I. GENERAL PROVISIONS



Nemours/Alfred I. duPont Hospital for ChildrenMedical Staff BylawsAdopted by Board of Managers: March 17, 2015 TOC \o "1-3" \h \z \u I.GENERAL PROVISIONS PAGEREF _Toc275162592 \h 5A.Purpose PAGEREF _Toc275162593 \h 5B.Definitions PAGEREF _Toc275162594 \h 5C.Confidentiality and Peer Review Protections PAGEREF _Toc275162595 \h 7D.Conflict of Interest Principles PAGEREF _Toc275162596 \h 8E.Indemnification When Performing Credentialing and Peer Review Functions PAGEREF _Toc275162597 \h 8F.Delegation of Functions PAGEREF _Toc275162598 \h ERNANCE AND STRUCTURE PAGEREF _Toc275162599 \h 9A.Categories of the Medical Staff PAGEREF _Toc275162600 \h 91.Active Employed Staff PAGEREF _Toc275162601 \h 102.Associate Employed Staff PAGEREF _Toc275162602 \h 113.Affiliate Employed Staff PAGEREF _Toc275162603 \h 124.Regional Medical Staff PAGEREF _Toc275162604 \h 13 5. Loss of Status …………………………………………………………………......126.Active Community Staff PAGEREF _Toc275162605 \h 147.Courtesy Community Staff PAGEREF _Toc275162606 \h 158.Consulting Community Staff PAGEREF _Toc275162607 \h 1610.Associate Community Staff PAGEREF _Toc275162608 \h 17B.Officers of the Medical Staff PAGEREF _Toc275162610 \h 181.Qualifications PAGEREF _Toc275162611 \h 182.Term of Office PAGEREF _Toc275162612 \h 193.Election of Officers PAGEREF _Toc275162613 \h 194.Vacancies in Office: PAGEREF _Toc275162614 \h 195.Duties of Officers PAGEREF _Toc275162615 \h 196.Removal of Elected Officers PAGEREF _Toc275162616 \h 20C.Departments PAGEREF _Toc275162617 \h anization PAGEREF _Toc275162618 \h 212.Department Chairpersons PAGEREF _Toc275162619 \h 213.Divisions and Division Chiefs PAGEREF _Toc275162620 \h 24D.Medical Staff Committees and Functions PAGEREF _Toc275162621 \h mittees PAGEREF _Toc275162622 \h 262.Standing Committees PAGEREF _Toc275162623 \h 263.Medical Executive Committee PAGEREF _Toc275162624 \h 274.Credentials Committee PAGEREF _Toc275162625 \h 295.Nominating Committee PAGEREF _Toc275162626 \h 306.Medical Staff Member Referral Team (MSMRT) PAGEREF _Toc275162627 \h 307.Graduate Medical Education Committee PAGEREF _Toc275162628 \h 308.Peer Review Committee PAGEREF _Toc275162629 \h 319.Special Committees PAGEREF _Toc275162630 \h 31E.Meetings PAGEREF _Toc275162631 \h 311.Medical Staff Year PAGEREF _Toc275162632 \h 312.Medical Staff Meetings PAGEREF _Toc275162633 \h 313.Department, Division and Committee Meetings PAGEREF _Toc275162634 \h 32F.Provisions Common to All Meetings PAGEREF _Toc275162635 \h 331.Notice of Meetings PAGEREF _Toc275162636 \h 332.Quorum and voting PAGEREF _Toc275162637 \h 333.Agenda PAGEREF _Toc275162638 \h 334.Rules of Order PAGEREF _Toc275162639 \h 33III.APPOINTMENT, REAPPOINTMENT, AND CLINICAL PRIVILEGES PAGEREF _Toc275162640 \h 34A.Qualifications, Conditions, and Responsibilities PAGEREF _Toc275162641 \h 341.Qualifications for Membership: PAGEREF _Toc275162642 \h 342.Waiver of Criteria PAGEREF _Toc275162643 \h 363.No Entitlement to Membership PAGEREF _Toc275162644 \h 364.Nondiscrimination Policy PAGEREF _Toc275162645 \h 365.Limitation of Privileges and Membership PAGEREF _Toc275162646 \h 36B.General Conditions of Appointment and Reappointment PAGEREF _Toc275162647 \h 371.Basic Responsibilities and Requirements for Applicants and Members PAGEREF _Toc275162648 \h 372.Burden of Providing Information PAGEREF _Toc275162649 \h 40C.Application PAGEREF _Toc275162650 \h rmation PAGEREF _Toc275162651 \h 41D.Grant of Immunity and Authorization to Obtain/Release Information PAGEREF _Toc275162652 \h 431.Immunity PAGEREF _Toc275162653 \h 432.Authorization to Obtain Information PAGEREF _Toc275162654 \h 443.Authorization to Release Information PAGEREF _Toc275162655 \h 44E.Procedure for Initial Appointment to the Medical Staff PAGEREF _Toc275162656 \h 451.Pre-Credentialing Process. Request for Application PAGEREF _Toc275162657 \h 452.Submission of Application. PAGEREF _Toc275162658 \h 463.Division Chief Procedure PAGEREF _Toc275162659 \h 464.Department Chairperson Procedure PAGEREF _Toc275162660 \h 475.Hospital Medical Director Procedure PAGEREF _Toc275162661 \h 476.Credentials Committee Procedure PAGEREF _Toc275162662 \h 477.Medical Executive Committee Procedure PAGEREF _Toc275162663 \h 488.Managers Procedure PAGEREF _Toc275162664 \h 49F.Provisional Status PAGEREF _Toc275162665 \h 511.Nature of Provisional Status PAGEREF _Toc275162666 \h 512.Focused Professional Practice Evaluation PAGEREF _Toc275162667 \h 513.Duration of Initial Provisional Membership PAGEREF _Toc275162668 \h 524.Duties of Provisional Members PAGEREF _Toc275162669 \h 52G.Clinical Privileges PAGEREF _Toc275162670 \h 531.Exercise of Privileges PAGEREF _Toc275162671 \h 532.Unavailable Clinical Privileges PAGEREF _Toc275162672 \h 543.Clinical Privileges for Dentists and Oral Surgeons PAGEREF _Toc275162673 \h 544.Clinical Privileges for Podiatrists PAGEREF _Toc275162674 \h 545.Clinical Privileges for New Procedures PAGEREF _Toc275162675 \h 556.Criteria for Clinical Privileges PAGEREF _Toc275162676 \h 557.Physicians-in-Training PAGEREF _Toc275162677 \h 568.Telemedicine Privileges PAGEREF _Toc275162678 \h 569.Emergency Clinical Privileges PAGEREF _Toc275162679 \h 5610. Temporary Privileges PAGEREF _Toc275162680 \h 5711. Disaster Privileges PAGEREF _Toc275162681 \h 57H.Procedures for reappointment PAGEREF _Toc275162682 \h 571.Applications for Reappointment PAGEREF _Toc275162683 \h 582.Factors to Be Considered PAGEREF _Toc275162684 \h 583.Division Chief Procedures PAGEREF _Toc275162685 \h 594.Hospital Medical Director Procedure PAGEREF _Toc275162686 \h 605.Credentials Committee Procedure PAGEREF _Toc275162687 \h 606.Medical Executive Committee Procedure PAGEREF _Toc275162688 \h 617.Managers Procedure PAGEREF _Toc275162689 \h 62IV.PEER REVIEW AND FAIR HEARING PROCEDURES PAGEREF _Toc275162690 \h 62A.Questions Involving Medical Staff Members PAGEREF _Toc275162691 \h 621.Collegial Intervention/Informal Proceedings PAGEREF _Toc275162692 \h 622.Deemed Resignations: PAGEREF _Toc275162693 \h 643.Application for Medical Staff Membership After Resignation: PAGEREF _Toc275162694 \h 644.Ongoing and Focused Professional Practice Evaluations PAGEREF _Toc275162695 \h 655.Investigations PAGEREF _Toc275162696 \h 656.Precautionary Suspension of Clinical Privileges PAGEREF _Toc275162697 \h 687.Medical Executive Committee Procedure. PAGEREF _Toc275162698 \h 698.Automatic Relinquishment PAGEREF _Toc275162699 \h 709.Leaves of Absence PAGEREF _Toc275162700 \h 72B.Hearings and Appeal Procedures PAGEREF _Toc275162701 \h 721.Initiation of Hearing PAGEREF _Toc275162702 \h 722.The Hearing PAGEREF _Toc275162703 \h 733.Pre-Hearing and Hearing Procedure PAGEREF _Toc275162704 \h 764.Hearing Conclusions, Deliberations, and Recommendations PAGEREF _Toc275162705 \h 795.Appeal Procedure PAGEREF _Toc275162706 \h 80V.AMENDMENTS, ADOPTION, AND MEDICAL STAFF RULES AND REGULATIONS AND POLICIES AND PROCEDURES PAGEREF _Toc275162707 \h 82A.Amendments/Adoption PAGEREF _Toc275162708 \h 82B.Medical Staff Policies and Procedures PAGEREF _Toc275162709 \h 83C.Conflict Management Process PAGEREF _Toc275162710 \h 83I. GENERAL PROVISIONSPURPOSEThe purposes of these Bylaws are to: Establish the formal structure of the Medical Staff of the Nemours/Alfred I. duPont Hospital for Children;Establish the requirements and processes for application for initial appointment and periodic reappointment to membership on the Medical Staff, for Clinical Privileges and for changes in status of membership on the Medical Staff;Establish the prerogatives and responsibilities of membership on the Medical Staff;Achieve a high level of professional performance by the Practitioners and Affiliate Professionals authorized to practice in the Hospital and affiliate sites through the appropriate delineation of the Clinical Privileges that each Practitioner and Affiliate Professional may exercise in the Hospital, and through an ongoing review and evaluation of each Practitioner’s and Affiliate Professional’s performance in the Hospital;Provide a means whereby issues concerning the Medical Staff and the Hospital may be discussed by the Medical Staff with the Managers and the Chief Executive Officer; andServe as a means for accountability to the Managers for the professional performance and ethical conduct of the Members and to strive towards assuring that patients treated at Nemours/Alfred I. duPont Hospital for Children, including without limitation inpatients, outpatients, ambulatory surgery patients (including patients seen at Nemours duPont Pediatrics, Ambulatory Surgery Center at Bryn Maw and any such other ambulatory surgical facility as Nemours/Alfred I. duPont Hospital for Children may open in the future) will receive high quality medical care. The Medical Staff will strive toward the continual upgrading of the quality and efficiency of patient care delivered, consistent with the state of the healing art and the resources locally available.DEFINITIONSThe following definitions shall apply to terms used in these Bylaws:“Administration” means those persons to whom the Chief Executive Officer and/or the Managers have delegated authority to carry our administrative responsibilities.