ARTICLE VI: APPOINTMENT AND REAPPOINTMENT TO THE MEDICAL STAFF
PART D: MODIFICATION OF CLINICAL PRIVILEGES
PART E: TEMPORARY CLINICAL PRIVILEGES
PART F: EMERGENCY CLINICAL PRIVILEGES
PART G: LIMITED PRIVILEGE PRACTITIONER
Section
1. Qualifications
for and Conditions of Appointment
A.
Appointment to the Medical Staff is a privilege which shall be
extended only to professionally competent physicians and dentists who
continuously meet the qualifications, standards and requirements set forth
in these Bylaws. All persons
practicing medicine and dentistry in the Hospital, unless excepted by
specific provisions of these Bylaws, must first have been appointed to the
faculty of the Medical School and to the
Medical Staff.
B.
Only physicians and dentists currently licensed to practice in the
State of Kansas who can document required continuing medical education,
their background, experience, training and demonstrated competence, their
adherence to the ethics of their profession, their good reputation and
character and their ability to work harmoniously with others sufficiently
to convince the Executive Committee that all patients treated by them in
the Hospital will receive a high quality of medical care and that the
Hospital and Medical Staff will be able to operate in an orderly manner
shall be qualified for appointment to the Medical Staff.
The word “character” is intended to include the applicant’s
mental and emotional stability.
C.
No physician or dentist shall be entitled to appointment to the
Medical Staff or to the exercise of particular clinical privileges in the
Hospital merely by virtue of the fact that such physician or dentist is a
member of the faculty of the Medical School, is duly licensed to practice
medicine or dentistry in Kansas or any other state, is a member of any
particular professional organization, or had in the past, or currently
has, medical staff appointment or privileges at another hospital.
D.
No physician or dentist shall be denied appointment on the basis of
sex, race, creed, color, or national origin.
E.
Acceptance of appointment to the Medical Staff shall constitute an
agreement of the physician or dentist that such physician or dentist will
abide by the particular code or codes of professional ethics of the
American Medical Association, the American Osteopathic Association or the
American Dental Association, whichever is applicable.
F.
Acceptance of appointment to the Medical Staff shall constitute the
agreement of the physician or dentist that they will promptly notify the
Chair of the Clinical Department to which such physician or dentist is
assigned and the Chief of Staff, in writing, of the revocation or
suspension of such physician’s or dentist’s professional license in
any state, or the imposition of terms of probation or limitation of
practice by any state or other governmental body or unit, or of such
physician’s or dentist’s loss of staff membership or loss or
restriction of privileges at any hospital or other health care
institution, or of receipt of notice of any formal charges or the
commencement of a formal investigation by any professional regulatory or
licensing agency or the filing of charges by the Department of Health and
Human Services, peer review organizations, or any law enforcement agency
or health regulatory agency of the United States or the State of Kansas,
or the filing of a claim against such physician or dentist alleging
professional liability.
G.
Appointment to the Medical Staff shall confer on the member only
such clinical privileges as have been granted by the Board and shall
require that each member assume such reasonable duties and
responsibilities as the Board and the Medical Staff shall require.
H.
All initial appointments to the medical staff shall be considered provisional for a period
not less than one (1) year following the effective date of appointment.
During such period of provisional status, the member shall be
permitted to admit patients to the Hospital and to serve on committees but shall not exercise any other prerogative of the member’s
category of Medical Staff membership.
At or near the conclusion of the member’s provisional
appointment, the member’s performance while on provisional status shall
be reviewed, and a final decision on the member’s appointment shall be
made in accordance with the Credentialing and Corrective Action Procedures
of the Medical Staff as they may be established and amended by the
Executive Committee with approval of the Board.
Section
2. Procedure for
Appointment
A.
The procedure for Appointment to the Medical Staff shall be that
described in the Credentialing and Corrective Action Procedures of the
Medical Staff as they may be established and amended by the Executive
Committee with the approval of the Board.
B. The applicant shall have the burden of producing adequate information for a proper evaluation of such applicant’s competence, character, ethics, and other qualifications and of resolving any doubts about such qualifications. The applicant shall have the burden of providing evidence, if challenged, that all of the statements made and the information given on such applicant’s application are factual and true.
Section
1. When Required.
Reappointment
to the Medical Staff shall be required on at least a biennial basis.
Section 2. Factors to be Considered for Reappointment.
Each
recommendation concerning reappointment of a member to the Medical Staff
shall be based upon:
A.
The member’s professional ethics, competence, and clinical
judgment in the treatment of patients as indicated by quality and risk
management information related to such member’s treatment of patients
within the hospital, information obtained from other hospitals, health
care facilities, and health plans, and updated information with respect to
such member’s professional liability experience.
B.
The member’s physical and mental capacity to treat
patients.
C.
The member’s compliance with the Bylaws of the Hospital
Authority, Hospital standard practices, and Medical Staff Bylaws, Rules,
Regulations and policies and procedures.
D.
The member’s use of the Hospital’s facilities for such member’s
patients, such member’s cooperation and relations with other
practitioners and such member’s general attitude toward patients, the
Hospital and the public.
Section
3. Procedure for
Reappointment
A.
The procedure for reappointment to the Medical Staff shall be that
described in the Credentialing and Corrective Action Procedures of the
Medical Staff as they may be established and amended by the Executive
Committee with the approval of the Board.
