the Medical Staff. All practitioner applicants for initial appointment must be either Board Certified or show proof of satisfactorily completing an American Medical Association approved residency, an American Osteopathic Healthcare Association approved residency, an American Podiatric Medical Association approved residency or an American Dental Association approved residency. No practitioner shall be entitled to membership on the Medical Staff or to the exercise of particular clinical privileges in the Hospital merely by virtue of the fact that he/she is duly licensed to practice medicine or dentistry or podiatry in this or any other state, or that he/she is a member of any professional organization, or that he/she had in the past, or presently has, such privileges at another hospital. Membership on the Medical Staff shall be limited by the Hospital's ability to provide adequate facilities and support services for the applicant and his/her patient. In the granting of membership, the Medical Staff will consider general patient care needs and the applicant's skill and training for meeting those needs.

b. Acceptance of membership on the Medical Staff shall constitute the staff member's agreement that he/she will strictly abide by the Principles of Medical Ethics of the American Medical Association, Principles of Medical Ethics of the American Osteopathic Association, the Code of Ethics of the American Podiatric Medical Association or by the Code of Ethics of the American Dental Association, whichever is applicable, and the Ethical and Religious Directives for Catholic Health Care Services as the same are appended and made a part of these Bylaws. In addition, by accepting Medical Staff membership, the practitioner agrees to provide all required governmental disclosures, including the reporting of professional misconduct of medical staff members and incident reports as required by applicable laws.

c. Applicants for active staff privileges shall have their primary office and residence located in reasonable proximity to the Hospital, as defined in the Medical Staff Credentials Manual, so that adequate coverage may be given to their inpatients. The Credentials Committee shall assess this fact in making recommendations to the Medical Board.

Section 3. Conditions and Duration of Appointment and Reappointment

a.Initial appointments and reappointments to the Medical Staff, with delineation of clinical privileges, shall be made by the Governing Body. The Governing Body shall act on appointments, reappointments, and modification of appointments upon the recommendation of the Medical Board consistent with the procedures set forth in these Bylaws and the Credentials Manual.

b. Initial appointment to the Medical Staff shall be for a probationary period of six months. During this probationary period, it is expected that the practitioner will use the Hospital, and through such use, allow the Hospital to monitor his/her exercise of clinical privileges. Failure to use the facility may be the basis for termination of appointment after the probationary period. At the end of this period, any of the following actions may be taken:

1) The practitioner may be promoted from probation.

2) The practitioner may be removed from the Medical Staff.

3) The practitioner may be placed on probation for a second six month period. In this last case, the second probationary period is a final one, at the end of which the practitioner will promoted from probation or removed from the Medical Staff.

c. Appointments and reappointments shall be for a period of not more than two years.

d. Appointments and reappointments to the Medical Staff shall confer on the appointee only such clinical privileges as have been granted by the Governing Body in accordance with these Bylaws.

e. Every application for staff appointment and reappointment shall be signed by the applicant and shall contain the applicant's specific agreement of his/her obligation to provide continuous care and supervision of his/her patients, to abide by the Medical Staff Bylaws, Rules and Regulations, to accept committee assignments, consultation assignments and to fulfill service requirements.

f. Each practitioner applying for Medical Staff appointment and reappointment must provide a verification that the information provided in the application is true and accurate. In addition, each practitioner agrees to the requirements delineated in the Credentials Manual, and the following:

• Specifically agrees to provide all necessary information to meet the provisions of Public Health Law 2805-J (a)-(e) and 2805-K as currently in effect and as amended from time to time.

• Agrees to provide evidence of appropriate physical and mental health status as may be required.
• Agrees to notify the Hospital of the relocation of his/her primary office or residence.· Agrees to provide continuous care to his/her patients.
• Agrees to sign practitioner attestation acknowledgment form(s) as required by state and federal authorities.
• Agrees to be in compliance with 10 NYCRR 405.1023 (I)(2)(v) prohibiting the division of fees.· Agrees not to accept any payment of referral fees except as permitted by law.
• Agrees not to discriminate unlawfully with respect to Hospital patients.
• Agrees to advise Administration of any changes in the applicant/ practitioner's licensure, malpractice coverage, or any material adverse change in the information contained in his/her application.
• Agrees to assist the Hospital in maintaining its accreditation and licensure status.
• Agrees to adhere to the provisions of the Hospital's Corporate Bylaws.
• Agrees to participate in and support the performance improvement and utilization review activities of the Hospital.
• Agrees, if requested by the Chairman of his/her Department to participating in medical education activities approved by the Hospital.
• Agrees to sign all documents necessary for the Hospital to acquire all pertinent information for the appointment/reappointment process.

ARTICLE IV - CATEGORIES OF THE MEDICAL STAFF

Section 1. The Medical Staff

The Medical Staff shall be divided into Honorary, Active, Consulting and Teaching Adjunct categories.

Section 2. The Honorary Medical Staff

The Honorary Medical Staff shall consist of practitioners who are honored by emeritus positions, those who are of outstanding reputation in the community, and practitioners who have retired from active practice of at least twenty years at the Hospital. Election to honorary status must occur within one year of retirement. In order for the Hospital community to benefit from their years of experience and expertise they may serve on Medical Staff committees at the pleasure of the President of the Medical Staff (not in the capacity of Chairman). These practitioners shall not be eligible to hold office, will not be able to vote and will not be required to pay dues. Since these practitioners do not have clinical privileges they are not subject to regulatory requirements or standards.

Section 3. The Active Medical Staff

The Active Medical Staff shall consist of practitioners who admit patients, participate in the care or treatment of patients or engage in educational or supervisory activities in the hospital and who assume all the functions and responsibilities of membership on the Active Medical Staff, including, where appropriate, emergency service care and consultation assignments. Members of the Active Medical Staff shall be appointed to a specific department(s), shall be eligible to vote, hold office and to serve on Medical Staff committees, and shall be required to attend Medical Staff meetings. The Active Medical Staff is subdivided into Senior Attending, Attending, Associate Attending and Assistant Attending according to the professional competency of the staff member, length of service and degree of active participation in the regular functions of the department(s) in which he/she serves. Promotion through these categories is made on the recommendation of the Chairman of the department(s) with approval of the recommendation by the Medical Board and final approval and appointment by the Governing Body. Members of the Department of Emergency Services other than the Chairman do not have admitting privileges to the Hospital.

Section 4. The Consulting Staff

A consultant shall be defined as a recognized specialist whose expertise is needed by the Hospital and not adequately available on the Active Staff. Membership on the Consulting staff shall be by invitation only. Department Chairmen shall make all recommendations for all such invitations to the Credentials Committee. If the Credentials Committee determines that the practitioner recommended by the Department Chairman has the appropriate credentials, the Credentials Committee shall pass on such recommendation to the Medical Board which may in its discretion pass on such recommendation to the Governing Body. Practitioners who accept invitations to join the Consulting Staff shall not be eligible to:· admit patients, vote, hold office or be required to pay dues. Consulting Staff members shall be encouraged to participate in the teaching program and shall be required to take regular call schedules for the appropriate department (unless otherwise agreed in advance by the Governing Body upon recommendation of the Medical Board). Referrals to consultants must be from appropriate specialists on the Active Staff as delineated by the Department Chairmen. · However, based on the needs of the Hospital for medical coverage of highly specialized areas, consultants may be approved with admitting privileges which are time-limited to these coverage situations. During times when adequate coverage is available, such admitting privileges will not be in effect.

Section 5. Teaching Adjunct

The Teaching Adjunct category shall consist of recognized practitioners who may be invited to accept the appointment because of a special need for Medical Staff training. The credentials of any applicant shall be reviewed by the Credentials Committee, followed by Medical Board evaluation and recommendation to the Governing Body. Practitioners appointed to this category of the Medical Staff will not have the privilege of direct patient care. Mandatory meeting attendance and obligation to pay dues will not apply to Teaching Adjuncts. Teaching Adjuncts shall not be eligible to vote or hold office.