“Administrator” means the Chief Executive Officer or other individual appointed to act in the overall administration of the Hospital.“Ambulatory Surgical facility” means a facility or portion thereof not located upon the premises of a hospital which provides specialty or multispecialty outpatient surgical treatment.“Ambulatory Surgery” means surgery which is performed on an outpatient basis in a facility which is not located in a hospital; on patients who do not require hospitalization but who do require constant medical supervision following the surgical procedure performed and whose total length of stay does not exceed a total of 8 hours (4 hours surgical time; 4 hour recovery time).Affiliate Professional” means any licensed, independent health care provider who is not a physician, dentist, or podiatrist, but who practices independently within the scope of his or her license to provide patient care services at the Hospital and who must be credentialed and granted Clinical Privileges through existing Medical Staff mechanisms. Such individuals include, but are not limited to, clinical psychologists, advanced practice nurses and physician assistants.Affiliate Sites- includes Ambulatory Care, Impatient Sites, Surgical centers covered by a Nemours Physicians within their scope of Practice“Bylaws” means these Medical Staff Bylaws of the Hospital.“Clinical Fellow” means a physician in training who has completed residency program and is receiving sub-specialty level training.“Clinical Privileges” means the permission granted to a Practitioner or Affiliate Professional to render specific diagnostic, therapeutic, medical, dental, or surgical services at the Hospital to inpatients and outpatients.“Credentials Committee” means the Credentials Committee of the Medical Staff.“Credentialing Department” means the Credentialing Department of Nemours.“Dentist” means a person who holds a doctor of dental surgery or doctor of dental medicine degree.“Ex Officio” means a role or function being performed by a person due to the person’s office or position held and, unless otherwise expressly provided, does not limit voting rights.“Hospital” means the Nemours/Alfred I. duPont Hospital for Children. “Hospital Medical Director” means the physician appointed by the Chief Medical Officer and the Administrator who has certain delegated responsibilities related to the Hospital and the Medical Staff and whose complete duties are contained in the job description for that position.“Managers” means the Board of Managers.“Medical Executive Committee” means the Executive Committee of the Medical Staff.“Medical Staff” or “Staff” means the Medical Staff of the Hospital.“Medical Staff Year” means the twelve-month period commencing on the first day of January in each year.“Member” or “Members” means a member or members of the Medical Staff.“Nemours” means The Nemours Foundation, a Florida non-profit corporation. “Medical Staff Member Referral Team” means the team consisting of the Hospital Medical Director, the President of the Medical Staff and the Chief Medical Officer that addresses concerns relating to impaired Members.“Physician Health Committee” means the Physician Health Committee of the Medical Society of Delaware or other Committee designated by the Delaware State Board of Licensure and Discipline.“Physician-in-Chief (Chief Medical Officer)” means a physician appointed to perform the duties described in these Bylaws.“Physician” means a person who holds a doctor of medicine (M.D.) or doctor of osteopathy (D.O.) degree.“Podiatrist” means a person who holds a doctor of podiatric medicine (D.P.M.) degree.“Policies and Procedures,” unless otherwise specified, means the Policies and Procedures of the Medical Staff.“Practitioner,” unless otherwise expressly limited, means any Physician, Podiatrist, Dentist or Oral Surgeon applying for or holding privileges in the Hospital.“Special Notice” means written notification sent by certified or registered mail, return receipt requested.Service line – Administrative structure of related services to facilitate patient care. “Peer Review Committee” means the group of Medical Staff Members formally convened by the Medical Executive Committee to review and evaluate the work of the Medical Staff.“Resident” means a physician in training receiving post-graduate level training through an ACGME accredited residency program.Words used in these Bylaws shall be read as the masculine or feminine gender, and as the singular or plural, as the context requires. The captions and headings are for convenience only and are not intended to limit or define the scope or effect of any provision of these Bylaws.CONDIFENTIALITY AND PEER REVIEW PROTECTIONSConfidentiality: Actions taken and recommendations made pursuant to Article III and Article IV shall be treated as confidential in accordance with applicable legal requirements and such policies regarding confidentiality as may be adopted by the Hospital and the Medical Staff.Reporting: Reports of actions taken pursuant to Article III and Article IV shall be made by the Chief Executive Officer or designee to such governmental agencies as may be required by law. The Nemours/Alfred I. duPont Hospital for Children shall disclose reports of actions taken pursuant to that reporting requirement to other health care organizations upon receipt of a formal request and authorization form to release the information signed by the affected physician.Records: All records and other information generated in connection with and/or as a result of professional review activities shall be confidential, and each individual or Committee member participating in such review activities shall make no disclosures of any such information except as authorized, in writing, by the Chief Executive Officer or designee or by legal counsel for the Hospital or as required by applicable law.Breach of Confidentiality: Any breach of confidentiality by an individual or Committee member may result in a professional review action by the Medical Staff, and/or may result in appropriate legal action to ensure that confidentiality is preserved, including application to a court of law for injunctive or other relief.Peer Review Protection: All minutes, reports, recommendations, communications, and actions made or taken pursuant to Article III and Article IV are deemed to be covered by the provisions of Title 24, Chapter 17 of the Delaware Code, or the corresponding provisions of any subsequent federal or state statute providing protection to peer review or related activities. Furthermore, the committees and/or panels charged with making reports, findings, recommendations, or investigations pursuant to Article IV shall be considered to be acting on behalf of the Hospital when engaged in such professional review activities and thus shall be deemed to be “professional review bodies” as that term is defined in the Health Care Quality Improvement Act of 1986. All Members agree to execute such documentation to confirm the confidential nature of the matters referred to in this section as may be developed from time to time by the Medical Executive Committee and approved by the Managers.CONFLICT OF INTEREST PRINCIPLESMembers of the Medical Staff shall conduct themselves with integrity, honesty and fairness to avoid any conflict between personal interests and the interests of Nemours/Alfred I. duPont Hospital for Children. Members shall not use their position with Nemours and/or the Alfred I. duPont Hospital for Children to influence decisions in which they know, or have reason