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DRAFT NL RHA MODEL BYLAWS RESPECTING MEDICAL STAFF 1 February 12, 2007 EDITED BY: Dr. Kevin Beamont, August 2007

DRAFT

Newfoundland and Labrador Regional Health Authorities Model By-Laws respecting Medical Staff:

for review by the Vice Presidents, Medical Services (Please read the introduction setting out the legislative framework and Ministerial directives for these model by-laws)


Introduction In April, 2005, the health and community services system in Newfoundland and Labrador implemented a significant change from fourteen health boards to four Regional Health Authorities (RHAs). The four RHAs each have the mandate to deliver and administer the entire range of provincial health and community services in an integrated manner in the four new health regions. New Medical Staff Bylaws are required for the RHAs to reflect the new structure in the health and community services system. These model Medical Staff Bylaws are intended to promote consistency across the province where required by legislation or ministerial direction, while providing flexibility in organizational structural issues so that RHAs can address individual regional circumstances and needs. Improving quality management at the practitioner level is one facet of the larger quality agenda and as such must recognize the unique relationship between the board, management and the practitioner staff. It is important to recognize the interdependent relationship of these groups rather than relying on the traditional approaches that have attempted to assign to these groups separate and unrelated activities. Only by recognizing the interdependence of the various groups and functions can progress be made on advancing a quality agenda. Basic Assumptions

(a) Physicians, irrespective of their mode of remuneration would be subject to Regional Health Authority Medical Staff Bylaws with respect to appointment, privileging, credentialing and discipline;

(b) Standard province-wide appointment and reappointment process;

(c) Standard province-wide privileging and credentialing process;

(d) Standard province-wide discipline process;

(e) requirement for a selection process for the appointment

of the senior physician leaders;

(f) requirement to establish a medical advisory committee;

(g) requirement to establish departments/programs based on regional needs; and

Comment [b1]: This took 2 years in Saskatchewan

Comment [b2]: Saskatchewan emphasizes cooperation and teamwork

Comment [b3]: These 4 conditions are included in the Saskatchewan By laws and may be an alternative way for physicians to interact


(h) requirement to establish a regional health authority –

physician liaison council (could be expanded to include other practitioners).

Legislative framework The powers of the Minister of Health and Community Services are defined in Section 4 of the Regional Health Authorities Act:

(1) The minister may determine

(a) Health and community services which shall be provided by an authority; and

(b) Standards for the provision of health and community services by an authority.

(2) Where the minister determines a health and community service or a standard under subsection (1) the authority to which it is applicable shall comply with the minister's determination.

The Minister of Health and Community Services has directed that Medical Staff Bylaws shall address standards relating to quality in the provision of health and community services by a Regional Health Authority to be applied consistently across the province in the following areas:

• Types of privileges • Appointments • Credentialing process • Discipline • Appeals

Further directions on the content of Medical Staff Bylaws are laid out in Section 10 (2) of the Regional Health Authorities Act, which states:

s. 10 (2) the board may make by-laws respecting medical staff of the authority, including by-laws respecting

(a) the granting, variation, suspension and revocation of medical staff privileges;

(b) categories of medical staff privileges; (c) the membership of a medical advisory committee; (d) the duties and functions of senior medical officers of the authority; and


(e) rules and regulations governing medical staff

Memorandum of Agreement Section 10.03 of the Memorandum of Agreement between the Government of Newfoundland and Labrador and the Newfoundland and Labrador Medical Association (NLMA), dated October 1, 2005 to September 30, 2009, also states that the NLMA will make best efforts to encourage all licensed physicians providing clinical services in the Province of Newfoundland and Labrador to be credentialed and privileged with a Regional Health Authority.

Key Principles

The Medical Staff Bylaws therefore incorporate the following principles:

(a) address the key elements of appointment, reappointment, privileging and discipline that all Regional Health Authorities will be required to follow;

(b) incorporate permissive language that will allow Regional Health Authorities to develop organizational structures that address regional needs;

(c) balance the obligations of Regional Health Authorities to address issues of risk management and patient/client/resident safety while at the same time ensure that the principles of due process and procedural fairness are maintained.

Future Steps All the parties involved in the development of these Bylaws are committed to a process of annual review and revision, as required, to ensure that the Bylaws support the provision of quality health services in the region and the province.


MODEL MEDICAL STAFF BYLAWS PART I

1. Title These are the Medical Staff Bylaws for the Eastern Regional Health Authority. 2. Purpose (1) These Medical Staff Bylaws are developed and enacted in order to:

(a) provide an administrative structure for the governance of the medical staff affairs within the Regional Health Authority;

(b) promote the provision of quality health services, ensuring patient safety and

quality assurance of medical care ( c ) promote adequate availability and maintain efficient use of resources;

( d) provide, maintain and improve educational standards. Comply with national undergraduate and postgraduate standards and work closely with the faculty of Medicine of Memorial University

( e ) promote participation in approved research;

(f) govern the procedures for the appointment, reappointment, suspension and

termination of appointment of physicians to the medical staff; (g) govern the procedures for the discipline of members of the medical staff; (h) provide a means of granting of privileges to members of the medical

staff,including the amendment, suspension or revocation thereof; (i) provide a means of effective and efficient communication between the

medical staff, the Regional Health Authority, and management within the health region; and

(j) provide for medical staff input into policy, rules, planning and budget

decisions of the Regional Health Authority. (k) promote a safe and healthy work environment


(l) encourage and promote a responsibility for personal health and the maintenance of wellness.

(2) These Medical Staff Bylaws apply to the members of the medical staff appointed pursuant to these Bylaws.

3. Definitions In these Medical Staff Bylaws, the following definitions apply:

(a) “board” means those persons appointed as members of the Board of the

Regional Health Authority by the Lieutenant Governor in Council pursuant to section 8 of the Regional Health Authorities Act;

(b) “Chief Executive Officer” means the person appointed by the Board of the

Regional Health Authority as Chief Executive Officer within the meaning of section 14 of the Regional Health Authorities Act, responsible to the Regional Health Authority for the day-to-day conduct and management of the affairs of and activities provided by the Regional Health Authority at its facilities or delivered through its programs and services, and includes a person to whom the powers, duties and responsibilities of the Chief Executive Officer are delegated by the Board in the absence or incapacity of the person appointed as Chief Executive Officer;

(c) “chiropractor” means a chiropractor who is entitled to practice chiropractic in

the province of Newfoundland and Labrador pursuant to the Chiropractors Act;

(d) “chiropractic staff” means those chiropractors who have been appointed as a

member of the chiropractic staff by the Chief Executive Officer in consultation with the Vice President Medical Services;

(e) “College” means in the case of a physician the College of Physicians and

Surgeons of Newfoundland and Labrador, in the case of a dentist the Newfoundland Dental Board and in the case of a chiropractor the Newfoundland and Labrador Chiropractic Board;

(f) “dentist” means a dentist who is entitled to practice dentistry in the province

of Newfoundland and Labrador pursuant to the Dental Act;

(g) “dental staff” means:

(i ) those dental specialists who have been appointed as a member of the dental staff by the Chief Executive Officer in consultation with the Vice

Comment [b4]: SAS general

Comment [b5]: Added

Comment [b6]: Do we still need? SAS and 2004 Board included

Comment [b7]: SAS oral an facial surgeons


President Medical Services to whom the Chief Executive Officer has granted admitting privileges; and

(ii ) those dentists who have been appointed as a member of the dental staff by the Chief Executive Officer, in consultation with the Vice President Medical Services, to whom the Chief Executive Officer has granted admitting privileges on the joint order of a member of the active medical staff.

(h) “non-medical scientist” means a doctoral graduate in science of an approved

university.

(i) “health region” means the Eastern Health region established pursuant to section 6 of the Regional Health Authorities Act;

(j) “impact analysis” means a study conducted by the Vice President Medical

Services, or designate, in consultation with the department, program and/or services head to determine the impact upon the resources of the Regional Health Authority and the clinical requirements of a proposed appointment of any person to the medical, dental or chiropractic staff;

(k) “medical staff” means those physicians who have been appointed as members

of the medical staff by the Chief Executive Officer in consultation with the Vice President Medical Services;

(l) “physician” means a physician who is entitled to practice medicine pursuant

to the Medical Act, 2005;

(m) “policies and procedures” means those policies and procedures that have been enacted by an officer of the Regional Health Authority with the authority to enact policies and procedures for the Regional Health Authority;

(n) “privileges” means the authority granted by the Chief Executive Officer in

consultation with the Vice President Medical Services in accordance with these Bylaws to a physician, dentist or chiropractor to admit, register, diagnose, treat or discharge patients/clients/residents in respect of a facility, program or service operated or delivered by the Regional Health Authority;

(o) “Provincial Medical Association” means the organized body of physicians who

practice in the health region and hold membership in the Newfoundland and Labrador Medical Association

(p) “Regional Health Authority” means the Eastern Regional Health Authority

established pursuant to section 6 of the Regional Health Authorities Act;

(q) "rules and regulations” means those rules and regulations governing the medical staff in the health region and in a particular department, program or

Comment [b8]: SAS and 2004 Board

Comment [b9]: ?Where is board

Comment [b10]: Formally Board


Comment [b12]: Regional was included in SAS


service, which have been established by the medical staff and approved by the Chief Executive Officer on the recommendations of the Vice President Medical Services and the Medical Advisory Committee;

(r) “Vice President Medical Services” means the physician appointed as Vice

President Medical Services by the Chief Executive Officer.

(s) “Credentials Committee” means that committee appointed by each Local Area Medical Advisory Committee to review appointments and re-appointments to the medical staff of Eastern Health and make recommendations to the appropriate Local Area Medical Advisory Committee.

The composition and terms of reference are attached as Appendix A. (t) “Program” is a term used to describe a group of clinical services of the Health

Care Corporation that are directed towards meeting the health care needs of a group of patients, in a patient focused and interdisciplinary manner;

(u) “Program Clinical Chief” is a term used to denote the medical staff member of the program leadership team;

(v) “Program Director” is a term used to denote the person who is administrative leader of the program leadership team;

(w) “Program Divisional Chief” is a term used to denote the medical staff leader of a division of a program, which may be site specific

(x) "University" means the Memorial University of Newfoundland;

(y) Provincial program is a term used to describe a clinical service that

encompasses and services the whole province

(z) Discipline Chair is the head of the relevant discipline of the faculty of medicine

(aa) Post Graduate Medical Trainee are physicians who have qualified and

completed a medical degree and who are pursuing further supervised training

(bb) Resident is a client/patient living in a facility of Eastern Health

(cc) ? more



(dd) PART II ORGANIZATION OF THE MEDICAL STAFF

4. Responsibilities of the Regional Health Authority (1) The Board is responsible for the management and affairs of the Eastern

Regional Health Authority in order to enable quality health care and promotion of community wellness.

(2) The Board may make Bylaws respecting medical staff of the Regional Health Authority, including by-laws respecting

(a) the granting, variation, suspension and revocation of medical staff privileges;

(b) categories of medical staff privileges; (c) the membership of a Medical Advisory Committee; (d) the duties and functions of senior medical officers of the Eastern Regional

Health Authority, including the Medical Advisory Committee(s); and

(e) rules and regulations governing medical staff.

(3) Under the authority of the Regional Health Authorities Act, the Minister of Health and Community Services has directed that Medical Staff Bylaws shall provide standards to be applied in all health regions relating to quality in the following areas:

• Types of privileges • Appointments • Credentialing process • Discipline, and • Appeals.

(4) The Board delegates to the Chief Executive Officer the responsibility for the Medical Staff Bylaws made according to subsection (2).

5. Responsibilities of the Chief Executive Officer The Regional Health Authority through its Chief Executive Officerr shall be responsible:

(a) to ensure the delivery of quality medical services within the health region, consistent with the strategic plan and mission of the Regional Health Authority, applicable legislation and these Bylaws;

Comment [b14]: Responsibility expanded. SAS resp for internal organization and proceedings of thr RHA and general conduct of affairs of facilities

Comment [b15]: Major change. Why?


(b) for the organization of the medical staff into such departments, programs and/or services as are warranted from time to time and as outlined in these Medical Staff Bylaws. In so doing, the Chief Executive Officer shall establish an organizational structure to implement and fulfil the strategic plan and mission of the Regional Health Authority, including but not limited to:

(i ) ensuring the appointment of department, program and/or service heads

by the Vice President Medical Services, as required; and

(ii ) establishment of a Medical Advisory Committee structure. 6. Vice President Medical Services Appointment The Chief Executive Officer shall appoint a Vice President responsible for Medical Services after giving consideration to the recommendations and advice of a Search Committee.. Subject to the confirmation of the Board, the chief executive officer has the sole right to appoint a senior medical officer. 7. Responsibilities of the Vice President Medical Services The Vice President Medical Services and the Chair MAC (rep) shall be accountable to the Chief Executive Officer and the board with respect to all matters regarding the management and organization of medical staff affairs under the jurisdiction of the Regional Health Authority, including the establishment of an organizational structure that supports the achievement of health outcomes, and ensures the delivery of medical services within the health region, consistent with the strategic plan and mission of the Regional Health Authority. The roles and responsibilities of the Vice President Medical Services shall include, but are not limited to:

(a) with respect to corporate management:

(i ) full membership on the senior management team of the regional health authority, participating in all management discussions and decisions including, but not limited to discussions and decisions regarding strategic planning, financial and program planning, human resources planning, the development, implementation and evaluation of patient/client/resident care programs and services, and resource allocation;

(b) with respect to medical staff administration:

(i ) developing, maintaining and updating medical staff rules and

regulations and policies and procedures pertaining to medical services

Comment [b16]: Do the members need to be listed as per SAS

Comment [b17]: 2004 responsible with chair MAC to board

Comment [b18]: New from 2004 but included in SAS


provided within the facilities, programs and services operated by the regional health authority;

(ii ) providing leadership and direction in collaboration with the clinical

chiefs on matters pertaining to clinical organization, medical technology and other relevant medical staff administrative matters;

(iii ) participating in any regional health authority committees, as required;

and

(iv ) providing leadership and direction to the department, program and section/services heads, other medical staff leaders, and the medical advisory committees and all its standing and ad hoc committees, so as to integrate the activities of the various departments, programs and committees with each other and with the goals of the regional health authority.

(c) with respect to the appointment, privileging and discipline, including

reappointment, termination, suspension and amendment thereof, of the medical staff in collaboration with clinical chiefs and discipline chairs:

(i ) ensuring that appropriate medical staff appointment, privileging, re-

appointment and discipline processes are in place and consistent with applicable law and legislation and with these bylaws.