Section 6. Residents

Residents are not members of the Medical Staff. Residents may write orders, as specified in Departmental Rules and Regulations, under the supervision of the attending practitioner.

ARTICLE V - PROCEDURE FOR APPOINTMENT AND REAPPOINTMENT

Section 1. Application for Appointment

a. All applications for appointment to the Medical Staff shall be in writing, shall be signed by the applicant, and shall be submitted on a form prescribed by the Governing Body after consultation with the Medical Board. The application shall require detailed information concerning the applicant's professional qualifications, shall include the name of at least three (3) persons who have had extensive experience in observing and working with the applicant and who can provide adequate references pertaining to the applicant's professional competence and ethical character, and shall include information as to whether the applicant's membership status and/or clinical privileges have ever been voluntarily/ involuntarily revoked, suspended, reduced or not renewed at any other hospital or institution, whether his/her membership in local, state or national medical societies, or his/her license or registration to practice any profession in any jurisdiction, has ever been voluntarily/involuntarily suspended or terminated, and whether his/her participation in any federal/state health care program has ever been suspended, restricted, terminated or not renewed. Other requirements of the application form and procedure, consistent with State, Federal and a federally approved health care accrediting agency, are delineated in the Credentials Manual approved by the Governing Body. The professional criteria specified in these Bylaws and the Credentials Manual will be uniformly applied to all applicants and/or Medical Staff members.

b. The applicant shall have the burden of submitting the completed application and producing adequate information for a proper evaluation of his/her application. This will include assessment of competence, character, ethics, physical and mental health status and other qualifications to resolve any doubts about such requirements.

c. The application shall be submitted to the Chief Executive Officer or his designee. The application shall be deemed complete after receiving the references and other materials delineated in the Credentials Manual. The application and all supporting materials will then be forwarded to the Credentials Committee for evaluation.

Section 2. Appointment Process

a. Initial applicants must be interviewed by the Departmental Director prior to being interviewed by the Credentials Committee. It is the responsibility of the applicant to provide all necessary information requested to complete the credentialing process. Such information must be submitted within 30 days of the request, unless otherwise specified. Failure to provide such information will be considered abandonment of the application.

b. The Hospital will not discriminate regarding age, race, religion, national origin or other legal requirements in connection with appointment to Medical Staff membership.

c. Within 90 days after receipt of a completed application for membership, the Credentials Committee shall make a written report of its investigation to the Medical Board. Prior to making this report, the Credentials Committee shall examine the evidence of the character, professional competence, physical and mental health status, qualifications and ethical standing of the applicant and shall determine, through information contained in references given by the applicant and from other sources available to the Committee including an appraisal from the clinical department(s) in which privileges are sought, whether the applicant has established and meets all of the necessary qualifications for the category of staff membership and the clinical privileges requested by him/her. Every department in which the applicant seeks clinical privileges shall provide the Credentials Committee with specific, written recommendations for delineating the applicant's clinical privileges and these recommendations shall be made a part of the report. Together with its report, the Credentials Committee shall forward to the Medical Board the completed application and a recommendation that the applicant be either appointed on a probationary status to the Medical Staff or rejected for Medical Staff membership, or that the application be deferred for further consideration.

d. Within 60 days after receipt of the application and the report and recommendation of the Credentials Committee, the Medical Board shall determine whether to recommend to the Governing Body that the applicant be appointed on a probationary status to the Medical Staff, that he/she be rejected for Medical Staff membership or that his/her application be deferred for further consideration. All recommendations for membership must also specifically recommend the clinical privileges to be granted.

e. When the recommendation of the Medical Board is to defer the application for further consideration, it must be followed up within 60 days with a subsequent recommendation for probationary appointment with specific clinical privileges, or for rejection for staff membership.

f. When the recommendation of the Medical Board is favorable to the applicant, the Medical Board shall promptly forward it, together with all supporting documentation, to the Governing Body for action at their next scheduled meeting which shall be no later than 60 days.

g. When the recommendation of the Medical Board is adverse to the applicant in respect to appointment or clinical privileges, the Chief Executive Officer or his designee, shall promptly so notify the applicant by certified mail, return receipt requested. No such adverse recommendation need be forwarded to the Governing Body until after the applicant has exercised or has been deemed to have waived his/her right to a hearing as provided in Article VIII of these Bylaws. Initial applicants are not entitled to an appellate review. The fact that the adverse decision is held in abeyance during the appeal process shall not be deemed to confer privileges where none exist.
h. All decisions to appoint shall include a delineation of the clinical privileges which the practitioner may exercise.

h. When the Governing Body's decision is final, it shall send notice of such decision through the Chief Executive Officer or his designee, to the President of the Medical Staff and to the Department concerned and by certified mail, return receipt requested, to the practitioner.

Section 3. Reappointment Process

a. The practitioner being considered for reappointment/ appraisal shall complete all necessary reappointment forms as specified in the Credentials Manual. Such information must be submitted within 30 days of its request, unless otherwise specified. Failure to provide such information will be considered abandonment of the reappointment process and the practitioner will not be reappointed. All applications for reappointment/appraisal must be accompanied by verification of current licensure.

b. The Chief Executive Officer or his/her designee will coordinate the reappointment process. The Chairmen of the departments, in cooperation and consultation with Senior Attendings, various Division Chiefs and the Chairman of the Credentials Committee shall review all pertinent information available on each practitioner scheduled for reappointment or appraisal. Such reappointment/appraisal will be performed every two years for each practitioner. The Department Chairman shall determine his/her recommendations for reappointments to the Medical Staff and for the granting of clinical privileges for the ensuing period and shall forward his/her recommendations, in writing, to the Medical Board. Where non-reappointment or a change in clinical privileges is recommended, the reason for such recommendation shall be stated and documented.

c. The recredentialling process will include an assessment of the experience, ability and current competence of the practitioner by the Department Chairman. This assessment of the practitioner will include, but not be limited to, the following:

1) evaluation of the ability to provide effective and appropriate patient care

2) knowledge and application of current medical/clinical science

3) ability to use practice-based learning to improve patient care services (best practices)

4) interpersonal and communication skills with the health care team, patients and families

5) professionalism, as defined by behavior that reflects a commitment to continuous professional development, ethical practice, sensitivity to diversity and a responsible attitude.

6) understanding of system-based practice, the context and systems in which healthcare is provided.

d. Evaluation of the following will be included in the assessment defined in (c) above:

1) Current licensure

2) Attendance at Medical Staff meetings, departmental meetings, and participation in medical staff affairs

3) Participation in continuing medical education programs

4) Compliance with Hospital Bylaws and Medical Staff Bylaws, Rules and Regulations

5) Mental and Physical Health status

Information will also be obtained as to whether the applicant's membership status and/or clinical privileges have ever been voluntarily/involuntarily revoked, suspended, reduced or not renewed at any other hospital or institution, whether his/her membership in local, state or national medical societies, or his/her license or registration to practice any profession in any jurisdiction has ever been voluntarily/involuntarily suspended or terminated and whether his/her participation in any federal/state health care program has ever been suspended, restricted, terminated or not renewed.

e. Prior to the next scheduled Governing Body meeting, the Medical Board shall make written recommendations to the Governing Body, concerning the reappointment, non-­reappointment and clinical privileges of each practitioner then scheduled for periodic appraisal. Where non-reappointment or a change in clinical privileges is recommended, the reasons for such recommend­ations shall be stated and documented. When such adverse recommendation is proposed, the due process procedures specified in Article VIII of these Bylaws shall be followed.

f. The Governing Body at its discretion may waive any specific requirement for Medical Staff membership upon recommendation of the Medical Board.

Section 4. Medical Malpractice Coverage Requirements

Each practitioner on the Medical Staff is required to maintain at a minimum medical malpractice coverage in an amount no less than $1,000,000/$3,000,000. The form of such coverage must be acceptable to the Hospital and both the practitioner and his/her insurance company are obligated to notify the Hospital in the event of any cancellation, reduction or non renewal of insurance coverage. The practitioner shall provide a certificate of insurance evidencing required coverage.