to believe, that they have a financial interest.INDEMNIFICATION WHEN PERFORMING CREDENTIALING AND PEER REVIEW FUNCTIONSMembers of the Medical Executive Committee, Medical Staff Credentials Committee, and Medical Staff Peer Review Committee will be immune under Title 24, Chapter 17, Section 1768 of the Delaware Code from any claim, suit, liability, damages, or any other recourse, civil or criminal, arising from any Peer Review Committee act, omission, proceeding, decision, or determination undertaken or performed, or from any recommendation made, so long as the member and/or Committee acted in good faith and without gross or wanton negligence in carrying out the responsibility, authority, duties, powers, and privileges of the officers conferred by law upon them. They and all Medical Staff members functioning as their designees shall be indemnified by Nemours to the fullest extent permitted by law.DELEGATION OF FUNCTIONSThe Medical Staff of the Nemours/Alfred I. duPont Hospital for Children authorizes the Medical Executive Committee to act on its behalf in the day-to-day matters relating to:Self-governance – policies, procedures, rulesCredentialing and PrivilegingGraduate Medical EducationPeer ReviewStrategic PlanningThe Medical Executive Committee will advise the Medical Staff as to the actions taken.From time to time the Administrative and Physician Leadership of Nemours/Alfred I. duPont Hospital for Children may create multi-disciplinary Service Lines to facilitate the delivery of efficient patient care. The Physician identified as Program Director has responsibility for the day to day operations of the Service Line; however the responsibility for credentialing, privileging, focused practitioner performance evaluation, on-going practitioner performance evaluation, and peer review decisions related to the physicians and other credentialed practitioners who function within the Service line rest with the Chief of the Medical Staff Division and Chairperson of the Medical Staff Department to which the individual practitioner is assigned.The authority delegated pursuant to the above may be removed by amendment of these Bylaws, or by resolution of the Medical Staff, approved by a 2/3 vote of the voting members of the Medical Staff, taken at a semi-annual or special meeting noticed to include the specific purpose of removing specifically-described authority of the Medical Executive Committee.(Joint Commission Standard- Medical Staff Bylaws: MS.01.01.01)GOVERNANCE AND STRUCTURE CATEGORIES OF THE MEDICAL STAFFThe Medical Staff shall be divided into the following categories: Active Employed, Associate Employed, Affiliate Employed, Regional Medical Staff, Active Community, Courtesy Community, Consultant Community, Associate Community, and Affiliate Community. Medical Staff Members who have retired from practice shall have the designation of “Retired.”Medical Staff Members who have made outstanding contributions to the field of medicine, the community or the Hospital shall have the designation “Emeritus” after being nominated for and approved for such designation.Active Employed StaffQualifications:The Active Employed Staff shall be limited to those qualified Physicians, Podiatrists, Dentists and oral surgeons who desire to practice actively at the Hospital. Active Employed staff members must meet all of the following:Meet the qualifications outlined in Article III.A;Be employed by the Nemours Children’s Clinic, Delaware Valley;Be appointed to a specific Department; Obtain board certification as required in Article III.A.1.e and maintain such certification or recertification; andSatisfy the requirement as set forth in Article III.A.1.f.Prerogatives:Members appointed to the Active Employed Staff shall be entitled to:Admit and treat an unlimited number of patients within the limits of their clinical privileges;Hold office on the Medical Staff;Be appointed to and serve on Medical Staff Committees and to serve as the Chairperson of a Medical Staff Committee; andVote on matters voted upon by the Medical Staff.Responsibilities:By accepting membership to the Active Employed Staff category, each Member agrees to assume all the following functions and responsibilities of membership to the Active Employed Staff:Attend Medical Staff meetings and Department meetings when possible. Attendance at Department and Division meetings and participation in teaching activities and committee work shall be considered by the Department Chairperson at the biannual reappointment. Excused absences will be permitted at the discretion of the Chairperson of the Department;Serve on Medical Staff Committees, as assigned;Faithfully perform the duties of any office or position to which the Member is elected or appointed;Participate in quality assessment and monitoring activities as may be assigned by the Department Chairperson, Division Chief, or committee chairperson, including the evaluation of provisional members;Complete teaching assignments as directed by the Department Chairperson;Provide care for unassigned patients, emergency service care, and consultation according to the requirements of the Member’s Division and/or Department and Medical Staff Policy; andSubmit bi-annual reappointment applications.Associate Employed StaffQualifications:The Associate Employed Staff shall be limited to those practitioners who are employed by the Nemours Children’s Clinic, Delaware Valley and who do not provide patient care services or hold clinical privileges at the Nemours/Alfred I. duPont Hospital for Children. This category includes Nemours employed physicians in administrative roles. An Associate Employed Staff Member must meet all of the following criteria:Maintain employment with Nemours;Maintain current licensure required by the state(s) in which the Member works on behalf of Nemours; andObtain board certification as required in Article III.A.1.e and maintain such certification or recertification.Prerogatives and Responsibilities:Associate Employed Staff Members:May not admit patients to the Nemours/Alfred I. duPont Hospital for Children;Must maintain appropriate medical licenses, DEA registration, CDS registrations (as necessary) and medical liability insurance;May be assigned to Medical Staff Committees;Must fulfill attendance requirements for committees, if assigned;May vote on committee proceedings if assigned to a committee;Must cooperate with and participate in Medical Staff quality assessment and monitoring activities;Must submit bi-annual reappointment applications; andMay attend Medical Staff meetings and department meetings.Physicians in Medico-Administrative Positions:Administrative without clinical duties: Physicians, Dentists, Podiatrists and psychologists employed by Nemours in a purely administrative capacity with no clinical duties or responsibilities are subject to the regular Human Resources policies of Nemours through their terms of employment; they need not be members of the Medical Staff. If they choose Medical Staff membership, these practitioners would be eligible for the Associate Employed Staff.Administrative with clinical duties:Medical Staff membership required: Physicians, Dentists, Podiatrists and psychologists employed by Nemours, either full or part-time, whose duties are medico-administrative in nature and include clinical responsibilities or functions involving their professional capabilities must be Members of the Medical Staff. Procedure for appointment: Appointment to the Medical Staff will be achieved through the same procedure as provided for other Medical Staff Members. Privileges will be delineated in terms of education, training, competence and character, as well as the terms of employment. Termination Review and Hearing Process: Termination of employment of a Physician, Dentists, Podiatrist, or psychologist in a medico-administrative position shall be subject to review pursuant to Nemours employment policies and procedures. The Credentials Committee of the Medical Staff shall review the reason for the action, and determine whether either or both of his Medical Staff membership and privileges should be affected.Termination of Staff Privileges: when the reason for the action is determined by the Credentials Committee to involve the individual’s medical competence, which includes his competence to supervise the professional activities of practitioners