(d) with respect to the provision of the quality of medical care in collaboration

with clinical chiefs and discipline chairs :

(i ) developing, establishing and maintaining quality assurance, quality improvement, risk management and utilization activities within the health region in compliance with all applicable legislation, bylaws, rules and regulations, and policies and procedures of the regional health authority; and

(ii ) collaborating with members of the medical staff and other staff to

ensure that patient/client/resident concerns regarding the quality of medical care are resolved in a timely manner.

(e) with respect to medical staff resource planning in collaboration with clinical

chiefs and discipline chairs:

(i ) submitting annually a regional medical staff human resource plan to the Chief Executive Officer and the regional health authority that addresses the needs of the health region; and

(ii ) providing leadership and direction on matters pertaining to physician

Comment [b19]: new


compensation, recruitment, orientation and retention.

(f) With respect to regional medical needs assessment: (i) conduct an annual medical needs assessment for the region; (ii) make recommendations as required based on the annual medical needs

assessment.

(g) with respect to the professional and ethical conduct of the medical staff:

(i ) encouraging, promoting and fostering the professional and ethical conduct of medical staff in relation to their practice, teaching, research and interactions with others; and

(ii ) addressing concerns arising from the professional and ethical conduct

of medical staff.

(h) with respect to continuing medical staff education: in collaboration with clinical chiefs and discipline chairs

(i ) encouraging, promoting and fostering participation in continuing

medical staff education on an ongoing basis; and

(ii ) assisting in identifying and addressing the management and leadership needs of physicians within the health region.

(i) with respect to provincial medical services issues:

i. co-operating and co-ordinating with other vice presidents of medical services in the province.

(j) with respect to teaching and research:

(i ) encouraging, promoting and fostering teaching and research within the

health region; and

(ii ) ensuring that appropriate processes and protocols are in place for the consideration and approval of research proposals and

(iii ) liasing with the faculty of medicine of Memorial University

8. Establishment of Departments, Programs and/or Services

Comment [b20]: new previously with clinical chief in SAS

Comment [b21]: new ? reference to CC/Ch. In SAS

Comment [b22]: Sections in SAS


1) The Vice President Medical Services may make recommendations to the Chief Executive Officer to establish or dissolve departments, programs and/or services, as considered appropriate from time to time.

2) The establishment or dissolution of any department, program and/or service by the Vice President Medical Services shall not take effect until confirmed by the Chief Executive Officer.

3) The composition and duties of each department, program and/or service shall be

described in the policies and procedures.

4) The Vice President Medical Services shall give consideration to the advice of the Medical Advisory Committee in the exercise of any of the powers under subsection 8(1).

Clinical Programs The following are the programs within the Eastern Health:

(a) Cancer Care; (b) Cardiac/Critical Care; (c) Children’s/Women’s Health; (c) Diagnostic Imaging; (d) Emergency/Ambulatory Care; (e) Laboratory Medicine; (f) Medicine; (g) Mental Health; (h) Perioperative;

(i) Rehabilitation/Continuing Care/Dr. Walter Templeman Health Centre; (j) Surgery (k) Long-Term Care - St. John’s (l) Medical Care Program – Avalon (m) Medical Care Program – Burin Peninsula (n) Medical Care Program – Clarenville / Bonavista Divisions The Chief Executive Officer, after considering the recommendation of the Local Area Medical Advisory Committee, following the recommendation of the Clinical Chief, may establish Divisions/Departments within a Program. Program/Division Each Program/Division/Department shall have a Clinical Chief/Divisional/Departmental Chief who is named through a selection process initiated by the Chief Executive Officer,


approved by the Medical Advisory Committee, and appointed by the Chief Executive Officer. The Medical Staff members of each program shall meet on a regular basis at least six times per year or at the call of the chair. Medical Staff members and Divisional/Departmental Chiefs of each Program shall be responsible to the Clinical Chief and members of a Division/Department responsible to the Chief of the Division/Department. Attendance at regular Program meetings shall not release the members from their obligation to attend the general meetings of the Medical Staff. 9. Appointment of Department, Program and Service Physician Head

1) In accordance with the policies and procedures, the Vice President Medical Services may appoint one or more individuals to be responsible for and serve as head of each department, program and/or service 2) Each Program/Division shall have a Clinical Chief/Divisional Chief who is named through a selection process initiated by the Chief Executive Officer, approved by the Medical Advisory Committee, and appointed by the Board.

3) The heads of each department, program and/or service shall normally be appointed and/or reappointed for a period of ?5__years unless otherwise provided for in the policies and procedures.

4) Reappointment should normally limited to a second term for a maximum of 2 consequetive terms

.5) Department, program and/or service physician heads shall undergo an annual performance review in accordance with the policies and procedures.

6) The Vice President Medical Services may at any time revoke or suspend the appointment of a department, program and/or service physician head.

7) No appointment, revocation or suspension of the appointment of a department, program and/or service head shall continue in effect for longer than five (5) days unless confirmed in writing by the Chief Executive Officer.

8) The Vice President Medical Services may appoint an acting department, program and/or service head where the department, program and/or service head is absent, unable or unwilling to carry out the responsibilities of a department, program and/or

Comment [b23]: ?new

Comment [b24]: Section in SAS

Comment [b25]: Current Process. ? role of chair

Comment [b26]: Need enforceable decision 3 vs 5

Comment [b27]: New from SAS where there was no limit


service head. An acting head of a department, program and/or service shall have all of the powers, duties and responsibilities of the head. 9) The Vice President Medical Services shall give consideration to the advice of the Medical Advisory Committee in the exercise of any of the powers under subsection 9(1).

10. Responsibilities of Department, Program and/or Service Physician Head (1) A department, program and/or service head is responsible to the Vice President Medical Services for the effective organization, management and functioning of the medical staff within the assigned department, program and/or service. (2) The roles and responsibilities of the department, program and/or service physician head shall be set out more fully in the policies and procedures.

Program Clinical Chief The Program Clinical Chief is jointly accountable with the Program Director or Chief Operating Officer, as appropriate, for the effective and efficient operation of the Program. The Clinical Chief shall be responsible through the Local Area Medical Advisory Committee for the quality of medical services delivered and for the promotion of an interdisciplinary approach in the delivery of patient care. The Program Clinical Chief is also responsible to work with the University Chair of the aligned discipline in accomplishing Eastern Health’s mandate and provide medical education and research. Depending on the size of the program, the Program Clinical Chief may also be assigned direct responsibility for Program Divisions/Departments. Clinical Chiefs’ appointments will normally be for a ?three-year term. Accountabilities for Program Clinical Chiefs The Program Clinical Chief will:

a) convene and chair regularly scheduled meetings of the Program;

b) ensure appropriate supervision of the professional care provided by members of the medical staff in the program or assign an active staff member to supervise the practice of medicine or dentistry of other members of the program for any period of time;

c) review the privileges granted to members of the medical staff in the program and

to make recommendations for changes in the kind and definition of such privileges to the Credentials Committee, as applicable, and the Local Area Medical Advisory Committee;

Comment [b28]: 2004 responsibilities


d) make written recommendation to the Credentials Committee and Local Area

Medical Advisory Committee respecting matters concerning members of the medical staff in his/her program or where there are applicants for a position on the medical staff within the programs;

e) either carry out or receive and review (from Divisional/Departmental Chiefs)

annual performance evaluations and recommendations concerning physicians within their programs ensuring that the evaluation and recommendations are forwarded when appropriate to the Credentials Committee in the month designated for their respective program;

f) ensure appropriate orientation of new members of the Medical Staff in the

program;

g) notify the Vice President, Medical Services, of his or her absence, and designate an alternate, who shall be responsible for the conduct of affairs in the case of such absence;

h) be responsible to the Chief Executive Officer with the vice president responsible

for medical services for the Medical Staff conformity to the By-laws. Quality Initiatives:

a) ensure the development and maintenance of quality patient focused care;

b) ensure the development and evaluation of standards of care as well as outcomes;

c) ensure the provision of quality services through a process of continuous quality

improvement;

d) support the creation of working environment which facilitates the involvement of students, all levels of staff, including physicians, dentists and post graduate medical traineesas well as input from consumers of the Program;

e) represent the program to patients and families receiving feedback related to

patient care, particularly as it applies to medical issues;

f) liaise with Discipline Chairs, other Clinical Chiefs and the Regional and Local Area Medical Advisory Committees to ensure achievement of clinical excellence.

Resource Management - Financial:

(a) ensure the effective and efficient use of resources particularly as it relates to the medical staff;


(b) develop, with the other members of the Program Leadership team and Divisional Chiefs and Mangers, an annual operating and capital budget and participate in the monitoring of the Program’s fiscal performance;

(c) coordinate a medical human resource plan for the Program with the

University Chairs, as appropriate, and in consultation with the vice president responsible for medical services;

(d) recruit medical staff members in collaboration with the University Chairs, as appropriate, and in consultation with the Vice President, Medical Services;

(e) advocates for an interdisciplinary approach to care delivery.

Planning:

(a) develop objectives and strategies for the Program which focus patient

outcomes, are consistent with the overall Mission, Values, Vision and Corporate Strategic Directions of the Eastern Health, and are supportive of and integrated with the key directions of other programs and services;

(b) participate in the implementation and evaluation of approved Program

Key Directions and Objectives.


Liaison:

(a) ensure the maintenance of a comprehensive consultation network within the program which supports interdisciplinary collaboration and decision-making;

(b) ensure liaison among all programs, particularly those programs with which it has strong linkages;

(c) liaise with the University Chairs and the vice president responsible for

medical services, with respect to medical resource issues;

(d) participate in appropriate medical staff activities associated with the local Medical Staff Organization;

(e) liaise with the appropriate University Chairs for issues related to

recruitment, education and research;

(f) liaise with appropriate external providers involved in the continuum of patient care;

(g) maintain an active involvement in committees of the Eastern Health.

Education: The Clinical Chief, in collaboration with the University Chairs, will support and promote:

(a) the undergraduate and postgraduate medical educational programs;

(b) the educational programs offered by the Eastern Health for other allied

health professionals in collaboration with Memorial University of Newfoundland and other agencies.

Research:

The University Chair has primary responsibility for research. The Clinical Chief will liaise with the University Chair and Divisional/Departmental Chiefs and Managers to ensure that clinical research meets the needs of the Eastern Health, this includes:

(a) the promotion of facilitation of research; (b) the promotion of evidence-based practice;


(c) the promotion of research into the delivery of health care. The Clinical Chief is primarily responsible for activities that monitor the delivery of care by the Program and the ongoing evaluation of quality of medical care. Divisional Chief

Divisional/Departmental Chiefs shall be appointed by the Chief Executive Officer following consultation with the Regional and Local Area Medical Advisory Committees and following nomination by the Clinical Chief of the Program concerned. They shall be responsible to the Clinical Chief and have such duties as assigned.

These duties may include:

(a) divisional/departmental leadership and overall supervision of clinical care,

both inpatient and ambulatory, given by members of the Division/Department;

(b) the convening and chairing of divisional/departmental meetings with

minimum of five meetings to be held in each calendar year. The agenda of these meetings should include a review of clinical affairs within the Division/Department, the liaison with other professional groups such as nursing, social services and physiotherapy and liaison with the Program Leadership Team;

(c) coordination of undergraduate and postgraduate teaching within the Division/Department, in liaison with individual program directors as appropriate;

(d) the promotion of clinical research within the Division/Department.

Divisional/Departmental Chiefs shall be responsible to the Clinical Chief of the Program concerned. Divisional/Departmental Chiefs may be reappointed after appropriate review and at appropriate intervals not exceeding three years.

11. Establishment of the Medical Advisory Committee Structure The Chief Executive Officer and Vice President Medical Services shall establish a regional and local Medical Advisory Committee structure.

Comment [b29]: Needed for diversity of region


12. Responsibilities of the Regional Medical Advisory Committee

1) The Regional Medical Advisory Committee(s) shall:

a) assist the Vice President Medical Services with the effective organization, management and functioning of the medical,staff;

b) in conjunction with the Vice President Medical Services, develop rules and regulations and policies and procedures relating to medical staff affairs; and

c) make recommendations to the Vice President Medical Services in accordance

with and as required by these Bylaws.

2) The responsibilities of the Regional Medical Advisory Committee(s) include, but are not limited to, providing policy advice and recommendations to the Vice President Medical Services, with a view to integrating and coordinating activities in a consistent manner throughout the health region on matters:

a) with respect to medical staff administration:

(i ) providing advice and recommendations to the Vice President Medical

Services on the development, maintenance and updating of medicalstaff policies and procedures pertaining to medical, dental and chiropractic care provided within facilities, programs and services operated by the Regional Health Authority;

(ii ) providing advice and recommendations to the Vice President Medical

Services on matters pertaining to clinical organization, medical technology and other relevant medical administrative matters; and

(iii ) providing advice and recommendations to the Vice President Medical

Services on matters pertaining to strategic planning, financial and program planning, the development, implementation and evaluation of patient/client/resident care programs and services and resource allocation.

b) with respect to the provision of the quality of medical, dental and chiropractic

care:

(i ) receiving, reviewing and making recommendations to the Vice President Medical Services on reports from quality review bodies and committees;

(ii ) making recommendations to the Vice President Medical Services

concerning the establishment and maintenance of professional standards in facilities, programs and services operated by the Regional


Health Authority in compliance with all applicable legislation, bylaws, rules and regulations and policies and procedures of the Regional Health Authority; and

(iii ) reporting and making recommendations to the Vice President Medical

Services on the quality, effectiveness and availability of medical, services provided in facilities, programs and services operated by the Regional Health Authority.

c) with respect to medical human resource planning:

i. making recommendations to the Vice President Medical

Services regarding medical, dental and chiropractic human resources required to meet the health needs of the population served by the Regional Health Authority.

d) with respect to the appointment, re-appointment, termination, suspension, discipline and privileging of medical staff providing recommendations to the Vice President Medical Services as required by these Bylaws

13 Regional Medical Advisory Committee(s) Composition A Regional Medical Advisory Committee(s) shall be established consisting of not more than ____ members and may include a representative or representatives from the medical programs and sites . The Regional Medical Advisory Committee for Eastern Health will be composed of the following 25 persons:

a) Chairs of Local Area Medical Advisory Committees or designates/representatives (4)

b) Vice President, Medical Services, (1) – ex-officio

c) Chief Operating Officers (6) – ex-officio

d) Medical School representative (1)

e) Medical staff organization representatives (4)

f) Chief Executive Officer (1) – ex-officio

g) Medical Officer of Health (1)

h) Clinical Chiefs (4)

- Long-Term Care


- Acute Care - Mental Health - Cancer Care

i) Director of Medical Services (1) – ex-officio

j) Clinical Chief, Research (1)

k) Independent Chair (1)

The Chair of the Regional Medical Advisory Committee shall be appointed by the Chief Executive Officer. The appointment shall be for a two-year term, agreed for a second term by members. The Chief Executive Officer may at any time revoke or suspend the Chairperson of the Regional Medical Advisory Committee and appoint an acting Chairperson until a replacement is found in accordance with this section or until the suspension is lifted, as the case may be. In accordance with the disciplinary process (Section?) The Vice-Chairperson of the Regional Medical Advisory Committee shall be appointed from among their number by the voting members of the Regional Medical Advisory Committee for a one-year term. In the absence of the Chairperson, he or she will assume all of the Chairperson’s duties and shall have all of his or her authority.