ARTICLE VI - CLINICAL PRIVILEGES

Section 1. Clinical Privileges Restricted

a. Every practitioner practicing at this Hospital by virtue of Medical Staff membership or otherwise, shall, in connection with such practice, be entitled to exercise only those clinical privileges specifically granted to him/her by the Governing Body, except as provided in Sections 2 and 3 of this Article VI.

b. Every initial application for staff appointment must contain a request for the specific clinical privileges desired by the applicant. The evaluation of such requests shall be based upon several factors including the applicant's education, training, experience, demonstrated current competence, references, information provided pursuant to Sections 2805-J and 2805-K of the New York State Public Health Law and other relevant information, including an appraisal by the department(s) in which such privileges are sought. The applicant shall have the burden of establishing his/her qualifications and competency in the clinical privileges he/she requests.

c. Periodic redetermination of clinical privileges and the increase or curtailment of same shall be based upon ongoing clinical review of a practitioner’s current competency, including the direct observation of care provided, review of the records of patients treated in this Hospital and review of the records of the Medical Staff which document the evaluation of the member's participation in the delivery of medical care.

d. The exercise of clinical privileges within any department is subject to the Rules and Regulations of that department and to the authority of that department's Chairman.

e. Privileges granted to dentists or podiatrists shall be based on factors including their training, experience and demonstrated current competence and judgment. The scope and extent of surgical procedures that each dentist or podiatrist may perform shall be specifically delineated and granted in the same manner as all other surgical privileges. Surgical procedures performed by dentists or podiatrists shall be under the overall supervision of the Chairman of Surgery. All dental or podiatric patients shall receive the same basic medical appraisal as patients admitted to other surgical services. A dental or podiatric member of the Medical Staff may be responsible for the admission of the patient; however, they must seek appropriate physician assessment, as outlined in the Rules and Regulations of the Department of Surgery, for the care of any medical problems that may be present at the time of admission or that may arise during hospital­ization that needs assessment or treatment outside the scope of his/her delineation of privileges.

f. In all matters regarding the granting of appointment, reappointment and clinical privileges, the Medical Staff Credentials Manual shall be utilized in conjunction with these Bylaws.

Section 2. Temporary Privileges

Temporary privileges may only be granted in the case where the hospital's and/or the patient's welfare is at stake, and in this case the Chief Executive Officer or his designee will grant temporary privileges after consultation with the Department Chairman and/or the President of the Medical Staff. The Chief Executive Officer or his designee must, at a minimum, receive assurances from the Departmental Chairman that the practitioner has a current license, meets the medical malpractice insurance coverage requirements, and that at least one reference has been contacted to verify the individual's competence and capabilities. Such temporary privileges will be in force for a specified period not to exceed 60 days, except such privileges may be extended for an additional 60 days where medical staff or allied health professional application is pending for Emergency Room coverage.

Section 3. Emergency and Disaster Privileges

In the case of emergency, any practitioner member of the Medical Staff, to the degree permitted by his/her license and regardless of service or staff status or lack of it, shall be permitted and assisted to do everything possible to save the life of a patient, using every facility of the Hospital necessary, including the calling for any consultation necessary, or desirable. When an emergency situation no longer exists, such practitioner may request the privileges necessary to continue to treat the patient or transfer care of the patient to another practitioner with appropriate clinical privileges. In the event such privileges are requested and denied, the patient shall be assigned to an appropriate member of the Medical Staff. For the purpose of this Section, an “emergency” is defined as a condition in which serious permanent harm would result to a patient or in which the life of a patient is in immediate danger and any delay in administering treatment would add to that danger.

When the Hospital’s emergency management plan has been activated, practitioners not on the Hospital’s Medical Staff may be granted disaster privileges in accordance with the Disaster Privileging policy in order to help the Hospital meet immediate patient care needs during this time of crisis.

Section 4. Monitoring of Clinical Privileges

The Department Chairman shall be responsible for insuring that a practitioner practices within the scope of the clinical privileges granted to that practitioner.

Section 5. Credentials Files

a. There shall be maintained in the Medical Staff Office a separate credentials file for each applicant and each member of the Medical Staff. The file for each applicant shall contain his or her application, references, appraisal from the clinical departments in which privileges are sought, the report of the Credentials Committee and the determination of the Governing Body.

b. The credentials file for each practitioner shall contain, in addition to the documents placed therein at the time of the initial appointment, the following documents in connection with each reappointment: the practitioner's reappointment application, the written recommendation of the Chairman of the Departments in which such practitioner has participated, the reappointment appraisal report of the Credentials Committee, the delineation of privileges of the practitioner, the determination of the Governing Body, and all relevant and appropriate information gathered from whatever source pursuant to Sections 2805-J(a)-(e) and 2805-K of the New York State Public Health Law.

ARTICLE VII - CORRECTIVE ACTION

Section 1. Procedure

a. Whenever the activities or professional conduct of any practitioner with clinical privileges are considered to be lower than the acceptable standards of the Medical Staff or to be disruptive to the operations of the Hospital (eg, Medical Staff Code of Behavior), investigation and/or corrective action against such practitioner maybe requested by any officer of the Medical Staff, by the Chairman of any department, by the Chairman of any standing committee of the Medical Staff, by the Chief Executive Officer, or by the Chairman or Vice Chairman of the Governing Body. All requests for investigation/corrective action shall be in writing, shall be made to the President of the Medical Staff, and shall be supported by the reference to the specific activities or conduct which constitute the grounds for the request.

b. The President of the Medical Staff may forward such request to the Chairman of the department wherein the practitioner has such privileges. Upon receipt of such request, the Chairman of the department shall immediately appoint an ad hoc committee to investigate the matter. As an alternative, provided due process can be assured, the President of the Medical Staff may forward the request to the Fair Hearing Committee of the Medical Board for purposes of conducting the investigation.

c. Within 30 days after the Committee's receipt of the request for investigation, the investigating Committee (ie, either a Departmental ad hoc Committee or the Fair Hearing Committee) shall report its findings and recom­mendations for corrective action to the Medical Board. Prior to completing its report, the practitioner against whom investigation and/or corrective action has been requested shall have an opportunity for an interview with the committee. At the interview, he/she shall be informed of the general nature of the charges against him/her and shall be invited to discuss, explain or refute them. This interview is an intraprofessional matter and shall not constitute a hearing. It shall be preliminary in nature and none of the procedural rules provided in these Bylaws with respect to hearings including presence of attorneys, shall apply thereto. A record of the interview shall be made by the investigating Committee and included with its report to the Medical Board.

d. Within 30 days following receipt of a report from the investigating Committee, the Medical Board shall act upon the findings and recommendations for corrective action. If the corrective action could involve a reduction, suspension or termination of clinical privileges, or a suspension or expulsion from the Medical Staff, the Medical Board may, at its option, invite the affected practitioner to make an appearance before the Medical Board prior to making its recommendation on such request. This appearance shall not constitute a hearing, shall be preliminary in nature, and none of the procedural rules provided in these Bylaws with respect to hearings including presence of attorneys, shall apply thereto. A record of such appearance shall be made by the Medical Board.

e. The recommendation of the Medical Board on a request for corrective action may be: to reject or modify the request for corrective action; to issue a warning, a letter of admonition or a letter of reprimand; to recommend further clinical training in specific areas; terms of pro­bation or a requirement for consultation; to recommend reduction, suspension or termination of clinical privileges; or to recommend that the practitioner's staff membership be suspended or revoked.

f. Recommendations of corrective action for probation, mandatory consultation, termination, reduction or suspension of privileges shall entitle the affected practitioner to procedural rights provided in Article VIII of these Bylaws.

g. The President of the Medical Staff shall promptly notify the Chief Executive Officer in writing of all requests for investigation and/or corrective action received by the Medical Board and shall continue to keep the Chief Executive Officer fully informed of all action taken in connection therewith. After the Medical Board has made its recommendation in the matter, the procedure to be followed shall be as provided in Article VIII, if applicable, of these Bylaws.