under his direction, the Medical Staff shall, if requested by the individual, provide for a review of the decision, including the right to a hearing and appeal, as stated in the Fair Hearing provisions of these Bylaws (Article IV). The Medical Staff shall further transmit a letter of recommendation to the Managers of any such action proposed.Termination of Administrative function: when the reason for the action is determined by the Credentials Committee to be purely administrative in nature and does not involve the individual’s medical competency, Nemours shall follow its usual personnel policies or the terms of the contract, if there be one.Affiliate Employed StaffQualifications:The Affiliate Employed Staff shall be limited to persons who are Affiliate Professionals, employed by the Nemours Children’s Clinic, Delaware Valley or the Nemours/Alfred I. duPont Hospital for Children, licensed in the State in which they provide services for Nemours and granted Clinical Privileges to provide specific independent patient care services at the Hospital. An Affiliate Employed Staff Member must meet all of the following criteria:Maintain employment with Nemours;Maintain active collaborative or supervisory agreement with a Nemours-employed physician (as appropriate per licensure requirements);Maintain current licensure as required;Obtain board certification as required in Article III.A.1.e and maintain such certification or recertification; andSatisfy the requirement set forth in Article III.A.1.f.Prerogatives and Responsibilities:Affiliated Employed Staff Members:May not admit patients to their own service, but may facilitate the admission of patients to their supervisor’s or collaborating physician’s service;May provide specific services within the scope of their delineated clinical privileges;May be assigned to Medical Staff committees;May not vote or hold office on the Medical Staff, except that Members of the Affiliate Employed Staff who are clinical psychologists employed by the Hospital are eligible to vote on all matters brought before the Medical Staff;Must fulfill attendance requirements for committees, if assigned;May vote on committee proceedings if assigned to a committee;Must submit bi-annual reappointment applications; andMay attend Medical Staff meetings and Department meetings, but are not required to do so.Regional Medical StaffQualifications:The Regional Medical Staff shall consist of those practitioners employed by the Nemours Children’s Clinic, Delaware Valley who provide pediatric health care at any of the Nemours health care facilities in Pennsylvania, New Jersey, Maryland or Delaware who do not meet the criteria for the Active Employed Medical Staff or are not otherwise members of the Active Employed Staff. Regional Medical Staff members must meet all of the following criteria:Maintain employment with Nemours;Maintain current licensure required by the state(s) in which they work on behalf of Nemours;Obtain board certification as required in Article III.A.1.e and maintain such certification or recertification; andSatisfy the requirements set forth in Article III.A.1.f.Prerogatives and Responsibilities:Regional Medical Staff Members:May not admit patients to the Nemours/Alfred I. duPont Hospital for Children;Must maintain appropriate medical licenses, DEA registration and CDS registrations and medical liability insurance as required by the state(s) in which they provide patient care services for Nemours;May provide specific services within the scope of their delineated clinical privileges at the Nemours health care facilities at which they work;Must maintain appropriate medical staff membership and privileges at a local hospital in order to provide for inpatient care of their patients;May be assigned to Medical Staff committees;Must fulfill attendance requirements for committees if assigned;May vote on committee proceedings if assigned to a committee;Must cooperate with and participate in Medical Staff quality assessment and monitoring activities;Must submit bi-annual reappointment applications; and May attend Medical Staff meetings and Department meetings.Loss of StatusLoss of Status-Regional Medical Staff:In the event that any of the conditions set forth above are not met and maintained, the practitioner shall automatically lose membership on the Medical Staff of the Hospital and shall not be entitled to any hearing or appeals proceedings in connection therewith. Otherwise, Members of the Regional Medical Staff shall be subject to interventions as set forth in these Bylaws.Loss of Status – Employed StaffIf a Member of an employed staff category ceases employment with Nemours or the Alfred I. duPont Hospital for Children, that individual’s Medical Staff appointment and privileges shall end until such time as a request for change in Medical Staff status is submitted, considered by the appropriate Division Chief and/or Department Chair and approved by the Credentials Committee, Medical Executive Committee and Board of Managers. Such request for a change in Medical Staff status must occur within 60 days of the cessation of employment.Active Community StaffQualifications:The Active Community Staff shall be limited to those qualified Physicians, Podiatrists, Dentists and oral surgeons who practice in the Delaware Valley community and desire to practice actively at the Hospital. Active Community Staff Members must meet all of the following:Meet the qualifications as outlined in Article III.A.1 (membership criteria);Be appointed to a specific Department;Obtain board certification as required in Article III.A.1.e and maintain such certification or recertification; andSatisfy the requirements set forth in Article III.A.1.fPrerogativesMembers appointed to the Active Community Staff shall be entitled to:Admit and treat an unlimited number of patients within the scope and limits of their clinical privileges;Hold office on the Medical Staff;By appointed to and serve on Medical Staff committees and to serve as the chairperson of a Medical Staff committee; andVote on matters voted upon by the Medical Staff.Responsibilities:By accepting membership to the Active Community Staff category, each Member agrees to assume all the following functions and responsibilities of membership on the Active Community Staff:Attend Department meetings when possible. Attendance at Department and Division meetings and participation in teaching activities and committee work shall be considered by the Department Chairperson at the bi-annual reappointments. Excused absences will be permitted at the discretion of the Chairperson of the Department;Serve on Medical Staff Committees, as assigned;Faithfully perform the duties of any office or position to which the Member is elected or appointed;Participate in quality assessment and monitoring activities as may be assigned by the Department Chairperson, Division Chief, or committee chairperson;Complete teaching assignments as directed by the Department Chairperson;Provide care for unassigned patients, emergency service care, and consultation according to the requirements of the Members’ Division and/or Department, and Medical Staff Policy; andSubmit bi-annual reappointment applications.Courtesy Community StaffQualifications:The Courtesy Community Staff shall be limited to Physicians, Podiatrists, Dentists, and oral surgeons who meet all the requirements for membership on the Active Community Staff but are not Members of the Active Community Staff, but are qualified for Staff membership and only occasionally admit or treat patients at the Hospital.A Courtesy Community Staff Member may apply through the procedures described in these Bylaws to be transferred to the Active Community Staff if Hospital activity, as judged by such factors as the number of admissions, procedures and patient contacts, is greater than the occasional activity contemplated in Courtesy Community Staff membership. Conversely, an Active Community Staff Member may apply to be transferred to the Courtesy Community Staff if his activity at the Hospital and willingness to assume Active Community Status committee assignments is below the level required to constitute fulfillment of the responsibilities of Active Community Staff Members.Prerogatives:Courtesy Community Staff Members shall:Be entitled to admit no more than six (6) inpatients annually or treat no more