2) The chair of the Regional Medical Advisory Committee shall:

a) preside at all meetings of the Regional Medical Advisory Committee; b) give such notice, as required in these bylaws, of all meetings of the Regional

Medical Advisory Committee; c) in consultation with the Vice President, Medical Services, develop the agenda

for Regional Medical Advisory Committee meetings; d) maintain the minutes of all meetings of the Regional Medical Advisory

Committee; e) maintain an attendance record of those attending all meetings of the Regional

Medical Advisory Committee; and f) perform such other duties as ordinarily pertain to this office and as the

regional health authority may from time to time direct.

3) The vice-chair of the Regional Medical Advisory Committee shall have all the powers and perform all the duties of the chair in the absence of the chair, together with such other duties as are usually incidental to such a position or as may be assigned by the regional health authority from time to time.


14. Standing and Ad Hoc Committees of Regional Medical Advisory Committee

1) The Regional Medical Advisory Committee(s) may establish such standing committees and ad hoc committees as required to advise the Vice President Medical Services.

2) The terms of reference, duties and composition of each standing and ad hoc

committee shall be recorded in the rules and regulations, policies and procedures or minutes of the Medical Advisory Committee(s).

3) The Medical Advisory Committee(s) shall appoint a chair of each standing committee and each ad hoc committee.

4) The chair of each standing or ad hoc committee shall submit the minutes, reports, and any recommendations of the standing or ad hoc committee on a regular basis, or as directed by the Medical Advisory Committee(s), and, at the request of the Medical Advisory Committee(s), be present to discuss all or part of any minutes, reports, or recommendations of the standing or ad hoc committee.

5) With the exception of the joint conference committees, the chairperson and membmbers of the standing committees shall be appointed annually by the Regional medical Advisory Committee.

14. Local Medical Advisory Committees The C.E.O. in consultation with the vice president responsible for medical services should provide for the establishment of Local Area Medical Advisory Committees in each of the following areas:

1) St. John’s 2) Burin Peninsula 3) Clarenville / Bonavista 4) Rural Avalon

These Local Area Medical Advisory Committees shall meet 10 times per year. The chair of each of these committees will be appointed by the C.E.O. in consultation with the vice president responsible for medical services. Appointments will be for a two-year period with renewal for a further two-year period if mutually agreeable. The Vice Chair will be elected from the other members of each Local Area Medical Advisory Committee on an annual basis. The roles of the Local Area Medical Advisory Committee are:

Comment [b30]: Is this still active SAS have Regional Health A Practitioner Liason Council Meetings - Advisory


1) Work with the Regional Medical Advisory Committee to promote quality medical care in their area of responsibility.

2) Advise the relevant Chief Operating Officer(s) on matters related to medical care and other issues as appropriate.

3) Serve as a forum for discussion and, if necessary, decision making among the various elements of these medical staff.

4) To consider, act on, or refer to the Regional Medical Advisory Committee items which are submitted by the Chief Operating Officers.

5) To review credentials and make recommendations initially and then at appropriate intervals to the C.E.O. or designate on the appointment, category of appointment (assignment of Programs) granting of privileges, reappointment, promotion and retirement of each medical staff member in keeping with policies as developed by Eastern Health.

The membership of each Local Area Medical Advisory Committee is outlined in Appendix C. Special committees shall be appointed by the Regional Medical Advisory Committee or the Local Area Medical Advisory Committee s from time to time as may be required to perform specific functions. Such committees shall confine their work to the purpose for which they were appointed and shall report in writing to the Medical Advisory Committee. Any special committees of the Medical Advisory Committees and other administrative or other committees or panels within the Eastern Health which in the opinion of the Medical Advisory Committees or the C.E.O. perform in whole or in part and from time to time functions relating to quality initiatives and/or peer review within the Eastern Health be designated by the Medical Advisory Committees or by the C.E.O. to be a quality assurance and/or peer review committee as such may from time to time be contemplated by Section 6.1(2) of the Evidence Act (Newfoundland) as amended. Additional committees of an administrative nature may be appointed from time to time to assist the medical administration of the Eastern Health. Such committees shall report in writing to the appropriate Medical Advisory Committee. 15. Medical Advisory Committee / Departmental / Medical Staff / Meeting (1) The Regional Medical Advisory Committee shall hold not less than ___ meetings in each fiscal year at the call of the chair and/or the Vice President Medical Services

Comment [b31]: Where is this/


.(2) In addition to the meetings described in subsection 15(1), four additional meetings of the medical staff, chaired by the Vice President, Medical Services, may be held in each fiscal year to discuss issues related to medical staff management, organization and other related matters. (3) The conduct of Medical Advisory Committee(s), department, program or section/services meetings and general meetings of the medical staff, as well as questions of procedure at both regular and special meetings of such bodies shall be determined in accordance with the rules and regulations or policies and procedures, as established from time to time. 16. MEDICAL STAFF ORGANIZATION 1.There will be one medical staff organization for each of the 4 areas within Eastern Health 2. The purposes of the medical staff organizations are as follows: 1. As a mechanism for the Board of Trustees 1.1 to ensure the accountability of medical staff members for quality of medical care they provide;

1.2 to allow medical staff input into the mission and direction of Eastern Health

1.3 to delineate the process by which medical staff members are appointed, re-appointed, terminated or suspended.

2. As a means for medical staff members

2.1 to be supported in carrying out their responsibility for ensuring that patients receive the best possible medical care

2.2 to communicate with each other;

2.3 to determine their role and their goals within the eastern health;

2.4 to have input into and influence decision-making with

respect to medical staff bylaws, policies rules and regulations.


3. As a means for the medical staff members who have privileges with the Health Care Corporation to link with Eastern Health’s administrative staff.

4. As a way of facilitating interaction with the Faculty of Medicine of Memorial University. 3. Medical staff members have a responsibility for ensuring that patients receive the best possible medical care. 4. Medical staff members are entrusted with the responsibility for day-to-day

medical care. 5. The medical staff organization will be flexible enough to accommodate the

differing needs of the medical staff members of larger and smaller facilities. 6. Members of the medical staff will have the opportunity to influence the

directions, planning and decision-making of Eastern Health. 7. Members of the medical staff will have direct access through their representatives to Eastern Health’s Board of Trustees. 8. Mechanisms exist to ensure that there is an appropriate and effective forum for dialogue between the Board and medical staff representatives when there is an apparent conflict between the Board’s decisions and the recommendations of medical staff. 9. The medical staff organizational structure will contain mechanisms to ensure that professional and ethical standards for medical staff members are maintained. 10. The organizational structure will facilitate the medical staff’s role as patient advocate. 11. The organizational structure will ensure an appropriate linkage with the Eastern

Health’s administration. 12. Medical staff members will continue to maintain their rights to self-governance as

these rights presently exist and will be reiterated within the framework of the agreed medical staff bylaws.

13. The organizational structure will facilitate appropriate medical staff influence

over medical staff bylaws, policies, rules and regulations, and patient management policies and guidelines.

14. There will be a reasonable and fair process for credentialing and reappointment of medical staff members.

Comment [b32]: Needs change


15. There will be an appeal mechanism available to medical staff members with

respect to specific decisions related to privileges, discipline and other decisions adversely affecting their right to practice.

16. The medical staff organization will facilitate the education role carried out by the medical staff members within Eastern Health. 17. The organization structure will ensure input from medical staff in the discussions

and decision-making with respect to the role of post-graduate trainees in Eastern Health

18. The medical staff organizational structure will allow an appropriate balance between participative decision-making and efficient implementation of decisions. 19. The medical staff organization will facilitate linkages with family physicians who

do not have privileges in Eastern health. 20. The medical staff organization will facilitate linkages with physicians involved in

Health and Community Services - St. John’s Region. 21. The organizational structure will ensure adequate input from the medical staff into the provincial physician resource plan. 22. The organizational structure will facilitate linkages with other regional medical

staff organizations, with the Faculty of Medicine of Memorial University, with the Newfoundland and Labrador Medical Association, and with other professional bodies.

Comment [b33]: ?no longer relevant

Comment [b34]: ? relevant


PART III STAFF CATEGORIES

Medical, Dental and Chiropractic Staff Categories 17 The staff shall be organized into the following categories:

a) medical; b) honorary.

18 The medical staff shall be organized into the following groups:

a) active; b) community c) assistant; d) associate; e) temporary; f) visiting (including consulting) g) (Post graduate Medical Trainee) h) Clinical Clerks i) non-medical scientist

19. Active Medical Staff (1) The active medical staff shall consist of those physicians who have been appointed according to Parts IV and V as active medical staff by the Chief Executive Officer in consultation with the Vice President Medical Services and relevant Clinical Chief

(2) Except where approved by the Chief Executive Officer, no physician with an active medical staff appointment with another Regional Health Authority shall be appointed to the active medical staff.

(3) Every physician applying for an appointment to the active medical staff will first be appointed to the associate medical staff unless the Chief Executive Officer directs otherwise.

(4) Unless otherwise specified in their appointment to the medical staff, all active medical staff shall have admitting privileges to Regional Health Authority facilities, which shall be outlined in the letters of appointment. (5) Active medical staff shall:

a) ensure that care is provided to his or her patients/clients/residents in Regional Health Authority facilities, programs and services, and, as required, ensure arrangements are in place for the ongoing care of his or her

Comment [b35]: Same as previous clinical associate

Comment [b36]: ? Why not


patients/clients/residents by another member of the medical staff with the appropriate privileges when he or she is unable to attend to his or her patients/clients/residents;

b) attend patients/clients/residents and undertake such medical and surgical treatments in accordance with the privileges granted by the Chief Executive Officer as advised by the relevant clinical chief and VP medicine

c) undertake such duties respecting patient/client/resident care as may be

reasonably assigned by the Vice President Medical Services and clinical chief in circumstances where additional medical human resources are required if within the scope of the original credentialing agreement

d) Scope of practice will not be altered unilaterally but by agreement of both the physician and administration

e) act as a mentor or supervisor of a member of the associate medical staff as

mutually agreed upon by the associate medical staff, the active staff, the Vice President Medical Services and the department, program and/or service physician head;

f) attend meetings of the medical staff as required by the rules and regulations

and policies and procedures of the Regional Health Authority; and

g) abide by applicable legislation, bylaws, rules and regulations and policies and procedures. h) attend educational rounds arranged by the medical staff member’s program and/or division; i) participate in the education of Medical, postgraduate and undergraduate colleagues and other Eastern health personnel in accordance with the Affiliation agreement between Eastern Health and Memorial University of Newfoundland. j) The medical staff involved in clinical educational experiences shall have Memorial and Eastern Health joint appointments in accordance with the Affiliation agreement between Eastern Health and Memorial University of Newfoundland.

(6) Active medical staff may refer any of his or her patients/clients/residents to services and programs provided by the Regional Health Authority consistent with any rules and regulations, privileges and policies and procedures established for the referral to those programs and services. (7) At the discretion of the chair of the Medical Advisory Committee or the Vice President Medical Services, active medical staff shall serve as a member or the

Comment [b37]: This is currently not referrenced


chairperson of any committee established by the Medical Advisory Committee or the Vice President Medical Services and vote at meetings of the medical staff or at any committee on which they hold membership. 20 Community Medical Staff (1) The community medical staff shall consist of those physicians who have been appointed as community medical staff by the Chief Executive Officer in consultation with the Vice President, Medical Services. The appropriate range of privileges shall be outlined in the letter of appointment. (2) The Chief Executive Officer may appoint a physician to the community medical staff if:

the applicant has patients/clients/residents within the health region;

the applicant has demonstrated a need to access Regional Health Authority programs and services such as diagnostic imaging, laboratory, rehabilitation, health promotion, health education and home care to serve the needs of his or her patients/clients/residents residing within the health region, and

the applicant does not provide active treatment in a facility of the Regional Health Authority.

(3) The community medical staff shall consist of those physicians who have been appointed according to Parts IV and V as limited medical staff by the Chief Executive Officer in consultation with the Vice President Medical Services. The appropriate range of privileges shall be outlined in the letter of appointment. (4) community medical staff shall not have admitting privileges (5) Every physician applying for an initial appointment to the community medical staff will first be appointed to the associate medical staff unless the Chief Executive Officer directs otherwise.

(6) community medical staff shall:

a) ensure that when care is required for his or her patients/clients/residents in Regional Health Authority facilities, programs and services, and as required, ensure arrangements are in place for the ongoing care of his or her patients/clients/residents by another member of the medical staff with the appropriate privileges when he or she is unable to attend patients/clients/residents;


b) abide by applicable legislation, bylaws, rules and regulations and policies and procedures; and

c) attend meetings of the medical staff as required by the rules and regulations

and policies and procedures of the Regional Health Authority. (7) At the discretion of the chair of the Medical Advisory Committee or the Vice President Medical Services, community medical staff shall serve as a member or the chairperson of any committee established by the Medical Advisory Committee or the Vice President Medical Services and vote at meetings of the medical staff or at any committee on which they hold membership. 21. Assistant Medical Staff 1. The Chief Executive Officer, in consultation with the Vice President Medical Services and Clinical Chief, may appoint a physician to the assistant medical staff if the applicant is to provide specific services within a department, program and/or service. 2. The assistant medical staff shall consist of those physicians who have been appointed according to Parts IV and V to the assistant medical staff by the Chief Executive Officer in consultation with the Vice President Medical Services. 3. Assistant medical staff shall not have admitting privileges.

4. Every physician applying for an initial appointment to the assistant medical staff will first be appointed to the associate medical staff unless the Chief Executive Officer directs otherwise. 5. Assistant medical staff shall:

a) under the supervision of an active or associate medical staff member(s) approved by the Vice President Medical Services attend patients/clients/residents and undertake such medical and surgical treatments in accordance with the privileges granted by the Chief Executive Officer;

b) have an annual review and evaluation conducted by the supervisor appointed

under subsection (5)(a);

c) attend meetings of the medical staff as required by the rules and regulations and policies and procedures of the Regional Health Authority; and

d) abide by applicable legislation, bylaws, rules and regulations and policies and

procedures.