Section 2. Summary Suspension

a. Any one of the following-the President of the Medical Staff, the Chairman of a Department, or the Chief Executive Officer or his/her designee shall each have the authority, whenever action must be taken immediately in the best interest of patient care in the Hospital or to protect the safety and welfare of any visitor, employee or other medical staff, member, to summarily suspend all or any portion of the clinical privileges of a practitioner, and such summary suspension shall become effective immediately upon imposition. Such summary suspension shall be deemed precautionary in nature and not a professional review action reportable to the National Practitioner Data Bank. It shall not imply any final findings of misconduct on the part of the affected practitioner. The practitioner shall receive a written notice of the precautionary summary suspension including the reasons for such suspension.

b. A practitioner whose clinical privileges have been summarily suspended shall be entitled to request that the Medical Board review his/her precautionary suspension. The President of the Medical Staff will determine if the action can be discussed directly at the next Medical Board meeting or whether the Medical Board should initiate an investigating committee which must report at the next regularly scheduled Medical Board meeting. In any event, such review by the Medical Board must be completed within forty five (45) days of the effective date of the summary suspension.

c. After review of the matter, the Medical Board may recommend modification, continuance or termination of the terms of the precautionary summary suspension. If, as a result of its review, the Medical Board does not recommend immediate termination of the summary suspension, the affected practitioner shall be entitled to the procedural rights provided in Article VIII of these Bylaws. The President of the Medical Staff shall keep the Chief Executive Officer informed of all action taken in connection with the summary suspension review. The terms of the summary suspension as sustained or as modified by the Medical Board shall remain in effect pending a final decision thereon by the Governing Body.

d. Immediately upon the imposition of a summary suspension, the President of the Medical Staff or responsible Departmental Chairman shall have authority to provide for alternative medical coverage for the patients of the suspended practitioner still in the Hospital at the time of suspension. The wishes of the patients shall be considered in the selection of such alternative practitioner.

Section 3. Automatic Suspension

a. A suspension in the form of withdrawal of a practitioner's admitting and clinical privileges, effective until medical records are completed or all Medicare/Medicaid attestations and similar mandatory reporting requirements are met, shall be imposed automatically according to the medical records suspension policy as determined by the Medical Board. This suspension shall not be deemed to be a professional review action and shall not affect the practitioner's treatment of any patient already in the Hospital and for which the practitioner already has had clinical responsibility prior to the automatic suspension.

b. When, according to the President of the Medical Staff, it is in the best interest of the patient, the President of the Medical Staff or his/her designee may suspend the provisions of paragraph (a) above for a period of 48 hours provided the reasons for such action are stated in writing by the President of the Medical Staff or his/her designee.

c. Willful failure to comply with the provisions of paragraph (a) of this section shall be sufficient for instituting further corrective action including termination of Medical Staff membership under this Article.

d. A practitioner shall not be entitled to a hearing and appellate review under Article VIII for the above noted automatic suspension.

e. A suspension in the form of withdrawal of a practitioner's admitting and clinical privileges for Medicare/Medicaid patients shall be imposed auto­matically upon a practitioner who, by reason of disciplinary action by the Medicare/Medicaid Program, is excluded from the program as a provider. The Medical Board shall review all such cases and the practitioner shall be entitled to a hearing and appellate review under Article VIII.

Section 4. Automatic Termination

A practitioner's medical staff membership and clinical privileges shall be automatically terminated for the following:

a) license revocation or suspension.

b) DEA number revocation or suspension.

c) failure to pay Medical Staff dues after final written notice by certified mail, return receipt requested.

d) failure to maintain medical malpractice insurance requirements of the Governing Body.

e) conviction of a felony.

f) falsification of membership and credentials appointment or reappointment information.

A practitioner shall not be entitled to due process for an automatic termination. Termination of medical staff membership and privileges for reasons described in subparagraphs (c) or (d) shall not be deemed to be professional review actions resulting from the affected practitioner's misconduct.

Section 5. Leave of Absence

A practitioner may be granted a leave of absence for cause for up to one year at the discretion of the Medical Board. During the leave of absence the practitioner relinquishes all clinical privileges and must contact the office of Medical Affairs at least 60 days prior to reinstatement of clinical privileges. Prior to return to the active staff, the practitioner will be required to provide updated information to demonstrate compliance with PHL Section 2805-K, may also be required to undergo re-evaluation by the Credentials Committee and must meet all Hospital and Medical Staff requirements for Medical Staff membership.

ARTICLE VIII - HEARING AND APPELLATE REVIEW PROCEDURE

Section 1. Right to Hearing and to Appellate Review

a. When any practitioner receives notice of a recommendation of the Medical Board that, if ratified by decision of the Governing Body, will adversely affect his/her exercise of clinical privileges, he/she shall be entitled to a hearing before an ad hoc committee of the Medical Staff in accordance with Section 4 of this Article. If the recommendation of the Medical Board following such hearing is still adverse to the affected practitioner, he/she shall then be entitled to an appellate review by the Governing Body before the Governing Body makes a final decision on the matter. Initial applicants for appointment to the Medical Staff are not entitled to an appellate review hearing.

b. When any practitioner receives notice of a proposed decision originating at the Governing Body that will affect his/her appointment or status as a member of the Medical Staff or his/her exercise of clinical privileges and such proposed decision is not based on a prior adverse recommendation by the Medical Board, he/she shall be entitled to a hearing by a committee appointed by the Governing Body which shall include the President and Past President of the Medical Staff. If the recommendation of the Governing Body is still adverse to the practitioner after consideration of the hearing committee's report, the practitioner shall be entitled to an appellate review by the Governing Body, before the Governing Body makes a final decision on the matter.

c. All hearings and appellate reviews shall be in accordance with the procedural safeguards set forth in this Article VIII to assure that the affected practitioner is accorded all rights to which he/she is entitled.

Section 2. Request for Hearing

a. If there has been a recommendation for adverse action by either the Medical Board or Governing Body, the Chief Executive Officer or his designee shall be responsible for giving prompt written notice of an adverse recommendation or proposed decision to any affected practitioner who is entitled to a hearing or to an appellate review, by certified mail, return receipt requested. Within 30 days following his/her receipt of such notice, a practitioner may request a hearing, such request to be made by written notice to the Chief Executive Officer or his designee by certified mail, return receipt requested.

b. The failure of a practitioner to request a hearing to which he/she is entitled by these Bylaws, within the time and in the manner herein provided, shall be deemed a waiver of his/her rights to such hearing and to any appellate review to which he/she might otherwise have been entitled on this matter. The failure of a practitioner to request an appellate review to which he/she is entitled by these Bylaws within the time and in the manner herein provided shall be deemed a waiver of his/her right to such appellate review on the matter.

c. When the waived hearing or appellate review relates to an adverse recommendation of the Medical Board or the Governing Body, the same shall thereupon become and remain effective against the practitioner pending the Governing Body's decision on the matter. When the waived hearing or appellate review relates to a proposed adverse decision by the Governing Body, the same shall thereupon become and remain effective against the practitioner in the same manner as a final decision of the Governing Body provided in Section 7 of this Article VIII. In either of such events, the Chief Executive officer or his designee shall promptly notify the affected practitioner of his/her status by certified mail, return receipt requested.