than six (6) outpatients annually within the limits of their assigned clinical privileges;Not be eligible to hold office on the Medical Staff;Not be eligible to vote on matters voted upon by the Medical Staff; andMay be appointed to and serve on Medical Staff Committees at the discretion of the Chair of the Medical Executive Committee; when such committee appointment is given, the Courtesy Community Staff member may vote on all committee proceedings.Responsibilities:By accepting membership to the Courtesy Community Staff category, each individual agrees to assume all the following functions and responsibilities of membership to the Courtesy Community Staff:Participate in quality assessment and monitoring activities as may be assigned by the Department Chairperson, Division Chief or committee chairperson, including the evaluation of provisional Members; andSubmit bi-annual reappointment applications.Responsibilities of the Courtesy Community Staff relating to consultation and teaching assignment shall be specific to the Division and/or Department.Consulting Community StaffQualifications:The Consulting Community Staff shall be limited to specialists who are appointed for the specific purposes of providing consultation in the diagnosis and treatment of patients, including physicians providing telemedicine services. Consulting Community Staff Members must meet all of the following:Meet the qualifications for membership outlined in Article III.A.1;Be appointed to a specific Department;Obtain board certification as required in Article III.A.1.e and maintain such certification or recertification; andSatisfy the requirement set forth in Article III.A.1.Prerogatives:Consulting Community Staff Members:May consult on and treat patients within the limits of their assigned clinical privileges, in consultation with Active or Courtesy Staff Member;May not admit patients to the Hospital;May be appointed to and serve on Medical Staff committees at the discretion of the Chair of the Medical Executive Committee; when such committee appointment is given, the Consulting Community Staff Member may vote on all committee proceedings;May attend Medical Staff meetings and Department meetings, but are not required to do so; andMay not hold Medical Staff office or vote on matters being voted upon by the Medical Staff.Responsibilities:Consulting Community Staff Members are responsible for:Submitting bi-annual applications for reappointment; andCooperating with and participating in Medical Staff quality assessment and monitoring activities.Associate Community StaffQualifications:The Associate Community Staff shall consist of those practitioners who meet the qualifications for Active Community Staff but who have no clinical privileges at the Nemours/Alfred I. duPont Hospital for Children. This category shall also include those physicians who have retired from active practice. Associate Community Staff Members must meet the qualifications outlined in Article III.A.1 and be appointed to a specific Department.Prerogatives:Associate Community Staff Members:May not admit patients to their own service;May not document in the Hospital medical records;May not hold office on the Medical Staff;May not vote on matters of the Medical Staff;May serve on Committees of the Medical Staff at the discretion of the Chairperson of the Medical Executive Committee and may vote on all matters brought before such Committee; andAre not required to submit bi-annual applications for reappointment.Affiliate Community StaffQualifications:The Affiliate Community Staff shall be limited to persons who are Affiliate Professionals licensed in Delaware and are granted Clinical Privileges to provide specific independent patient care services for their collaborating or supervising physicians at the Hospital.Prerogatives and Responsibilities:Affiliate Community Staff Members:May not admit patients to their own service, but may facilitate the admission of patients to the service of their collaborating or supervising physicians;May provide specific services to the patients of their supervising or collaborating physicians within the scope of their delineated clinical privileges;May be assigned to Medical Staff committees;May not vote or hold office on the Medical Staff;Must fulfill attendance requirements for committees, if assigned;May vote on committee proceedings if assigned to a committee;Must submit bi-annual reappointment applications; andMay attend Medical Staff meetings and Department meetings, but are not required to do so.(Joint Commission Standard – Medical Staff Bylaws: MS.01.01.01)OFFICERS OF THE MEDICAL STAFFThe elected officers of the Medical Staff shall be the President and the President-Elect.QualificationsOnly those Active Employed Staff and Active Community Staff Members who satisfy all of the following criteria shall be eligible to serve as Medical Staff officers:Have been Members in good standing on the Active Employed Staff or Active Community Staff and continue so during their term of office;Meet the criteria for the office for which they are being considered;Are qualified by training, experience, or demonstrated ability for the office;Have no pending adverse recommendations concerning Staff membership and/or clinical privileges;Utilize the Hospital as one of their primary hospitals;Are not serving as medical staff officers or department chairpersons at another hospital or health care facility during the term of office;Are willing to discharge faithfully the duties and responsibilities of the office to which the individual is elected;Do not have an employment or other contractual arrangement that may give rise to a conflict of interest with another entity;Are knowledgeable concerning the duties of the office; andHave constructively participated in Medical Staff affairs at the Hospital, including peer review activity.Term of OfficeThe President and President-Elect shall each serve a two-year term beginning on the first of January immediately following their election. The President-Elect shall serve as President immediately upon the end of his two-year term as President-Elect. The President may not be elected as President-Elect immediately following the conclusion of his term as President.Election of OfficersThe President-Elect shall be elected by the Active Employed Staff and Active Community Medical Staff Members as described in Article II.D.3.Vacancies in OfficeA vacancy in the office of President-Elect shall be filled by the Medical Executive Committee. If there is a vacancy in the office of the President, the President-Elect shall serve out the remaining term. Vacancies in both offices of President and President-Elect shall be filled by a special vote of the Medical Executive Committee. The terms of office for such special election shall be to complete the remainder of the terms of the vacated offices.Duties of OfficersPresidentThe President shall:Act in coordination and cooperate with the Chief Medical Officer and the Hospital Medical Director in all matters of mutual concern within the Hospital;Call, preside at, and be responsible for the agenda of all meetings of the Medical Staff;Serve on the Medical Executive Committee and act as its Chairperson;In conjunction with the Hospital Medical Director, be responsible for the enforcement of these Bylaws and any Policies and Procedures, for the implementation of sanctions where these are indicated, and for the Medical Staff’s compliance with procedural safeguards in all instances where corrective actions have been imposed on a Member of the Medical staff;Appoint Members to all Medical Staff committees in consultation with the Chief Medical Officer and the Hospital Medical Director (except as otherwise stated in these Bylaws);Represent the views, policies, needs, and grievances of the Medical Staff to the Hospital Medical Director and the Chief Executive Officer and represent the Medical Staff to the Managers;Receive and interpret for the Medical Staff the policies of the Managers and report to the Managers with the Chief Medical Officer, Hospital Medical Director and Chief Executive Officer on the performance and maintenance of quality with respect to the Medical Staff’s delegated responsibilities to provide medical care;Be the spokesperson for the Medical Staff; andBe a member of the Medical Staff Member Referral TeamPresident-Elect:The President Elect shall automatically become President upon completion of the President’s term of office. In the absence of the President, the President-Elect shall discharge all duties and authority of the President. The President-Elect shall be a member of the Medical Executive Committee and act as its Vice Chairperson. The President-Elect shall automatically succeed the President when the latter fails to serve for any reason. The President-Elect shall serve as Chairperson of the Medical Staff Policy Committee. The President-Elect shall also assume such other duties as may be assigned to him from time to time by the President of the Medical Staff.Removal of Elected OfficersElected officers of the Medical Staff and Members-at-Large of the Medical Executive Committee may be removed from office only upon good cause shown. Good cause shown shall mean that an officer has performed his duties in an incompetent manner, has brought discredit upon the Medical Staff or the Hospital, or is found to be unable to perform the duties of the office. An elected officer may be removed from office only upon an affirmative vote for removal of not less than two-thirds of the entire Medical Executive Committee.