Comment [b38]: ? Same as previous Clinical Associate

Comment [b39]: Is this necessary. Should this category be for noncertified physicians on a limited licence


(6) At the discretion of the chair of the Medical Advisory Committee or the Vice President Medical Services, assistant medical staff shall serve as a member of any committee established by the Medical Advisory Committee or the Vice President Medical Services. 22. Associate Medical Staff (1) The associate medical staff shall consist of those physicians who apply for an initial appointment to the active, community or assistant medical staff, and who are appointed according to Parts IV and V by the Chief Executive Officer in consultation with the Vice President Medical Services and Clinical Chief to the associate medical staff. Appointment to the associate medical staff shall be considered a probationary appointment during which time the Medical Advisory Committee and the appropriate department, program and/or services head shall evaluate the member.

(2) Each associate medical staff member shall have such privileges that are appropriate to the active, community or assistant medical staff category to which they applied, unless otherwise specified in the appointment. These privileges shall be outlined in the letter of appointment by the Chief Executive Officer. (3) Subject to subsections (4) and (5), an associate medical staff member shall work for a twelve month probationary period under the mentorship or supervision of an active medical staff assigned by the Vice President Medical Services pursuant to the recommendation of the department or program chief and/or service physician head to whom the associate medical staff member has been assigned. (4) In exceptional circumstances, the Vice President Medical Services may recommend to the Chief Executive Officer waiver or reduction of the twelve-month probationary period, and the Chief Executive Officer may waive or reduce the probationary period. If the Chief Executive Officer agrees with the recommendation, the Chief Executive Officer may grant an appointment for the balance of the term to the category of medical staff to which the physician initially applied. If issues are identified early within this time period, an interim evaluation will be provided after 6 months. (5) At the end of the twelve-month probationary appointment, and subject to the provisions of these Bylaws respecting reappointment, the Medical Advisory Committee in consultation with the clinical chief shall review the performance of the associate medical staff member and recommend to the Vice President Medical Services and the Chief Executive Officer either:

a) the appointment of the physician in accordance with the category of appointment sought and privileges requested;


b) the appointment of the physician but the category of medical staff or privileges be modified from those requested by the physician;

c) the physician be subject to a further probationary period by reappointment to

the associate medical staff for a further period not exceeding twelve months; or

d) the application be refused

(6) No associate medical staff shall be appointed to the associate medical staff for more than twenty-four consecutive months. (7) The department head may request the Vice President Medical Services to assign a different mentor or supervisor at any time during the physician’s appointment to the associate medical staff member. (8) At any time, the Medical Advisory Committee may recommend to the Vice President Medical Services that the appointment of a physician to the associate medical staff be terminated. If the Medical Advisory Committee recommends termination, the Medical Advisory Committee shall prepare written reasons with respect to its recommendation and the process described in sections 34 and 36 inclusive, with any necessary modification, shall be followed. (9) At any time, the Medical Advisory Committee may recommend to the Vice President Medical Services that the privileges outlined in subsection (2) may be changed or modified. (10) Associate medical staff may have such membership and voting rights, and be subject to such duties and obligations commensurate with the active, limited or assistant medical staff category to which they are appointed.

(11) Unless otherwise specified in their appointment to the medical staff, associate medical staff shall have admitting privileges to Regional Health Authority facilities, which shall be outlined in the letters of appointment. (12) Associate medical staff shall:

a) ensure that care is provided to his or her patients/clients/residents in Regional Health Authority facilities, programs and services, and, as required, ensure arrangements are in place for the ongoing care of his or her patients/clients/residents by another member of the medical staff with the appropriate privileges when he or she is unable to attend to his or her patients/clients/residents;


b) attend patients/clients/residents and undertake such medical and surgical treatments in accordance with the privileges granted by the Chief Executive Officer;

c) undertake such duties respecting patient/client/resident care as may be

reasonably assigned by the Vice President Medical Services in circumstances where additional medical human resources are required;

d) attend meetings of the medical staff as required by the rules and regulations

and policies and procedures of the Regional Health Authority; and

e) abide by applicable legislation, bylaws, rules and regulations and policies and procedures.

f) attend educational rounds arranged by the medical staff member’s program

and/or division; g) participate in the education of Medical, postgraduate and undergraduate colleagues and other Eastern health personnel. h) The medical staff involved in clinical educational experiences shall have Memorial and Eastern Health joint appointments in accordance with the Affiliation agreement between Eastern Health and Memorial University of Newfoundland.

(13) Associate medical staff may refer any of his or her patients/clients/residents to services and programs provided by the Regional Health Authority consistent with any rules and regulations, privileges and policies and procedures established for the referral to those programs and services. (14) At the discretion of the chair of the Medical Advisory Committee or the Vice President Medical Services, associate medical staff shall serve as a member or the chairperson of any committee established by the Medical Advisory Committee or the Vice President Medical Services and vote at meetings of any committee on which they hold membership. 23. Temporary Medical Staff 1. The Chief Executive Officer in consultation with the Vice President Medical Services may appoint a physician to the temporary medical staff with such privileges as deemed appropriate, where the appointment is:

a) for a defined period of less than 6 months and for a specific purpose; or


b) to provide temporary replacement or support for a member of the active or

community medical staff.

c) Non full time Physician who provides intermittent services

2.The temporary medical staff shall consist of those physicians who have been appointed to the temporary medical staff by the chief executive officer in consultation with the Vice President Medical Services and Relevant Clinical Chief.:. 3.Notwithstanding subsection (1) and subsection 28 (1), the Vice President Medical Services

a) Appoint the physician who is not a member of the medical staff, to the

temporary medical staff and grant temporary privileges where, in the opinion of the Vice President Medical Services and Clinical Chief, there is an immediate need for the service and it is not practical for the applicant to submit all of the information required to be submitted pursuant to this Bylaw provided the Vice President Medical Services is satisfied that the applicant meets the criteria for appointment set out in section 31; and

b) grant temporary privileges to a physician who is a member of the medical

staff where, in the opinion of the Vice President Medical Services, and Clinical Chief there is an immediate need for the service.

4.The privileges which may be granted to a member of the temporary staff pursuant to subsection (1) or (2) include the privilege to attend, admit patients/clients/residents or perform surgical or other operative procedures in a hospital(s) or health centre(s).

5. Each member of the temporary medical staff shall:

a) ensure that care is provided to his or her patients/clients/residents in regional health authority facilities, programs and services, and as required, ensure arrangements are in place for the ongoing care of his or her patients/clients/residents by another member of the medical staff with the commensurate privileges when he or she is unable to attend patients/clients/residents;

b) attend patients/clients/residents and undertake such medical and surgical treatments in accordance with the privileges granted by the chief executive officer in consultation with the vice president medical services and Clinical Chief;

c)undertake such duties respecting patient/client/resident care as may be reasonably assigned by the vice president medical services in circumstances


where additional medical human resources are required; in accordance with the initial agreement

d)abide by applicable legislation, bylaws, rules and regulations and policies and procedures.

6. Temporary medical staff may refer any of their patients/clients/residents to

services and programs provided by the regional health authority consistent with any rules and regulations and policies and procedures established for the referral to those programs and services.

7. Members of the temporary medical staff shall have no voting rights and may not

hold any office or be a voting member on any committee. 24. Visiting Medical Staff 1. The Chief Executive Officer in consultation with the Vice President Medical Services and Clinical Chief may only appoint a physician to the visiting medical staff category where:

a) the applicant has an active medical staff appointment with another Regional Health Authority, health authority, hospital or other similar health care organization in Canada;

b) the applicant has demonstrated a need to access diagnostic imaging,

laboratory, rehabilitation, health promotion and health education, and home care programs and services to serve the needs of his or her patients/clients/residents residing within the health region; or

c) the applicant has established consultant clinics or performs itinerant services

in any of the regional health authority facilities. 2. The visiting medical staff shall consist of those physicians who have been appointed to the visiting medical staff by the Chief Executive Officer in consultation with the Vice President Medical Services with such privileges as deemed appropriate.

3. Visiting medical staff shall: a) ensure that care is provided to his or her patients/clients/residents in Regional Health

Authority facilities, programs and services, and as required, ensure arrangements are in place for the ongoing care of his or her patients/clients/residents by another member of the medical staff with the commensurate privileges when he or she is unable to attend patients/clients/residents;

Comment [b40]: Do we need Emergency category. Locum can be temporary or associate


b) attend patients/clients/residents and undertake treatment and operative procedures only in accordance with the privileges granted by the Chief Executive Officer in consultation with the Vice President Medical Services; and

c) abide by applicable legislation, bylaws, rules and regulations and policies and

procedures. 4. Visiting medical staff may refer any of their patients/clients/residents to services and programs provided by the Regional Health Authority consistent with any rules and regulations and policies and procedures established for the referral to those programs and services. 5. Visiting medical staff shall have no voting rights and may not hold any office or be a voting member on any committee. 25. Post Graduate Medical Trainee (1) The Post graduate Medical Trainee (PG) shall consist of those physicians who have been appointed by the Chief Executive Officer in consultation with the Vice President, Medical Services, to the PG medical staff. (2) The regional health authority may grant a physician an appointment to the PG medical staff with such privileges that are consistent with the faculty of medicine’s learning objectives for the physician. The PG trainee must be:

(a) participating in an approved training program recognized by the College of

Physicians and Surgeons of Newfoundland and Labrador; and (b) working under the direct supervision of the academic medical department

head, or a designated member of that department, who shall act as the PG trainee’s supervisor and be responsible for the PG trainee’s work

(3) PG staff shall:

(a) attend patient/client/residents and undertake such medical and surgical treatments in accordance with the privileges granted by the Chief Executive Officer in consultation with the Vice President, Medical Services as recommended by the clinical chief and discipline chair

(b) abide by applicable legislation, bylaws, rules and regulations and policies and

procedures.


26. Clinical Clerks

Students undergoing a period of training and registered with Memorial University Medical School shall be permitted to do histories and physicals, provide treatment supervised by the attending physician, and participate in educational and research activities. They shall not be required to attend Medical Staff meetings and may not vote or have admitting privileges. They may be expected to serve on certain Medical Staff committees.

27 Honorary Staff The Honorary Medical Staff shall consist of physicians, dentists or non-medical scientists, who are not active in the facilities of the Eastern Health and who are honoured by emeritus position. These shall be physicians, dentists or non-medical scientists who have retired from active service and are of outstanding reputation. The Honorary Medical Staff shall be appointed by the Chief Executive Officer on recommendation of the Regional Medical Advisory Committee after nomination by the appropriate Medical Staff Association. They shall have no assigned duties or responsibilities, they shall have no voting or admitting privileges and shall not hold office. Members of the Honorary Medical Staff are appointed for life or until membership is withdrawn by the Chief Executive Officer. There shall be no appeal from a withdrawal of membership of the Honorary Medical Staff. (1) The honorary staff category is to recognize physicians, dentists or chiropractors who have provided distinguished service to the patients/clients/residents of the health region. (2) A physician, dentist or chiropractor may be appointed to the honorary staff by the Chief Executive Officer in consultation with the Vice President Medical Services on the recommendation of the Medical Advisory Committee. Parts IV and V of these Medical Staff Bylaws do not apply to an appointment to this category. (3) Members of the honorary staff hold no privileges. (4) Members of the honorary staff: subject to subsection (5), may attend meetings of the medical, dental or chiropractic staff established by the Medical Advisory Committee or the Vice President Medical Services but shall have no voting rights; may not hold any office or be a voting member on any committee; and


are not subject to mandatory meeting attendance as required by the rules and regulations and policies and procedures of the Regional Health Authority. (5) An honorary staff member may be excluded from any meeting or portion of a meeting of a committee established by the Medical Advisory Committee or the Vice President Medical Services at the discretion of the chair, where personal information, personal health information or confidential information is being discussed. (6) The Chief Executive Officer may at any time, where considered appropriate, terminate the appointment of a physician, dentist or chiropractor from the honorary staff. 28. Non-Medical Scientist Staff The category of Non-Medical Scientist shall be reserved for scientists who are doctoral graduates in science from an approved university, who have a position of recognized professional responsibility in the Eastern Health and whose training and knowledge are of comparable standing with those of a Doctor of Medicine. This category of staff shall not be entitled to admit patients. Appointments to this category will be for an initial term of one year and then thereafter for terms of three years. 29. Responsibilities of the Medical Staff (1) Collectively, the medical staff have a responsibility and accountability to the Regional Health Authority to:

a)promote and provide a level of quality care in the Regional Health Authority facilities, programs and services that is directed towards satisfying the needs of the patient/client/resident and meets the standards set out by recognized bodies of the profession, such as licensing bodies, national clinical societies and others where the essential components of quality include competence, accessibility, acceptability, effectiveness, appropriateness, efficiency, affordability and safety;

b)report any change in professional status to the Vice President Medical Services;

c)participate in appropriate quality improvement initiatives aimed at improving access to and quality of care provided within the health region;

d)promote appropriate use of evidence-based clinical practice; and

e)assist in fulfilling the mission of the Regional Health Authority by contributing where reasonably possible to the strategic planning, community needs assessment, resource utilization management and quality management activities.


f)Practice in accordance with the RCSPC and CCFP CanMEDS Roles of competent physicians: Medical Expert (the central Role), Communicator, Collaborator, Health Advocate, Manager, Scholar and Professional.

(2) Each member of the medical, staff has a responsibility to the regional health authority to:

a)ensure that a high professional and ethical standard of care is provided to patients/clients/residents under his or her care and abide by the Code of Ethics adopted by the appropriate College in Newfoundland and Labrador;

b)practice within the limits of the privileges provided and his or her professional competency and skill;

c)meet the requirements for continuing medical, dental or chiropractic education and continuing professional learning as established by the appropriate professional regulatory authority and the Regional Health Authority;

d)participate in such education and training initiatives as appropriate that support the Regional Health Authority in providing quality health services;

e)recognize the authority of the department, program, and/or service physician head, the Medical Advisory Committee, the Vice President Medical Services and the Chief Executive Officer; and the Board

f)abide by applicable legislation, bylaws, rules and regulations and policies and procedures;

g)participate in appropriate quality improvement initiatives;

h)work, cooperate with and relate to others in a collegial and professional manner;

i)conduct him or herself in a manner consistent with the Regional Health Authority’s mission, vision and values and in accordance with the requirements of the licensing College.

j)serve where required by these Medical Staff Bylaws on various Regional Health Authority and medical staff committees; and

Comment [b41]: Does this apply when outside juristriction


k)utilize health care resources within Regional Health Authority facilities and programs in a manner consistent with Regional Health Authority policies and procedures and practices.