 Section 3. Notice of Hearing

a.    Within seven (7) days after receipt of a request for hearing from a practitioner entitled to the same, the Medical Board or the Governing Body, whichever is appropriate, shall schedule and arrange for such a hearing and shall, through the Chief Executive Officer or his designee, notify the practitioner of the time, place and date so scheduled, by certified mail, return receipt requested. The hearing date shall be not less than fifteen (15) days nor more than forty-five (45) days from the date of receipt of the request for hearing provided, however, that a hearing for a practitioner who is under suspension which is then in effect shall be held as soon as arrangements may reasonably be made, but not later than fifteen (15) days from the date of receipt of such practitioner's request for hearing.

b.    The notice of hearing shall state the acts or omissions with which the practitioner is charged, a list of specific or representative medical records being questioned, and/or the other reasons or subject matter that was considered in making the adverse recommendation or pro­posed decision.­

Section 4. Composition of Ad Hoc Hearing Committee

a. When a hearing relates to an adverse recommendation of the Medical Board, such hearing shall be conducted by an ad hoc hearing committee of impartial peers to include no less than 5 members of the Medical Staff appointed by the President of the Medical Staff in consultation with the Executive Committee, and one of the members so appointed shall be designated as chairman. No staff member who has actively participated in the initiation or investigation of the original complaint shall be appointed a member of this hearing committee unless it is otherwise impossible to select a representative group, due to the size of the Medical Staff.

b. When a hearing relates to a proposed adverse decision originating at the Governing Body, the Governing Body shall appoint a hearing committee of not less than five (5) members of the Governing Body including the President and Past President of the Medical Staff to conducting such hearing and shall designate one of the members of this committee as chairman.

Section 5. Conduct of Hearing

a. There shall be at least four (4) members of the Hearing Committee present when the hearing takes place and no member may vote by proxy.

b. An accurate record of the hearing must be kept. The mechanism shall be established by the Hearing Committee and may be accomplished by use of a court reporter, electronic recording unit, detailed transcription or by the taking of adequate minutes.

c. The personal presence of the practitioner for whom the hearing has been scheduled shall be required. A practitioner who fails without good cause to appear and proceed at such hearing shall be deemed to have waived his/her rights in the same manner as provided in Section 2 of this Article VIII and to have accepted the adverse recommendation or proposed decision involved, and the same shall thereupon become and remain in effect as provided in said Section 2.

d. Postponement of hearings beyond the time set forth in these Bylaws shall be made only with the approval of the Hearing Committee. Granting of such postponements shall only be for good cause shown and in the sole discretion of the Hearing Committee.

e. The affected practitioner shall be entitled to be accompanied by and/or represented at the hearing by a member of the Medical Staff in good standing or by a member of his/her local professional society.

f. The chairman of the Hearing Committee or his/her designee shall preside over the hearing to determine the order of procedure during the hearing, to assure that all participants in the hearing have a reasonable opportunity to present relevant oral and documentary evidence and to maintain decorum.

g. The hearing need not be conducted strictly according to rules of law relating to the examination of witnesses or presentation of evidence. Any relevant matter upon which responsible persons customarily rely in the conduct of serious affairs shall be considered, regardless of the existence of any common law or statutory rule which might make evidence inadmissible over objection in civil or criminal action. The practitioner for whom the hearing is being held, shall, prior to or during the hearing, be entitled to submit memoranda concerning any issue of procedure or of fact and such memoranda shall become a part of the hearing record.

h. The Medical Board, when its recommendation has prompted the hearing, shall appoint one of its members or some other Medical Staff member to present the facts at the hearing in support of its adverse recommendation, and to examine witnesses. The Governing Body, when its proposed action has prompted the hearing, shall appoint one of its members to present the facts at the hearing in support of its proposed adverse decision and to examine witnesses. It shall be the obligation of such representative(s) to present appropriate evidence in support of the adverse recommendation or proposed decision. The affected practitioner shall thereafter be responsible for supporting his/her challenge to the adverse recommendation or proposed decision by an appropriate showing that the charges or grounds involved lack any factual basis or that such basis or any action based thereon is either arbitrary, unreasonable or capricious.

i. The affected practitioner shall have the following rights: to call and examine witnesses, to introduce written evidence, to cross-examine any witness on any matter relevant to the issue of the hearing, to challenge any witness and to rebut any evidence. If the practitioner does not testify in his/her own behalf, he/she may be called and examined as if under cross examination.

j. The hearings provided for in these Bylaws are for the purpose of resolving, on an intraprofessional basis, matters bearing on profes­sional competency and conduct. Accordingly, neither the affected practitioner, nor the Medical Board nor the Governing Body, shall be represented at any phase of the hearing procedure by an attorney at law unless the Hearing Committee, in its discretion, permits both sides to be represented by counsel. The foregoing shall not be deemed to deprive the practitioner, the Medical Board or the Governing Body of the right to legal counsel in connection with preparation for the hearing or for a possible appeal.

k. The Hearing Committee may, without special notice, recess the hearing and reconvene the same for the convenience of the participants or for the purpose of obtaining new or additional evidence or consultation. Upon conclusion of the presentation of oral and written evidence, the hearing shall be closed. The Hearing Committee may thereupon, at a time convenient to itself, conduct its deliberations outside the presence of the practitioner for whom the hearing was convened.

l. Within 10 days after final adjournment of the hearing, the Hearing Committee shall make a written report and recommendation and shall forward the same together with the hearing record and all other documentation to the Medical Board or to the Governing Body, whichever appointed it. The report may recommend confirmation, modification or rejection of the original adverse recommendation of the Medical Board or proposed decision of the Governing Body. In the event of an adverse outcome, the practitioner is entitled to an appellate review of the hearing as detailed in Section 6 of this Article.

Section 6. Appellate Review

a. Within 30 days after receipt of a notice by an affected practitioner of an adverse recommendation of the Medical Board or proposed decision of the Governing Body made or adhered to after a hearing as above provided, he/she may by written notice to the Governing Body delivered through the Chief Executive Officer or his designee by certified mail, return receipt requested, request an appellate review to be held only on the record on which the adverse recommendation or proposed decision is based, as supported by the practitioner's written statement provided for below, or may also request that oral argument be permitted as part of the appellate review.

b. If such appellate review is not requested within 30 days, the affected practitioner shall be deemed to have waived his/her rights to the same, and to have accepted such adverse recommendations or proposed decision, and the same shall become effective immediately as provided in Section 7 of this Article VIII.

c. Within 7 days after receipt of such notice of request for appellate review, the Governing Body shall schedule a date for such review, including, a time and place for oral argument if such has been requested, and shall, through the Chief Executive Officer or his designee, by written notice sent by certified mail, return receipt requested, notify the affected practitioner of the same. The date of the appellate review shall not be less than 15 days, nor more than 45 days, from the date of receipt of the notice of request for appellate review, except that when the practitioner requesting the review is under a suspension, which is then in effect, such review shall be scheduled as soon as the arrangements for it may reasonably be made but not more than 15 days from the date of receipt of such notice.

d. The appellate review shall be conducted by the Governing Body or by a duly appointed Appellate Review Committee of the Governing Body of not less than 5 members. One of the members shall be designated as Chairman.

e. The affected practitioner shall have the right to receive and review the Hearing Committee minutes (and transcription, if any) and all other material, favorable or unfavorable, that was presented in making the adverse recommendation or proposed decision against him/her. The deliberation of the Hearing Committee per se shall remain confidential. The practitioner shall have until seven (7) days prior to the appellate review committee meeting to submit a written statement in his/her own behalf, in which those factual and procedural matters with which he/she disagrees, and his/her reasons for such disagreement, shall be specified. This written statement may cover any matters raised at any step in the procedure to which the appeal is related, and legal counsel may assist in its preparation. Such written statement shall be forwarded to the Governing Body by the Chief Executive Officer or his designee by certified mail, return receipt requested, at least three (3)days prior to the scheduled date for the appellate review. A similar statement may be submitted by the Medical Board or by the Chairman of the Hearing Committee, and if submitted, the Chief Executive Officer shall provide a copy thereof to the practitioner at least three (3) days prior to the date of such appellate review by certified mail, return receipt requested.