(Joint Commission Standard – Medical Staff Bylaws: MS.01.0 1.01)DepartmentsThe Clinical Departments of the Medical Staff shall consist of the following:Anesthesiology and Critical CareMedical ImagingOrthopedic SurgeryPathology/Clinical LaboratoryPediatricsSurgeryOrganizationDepartments shall be organized into Divisions as determined by the Chief Medical Officer in consultation with the Department Chairperson and approved by the Medical Executive Committee. Divisions are subdivisions of Departments. The Physician leadership for the Departments and Divisions shall be responsible for performing the duties and responsibilities set forth in these Bylaws. The descriptions of the Departments and Divisions are attached to these Bylaws as Appendix A. Appendix A may be modified or supplemented from time to time by action of the appropriate Department Chairperson and the Chief Medical Officer, without the necessity of amendment of this Article.Department ChairpersonsProcedure for Appointment and TermThe appointment of all Department Chairpersons shall be made by the Chief Medical Officer.All Department Chairpersons shall be appropriately qualified in the Department and shall serve at the pleasure of the Chief Medical Officer.In the event of a vacancy in an office of a Department Chairperson for any reason other than a requested leave of absence or retirement, an acting Chairperson shall be appointed by the Chief Medical Officer until a permanent Chairperson is appointed in accordance with this Article.A Department Chairperson shall be certified by an appropriate specialty board or have demonstrated affirmatively established comparable competency through the credentialing process.Only an individual who as an Active Employed Staff Member shall be eligible to serve as a Department Chairperson.Duties and ResponsibilitiesEach Department Chairperson shall be responsible for all of the following:The clinically and administrative related activities of the Department, and where applicable, for the teaching and any research program within the Department;Continuing surveillance of the professional performance of all individuals in the Department who have delineated clinical privileges;Recommending the criteria for clinical privileges that are relevant to the care provided in the Department;Being a member of the Medical Executive Committee in accordance with the composition of that Committee as described in Article II.D.3;Making an appraisal and recommendation regarding individuals applying for Medical Staff membership and Clinical Privileges in the Department and regarding Department members applying for reappointment and Clinical Privileges to the Credentials Committee;Integrating the Department into the primary functions of the Hospital and coordinating and integrating interdepartmental and intradepartmental services;Assessing and recommending off-site sources for needed patient care services not provided by the Department or the Hospital;Developing and implementing Department policies and procedures that guide and support the provision of services;Recommending a sufficient number of qualified and competent persons to provide care or service;Determining the qualifications and competence of Department or service personnel who are not licensed independent practitioners and who provide patient care services;Continually assessing and improving the quality of care and services provided;Maintaining quality control programs as appropriate;Providing orientation and continuing education of all persons in the Department;Making recommendations for space and other resources needed by the Department; andAppointing a Department member, subject to the approval of the Chief Medical Officer, to be responsible for Chairperson duties in the event of the Chairperson’s absence for a period of time of more than one month. In the event the Chairperson is unable to perform his duties, the Chief Medical Officer shall appoint a Departmental member to be responsible for the Chairperson’s duties.Removal of a ChairpersonFailure of a Department Chairperson to maintain status as a Member of the Active Employed Medical Staff shall immediately disqualify that person from holding such position and shall be deemed to create a vacancy therein. A Chairperson may be removed at any time, with or without cause, by the Chief Medical Officer, in his sole discretion. Any such removal shall not, in and of itself, entitle the Chairperson to the procedural rights afforded by the hearing process in Article IV and shall not affect his Medical Staff membership status or Clinical Privileges.Divisions and Division ChiefsProcedures for Appointment and TermThe appointment of all Division Chiefs shall be made by the Chief Medical Officer and the appropriate Department Chairpersons.All Division Chiefs shall serve at the pleasure of the Chief Medical Officer.Only an individual who is an Active Employed Staff or Active Community Staff Member shall be eligible to serve as a Division Chief.In the event of a vacancy in an office of a Division Chief for any reason other than a requested leave of absence or retirement, an acting Division Chief shall be appointed by the Chief Medical Officer in consultation with the Department Chairperson until a permanent Division Chief has been appointed in accordance with this Article. Duties and ResponsibilitiesEach Division Chief shall be responsible for all of the following:The clinically and administrative related activities of the Division, and where applicable, for the teaching and any research program within the Division;Continuing surveillance of the professional performance of all individuals in the Division who have delineated clinical privileges;Recommending the criteria for clinical privileges that are relevant to the care provided in the Division;Making an appraisal and recommendation regarding individuals applying for Medical Staff membership and Clinical Privileges in the Division and regarding Division members applying for reappointment and Clinical Privileges to the Credentials Committee;Integrating the Division into the primary functions of the Hospital and coordinating and integrating interdivisional and intradivisional services;Assessing and recommending off-site sources for needed patient care services not provided by the Division or the Hospital;Developing and implementing Division policies and procedures that guide and support the provision of services;Recommending a sufficient number of qualified and competent persons to provide care or service;Determining the qualifications and competence of Division or service personnel who are not licensed independent practitioners and who provide patient care services;Continually assessing and improving the quality of care and services provided;Maintaining quality control programs as appropriate;Providing orientation and continuing education of all persons in the Division;Making recommendations for space and other resources needed by the Division; andAppointing a Division member, subject to the approval of the Department Chairperson, to be responsible for Division Chief duties in the event of the Chief’s absence for a period of time of more than one