30. Leave of Absence (1) A member of the medical staff may apply to the Vice President, Medical Services, for a leave of absence. Under normal circumstances this would be at least 3 months prior to the leave of absence. (2) The Vice President, Medical Services, may grant a leave of absence for a period not exceeding twelve months in any of the following circumstances:

(a) the medical staff member has enrolled in an educational program approved by the Vice President, Medical Services;

(b) maternity/family leave or disability/illness;

(c) in any other circumstance which the Vice President, Medical Services,

considers appropriate; or

(d) the medical staff member has a sabbatical leave granted by the Dean of Medicine.

(3) Medical staff may apply for consecutive leaves of absence, which the Chief Executive Officer may approve if he or she considers it advisable. (4) If the member’s reappointment comes due during the period of the member’s leave of absence, the member shall apply for reappointment. (5) While on an approved leave of absence, members of the medical staff maintain their medical staff appointment to the category of medical staff to which they are appointed but:

(a) are exempt from department, program and section/services duties, including the requirement to attend department and program and section meetings; and

(b) do not have any admitting, discharge or procedural privileges.

(6) While on an approved leave of absence, members are required to maintain licensure with the College of Physicians and Surgeons of Newfoundland and Labrador and shall maintain professional liability insurance satisfactory to the regional health authority. (7) Prior to commencing the leave of absence, members must ensure arrangements are in place for the ongoing care of their patient/client/residents by another member of the


medical staff and shall notify the Vice President, Medical Services, of the member of the medical staff who will be attending to their patient/client/residents in their absenc. e. If three months notice has been given, the individual should not be deprived of leave of absence. Following approval the leave of absence cannot be reneged


PART IV APPOINTMENT and REAPPOINTMENT - GENERAL

33. Power to Appoint and Reappoint (1) Except for a temporary appointment or the granting of temporary privileges pursuant to clause 22 (3), subsequent to the successful conclusion of a probationary appointment as an associate medical staff member under section 21, the Chief Executive Officer has the power to appoint and reappoint members to the medicalstaffand to grant privileges. In considering whether to make an appointment or reappointment to the medical staff, or to grant privileges, the Chief Executive Officer shall consider the recommendations of the Vice President Medical Services, the Medical Advisory Committee, and Clinical Chief. However the Chief Executive Officer is not bound by those recommendations. If the CEO rejects the advice of the above individuals, the applying physician has a right of appeal to the board or a subcommittee of the board. Refusal to reappoint should be on the basis of documented concerns following procedures described below with again the right to appeal to the board or a subcommittee of the board. (2) Except in the circumstances mentioned in clause 22 (3), a physician must hold an appointment to the medical staff in order:

a) to hold any privilege under these Bylaws;

b) to provide any service to an individual or patient/client/resident in a facility operated or program offered by the Regional Health Authority; or

c) to refer any individual or patient/client/resident to any service or

diagnostic procedure provided by the Regional Health Authority. (3) Any member of the medical staff who resigned or otherwise caused or permitted termination from the medical staff, or whose medical staff membership has been terminated by the Chief Executive Officer and who subsequently wishes to become a member of the medical staff, is required to make application and follow the process for an initial appointment. 34. Term of Appointment or Reappointment (1) Subsequent to the successful completion of a probationary appointment as an associate medical staff member under section 21, unless otherwise specified in an appointment or terminated prior to the expiration of the term of the appointment, an appointment expires on that day that is five years from the date on which the appointment is granted;

Comment [b42]: Need to chack #


(2) Each appointment to the Medical Staff shall state the category of appointment, program assignments, and description of clinical responsibilities to each Program and Division to which the member is appointed, and shall confer on the appointee only such privileges as may hereinafter be defined. Category of appointment, program assignments, and clinical responsibilities shall not be amended without the agreement of the member and the responsible Program and Divisional/Departmental chiefs, but will be reviewed and may be revised at the time of the annual review of privileges or at the time of reappointment. (3) There will be an annual review of privileges; and (4) Notice of resignation except for a temporary appointment, shall be provided to the Vice President Medical Services at least three months in advance of the date on which the resignation takes effect.


PART V INITIAL APPOINTMENT

35. Initial Appointment Procedure (1) An application for initial appointment to the medical staff shall be processed in accordance with the provisions of the Regional Health Authorities Act, these Bylaws, the rules and regulations and the policies and procedures of the Regional Health Authority. (2) The Vice President Medical Services shall supply a copy of these Bylaws to each physician who expresses an intention to apply for appointment to the medical staff. (3) An applicant for initial appointment to the medical staff shall submit an application in writing to the Vice President Medical Services, in the standard appointment application form approved by the Vice Presidents Medical Services of the Regional Health Authorities, together with all information required to be submitted by these Bylaws. The Vice President Medical Services will also require the applicant and/or relevant program to complete an impact analysis questionnaire. (4) Each application must include:

a) an indication of the category of medical staff appointment being sought and the medical staff privileges requested;

b) an up-to-date curriculum vitae which shall include a chronological account

of the applicant’s education, training, academic qualifications, continuing education and continuing professional learning, the applicant’s professional experience and memberships and positions held in professional organizations and committees;

c) a statement detailing any completed proceedings in which there was a

failure to obtain, or subsequent reduction in classification or voluntary or involuntary resignation, or termination or suspension of any professional license or certification, fellowship, professional academic appointment or privileges at any other hospital, health authority, other health organization or health clinic;

d) information regarding any criminal proceedings or convictions involving

the applicant which may impact the applicant’s ability to practice;

e) information regarding any pending adverse decisions or out-of-court settlements in any civil suit related to medical practice in which the applicant has been involved;


f) information regarding any physical or mental impairment or health condition known to the applicant that affects, or may affect the applicant’s ability to exercise the necessary skill, ability and judgment to provide appropriate care;

g) evidence of a current license or proof of eligibility to obtain a license in

the case of a physician from the College of Physicians and Surgeons of Newfoundland and Labrador, or the College of Family Physicians of Canada, and, where applicable, the appropriate Certification or Fellowship of the Royal College of Physicians and Surgeons of Canada, or the College of Family Physicians of Canada, or current eligibility to write the appropriate specialty examination of the Royal College of Physicians and Surgeons of Canada;

h) evidence of membership in the Canadian Medical Protective Association,

or equivalent professional liability insurance satisfactory to the Regional Health Authority;

i) either directly from the applicant or from the College, results of a current

criminal records check regarding the applicant and, if applicable, a notarized copy of the Police Clearance Certificate from the applicant’s country of origin;

j) a signed consent authorizing a professional licensing body, hospital, health

authority, other health organization or health clinic in which the applicant provided services to disclose:

i) a report on any action taken by a disciplinary committee, Medical

Advisory Committee, other health organization or health clinic;

ii) a recital and description of any pending or completed disciplinary actions by such professional licensing body, hospital, health authority, other health organization or health clinic, voluntary restriction of privileges, competency investigations, performance reviews, and details with respect to prior privileges disputes with other hospitals, health authorities, other health organizations or health clinics regarding appointment, reappointment, change of privileges, restriction or cancellation of privileges, or mid-term suspension or revocation of privileges; and

iii) a letter of good standing.

k) a direction authorizing the Vice President Medical Services to contact any previous hospitals, health authorities, other health organizations or health clinics where the applicant has provided services with such direction to include the names and addresses of the following:

Comment [b43]: Cathy please comment


i. the Chief Executive Officer and the Vice President Medical

Services, or a person exercising similar responsibilities of the most recent hospital, health authority, other health organization or health clinic where the applicant held privileges or received training;

ii. the service director or head of a training program, if the applicant

was enrolled in a graduate training program within the past three years;

iii. in the case of recent graduates within three years, the dean of

medicine, dean of dentistry or program head of the last educational institution in which the applicant held an appointment or was trained; and

iv. at least three referees who can attest to the character and medical

competence of the applicant, based on first-hand knowledge of the applicant within the previous four years.

l) a signed authorization to any applicable hospital, health authority,

regulatory body, other health organization or health clinic to release and disclose personal information respecting the applicant on any matter required by this section;

m) any additional relevant information that the Vice President Medical

Services, department head, Medical Advisory Committee or the Chief Executive Officer, in the course of the review of the applicant’s application, deems necessary to make a determination regarding the application;

n) a statement by the applicant confirming that the applicant has read the

Medical Staff Bylaws;

o) an undertaking that, if appointed to the medical staff, the applicant will provide those services to the health region which have been agreed upon, will participate in the discharge of medicalstaff obligations applicable to the membership category to which the applicant is assigned and will act in accordance with applicable legislation, these Bylaws, rules and regulations, or policies and procedures and such professional and ethical standards as established from time to time; and

p) a statement signed by the applicant declaring the truth of the information

outlined in the application and supporting materials provided by the applicant, and acknowledging that the discovery of any untruth therein may result in the appointment not being granted or, where such occurs


following the appointment being granted, the immediate revocation of the privileges and appointment granted.

(5) For a proper evaluation of the applicant’s competence, character, ethics and other qualifications, the applicant has the burden of producing adequate information to address the requirements of this section. The applicant may produce any additional information in support of the application, should the applicant so desire, prior to consideration by the Chief Executive Officer and the Vice President Medical Services or the Medical Advisory Committee’s recommendation concerning the application. (6) Until the applicant has provided all the information required by these Bylaws or requested by the Vice President Medical Services, the application for appointment will be deemed incomplete and will not be processed. If the information required by this section is not provided within sixty (60) days from the date of submission of the initial application, the application is deemed withdrawn. 36. Criteria for Appointment (1) Each applicant seeking appointment to the medical staff is required to meet the following criteria: a) In the case of a physician:

i. the applicant is a member in good standing with the College of Physicians and Surgeons of Newfoundland and Labrador and is entitled to practice medicine pursuant to the Medical Act, 2005;

ii. the applicant shall have education, training and experience appropriate to the

privileges being sought; iii. an applicant seeking to practice in a specialty must be licensed by the College

of Physicians and Surgeons of Newfoundland and Labrador on the basis of the physician’s training and experience in that specialty.

iv. Agree to participate in continuing Medical education

v. Agree to appropriate participation in the University’s undergraduate and

postgraduate program and to joint appointment with the faculty of medicine where there is involvement with clinical educational experiences as per the liason agreement between Memorial University and eastern Health

vi.

i.

i.

Comment [b44]: ? short

Comment [b45]: ?Royal College Mocom


(2) The applicant will have demonstrated: a) the ability to provide patient/client/resident care at an appropriate level of quality and

efficiency; b) the ability to work and cooperate with and relate to others in a collegial and

professional manner; c) the ability to communicate and relate appropriately with patients/clients/residents and

patients/clients/residents’ families; d) the willingness to participate in the committee and other obligations appropriate to the

membership category; e) ethical character, performance and behavior; and ability to practice in accordance

with the RCSPC and CCFP CanMEDS Roles of competent physicians: Medical Expert (the central Role), Communicator, Collaborator, Health Advocate, Manager, Scholar and Professional.

f) evidence of membership in the Canadian Medical Protective Association, or

equivalent professional liability insurance satisfactory to the Regional Health Authority.

(3) If applicable, the applicant shall hold an academic appointment with the School of Medicine, Memorial University or another recognized faculty of medicine. (4) All appointments to medical staff shall be: a) consistent with the need for service, as determined by the Regional Health Authority,

from time to time; b) consistent with the provincial and regional medical staff human resource plan, if any; c) consistent with the strategic plan and mission of the Regional Health Authority; d) supported by a demonstrated sufficiency of resources within the Regional Health

Authority and the department, program and/or services to which the applicant is applying; and

e) in the best interest of the Regional Health Authority. Emergency Privileges M3:31 In the case of an emergency, the Medical Staff member attending

the patient shall be expected to do all in his or her power to save the life of

Comment [b46]: Does this paragraph need to be included? What about procedures for Temp privilidges?


the patient (within regulations), including such consultation(s) as may be quickly available, subject to the expressed wishes of the patient or substitute decision-maker. For the purpose of this section, an emergency is defined as a condition in which the life of the patient is in immediate danger and in which any delay in administering treatment would add to that danger. If a member of the Active Medical Staff is not available, then the Chief Executive Officer or designate shall be empowered and have discretion to appoint any individual Medical Staff member to attend to the emergency. The treatment provided by the Medical Staff member shall be restricted to dealing with the particular emergency. Consent will be obtained as soon as possible for any procedures that are not related to the emergency.

37. Chief Executive Officer May Refuse to Appoint In accordance with these Bylaws, the Chief Executive Officer may refuse to appoint any applicant to the medical staff. 38. Process on Initial Appointment (1) Subject to subsection (2), upon receipt of a completed application for appointment, the Vice President Medical Services, being of the initial opinion that the applicant meets the criteria set out in section 31, shall forward the completed application and all supporting material to the Credentials Committee of the Medical Advisory Committee for consideration and recommendation. (2) If the Vice President Medical Services is of the initial opinion that the application fails to meet the criteria set out in section 31, the Vice President Medical Services may refuse to process the application for appointment and shall report the refusal to the Chief Executive Officer. (3) If the Chief Executive Officer adopts the recommendation of the Vice President Medical Services to refuse to process the application for appointment, the applicant shall be advised in writing by the Chief Executive Officer of the decisions and the reasons for the decision within thirty (30) days after rendering the decision. (4) If the Chief Executive Officer is of the initial opinion that the application meets the criteria set out in section 31 and the Chief Executive Officer refuses to adopt the recommendation of the Vice President Medical Services not to process the application for appointment, the process described in sections 34 - 41 inclusive, with any necessary modification, shall be followed. 39. Review of Application for Appointment by the Credentials Committee (1) In considering an application for appointment, the Credentials Committee:


a) shall evaluate the applicant with regard to the criteria set out in section 31;

b) shall evaluate the information submitted or obtained from the applicant;

c) shall consider the advice of the appropriate head of the department or

program and/or services, if any; and

d) may interview the applicant. (2) Following consideration of the application, and the material and information referred to in subsection (1), the Credentials Committee shall make a recommendation to the Medical Advisory Committee respecting the application for initial appointment, that either:

a. the application be accepted in accordance with the category of appointment sought and privileges requested;

b. the application be accepted but the category of medical staff or the

privileges of medical staff be modified from those requested by the applicant; or

c. the application be refused.