f. The Governing Body or its appointed Review Committee shall act as an appellate body. It shall review the record created in the proceedings, and shall consider the written statements submitted pursuant to subparagraph (e) of this Section 6, for the purpose of determining whether the adverse recommendation or proposed decision against the affected practitioner was justified and was not arbitrary or capricious. If oral argument is requested as part of the review procedure, the affected practitioner shall be present at such appellate review, shall be permitted to speak against the adverse recommendation or proposed decision, and shall answer questions put to him/her by any member of the appellate review body. The Medical Board or the Governing Body, whichever is appropriate, shall also be represented by an individual who shall be permitted to speak in support of the adverse recommendation or proposed decision and shall answer questions put to him/her by any member of the appellate review body.

g. New or additional matters not raised during the original hearing or in the Hearing Committee report, nor otherwise reflected in the record, shall only be introduced at the appellate review under unusual circumstances, and the Governing Body or the committee thereof appointed to conduct the appellate review shall in its sole discretion determine whether such new matters shall be accepted.

h. If the appellate review is conducted by the Governing Body, it may affirm, modify or reverse its proposed decision, or in its discretion, refer the matter back to the Medical Board for further review and recommendation within l0 days. Such referral may include a request that the Medical Board arrange for a further, hearing to resolve specified disputed issues.

i. If the appellate review is conducted by a committee of the Governing Body, such committee shall, within 10 days after the scheduled or adjourned date of the appellate review, either make a written report recommending that the Governing Body affirm, modify or reverse its proposed decision, or refer the matter back to the Medical Board for further review and recommendation within 10 days. Such referral may include a request that the Medical Board arrange for a further hearing to resolve disputed issues. Within 10 days after receipt of such recommendation after referral, the committee shall make its recommendation to the Governing Body as above provided.

j. The appellate review shall not be deemed to be concluded until all of the procedural steps provided in this Section 6 have been completed or waived. Where permitted by the Hospital Bylaws, all action required by the Governing Body may be taken by a committee of the Governing Body duly authorized to act.

Section 7. Final Decision by Governing Body

a. Within 10 days after the conclusion of the appellate review, the Governing Body shall make its final decision in the matter and shall send notice thereof to the Medical Board and through the Chief Executive Officer or his designee, to the affected practitioner, by certified mail, return receipt requested.

b. Notwithstanding any other provision of these Bylaws, no practitioner shall be entitled as a right to more than one hearing and one appellate review on any matter which shall have been the subject of review by the Medical Board, or action by the Governing Body, or by a duly authorized committee of the Governing Body or by both.

ARTICLE IX – OFFICERS

Section 1. Officers of the Medical Staff

The officers of the Medical Board shall be the officers of the Medical Staff and shall consist of:

1) President

2) Vice President

3) Secretary/Treasurer

Section 2. Qualifications of Officers

Section 3. Election of Officers

Officers of the Medical Board are elected at the December meeting of the Medical Board, subject to ratification by the Governing Body. A Nominating Committee consisting of three (3) members of the Medical Board, one of whom shall be a member of the Liaison Committee, shall be appointed by the President in October and shall submit a slate of officers at the November meeting.

Section 4. Term of Office

All officers shall serve a one-year term from their election date or until a successor is elected. Officers shall take office on the first day of the calendar year. While the term of office is for one year, the officers are traditionally offered a second year in order to provide for better continuity.

Section 5. Vacancies in Office

Vacancies in office during the calendar year shall be filled by election by the Medical Board using the procedure outlined in Section 3 of this Article, except for the office of President which shall be filled by the Vice President.

Section 6. Removal of Elected Officers

Section 7. Duties of Officers

a. President: The President shall serve as the chief administrative officer of the Medical Staff to:

1) Act in coordination with the Chief Executive Officer in all matters of mutual concern within the Hospital;

2) Call, preside at, and be responsible for the agenda of all Medical Board meetings and all general meetings of the Medical Staff;

3) Serve as ex-officio member of all other Medical Staff committees without vote;

4) Be responsible for the enforcement of Medical Staff Bylaws, Rules and Regulations and for implementation of sanctions where these are indicated and for the Medical Staffs compliance with procedural safe­guards in all instances where corrective action has been requested against a practitioner;

5) Appoint committee members to all Standing, Special and Specific Function Medical Staff committees and Committee Chairmen as appropriate;

6) Represent the views, policies, needs and grievances of the Medical Staff to the Governing Body and to the Chief Executive Officer;

7) Receive and report the policies of the Governing Body to the Medical Staff and to report to the Governing Body on the performance and maintenance of quality with respect to the Medical Staff's responsi­bility to provide medical care;

8) Be responsible for the educational activities of the Medical Staff and the formulation of a program of Continuing Medical Education in conjunction with the Director of Medical Education; and

9) Be the spokesman for the Medical Staff in its external professional and public relations.

b. Vice President: In the absence of the President, he/she shall assume all the duties and have the authority of the President. He/she shall automatically succeed the President when the latter fails to serve for any reason.

c. Secretary/Treasurer: He/she shall keep an accurate audit of all funds received and disbursed each month. It shall also be his/her duty to submit an annual budget to the Medical Staff for its approval at the October meeting. Emergency expenditures for which provision had not been made in the annual budget would be subject to a ruling of the Medical Board. Expenditure of greater than $1,500 for non-approved budget items must be approved by the Medical Staff.

Section 8. Liaison Committee of the Medical Staff

a. Two (2) members of the Active Staff shall be elected annually at the October meeting to serve a three-year term as members of the Medical Board. The President of the Medical Staff in consultation with the Chairman of the Liaison Committee shall appoint a Nominating Committee consisting of one (1) member of the Liaison Committee whose term is not expiring who shall serve as chairman and two (2) members of the Medical Staff with Medical Board experience. The Nominating Committee shall submit a slate of nominees at the April meeting of the Medical Staff. Nominations may be made from the floor at the time the Nominating Committee makes its slate known.

b. The six (6) elected members from the Medical Staff shall constitute the, Liaison Committee of the Medical Staff. They shall elect one (1) of their members to act as Chairman at their last meeting in the calendar year.

ARTICLE X - CLINICAL DEPARTMENTS

Section 1. Organization of Clinical Departments

Each department shall be organized as a separate part of the Medical Staff and shall have a Chairman who shall be responsible for the overall supervision of the quality of care within the department. Divisions of a department shall be supervised by a member of the Active Staff who shall be designated Chief of Division. The Division Chiefs shall be appointed by the Chairman of the Department and may be removed at any time at the Chairman’s discretion. The Active Staff shall divided into the following departments and divisions:

CLINICAL DEPARTMENTS:

Department of Anesthesiology

Division of Pain Management

Department of Emergency Services and Community Medicine

Department of Family Medicine

Department of Internal Medicine

Cardiology

Dermatology

Endocrinology and Metabolism

Gastroenterology

Geriatrics

Hematology/Oncology

Infectious Diseases

Nephrology

Neurology

Pulmonary Medicine

Department of Medical Education

Department of Obstetrics and Gynecology

Division of Obstetrics

Division of Gynecology

Division of Maternal-Fetal Medicine

Department of Pathology

Department of Pediatrics

Division of Neonatology

Division of Pediatric Allergy and Immunology

Division of Pediatric Cardiology

Division of Pediatric Critical care

Division of Pediatric Neurology

Division of Pediatric Pulmonary

Department of Psychiatry

Department of Radiology

Division of Diagnostic Radiology

Division of Radiation Therapy

Department of Surgery

Division of Ambulatory Surgery

Division of General Surgery

Division of Neurosurgery

Division of Ophthalmology

Division of Oral Surgery

Division of Orthopaedic Surgery

Division of Otolaryngology

Division of Plastic Surgery

Division of Podiatric Surgery

Division of Thoracic and Cardiovascular Surgery

Division of Urology

Section 2. Qualifications, Selection and Tenure of Department Chairmen

a. Each Chairman shall be a member of the active Staff qualified by training, experience and demonstrated ability for the position. Such qualifications will include, but not be limited to, board certification or the equivalent as determined by the Medical Board.

b. Each Chairman of a Clinical Department shall be appointed by the Governing Body for a period of five (5) years, except if the Chairman is 65 years of age or older.

c. Removal of a Chairman of a Clinical Department for cause during his/her term of office may be initiated by a two-thirds majority vote of all Active Staff members of the department concerned, but no such removal shall be effective unless and until it has been approved by the Medical Board and the Governing Body. Notwithstanding the aforementioned, the Governing Body reserves the right to remove a Chairman (“Clinical Chief of Service”) as specified by the Hospital's Corporate Bylaws.

d. All Chairmen of the clinical departments shall be formally re-evaluated every five (5) years by an Evaluation Committee composed of the following members:

1. The President of the Medical Staff.

2. The Chairman of the Liaison Committee of the Medical Staff.

3. Two (2) members of the Medical Board appointed by the President with the approval of the Medical Board.

4. Two (2) members of the Active Staff who are members of the department undergoing evaluation, one (1) such member appointed by the President of the Medical Staff with the approval of the Medical Board and the other member appointed by the Chairman of the Liaison Committee. Neither of these two (2) members may be considered for appointment as Chairman of the Department while sitting on the Evaluation Committee.