B.
The member applying for reappointment shall have the burden of
providing adequate information for a proper evaluation of such member’s
competence, character, ethics, and other qualifications and of resolving
any doubts about such qualifications.
Such member shall have the burden of providing evidence, if
challenged, that all of the statements made and the information given on
such member’s application are factual and true.
Section
1. Delineation and
Scope
A.
Medical Staff appointment or reappointment shall not automatically
confer any clinical privileges or right to practice in the Hospital.
Each physician or dentist who has been given an appointment to the
Medical Staff of the Hospital shall be entitled to exercise only those
clinical privileges specifically recommended by the Medical Staff and
approved by Board.
B.
The clinical privileges recommended to the Board shall be based
upon the applicant’s education, training, experience, demonstrated
competence and judgment, references and other relevant information.
C.
Surgical procedures performed by dentists shall be under the
overall supervision of the Chair of the Clinical Department to which they
have been assigned or such Chair’s designee.
A medical history and physical examination of any patient upon whom
a surgical procedure is to be performed by a dentist shall be made and
recorded by a physician who is a member of the Medical Staff before the
surgery is performed, and a designated physician who is a member of the
Medical Staff shall be responsible for the diagnosis and management of the
medical problems of any such patient which may be present or arise during
the period of hospitalization.
Section
2. Procedure for
Assignment of Clinical Privileges
A.
The procedure for assignment of clinical privileges shall be that
described in the Credentialing and Corrective Action Procedures of the
Medical Staff as they are established and amended by the Executive
Committee with the approval of the Board.
B. The member applying for reappointment shall have the burden of providing sufficient evidence to support such member’s qualifications and competence to exercise any clinical privileges such member’s requests.
PART
D: MODIFICATION
OF CLINICAL PRIVILEGES
Section
1. Qualifications
Any member
of the Medical Staff who wishes to augment or otherwise modify such member’s
clinical privileges may be granted such augmentation or modification upon
such member’s demonstration that such member possesses the requisite
training, skill, and experience necessary to competently exercise the
clinical privileges sought.
Section
2. Procedure for
Modification of Clinical Privileges
A.
The procedure for modification of clinical privileges shall be that
described in the Credentialing and Corrective Action Procedures of the
Medical Staff as they are established and amended by the Executive
Committee with the approval of the Board.
B.
The member shall
have the burden of providing sufficient evidence to support such member’s
qualifications and competence to exercise any additional clinical
privileges such member requests.
PART E: EMERGENCY CLINICAL PRIVILEGES
In an emergency, any physician or dentist who is not a member of the Medical Staff, to the degree permitted by such physician’s or dentist’s license and regardless of clinical privileges, may be permitted to do, and shall be assisted in doing, everything possible to save the life of a patient in the Hospital, using every facility of the Hospital necessary, including calling for any consultation necessary or desirable. When the emergency situation no longer exists, 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 which could result in serious permanent harm to a patient or in which the life of a patient is in immediate danger and in which any delay in administering treatment would add to that danger.
PART F: LIMITED PRIVILEGE PRACTITIONER
At the invitation of a member, limited clinical privileges 1) to care for a specific patient, with the duration of the temporary privileges limited to the period of that patient’s stay in the Hospital; or 2) for specific clinical services, with the duration of the limited privileges to be specified in advance and limited only to the period necessary to render such clinical services, may be requested by a practitioner who is not a member of the Medical Staff. The procedure for granting such limited privileges is outlined in the Credentialing and Corrective Action Procedures of the Medical Staff.
PART G: TEMPORARY CLINICAL PRIVILEGES
Section 1. Temporary clinical privileges may be granted to certain applicants who strictly meet the following criteria:
A. The applicant’s application for clinical privileges is complete, has been completely processed in accordance with the Credentialing and Corrective Action Procedures of the Medical Staff, and is awaiting action by the Executive Committee or any Credentialing Committee;
B. Neither the applicant’s application, the materials submitted in support thereof, nor the information generated by the processing of the application and supporting materials pursuant to the Credentialing and Corrective Action Procedures of the Medical Staff contains any discrepancy or any information that would require further investigation before the application is approved; and
C. The Hospital has an immediate need for the applicant’s services in order to render care to patients who cannot reasonably be cared for at the Hospital by any other physician.
Section 2. All applicants granted temporary clinical privileges shall be subject to the supervision of the Chief of Staff or the Chief of Staff’s designee and shall submit to any personal supervision and/or proctoring deemed necessary by the Chief of Staff, the CEO, or the Board.
Section 3.
Temporary clinical privileges shall be
granted for a maximum period of sixty (60) days or until the applicant’s
application is approved by the Executive Committee, whichever period is
shorter, and shall expire automatically at the end of said period.
During such period, the applicant shall have the same prerogatives as
members of the Provisional Staff.
Section 4. The procedure for granting, modifying, suspending, or revoking temporary clinical privileges shall be that stated in the Credentialing and Corrective Action Procedures of the Medical Staff.
ARTICLE IV: ORGANIZATION OF CLINICAL DEPARTMENTS
OF THE MEDICAL STAFF
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ARTICLE VII: ACTIONS AFFECTING MEDICAL STAFF MEMBERS