40. Recommendation of Local Medical Advisory Committee (1) Having regard to the recommendations of the Credentials Committee and the information referred to in section 34, the Local Area Medical Advisory Committee shall make a recommendation to the Vice President Medical Services respecting the application for initial appointment, that either:

a) the application be accepted in accordance with the category of

appointment sought and privileges requested;

b) the application be accepted but the category of medical staff or the privileges of medicalstaff be modified from those requested by the applicant; or

c) the application be refused.

(2) If the Local Area Medical Advisory Committee recommends to the Vice President Medical Services that the application be granted in accordance with the category of appointment sought and privileges requested, the Vice President Medical Services shall then forward the recommendation of the Medical Advisory Committee to the Chief Executive Officer for consideration along with his or her comments.


(3) If the recommendation of the Medical Advisory Committee varies from the appointment sought or and privileges requested by the applicant, the Medical Advisory Committee shall prepare written reasons with respect to its recommendation. 41. Decision of the Chief Executive Officer (1) Upon consideration of the application and all supporting information, the recommendations of the Medical Advisory Committee, including the reasons therefore, and the representations of the applicant, if any, the Chief Executive Officer may, in consultation with the Vice President Medical Services:

a) appoint the applicant to the medicalstaff and grant privileges to the category of appointment sought and privileges requested by the applicant;

b) appoint the applicant to the medical staff and grant privileges to the

category and with the privileges considered appropriate by the Chief Executive Officer; or

c) refuse the application for appointment.

(2) If the Chief Executive Officer refuses to adopt the recommendation of the Local Area Medical Advisory Committee to accept the application for appointment to the medical staff and grant privileges to the category of appointment sought and privileges requested by the applicant, the applicant shall be advised in writing of the decisions and the reasons for the decision. The applicant has the right of appeal as outlined in section M3:23-30

(3) The Chief Executive Officer shall ensure that a copy of his or her decision and the reasons for the decision is received by the applicant, the Vice President Medical Services and the Medical Advisory Committee within thirty (30) days after rendering the decision.

42. Notification of Chief Executive Officer Decision The Chief Executive Officer shall send a copy of his or her decision to the applicant within thirty (30) days after rendering the decision, and where the decision of the Chief Executive Officer varies from the request of the applicant, the Chief Executive Officer shall provide written reasons to the applicant. Appeals M3:23 Where, following consideration of the recommendation of the

Medical Advisory Committee, submitted pursuant to these By-laws, the Board refuses appointment or reappointment of the Applicant, or reduces,


suspends, or terminates the privileges of a member of the Medical Staff ("Affected Member"), or where the Chief Executive Officer or designate on behalf of the Board refuses appointment or reappointment of the Applicant, or reduces, suspends, or terminates the privileges of a member of the Medical Staff or confirms a suspension of privileges pursuant to Article M8, Section M8:12 the Vice President, Medical Services shall notify the Applicant or Affected Member of the decision. The Vice President shall also notify in writing the Applicant or the Affected Member of his or her right to appeal, of the procedures governing the appeal and of the right to be represented at the appeal hearing. Except in cases of refusal of appointment, the Vice President shall also notify the President of the Medical Staff.

M3:24 If the Applicant so requests, he or she shall be given an

opportunity to present his or her case in appeal before a meeting of the Board, or any committee of the Board appointed by the Board for that purpose. Notification of the intent to appeal must be provided in writing to the Chief Executive Officer within thirty (30) calendar days of receipt of notification from the Vice President, Medical Services of the Board's decision in the matter. The appeal hearing shall be conducted within thirty (30) days of receipt of the notice of appeal, or within such other time as the Applicant or Affected Member and the Chief Executive Officer may agree on.

M3:25 At the appeal hearing, the Board, or if a subcommittee of the Board

is appointed pursuant to Section M3:24, then that sub-committee, may invite the Medical Advisory Committee and/or the Credentials Committee, or the designated representatives of either one or both of such committees to present the position of these committees.

M3:26 For the purposes of preparing for the appeal, the Applicant or

Affected Member may, on request, review and receive copies of the recommendations of the Medical Advisory Committee and/or the Credentials Committee, but in no event shall the Applicant or Affected Member be permitted to review or receive the reports of the referees obtained for the purpose of assessing the Applicant or Affected Member.

M3:27 Any Trustee who has moved or seconded the original Board

resolution for rejection of the application or for withdrawal, suspension or reduction in privileges, shall not vote on the appeal.

M3:28 A two-thirds majority decision of the Trustees voting on the appeal

shall be final and binding. M3:29 After completion of the appeal hearing, the Board, or if a sub-

committee of the Board is appointed pursuant to Section M3:24, then that


sub-committee, shall within thirty (30) days of such hearing render such decision in the matter, which decision shall be final and not be subject to further appeal or other review within the Health Care Corporation. The decision shall be forwarded to the Applicant or Affected Member in writing indicating the reasons for the decision and the reasoning process by which the decision was made.

M3:30 Privileges reduced, suspended, or terminated during the term of

appointment shall remain reduced, suspended or terminated until the Board reaches a final decision in the appeal.


PART VI REAPPOINTMENT

43. Application for Reappointment (1) Five years after the original appointment and every five years thereafter, each active and limited member of the medical staff shall apply for reappointment. The member shall submit to the Vice President Medical Services:

a) a completed application for reappointment on a form approved by the Vice President Medical Services and by no later than the date specified by the Vice President Medical Services; and

b) the information set out in section ???? and such other information as may

be requested by the Vice President Medical Services. (2) An application for reappointment to the medical staff shall be processed in accordance with the provisions of the Regional Health Authorities Act and regulations, these Bylaws, the rules and regulations and the policies and procedures.

(3) Where a member applies for reappointment pursuant to this section, his or her appointment to the medical staff shall be deemed to continue until the application for reappointment is determined by the Chief Executive Officer in accordance with these Bylaws. 44. Information to be Submitted The member shall submit details of:

a) a current license with the appropriate College;

b) continuing medical education activities undertaken during the preceding five year period; ? add royal college MOCUM

c) additional training or academic achievement during the preceding five

year period;

d) administrative, teaching, research, scholarly work or special responsibilities assumed or continued during the preceding five year period;

e) evidence of current Canadian Medical Protective Association or other

appropriate liability coverage satisfactory to the Regional Health Authority;

Comment [b47]: Do we want to make royal College Mocum Manditory?


f) any updated information respecting the matters outlined in section 30 in

relation to the preceding five year period; and

g) the category of reappointment, the department, program and/or services to which the reappointment is requested and the privileges requested.

45. Application Deemed Incomplete Notwithstanding subsection until the member has provided all the information required to be submitted pursuant to these Bylaws, the application for reappointment will be deemed incomplete and will not be processed. If the information required by this section is not provided within sixty (60) days from the date of submission of the application for reappointment, the application for reappointment is deemed withdrawn. 46. Criteria for Reappointment to the Medical Staff A member shall be eligible for reappointment if the member:

a) continues to meet the criteria set out in subsections ); and

b) has demonstrated an appropriate use of regional health authority resources in a manner consistent with the policies and procedures of the respective department, program or service.

47. Process on Reappointment Upon receipt of the completed application for reappointment, the Vice President Medical Services being satisfied that the member meets the criteria set out in the sub sections (37-40) shall forward the completed application and all supporting material to the Credentials Committee for consideration and recommendation. 48. Review of Application for Reappointment by Credentials Committee (1) In considering the application for reappointment, the Credentials Committee shall:

a) evaluate the member with respect to the matters referred to in subsections 31(1)-(3);

b) evaluate the information submitted or obtained from the member;

c) evaluate the information submitted or obtained from the department,

program and/or physician service head if applicable


d) assess the member’s:

(i) performance and health over the preceding years;

(ii) utilization of Regional Health Authority resources. (2) The Credentials Committee, in considering the application for reappointment:

a) may interview the member;

b) consult with the appropriate department, program and/or physician services head, if any.

(3) If a member seeking reappointment will be seventy (70) years of age or older on the date that the member’s existing appointment expires, the Credentials Committee shall, in addition to the requirements set out in sections 38 and 40, conduct with the member the following:

a) a review of the member’s performance and health during the preceding appointment period;

b) a discussion of the member’s plans for any changes in the privileges

and/or category of appointment of the member, and/or changes in the type or level of service to be provided by the member;

c) a discussion of the member’s plans to reduce his or her type or level of

service and/or relinquish his or her privileges and/or appointment; and

d) a discussion of any other matter listed in section 31.

e) Require a written statement from the appropriate department, program and/or services physician head to justify the need to continue the appointment.

(4) Following consideration of the application for reappointment and all materials and information submitted by the member, the Credentials Committee shall make a recommendation to the Medical Advisory Committee respecting the application for reappointment that either:

a) the application for reappointment be accepted to the category of appointment sought and privileges requested;

b) the application for reappointment be accepted but the category of

practitioner staff or privileges be modified from those requested by the member; or


c) the application for reappointment be refused. (5) If the Credentials Committee recommends to the Local Area Medical Advisory Committee that the application for reappointment be granted in accordance with the category of appointment sought and privileges requested, the Vice President Medical Services shall forward the recommendation of the Credentials Committee to the Local Area Medical Advisory Committee for its consideration at its next regular meeting. (6) If the recommendation of the Credentials Committee varies from the reappointment sought or privileges requested by the member, the Credentials Committee shall prepare written reasons with respect to its recommendation. 49. Notification of Local Area Medical Advisory Committee Meeting (1) Subject to subsection (2), the Vice President, Medical Services, shall ensure the member receives a written notification at least fourteen (14) days before the hearing of the Local Medical Advisory Committee at which the member’s application for reappointment and recommendation of the Credentials Committee will be considered, and which notice shall:

(a) include a copy of the recommendation together with written reasons for the recommendation of the Credentials Committee made pursuant to Appendix A of these By-laws.

50. Recommendation of Medical Advisory Committee (1) Upon consideration of the application for reappointment and the recommendations of the Credentials Committee, including the reasons for the recommendations, the Medical Advisory Committee shall make a recommendation to the Vice President Medical Services respecting the application for reappointment, that either:

a) the application for reappointment be accepted to the category of appointment sought and privileges requested;

b) the application for reappointment be accepted but the category of

medical, dental or chiropractic staff or privileges be modified from those requested by the member; or

c) the application for reappointment be refused.

(2) If the Local Area Medical Advisory Committee recommends to the Vice President Medical Services that the application for reappointment be granted in accordance with the category of appointment sought and privileges requested, the Vice President Medical Services shall forward the recommendation of the Medical Advisory Committee to the Chief Executive Officer.


(3) If the recommendation of the Medical Advisory Committee to the Vice President Medical Services varies from the reappointment sought or privileges requested by the member, the Medical Advisory Committee shall prepare written reasons with respect to its recommendation and the Vice President Medical Services shall forward the recommendation and the written reasons to the Chief Executive Officer. 52. Chief Executive Officer Decision (1) Upon consideration of the application for reappointment and all supporting information and the recommendations of the Vice President Medical Services and the Medical Advisory Committee, including the reasons if made according to subsection 43 (3), the Chief Executive Officer shall:

a) reappoint the member to the medical staff and grant the privileges to the category of appointment sought and privileges requested by the member;

b) reappoint the member to the medical staff and grant the privileges to the

category and with the privileges considered appropriate by the Chief Executive Officer; or

c) refuse the application for reappointment.

53. Notification of Chief Executive Officer Decision The Chief Executive Officer shall ensure that the member receives a copy of his or her decision within thirty (30) days after rendering the decision, and where the decision of the Chief Executive Officer varies from the request of the member, the Chief Executive Officer shall provide written reasons to the member. If the Chief Executive Officer refuses to adopt the recommendation of the Local Area Medical Advisory Committee to accept the application for appointment to the medical staff and grant privileges to the category of appointment sought and privileges requested by the applicant, the applicant shall be advised in writing of the decisions and the reasons for the decision. The applicant has the right of appeal as outlined in section M3:23-30

54. Request for Change of Category or Privileges A member of the medical staff may request a change of medical, staff category or privileges during the term of the member’s appointment by written application to the Vice President Medical Services. An impact analysis may be done if deemed appropriate by the Vice President Medical Services.


The process previously outlined in section 37-43 shall apply, with necessary modification, to a mid-term request.


PART VII DISCIPLINE

55. General All members of the medical staff including administrative members are subject to the disciplinary proceedings and provisions outlined in this Part describing investigative processes and disciplinary proceedings for just cause. The basic premise of the Eastern Regional Health Authority toward discipline is that of procedural due process under the tenets of administrative law with avenues for alternate dispute mechanisms and remediation being attempted before more severe disciplinary actions are undertaken. It is a principle of the Eastern Regional Health Authority that disputes and disciplinary concerns within a department or program be resolved internally through informal discussions and communication. When such mechanisms fail, or when clinical competence and patient safety issues are identified, the formal processes outlined below are to be followed. . Disciplinary action or penalties may include, but are not limited to in order of increasing severity:

a) a verbal or written reprimand;

b) the requirement to adhere to conditions;

c) the amendment suspension or revocation of privileges; and

d) the suspension or termination of appointment from the medical staff. 56. Conduct Subject to Discipline (1) Conduct subject to discipline includes, but is not limited to acts, omissions, statements, demeanor or professional conduct during the course of members activities within or actions outside of the Regional Health Authority, which exposes, or is reasonably likely to expose patients/clients/residents/staff to harm or injury, or is reasonably likely to be detrimental to patient/client/resident/staff safety or to the delivery of quality patient/client/resident care within the Regional Health Authority, or is reasonably likely to be detrimental to the Regional Health Authority operations, or is reasonably likely to constitute abuse, physical, verbal or psychological of patients/clients/residents/staff, or if the said conduct results in the imposition of sanctions by a College, or is contrary to the bylaws, rules and regulations, and policies and procedures of the Regional Health Authority, or any applicable and relevant laws or legislated requirements.