month. Removal of a Division ChiefFailure of a Division Chief to maintain status as a Member of the Active Employed Staff or Active Community Staff shall immediately disqualify that person from holding such position and shall be deemed to create a vacancy therein. A Division Chief may be removed, at any time, with or without cause, by the Chief Medical Officer, in his sole discretion. Any such removal shall not, in and of itself, entitle the Division Chief to the procedural rights afforded by the hearing process in Article IV and shall not affect his Medical Staff membership status or Clinical Privileges.Creation of New Divisions or Elimination of Existing DivisionsThe Department Chairperson may recommend to the Chief Medical Officer the formation of additional Divisions within the Department or the elimination of existing Divisions. The Chief Medical Officer may, create a new Division or eliminate an existing Division upon approval of the Medical Executive Committee. Criteria to be considered when forming a new Division include:Membership of the new Division shall consist of more than three (3) Members, unless otherwise approved by the Chief Medical Officer; andThe function of the Members is significantly different than that of the rest of the current Division assignments.Medical Staff Committees and FunctionsCommitteesCommittees of the Medical Staff shall be standing and special as approved by the Medical Executive Committee. A quorum will consist of the presence of at least three (3) Physician members of the committee, unless otherwise specified in these Bylaws. All committee responsibility, quorum requirements, composition, chairpersons, terms, election procedures, and other committee rules not stated in these Bylaws shall be addressed in the Medical Staff Policies and Procedures.There may be Standing Committees and Ad Hoc Committees of the Medical Staff. The Standing Committees shall be those described in these Bylaws. In addition, the President of the Medical Staff may appoint Ad Hoc Committees with the approval of the Medical Executive Committee for such purposes and duration and with such composition as he deems appropriate.Standing CommitteesThe Standing Committees shall be:Medical Executive committeeCredentials CommitteeMedical Staff Policy CommitteeNominating CommitteeGraduate Medical Education CommitteePeer Review CommitteeMedical Staff Member Referral TeamProcedural Sedation Ethics and Patient RightsInfection ControlBlood Utilization Pharmacy and Therapeutics And others as may become necessary or desirable, as determined by the Medical Executive Committee.(Joint Commission Standard- Medical Staff Bylaws: MS.01.01.01)Medical Executive CommitteeQuorumA quorum for the Medical Executive Committee shall consist of the presence of seven (7) of the members of the Medical Executive Committee, except for an emergency meeting called by the Medical Staff President or the Chief Medical Officer when the presence of twenty percent (20%) of such Committee’s members shall constitute a positionThe Medical Executive Committee shall consist of:President of the Medical StaffPresident-Elect of the Medical StaffHospital Medical DirectorChief Medical Officer or his DesigneeMedical Director of the Ambulatory Surgery CenterChief Executive Officer of the Hospital Chief Operating Officer of the HospitalChief Nurse Executive of the HospitalChairpersons (or clinical Directors) of the Department of Pediatrics, Surgery, Anesthesiology & Critical Care Medicine, Orthopedic Surgery, Medical Imaging, and Pathology & Clinical Laboratory MedicineFour (4) at-large members (each serving a two-year term)Four(4) to be elected from the Active Employed Medical Staff and/or the Active Community Medical StaffTermEach member elected at-large shall serve for two years, after which time he may be re-elected.Chairperson and Vice ChairpersonThe President of the Medical Staff shall serve as Chairperson of the Medical Executive Committee. The President-Elect of the Medical Staff shall serve as Vice Chairperson. If the Chairperson cannot preside due to incapacity or absence, the Vice Chairperson shall conduct the meetings of the committee.Election of MembersOfficers and “at large” representatives shall be elected by the Active Community Staff and Active Employed Staff. Nominations shall be made by the Nominating Committee at least ninety (90) days in advance of the Fall meeting of the Medical Staff. The election shall occur via ballots sent by mail to all Members of the Active Community Staff and Active Employed Staff at least forty-five (45) days in advance of the Fall meeting of the Medical Staff. Results of the election shall be announced at the Fall meeting.Executive SessionThe Committee may call an executive session for discussion and consideration of peer review and other confidential information. Attendance at executive sessions shall be limited to Members of the Medical Staff who are voting and/or Ex Officio members of the Medical Executive Committee. The Committee may invite others to an executive session where appropriate.Duties:The Committee shall be responsible for at least the following duties and for recommendations to the Managers for governing-body approval. The Medical Executive Committee shall be empowered to act for the Medical Staff in intervals between Staff meetings.Recommend Medical Staff Department structure;Create such sub-committees as necessary to conduct its work;Coordinate and oversee the clinical policies and activities of the Medical Staff;Provide oversight to the provision of care at the Hospital and its affiliated ambulatory surgical centers;Receive and act upon recommendations and reports from Medical Staff Committees, Departments, and assigned activity groups, including Service lines;Recommend standardized credentialing and recredentialing criteria and processes for all applicants for Medical Staff membership;Review and recommend applications for appointment and reappointment to membership on the Medical Staff and delineated Clinical Privileges for each eligible individual;Establish standards for clinical competence and review periodically all information available regarding Member performance against these standards for patient care and clinical quality;Monitor professional conduct to ensure all ethical standards are complied with;Authorize and implement remedial action when and if necessary;Consider and recommend action to the Managers on matters of medical administrative nature;Report to the Managers on matters affecting Medical Staff participants;Report at each Medical Staff meeting;Oversee Medical Staff participation in organized performance improvement activities;Oversee medical education programs and activities; andDocument its conclusions, recommendations, and actions taken.Filling VacanciesIn the case of the death, resignation, disability or upon completion of a term of any elected or selected member of the Committee, the Medical Staff President may appoint a successor to fill the unexpired term.MeetingsThe Medical Executive Committee shall meet approximately monthly, but not less than ten times annually.