5. One (1) member of the Governing Body appointed by the Chairman or Vice Chairman of the Governing Body with the approval of the Governing Body.

6. In its evaluation, the Committee shall use information obtained by submitting a questionnaire to the active members of the department under consideration. This questionnaire may contain statements concerning the staff members' satisfaction with the present Chairman, comments and suggestions concerning the Chairman and a recommendation for Chairman. The Committee, in its discretion or upon request of representatives of the department, may interview any or all members of the department. After due deliberation, the Evaluation Committee will make a recommendation for a Chairman. The recommendation by the Evaluation Committee would not supplant the biennial appointment by the Governing Body. The questionnaire shall be distributed to the members of the Active Staff of the department undergoing evaluation in a timely manner. The Evaluation Committee will be organized in order to have its recommendation prior to the November meeting of the Medical Board. The Medical Board will act upon this recommendation and submit its recommendation to the Governing Body. In the event that the President of Medical Staff or the Chairman of Liaison Committee is being considered for Department Chairmanship (appointment/reappointment), he/she is to defer all assigned responsibilities for the evaluation/selection process to the Vice President or another Liaison Committee member (ie, he/she cannot chair the Committee nor choose members to serve on the Committee). In the event that the Vice President is also a candidate for the Department Chairman role, such responsibilities will be assigned to the Secretary/Treasurer.

e. A Chairman of a Clinical Department shall be limited to two five (5) year terms. In unusual circumstances, a third term may be possible. Department Chairmen of Anesthesiology, Emergency Services, Medical Education, Pathology and Radiology shall be excluded from term limits, but must undergo re-evaluation every 5 years in accordance with the provisions of Paragraph d. When a Chairman has completed his or her term(s), the Evaluation Committee as outlined above will be considered a "Search" Committee for a new Chairman. The Search Committee shall solicit candidates from the involved department and may nominate one or more members from the department. The Search Committee may interview those members being considered for Chairman. The opinion of the current Chairman should be taken into consideration by the Search Committee. At the end of the process, the Search Committee shall recommend a single candidate to the Medical Board, which would then be forwarded to the Governing Body for approval.

f. Retirement age for Chairman of Clinical Departments and Chiefs of Divisions shall be 65 years. However, the Chairman/Chief may continue at the discretion of the Medical Board with the approval of the Governing Body until age 70, subject to an annual review.

Section 3. Functions of Department Chairmen

Each Chairman shall:

a. Be accountable for all professional and medical activities within his/her department;

b. Be a member of the Medical Board, giving guidance on the overall medical policies of the Hospital and making specific recommendations and suggestions regarding his/her own department in order to assure quality patient care;

c. Be responsible for the integration of the department into the primary functions of the Hospital, as well as the coordination and integration of interdepartmental and intradepartmental activities;

d. Maintain continuing review of the professional performance of all practitioners with clinical privileges in his/her department and report regularly thereon to the Medical Board;

e. Appoint a Performance Improvement Committee to conduct the evaluation of patient care as required by these Bylaws;

f. Be responsible for enforcement of the Hospital Bylaws and of the Medical Staff Bylaws, Rules and Regulations within his/her departments;

g. Be responsible for implementation within his/her department of actions taken by the Medical Board;

h. Be responsible for maintaining the quality of medical records in his/her department;

i. Make recommendations to Administration regarding the planning of Hospital facilities, purchase of equipment, routine procedures and any other matters concerning patient care;

j. Transmit to the Medical Board his/her department's recommendations concerning the staff classification, the appointment/reappointment, and the delineation of clinical privileges for all practitioners in his/her department;

k. Assess and recommend the off-site sources for needed patient care, treatment and services not provided by the department or Hospital;

l. Be responsible for the orientation, teaching, education and research program in his/her department;

m. Participate in the administration of his/her department through cooperation with the nursing service and the Hospital administration in matters affecting patient care, including personnel, supplies, special regulations, standing orders and techniques;

n. Assist in the preparation of such annual reports, including budgetary planning, pertaining to his/her department as may be required by the Medical Board, the Chief Executive Officer or the Governing Body; and

o. Division Chiefs in each Clinical Department are appointed by and serve at the pleasure of the Department Chairman. They will be appointed for a five (5) year term at the end of which time they will be formally evaluated by the Department Chairman. They may be reappointed for a second five (5) year term. In unusual circumstances, in order to satisfy the needs of the Department, they may be reappointed for a third and final term of five (5) years. The duties and responsibilities of the Division Chief shall be assigned by the Chairman.

p. Provide input to the Administration and Medical Board regarding Performance Improvement activities, patient care incidents and medical economic considerations.

Section 4. Functions of Departments

a. Each department shall establish its own criteria for granting of clinical privileges. These criteria must be consistent with the policies of the Medical Staff and the Governing Body and the recommendations of a federally approved health care accrediting agency and the laws and regulations of the State of New York.

b. Each department shall participate in performance improvement activities which shall include the review of select cases, including, but not limited to, mortalities for standard of care. Cases will be presented at Departmental meetings for purposes of information and education.

c. The Department shall assist the Chairman in performing his/her duties as defined in Section 3 of this Article.

d. A report shall be provided to the Medical Board detailing such department analysis of patient care. These reports or summaries thereof are to be submitted through the Sr. VP of Medical Affairs to the Performance Improvement Committee of the Governing Body for review and action as appropriate.

Section 5. Assignment to Departments

The Medical Board shall, after consideration of the recommendations of the departments as transmitted through the Credentials Committee, recommend initial departmental assignments for all Medical Staff members and for all other Allied Health Professionals with clinical privileges.

Section 6. Allied Health Professionals

a. STATUS:

1) Members of the Allied Health Professions, including physician assistants, occupational therapists, midwives, speech therapists, physiotherapists, licensed nurse practitioners and others, shall not be deemed members of the Medical Staff at Good Samaritan Hospital. Medical Staff membership is limited to physicians, dentists and podiatrists duly licensed and qualified as provided in these Bylaws.

2) Such members of the Allied Health Professions shall be organized for administrative purposes only into an adjunct staff and its members shall be designated as “Adjunct Staff”

b. QUALIFICATIONS: Only Allied Health Professionals (AHPs) who hold a license/certificate or other legal credential as required by New York State Law shall be eligible to provide specified patient care services in the Hospital. In addition, AHPs must:

    1) Document to the Credentials Committee their experience, background, education, training, demonstrated ability, physical health status, and upon request, mental health status, with sufficient adequacy to demonstrate that any patient treated by them will receive care at a generally recognized level of quality and that they are qualified to provide a needed service within the Hospital.