(2) For the clarity of disciplinary procedures and investigations in this part, those concerns related to clinical competence and patient safety would proceed through the Clinical Discipline Stream and the outlined Peer Review Process, and all other disciplinary concerns will follow the Professional Conduct Discipline Stream and the outlined Investigative Process. (3a) With respect to Clinical Competence concerns, the Clinical Peer Review Policies and Procedures will be followed. Without limiting the generality of the foregoing, the following are examples of “Sentinel Events” which would trigger an investigation of the clinical conduct of a medical staff member to be subject to discipline:

• A patient safety concern following an exceptionally serious event or series of events

• Quality of care concerns flagged during internal quality assurance exercises where problems have been identified, and remedial action declined or not resulting in improvement of the identified deficiency(ies)

• Those actions or omissions described in the Medical Act, 2005 applicable to clinical competence resulting in revocation or limitation of licensure

• • incompetence or demonstrated deficiencies in clinical practice;

3b) With respect to Professional Conduct concerns, the Professional Peer Review Policies and Procedures will be followed. Without limiting the generality of the foregoing, the following are examples of Professional conduct subject to discipline:

Those actions or omissions described in

the Medical Act, 2005 as constituting "conduct deserving of sanction;”

a)

b)disruptive workplace behavior meaning behavior, either verbal or non-verbal, which by its nature may:

(i) demonstrate disrespect to others in the workplace;

(ii) affect or have the potential to affect adversely the care provided to patients/clients/residents; or

(iii) reflect a misuse of a power imbalance between the parties.

c)

Comment [AC&T48]: Original quote, other things can be added to list.

Comment [b49]: breach of any Regional Health Authority policies regarding conduct of employees MD’s ar e not employees unless salaried


d)breach of these Bylaws, any rules and regulations, applicable and relevant legislation, or policies and procedures of the Regional Health Authority; e) f)failure to assist or cooperate with the appointment, reappointment or discipline process established in these Bylaws where this was mutually agreed to in a medical staff members appointment;; g)failure to comply with the conditions of any disciplinary action, penalty, or remedial steps imposed on a member or the terms of an alternative dispute resolution or outcome of peer review assessment;; and h)failure to undertake mutually agreed upon assigned administrative, clinical teaching and research commitments. 57. Disciplinary Procedure for Professional Conduct Stream (1) A clinical chief, clinical department, program and/or physician services head, the Vice President Medical Services or the Chief Executive Officer may receive complaints made against a member of the medical staff with respect to professional conduct concerns. respecting any matter set out in section 48. Complaints should be in writing outlining in detail the concerns regarding the medical staff member.

(2) The department, program and/or physician services head, the Vice President Medical Services or the Chief Executive Officer shall advise each other if any one of them receives a substantial complaint made against a medical staff member respecting any matter set out in section 48.

• .

• (2) The medical staff member shall be advised of the nature of the complaint and given a copy of the detailed letter of complaint within two business days of receipt of the complaint by the Vice President Medical Services and/or the clinical department, program and/or physician services head. The medical staff member will be given a reasonable opportunity to present relevant information on his or her own behalf with counsel if so desired within 10 business days of receipt of the complaint.

Comment [b50]: failure to follow a lawful order or direction issued by the Chief Executive Officer, Vice President Medical Services or anyone having authority under these Medical Staff Bylaws, rules or regulations or policies and procedures of the Regional Health Authority; This is too broad and unilateral

Comment [AC&T51]: Added where mutually agreed to, otherwise unilateral


(5) The Vice President Medical Services and the department, program and/or physician services head shall review any report with the medical staff member and may following discussions with the medical staff member:

a)determine that the complaint is unsubstantiated and/or that the matter does not warrant further steps and advise the medical staff member accordingly;

(b) If the complaint is substantiated:

1)give a verbal or written reprimand to the medical, dental or chiropractic staff member and place a report to that effect or copy of the report on the medical, staff member’s file;

2) utilize an alternative dispute resolution process(es) under subsection (6) to deal with the matter; or

3) refer the complaint to the Investigations Committee under section 51.

(e) If the medical staff member disagrees with the outcome of this first level of review, he/she may appeal to the CEO, the board or a subcommittee of the board.

(6) The alternative dispute resolution process adopted pursuant to subsection 3b) shall

be conducted on a without prejudice basis to the parties,

a)the Chief Executive Officer, VP Medical Services or Chair MAC shall appoint a chair for the alternative dispute resolution process who is acceptable to the parties, The Chair of the ADR process shall appoint a mutually acceptable ADR specialist in mediation and negotiation from a standard list of experts in medical / healthcare ADR. This person will oversee the process adhering to the aforementioned precepts of procedural due processafforded in administrative law, tribunals and committee.s.

b)any communications or discussions during the process are privileged and shall not

be disclosed in subsequent disciplinary proceeding, if any; c)if the matter is resolved through the process,

(i) the matter and the proposed resolution shall be reported to the Chief Executive Officer, and Chair MAC for consideration in consultation with the Vice President Medical Services;

if the proposed resolution is approved by the Chief Executive Officer

(Chair MAC???) , the resolution of the matter shall be disclosed in any subsequent disciplinary proceeding

Comment [b52]: Who pays?


if the proposed resolution is not approved by the Vice President Medical Services or Chief Executive Officer, the complaint will be referred to the Investigations Committee under section 58;

(d) If the matter is not resolved through the alternative dispute resolution process,

the Vice President Medical Services shall refer the complaint to the Investigations Committee under section 51;

(e) The Vice President Medical Services shall advise the College where the alternate dispute resolution process results in:

(i) privileges being suspended or revoked;

(ii) medical, staff category being changed; or

(iii) medical, staff appointment being suspended or terminated. 58. Composition of the Investigations Committee (1) For the purposes of these Bylaws, the Investigations Committee shall be composed of three or more members . with at least one member being a physician from the MAC, one external peer review member mutually acceptable to the parties, and a third member from the medical staff at large acceptable to all parties.

(2) Any member of the Investigations Committee who resigns prior to the conclusion of a disciplinary hearing before it, but who was involved in the discipline matter prior to the resignation, may continue to sit as a member of the Investigations Committee, but only for the purposes of completing the matter before it. 59. Referral to Investigations Committee (1) In the event the Vice President Medical Services refers a complaint to the Investigations Committee pursuant to subsections 49 (5)(d) or (6)(c), the Vice President Medical Services shall notify the member in writing of the particulars of the allegations and refer the matter together with a copy of the particulars of the allegations to the chair of the Investigations Committee. (2) The Vice President Medical Services or Chief Executive Officer may simultaneously refer the matter to the College. The referral may be made for the purposes of parallel disciplinary action.t. 60. Investigations Committee Hearing

Comment [b53]: Request for change of category of privileges section?

Comment [b54]: This committee is not mutually acceptable like ADR process was.

Comment [b55]: Peer assessment section


(1) The chair of the Investigations Committee shall inform the medical, staff member in writing at least twenty-one (21) days before the hearing of the Investigations Committee at which the complaint against the medical, staff member will be considered, setting out:

a) The particulars of the complaint allegations;

b) the date, time and place of the hearing of the Investigations Committee;

c) the right of the medical, staff member to make representations to the Investigations Committee, and to appear personally before the Investigations Committee;

d) the right of the medical, staff member to examine prior to the hearing any

written information or reports that were provided or obtained in relation to the complaint;

e) the fact that if the medical, staff member does not wish to appear in

person at the hearing of the Investigations Committee, the Investigations Committee may proceed with consideration of the complaint in his or her absence, may adjourn or may extend the time for the hearing.

f) The member may bring his/her own counsel, member of medical staff etc

to the meeting.

g) The right of the medical staff member to be notified of any witnesses to testify in relation to the complaint and the opportunity to respond to and question the witnesses.

(2) The medical, staff member shall be given full opportunity to answer each allegation. (3) Members of the Investigations Committee shall not have taken part in any consideration of the subject matter of the hearing before the hearing takes place and shall not directly or indirectly communicate on the subject matter of the hearing with anyone involved in the hearing before the hearing takes place.

(4) No member of the Investigations Committee shall participate in a decision of the Investigations Committee resulting from a hearing unless he or she was present throughout the hearing. 61. Investigations Committee Recommendation (1) Upon consideration of the complaints, information presented and the discussions with the parties the Investigations Committee shall, within thirty (30) days after conclusion of the hearing, prepare a report of its findings and recommendations and the report shall be forwarded to the Chief Executive Officer, the Vice President Medical Services,Chair MAC and president of the medical staff for consideration.


(2) The Investigations Committee’s recommendations on disciplinary action may include but are not limited to:

a)no action be taken against the medical staff member;

a) require the medical, dental or chiropractic staff member to undertake a period of clinical supervision with retrospective review of cases but without special requirements of prior or concurrent consultation or direct supervision;

b) require the medical, dental or chiropractic staff member to undertake a period of clinical supervision with concurrent consultation or direct supervision;

c) in the case of conduct which is unprofessional, unethical, unbecoming, improper or disruptive to the safe and respectful workplace environment of the Regional Health Authority or is deemed to be disruptive workplace behaviour, require the medical, staff member to undertake such remedial measures to address the matter that gave rise to the complaint;

d) the medical, staff member’s privileges be amended, suspended or revoked;

e) the medical, staff member’s medical, staff category be changed; and

f) the suspension or termination of the medical, staff member’s medical,

dental or chiropractic staff appointment;

g) or other action such as anger management training or substance abuse program.

62. Chief Executive Officer Decision 4 (1) Upon consideration of the report and recommendations of the Investigations Committee, the Chief Executive Officer may, in consultation with the Vice President Medical Services:

a. accept the report and recommendations of the Investigations Committee;

b. accept the report and recommendations of the Investigations Committee with modifications;

c. reject the report and recommendations of the Investigations Committee.

Comment [b56]: In clinical compentence section

Comment [b57]: In competence section

Comment [b58]: would a CEO supersede a clinical professional recommendation??? When the docs did not enforce


63. Notification of Chief Executive Officer Decision 64. The Chief Executive Officer shall ensure that a copy of his or her decision and

written reasons is received by the medical, dental or chiropractic staff member within five (5) days after rendering the decision.

65. Mechanisms of Appeal If the medical staff member disagrees with the outcome of the investigation’s committee report and recommendations, he/she may appeal the decision or irregularities in process to the board or subcommittee of the board within 30 calendar days of receipt of the decision. The board will evaluate the report and submissions from the Investigations Committee and the medical staff member as to the report and recommendations. The medical staff member may request to meet the board to present his/her case as may the Chair of the Investigation’s Committee. The board will render a decision within 30 days of the appeal. They may recommend:

a. accept the report and recommendations of the Investigations Committee;

b. accept the report and recommendations of the Investigations Committee with modifications;

c. reject the report and recommendations of the Investigations Committee.

66. Appeal outside the RHA:

If the Medical Staff member disagrees with the decision of the Board of Directors of the Health Authority, he/she may follow the procedure of appeal through the administrative processes available through the Superior Court NL.

67. Disciplinary Procedure for Clinical Competence Stream (1) A Clinical Chief, Clinical department, program and/or physician services head, and/or the Vice President Medical Services may receive complaints made against a member of the medical staff with respect to clinical concerns. Complaints should be in writing outlining in detail the concerns regarding the medical staff member.


(2) Clinical competence and patient safety concerns may be identified at the time of annual or regular scheduled reviews of a medical staff member with the Clinical Chief or Clinical Program, Department or Services Head.

• (3) The medical staff member shall be advised of the nature of the complaint, or concerns raised at scheduled departmental review; and given a copy of the detailed letter of complaint or review concerns within two business days of receipt of the complaint or review by the Vice President Medical Services and/or the clinical department, program and/or services head.

• (4) The medical staff member will be given a reasonable opportunity to present relevant information on his or her own behalf with counsel if so desired within 10 business days of receipt of the complaint.

• (5) following discussions with the medical staff member, the VP Medical Services and or Clinical chief, department and or/services head shall:

(a) Determine that the complaint or clinical concerns are unsubstantiated and/or that the matter does not warrant further steps such as formal investigation or peer review and advise the medical staff member accordingly;

(b) If the complaint is substantiated the VP Medical Services, Clinical Chief, Clinical Program and/or physician Services Head may

(i) require the medical staff member to undertake a period of clinical supervision with concurrent consultation or direct supervision;

(ii) require the medical staff member to undertake a period of clinical supervision with retrospective review of cases but without special requirements of prior or concurrent consultation or direct supervision

(iii) refer the complaint to the Peer Review Committee under section .? (iv) If the medical staff member disagrees with the outcome of this first level of

review, he/she may appeal to the CEO, the board or a subcommittee of the board

• (4) The Clinical department, program and/or physician services head, the Vice President Medical Services, and Chair of MAC?shall advise each other if any one of them has received a substantiated complaint made against a medical staff member respecting any clinical matter of competence set out in section 48 within five working days of meeting with the medical staff member. The president of the Medical Staff (or medical staff complaints representative) shall also be informed of

Comment [AC&T59]: Appeal should be in place but to whom?


the nature of the complaint and the medical staff member’s identity, the latter, only at his/her request.

(5) The alternative dispute resolution process adopted pursuant to subsection 3.b.ii shall be offered and conducted on a without prejudice basis to the parties,

(a) the VP Medical Services or Chair MAC shall appoint a chair for the alternative

dispute resolution process who is acceptable to the parties, (b) any communications or discussions during the process are privileged and shall

not be disclosed in subsequent disciplinary proceeding, if any; (c) if the matter is resolved through the process,

(i) the matter and the proposed resolution shall be reported to the Chair MAC, CEO for consideration in consultation with the Vice President Medical Services;

if the proposed resolution is approved by the CEO, (Chair MAC) ,

the resolution of the matter shall be disclosed in any subsequent disciplinary proceeding

if the proposed resolution is not approved by the CEO, Chair MAC?,

the complaint will be referred to the Investigations Committee under section 51;

(d) If the matter is not resolved through the alternative dispute resolution process, the Vice President Medical Services shall refer the complaint to the Peer Review Committee under section ???;

(e) The Vice President Medical Services shall advise the College where the alternate dispute resolution process results in:

(i) privileges being suspended or revoked;

(ii) medical staff category being changed; or

(iii) medical staff appointment being suspended or terminated. 68. Composition of the Peer Review Committee (1) For the purposes of these Bylaws, the Peer Review Committee shall be composed of three or more members, mutually acceptable to all parties. One member appointed by the Clinical Chief , Academic Discipline Chair or the VP responsible for the program.

Comment [b60]: Is this necessary? Would not the clinical chief be more relevant?

Comment [AC&T61]: Changed numbering from 5c


The second member, a representative of the Medical Staff knowledgeable in the clinical field of concern. and a third member from the medical staff at large, mutually acceptable to all parties. Where the Clinical Chief and or Discipline chair is under review, the alternative individual will serve on the Peer Review Team. If the Clinical Chief is the Discipline chair and under review, the VP Medical Services will serve on the Peer Review Committee.

(2) Any member of the Peer Review Committee who resigns prior to the conclusion of a disciplinary hearing before it, but who was involved in the discipline matter prior to the resignation, may continue to sit as a member of the Peer Review Committee, but only for the purposes of completing the matter before it. 69. Referral to Peer Review Committee (1) In the event the Vice President Medical Services refers a complaint to the Peer Review Team pursuant to subsections???????, the Vice President Medical Services shall notify the member in writing of the particulars of the allegations and refer the matter together with a copy of the particulars of the allegations to the chair of the Peer Review Team. (2) The Vice President Medical Services on behalf of the CEO may simultaneously refer the matter to the College. The referral may be made for the purposes of parallel disciplinary action or competency assessment. 70. Peer Review Committee Hearing (1) The chair of the Peer Review Committee shall inform the medical staff member in writing at least twenty-one (21) days before the hearing of the Peer Review Committee at which the complaint against the medical staff member will be considered, setting out:

h) The particulars of the complaint allegations;

i) the date, time and place of the hearing of the Peer Review Committee;

j) the right of the medical staff member to make representations to the Peer Review Committee, and to appear personally before the Peer Review Committee;

k) the right of the medical staff member to examine prior to the hearing any

written information or reports that were provided or obtained in relation to the complaint;

l) the fact that if the medical staff member does not wish to appear in person

at the hearing of the Peer Review Committee, the Peer Review Committee


may proceed with consideration of the complaint in his or her absence, may adjourn or may extend the time for the hearing.

m) The member may bring his/her own counsel, representative such as

colleague member of medical staff ???to the meeting.

n) The right of the medical staff member to be notified of any witnesses to testify in relation to the complaint and the opportunity to respond to and question the witnesses.

(2) The medical staff member shall be given full opportunity to answer each allegation. (3) Members of the Peer Review Committee shall not have taken part in any consideration of the subject matter of the hearing before the hearing takes place and shall not directly or indirectly communicate on the subject matter of the hearing with anyone involved in the hearing before the hearing takes place.

(4) No member of the Peer Review Committee shall participate in a decision of the Peer Review Committee resulting from a hearing unless he or she was present throughout the hearing. 71. Peer Review Committee Recommendation (1) Upon consideration of the complaints, information presented and the discussions with the parties the Peer Review Committee shall, within thirty (15) days after conclusion of the hearing, prepare a report of its findings and recommendations and the report shall be forwarded to the CEO, the Vice President Medical Services and Chair of MAC for consideration.

(2) The Peer Review Committee’s recommendations on disciplinary action may include but are not limited to:

a. no action be taken against the medical staff member;

b. require the medical staff member to undertake a period of clinical supervision with concurrent consultation or direct supervision;

c. require the medical staff member to undertake a period of clinical supervision with retrospective review of cases but without special requirements of prior or concurrent consultation or direct supervision.

d. refer the complaint for Peer Review Evaluation under section 2h

e. the medical staff member’s privileges be amended, suspended or revoked;

f. the medical staff member’s medical staff category be changed; and


h) the suspension or termination of the medical staff member’s medical staff appointment;

i) A peer review assessment will be undertaken according to the policies set out under the peer review policies RHA (appendix). Upon receipt of the peer review report, the Peer Review committee will make recommendations under section 71.2.

72. Chief Executive Officer Decision 4 (1) Upon consideration of the report and recommendations of the Peer Review Committee, the Chief Executive Officer may, in consultation with the Vice President Medical Services:

a. accept the report and recommendations of the Peer Review Committee;

b. accept the report and recommendations of the Peer review Committee with modifications;

c. reject the report and recommendations of the Peer review Committee.

If the CEO rejects the recommendations, he / she must state reasons to ther committee to pass along to the medical staff member under investigation.. 73.Appeal to Board of Decision of Peer Review Committee and CEO The Chief Executive Officer shall ensure that a copy of the investigation’s committee findings, recommendations and his / her decision and written reasons are received by the medical staff member within five (5) days after rendering the decision.

j) Mechanisms of Appeal If the medical staff member disagrees with the outcome of the Peer Review committee’s or CEO’s report and recommendations, he/she may appeal the decision or irregularities in process to the board or subcommittee of the board within 30 calendar days of receipt of the decision. The board will evaluate the report and submissions from the Peer Review Committee and the medical staff member as to the report and recommendations. The medical staff member may request to meet the board to present his/her case as may the Chair of the Peer Review Committee. The board will render a decision within 30 days of the appeal. He may recommend:

a. accept the report and recommendations of the Peer Review Committee and/or CEO’s;

Comment [AC&T62]: Peer review template from March 2004 HCCSJ can be used for the peer reviewer etc.

Comment [b63]: would a CEO supersede a clinical professional recommendation??? When the docs did not enforce

Comment [AC&T64]: When would a CEO supersede a clinical professional recommendation???


b. accept the report and recommendations of the Peer Review Committee and/or CEO’s with modifications;

c. reject the report and recommendations of the Peer Review Committee and/or CEO’s.

75. Appeal outside the RHA:

If the Medical Staff member disagrees with the decision of the Board of Directors of the Health Authority, he/she may follow the procedure of appeal through the administrative processes available through the Superior Court NL.

Comment [AC&T65]: When would this happen?


PART VIII IMMEDIATE SUSPENSION

Immediate Suspension of Appointment or Privileges 56 (1) Notwithstanding anything in these Bylaws, the Vice President Medical Services or the Chief Executive Officer may immediately suspend the appointment of a medical staff member or the medical staff member’s privileges in circumstances where in the opinion of the Vice President Medical Services or Chief Executive Officer: the conduct, performance or competence of a medical staff member exposes, or is reasonably likely to expose patients/clients/residents or others to harm or injury, or is reasonably likely to be detrimental to the delivery of quality patient/client/resident care provided by the Regional Health Authority; and immediate action must be taken to protect the patients/clients/residents/staff or others, or to avoid detriment to the delivery of safe patient/client/resident care. (2) The Vice President Medical Services or the Chief Executive Officer shall immediately advise the medical staff member of the suspension. (3) Within forty-eight (48) hours of the immediate suspension, the Vice President Medical Services or Chief Executive Officer who suspended the medical staff member shall provide the medical staff member with written reasons for the suspension, which shall constitute a referral under clause 49 (5)(d). (4) The Vice President Medical Services or Chief Executive Officer, with the assistance of the medical staff member, shall immediately appoint another member of the active medical staff to assume responsibility for the care of all of the patients/clients/residents of the suspended medical staff member within the facilities of the Regional Health Authority, as required. The medical staff member appointed will have agreed to the assumption of patient care, and where manpower is not available for safe patient oversight, the VP medical services will fill the vacancy with a locum within 2 weeks of the suspension. (5) The Vice President Medical Services or the Chief Executive Officer shall also notify the College and the Chair of MAC of the suspension. Chief Executive Officer Decision 57(1) Upon investigation and consideration of the circumstances giving rise to the immediate suspension of appointment or privileges, and the representations of the


member, if any, the Chief Executive Officer may, within five (5) days, without limitation:

overturn the immediate suspension of appointment or privileges;

confirm the immediate suspension of appointment or privileges for a specified period of time; or

confirm the immediate suspension of appointment or privileges and refer the

matter to the Investigations Committee. Notification of Chief Executive Officer Decision 58(1) The Chief Executive Officer shall ensure that a copy of his or her decision and written reasons is received by the medical, dental or chiropractic staff member within five (5) days after rendering the decision. The decision shall include a notice advising the member that if the member is aggrieved

by the decision of the Chief Executive Officer, the member may appeal that decision through the process set out in Part IX.


PART X APPEALS

Appeal of Chief Executive Officer Decision 59 An appeal of a decision by the Chief Executive Officer may be made by a duly qualified physician; who has filed an application and who has not been notified by the Chief Executive Officer within the time limits provided in these Bylaws; or whose application has been refused in whole or in part; or whose privileges have been cancelled, suspended, restricted, or not renewed. 60 A duly qualified physician who wishes to appeal a decision by the Chief Executive Officer is entitled, on application in writing to the Chief Executive Officer, to appear in person and make representations and the Chief Executive Officer shall hear, consider or reconsider the matter. Notification of Chief Executive Officer Decision 61 The Chief Executive Officerr shall ensure that a copy of his or her decision and written reasons is received by the medical staff member, the Vice President Medical Services and the Medical Advisory Committee within five (5) days after rendering the decision. Right of Appeal 62 Nothing in these Bylaws limits or restricts any right of appeal or other legal recourse, which is available to an individual pursuant to the Regional Health Authorities Act and Regulations, or any other applicable law.


PART XI GENERAL PROCEDURES

Requirement to Provide Information 63 (1) The Chief Executive Officer, Vice President Medical Services or a department, program and/or services head may, at any time, request information and explanations from a member of the medical staff relating to any matter contained in these Bylaws. (2) Upon receipt of a written request pursuant to subsection (1), a member of the medical staff shall: respond to the request in writing by providing the information or explanation requested, to the best of the member’s ability to do so; provide originals or certified copies of documents requested, if originals are requested, or legible copies of documents if copies are requested; and provide a printed or electronic record if the requested information or documents are stored in an electronic computer storage form or similar form. (3) A medical staff member shall provide the requested information within fourteen (14) days of receipt of the request, or such additional time as the Chief Executive Officer, Vice President Medical Services or a department head for the response may grant. Conflict of Interest 64 (1) Any medical staff member who has a conflict of interest or possible conflict of interest shall disclose such conflict to the Vice President Medical Services at the earliest opportunity where that medical, dental or chiropractic staff member is involved: in making recommendations to Chief Executive Officer on any matter; or

in considering or recommending any applicant for appointment, reappointment, privileges or discipline. (2) The Vice President Medical Services, in keeping with applicable law, rules and regulations and policies and procedures of the Regional Health Authority regarding conflict of interest and bias, shall determine whether the medical staff member has a conflict of interest and outline what, if any, involvement in the discussion and voting the medical staff member may have concerning the issue with respect to which the conflict exists.


Bias 65 In all proceedings before the Chief Executive Officer or the Vice President Medical Services pursuant to these Bylaws, he or she shall not have taken part in any discussion or review of the subject matter of the hearing before the hearing takes place and shall not directly or indirectly communicate on the subject matter of the hearing with anyone involved in the hearing before the hearing takes place. Alternate Dispute Resolution Process 66 With the consent of the parties, and without restricting the final authority and discretion of the Chief Executive Officer on matters falling under Parts V, VI, VII and VIII of these Bylaws, the parties to proceedings under Parts V, VI, VII and VIII may agree to an alternative dispute resolution process where the circumstances warrant.

PART X

OFFICERS AND COMMITTEES 52. Elected Officers: Executive Committee Each of St. John’s, Avalon, Burin Peninsula and Clarenville / Bonavista shall have Local Area Medical Staff Associations. The elected officers of the Medical Staff Association shall be the President, Vice-President, Secretary-Treasurer and others as decided by the Medical Staff Association who shall constitute the executive of the Medical Staff Associations. They shall be elected by the Active, Associate, Limited and Assistant Medical Staff at the annual meeting. The President and Vice President of the Medical Staff Association shall sit on the appropriate Local Area Medical Advisory Committee. The elected officers shall be responsible for the collection, use and disbursement of Medical Staff funds as directed by the Medical Staff. The President The President shall be responsible for calling and presiding at the Medical Staff Association meetings and shall be a member, ex-officio, of all Standing Medical Staff committees. He or she shall be a member of and represent the Medical Staff at meetings of the Credentials Committee. In the case of disciplinary action taken with respect to an individual Medical Staff member, it shall be the duty of the President to apprise the member of all proper avenues of appeal. The Vice-President


The Vice-President, in the absence of the President, shall be empowered to assume all of the President's duties and have all of his or her authority. He or she shall be expected to perform such other duties as may be assigned by the President. The Secretary-Treasurer The Secretary-Treasurer shall be responsible for keeping accurate and complete minutes of all Medical Staff meetings, calling meetings on order of the President, attending to all correspondence and performing such other duties as ordinarily pertain to that office. He or she shall be accountable for all Medical Staff funds and will be responsible for the preparation and presentation to Medical Staff of a yearly audit of such funds. Appointed Officers The appointed officers of the Medical Staff shall be the Chairperson of the Regoinal Medical Advisory Committee, Chairperson of the Local Area Medical Advisory Committees, Vice-Chairperson of the Regional Medical Advisory Committee, Clinical Chiefs of the Programs, and Divisional/Departmental Chiefs. 53. Meetings Annual Meeting The annual meeting of each Local Area Medical Staff shall be held in June and the President shall present his or her annual report including the financial statement of the Medical Staff Association. The election of officers shall take place. Voting, if necessary, shall be by ballot by the Active, Associate, Limited and Assistant Medical Staff. Regular Meetings Regular meetings of the Medical Staff shall be held at least quarterly. These quarterly meetings shall not release Medical Staff members from their obligations to attend the regular meetings of the Program. In addition to matters of organization, the Agenda of these meetings must include a report of the Local Area Medical Advisory Committee and Regional Medical Advisory Committee. Special Meetings Special meetings of the Medical Staff may be called at any time by the President, and shall be called at the written request of the Local Area Medical Advisory Committee, the Executive Committee or any five members of the Active Medical Staff. At any special meeting, no business shall be transacted except that stated in the notice calling the meeting. Notice of any meeting shall be mailed at least eight days before the time set for


the meeting with the exception that special meetings called in relation to the election of officers shall require a minimum of ten days' notice. The requirements for attendance, quorum, power to excuse absence, the agenda-setting process and other matters relating to these Local Area Medical Staff Associations are set out in Appendix D.


PART XII AMENDMENTS

Amendments 67 (1) Amendments to these bylaws may be proposed by: the Medical Advisory Committee; the Vice President Medical Services; or the Chief Executive Officer. The executive of the medical staff association (2) An amendment proposed pursuant to subsection (1) (a) or (b) shall be presented to the Chief Executive Officer for consideration. (3) The Chief Executive Officer shall approve, amend or reject any amendment(s) presented for his or her consideration in accordance with the Regional Health Authorities Act and Regulations and the directions given by the Minister as outlined in the Introduction and section 4 of these Bylaws.


PART XIII ADOPTION AND APPROVAL

Adoption of Bylaw 68 These Medical Staff Bylaws of the _________________________ Regional Health Authority are adopted and shall replace any Medical Staff Bylaw previously enacted by the Regional Health Authority or its predecessor. Transitional Provisions Required 71 (1) The replacement of a Medical Staff Bylaw does not: affect the previous operation of the replaced Bylaw or anything done or permitted pursuant to it; affect a right or obligation acquired pursuant to the replaced Bylaw; prevent or affect any investigation or disciplinary proceedings, and any investigation or proceeding may be continued and enforced and any penalty or sanction imposed as if the Bylaw had not been replaced. Approval 72 ADOPTED by the ___________ Regional Health Authority the _____ day of _________, 20 . ______________________________________ Chief Executive Officer

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