    2) Be found, on the basis of documented references to adhere strictly to the ethics of their respective professions, and to work cooperatively with others.

c. Where appropriate, the Medical Board may establish particular qualifications for members of a specific category of AHPs, provided that such qualifications are not founded on an arbitrary or discriminatory basis and are in conformance with applicable law.

d. APPLICATION FOR ADJUNCT STAFF STATUS AND CLINICAL PRIVILEGES: An application for Adjunct Staff status and for clinical privileges for an AHP shall be submitted and processed in the same manner as provided for Medical Staff membership. The Credentials Committee shall make recommendations to the Medical Board. The Medical Board shall make recommendations to the Governing Body for applicants to the Adjunct Staff. The Governing Body shall approve such recommendations. The AHP shall be individually assigned to clinical departments appropriate to his or her professional training and shall be subject, in general, to the same terms and conditions as specified for Medical Staff appointments. Except as otherwise specifically provided in the Bylaws or applicable law, an AHP who is an employee of the Hospital shall be entitled to an appellate review process as a result of any adverse action with respect to Adjunct Staff status as described above or clinical privileges in accordance with the Hospital's Human Resources policy with input from the appropriate Department Chairman and Medical Board. In the event of any adverse action with respect to Adjunct Staff status as described above or clinical privileges, an AHP who is not an employee of the Hospital shall be entitled to an appellate review process similar to that described for the Medical Staff.

e. PRIVILEGES: The privileges of an AHP shall be to:

    1) Provide specified patient care services under the supervision or direction of the Medical Staff (except as otherwise expressly provided by resolution of the department which has been approved by the Medical Board) and consistent with limitation so stated;

    2) Write orders and perform functions only to the extent established by the Medical Board, but not beyond the scope of the AHP's license, certificate, registration, or other form of authority to practice;

    3) Attend meetings of the staff and department to which he/she is assigned and to attend hospital education programs; and

    4) Exercise such other privileges as shall, by resolution or written policy duly adopted by the staff or by any of its departments or committees and approved by the Medical Board.

f. RESPONSIBILITIES: Each AHP shall:

   1) Meet the same basic responsibilities as required for a Medical Staff Member;

   2) Retain appropriate responsibility within his/her area of professional competence for the care and supervision of each patient in the hospital for whom he/she is providing services, or arrange a suitable alternate for such care and supervision;

   3) Participate, as appropriate, in the patient care evaluation and other quality review, evaluation and monitoring activities required of the staff, participate in supervising initial appointees of his/her same profession during the observation period, and participate in discharging such other staff functions as may be required from time to time; and

   4) Satisfy the requirements set forth for attendance at meetings of the staff and of the department and committees of which the AHP may be a member.

g. PROVISIONS REGARDING AHPs:

   1) Midwives may be involved in the care of obstetrical patients as determined by the Rules and Regulations of the OB/GYN Department.

   2) Physician Assistants and licensed Nurse Practitioners may be employed by the Hospital to assist in the care of hospital, Emergency Room, and Ambulatory Care patients. Physician Assistants and licensed Nurse Practitioners will be under the supervision of a physician.

   3) Physical Therapists, Speech Therapists, and Occupational Therapists may see and treat patients at the written order of the attending physician.

ARTICLE XI – COMMITTEES

The Governing Board shall appoint a board of practitioners to be known as the Medical Board who shall be responsible for the supervision of quality of medical care rendered to all patients within the confines of the Hospital and all other facilities under its jurisdiction.

Section 1. Medical Board

a.  Composition: For the purpose of organization, the Medical Board is considered a Standing Committee and shall consist of the following members:

1. Chairman of Anesthesiology

2. Chairman of Emergency Medicine & Community Medicine

3. Chairman of Family Medicine

4. Chairman of Internal Medicine

5. Chairman of Medical Education

6. Chairman of Obstetrics & Gynecology

7. Chairman of Pathology

8. Chairman of Pediatrics

9. Chairman of Psychiatry

10. Chairman of Radiology

11. Chairman of Surgery

12. Chairman of the Credentials Committee

13. Chairman of the Health Information Management Committee

14. Chairman of the Surgical Case Review Committee

15. Chairman of the Pharmacy & Therapeutics/Drug Usage Committee

16. Chairman of the Bylaws Committee

17. Duly appointed Officers of the Medical Staff (ie, President, Vice President and Secretary/Treasurer)

18. Six (6) members elected from the Active Medical Staff(ie, Liaison Committee), each to serve three (3) years.

19. One (1) or more members at large as may be appointed by the Governing Body.

20. The immediate Past President of the Medical Staff

21. The Chief Executive Officer of the Hospital, or his designee, as an ex-officio member without a vote.

22. The Sr. VP Medical Affairs, as an ex-officio member without a vote.

b.  Duties: The Medical Board is responsible for making Medical Staff recommendations regarding the following activities directly to the Governing Body for its approval:

     1) To formulate and implement policy regarding the Medical Staff;

      2) To represent and act on behalf of the Medical Staff, subject to such limitations as may be imposed by these Bylaws;

      3) To coordinate the activities and general policies of the various departments;

      4) To receive and act upon committee reports;

      5) To implement policies of the Medical Staff not otherwise the responsibility of the departments;

      6) To provide liaison between the Medical Staff and the Chief Executive Officer and the Governing Body;

      7) To recommend action to the Chief Executive Officer on matters of a medico-administrative nature;

      8) To make recommendations on hospital management matters to the Governing Body through the Chief Executive Officer;

      9) To conduct an ongoing review and appraisal of the quality of professional care rendered in the Hospital and report on such assessment to the Governing Body;

    10) To insure that the Medical Staff fulfills its obligation to maintain the accreditation status of the Hospital;

    11) To provide for the preparation of all meeting programs, either directly or through delegation to a program committee or other suitable agent;

    12) To review the credentials of all applicants and to make recommendations for staff membership, assignments to departments and delineation of clinical privileges;

    13) To review periodically all information available regarding the performance and current clinical competence of staff members and other practitioners with clinical privileges and as a result of such a review, to make recommendations for reappointments and renewal or changes in clinical privileges;

    14) To take all reasonable steps to insure professionally ethical conduct and competent clinical performance on the part of all members of the Medical Staff, including the initiation of and/or participation in medical Staff corrective or review measures when warranted;

    15) To levy and assess dues for proper functions of the Medical Staff; and16) To report at each General Staff meeting.

c.  Meetings: The Medical Board shall meet monthly at least ten times each year and maintain a permanent record of its proceedings.

Section 2. Standing Committees

1. EXECUTIVE COMMITTEE

    a. Composition: Membership shall consist of the officers of the Medical Board, the Chairman of the Liaison Committee, the Chairmen of Family Medicine, Internal Medicine, Ob/Gyn, Pediatrics and Surgery, the Chief Executive officer or his/her designee, on an ex-officio basis without a vote and the Sr. VP of Medical Affairs, on an ex-officio basis without a vote.

    b. Duties: The Committee shall act in the absence of the full Medical Board when a significant issue must be addressed and time and scheduling do not permit a full Medical Board meeting.

    c. Meetings of the Executive Committee are called by the President of the Medical Staff. Its deliberations shall be reported at the next Medical Board meeting.

2. JOINT CONFERENCE

    a. Composition: The Joint Conference Committee shall consist of the Executive Committee of the Governing Body and the Executive Committee of the Medical Board. The Chairmen of departments shall be invited to participate in all matters before the Joint Conference Committee which relate to their departments.    

    b. Duties: The Joint Conference Committee shall conduct itself as a forum for the discussion of matters of Hospital policy and practice, especially those pertaining to efficient and effective patient care and plans for growth. It shall provide medico-administrative liaison with the Governing Body and the Chief Executive Officer on issues affecting medical care which arise in the operation and affairs of the Hospital.

    c. Meetings: The Joint Conference shall meet at least biennially.

3. CREDENTIALS

    a. Composition: The Credentials Committee shall consist of members of the Active Staff selected by the President of the Medical Staff on a basis that will insure representation of the major clinical and service departments and the Medical Staff at large. One member of the Governing Body and the Chief Executive Officer and/or his/h