(Joint Commission Standard- Medical Staff Bylaws: MS 01.01.01 and Medical Staff Structure and Role of Medical Staff Executive Committee: MS.02.01.01)Credentials CommitteeDutiesThe Credentials Committee shall investigate the qualifications of all applicants for appointment or reappointment to membership on the Medical Staff and Clinical Privileges in accordance with the provisions regarding membership and Clinical Privileges set forth in Article III.A.1.The Committee shall be responsible for the establishment of criteria for Clinical Privileges in conjunction with the Department Chairpersons and Division Chiefs.The Credentials Committee shall also be responsible for evaluating requests for new privileges and new technology to assure that appropriate criteria for delineation of such privileges are developed and to assure that the Hospital possess appropriately trained staff and has the equipment available to support such requests.ChairpersonThe Credentials Committee Chairperson shall be appointed by the Chief Medical Officer and shall:Oversee the activities of the Credentials Committee and any sub-committees;Prepare a report of the Credentials Committee actions for submission to the Medical Executive Committee, which may include the report of any sub-committees;Select Chairpersons for any subcommittee meetings; andPresent the Credentials Committee recommendations and reports to the Medical Executive positionThe Credentials Committee shall consist of at least one Member from three of the Medical Staff Departments appointed by the Chief Medical Officer plus four (4) additional Members appointed by the Chief Medical Officer, and the Immediate Past President of the Medical Staff. Each Committee member shall serve a two-year term and shall be eligible to serve additional terms. The Committee shall meet approximately monthly. QuorumA quorum for the Credentials Committee shall consist of the presence of at least four (4) of its members.Nominating CommitteeCompositionThe Chief Medical Officer and the Medical Staff President shall jointly appoint a Nominating Committee, with the approval of the Medical Executive Committee, at least six (6) months prior to the annual general meeting of the Medical Staff. The Nominating Committee shall consist of six (6) Physicians who are members of the Active Community Staff and Active Employed Staff. The Immediate Past President of the Medical Staff shall serve as Chairperson.DutiesThe Nominating Committee shall be responsible for nominating officers of the Medical Staff and “at large” members of the Medical Executive Committee.Medical Staff Member Referral Team (MSMRT)CompositionThe Hospital Medical Director, the Chief Medical Officer, the President of the Medical Staff, and the Chief Executive Officer shall comprise the Medical Staff Member Referral Team. The Hospital Medical Director shall chair the Medical Staff Member Referral Health Team.DutiesPursuant to Medical Staff Policies and Procedures and these Bylaws, the Medical Staff Member Referral Team shall address concerns about the actual or possible impaired health or functioning of Medical Staff Members that threaten or may threaten patient care. The MSMRT shall report its activities to the Medical Executive Committee. Graduate Medical Education CommitteeCompositionThe Chief Medical Officer and the Medical Staff President shall jointly appoint the members of the Graduate Medical Education Committee. The Director of Graduate Medication Education at the Hospital shall serve as Chairperson.DutiesThe Graduate Medical Education Committee shall be responsible for overseeing the graduate medical education programs at the Hospital, for assuring compliance with residency review committee standards, and for reporting to the Medical Executive Committee and the Board of Managers about the safety and quality of patient care, treatment, and services provided by, and the related educational and supervisory needs, of, the participants in professional graduate education programs.(Joint Commission Standard – Medical Staff Role in Graduate Education Programs: MS.04.01.01)Peer Review CommitteeCompositionThe Peer Review Committee shall be composed of representatives from the Medical Staff Departments. The Chairperson shall be appointed by the Hospital Medical Director in consultation with the Medical Staff President and the Chief Medical Officer.DutiesThe Peer Review Committee shall be responsible for overseeing the Medical Staff peer review process, for reviewing and evaluating performance improvement data, and for recommending actions to improve the quality of care, treatment, and services provided by the Medical Staff and to improve patient safety. The Peer Review Committee shall report its activities to the Medical Executive Committee.Special CommitteesFrom time to time, the President of the Medical Staff may, in consultation with the Chief Medical Officer, appoint special committees. In the event of the appointment of a special committee, the purpose, composition, and any time limitation on the existence of the committee shall be set forth in writing by the President.(Joint Commission – Medical Staff Structure and Role of Medical Executive Committee: MS 02.01.01)MeetingsMedical Staff YearThe Medical Staff year is the calendar year – January 1 through December 31.Medical Staff MeetingsRegular MeetingsMeeting Schedule – There shall be at least two regular Medical Staff meetings held each year, one each in the fall and the spring on dates designated by the Medical Executive Committee.Annual General Meeting – The fall regular meeting shall be the annual general meeting of the Medical Staff. At this meeting, elections shall be held and a review of the year’s work presented.Special MeetingsSpecial Meetings of the Medical Staff may be called at any time upon not less than forty-eight (48) hours’ notice to all Members by the Chief Medical Officer, the Hospital Medical Director, the President of the Medical Staff, or the Medical Executive Committee and, upon like notice, shall be called at the request of the Managers or at least twenty-five percent (25%) of the aggregate Members of the Active Community Staff and the Active Employed Staff. The notice to Members shall specify the reason for the meeting. At any special meeting, no business shall be transacted except that stated in the notice calling the meeting.Department, Division and Committee MeetingsRegular MeetingsGeneralEach Department shall hold periodic meetings, the frequency of which to be determined by the Department Chairperson. Written minutes shall be kept and shall be submitted to the Medical Executive Committee. The purpose of the meetings shall be to discuss Departmental business, to keep the members of the Department informed of significant matters, and to review care rendered to patients. At a minimum, each Department shall meet quarterly to discuss quality issues.MinutesMinutes shall include the findings and conclusions of monitoring activities within the Department and actions taken by the Department as a result of such monitoring. If monthly Department meetings are not held, the Department must document (a) the mechanisms in place to involve all members of the Department in the monitoring and evaluation activities conducted by the Department; (b) the periodic review of care provided by Department members in order to draw conclusions, formulate recommendations, and initiate actions; and (c) the mechanisms to communicate to members of the Department the findings, conclusions, recommendations, and actions taken.Provisions Common to All MeetingsNotice of MeetingsStanding Meetings The dates and times of standing Medical Staff meetings shall be set at the beginning of the Medical Staff year and communicated at that time to Medical Staff Members. Agendas for a specific standing meeting shall distributed at least 1 week prior to such meeting.Special Meetings Notice of a special meeting shall be distributed at least 48 hours in advance of the meeting.Quorum and votingQuorum Those Members eligible to vote and who are present shall constitute a quorum for all Medical Staff meetings, unless otherwise specified in these Bylaws.Vote A majority of the voting Staff present at any regular or special meeting shall decide each question, unless otherwise specified in these Bylaws.AgendaThe agendas for standing meetings shall be developed by the Chairperson and distributed in advance of such meetings.The agenda for a special meeting shall be determined by the individual or group requesting such special meeting and shall be distributed at the time of the notice of such meeting.Rules of OrderParliamentary Procedure Formal rules of order may be used as a reference in the discretion of the presiding officer for the meeting. Rather, specific provisions of these Bylaws and Medical Staff, Department or Committee custom shall prevail at all meetings, and the Department or Committee Chairperson shall have the authority to rule definitively on all matters of procedure.Reports, Minutes, RecommendationsMinutes, reports and recommendations from Medical Staff meetings, committee meetings and Department meetings shall be maintained in writing including electronic version in the Medical Staff Services Department. Periodic reports from Medical Staff committees, Departments and other designated groups shall be submitted to the Medical Executive Committee.Attendance RequirementsAttendance by all Members at the regularly scheduled Medical Staff, Division, Department meetings and to committees which assigned shall be strongly encouraged.(Joint Commission Standard – Medical Staff Bylaws: MS.01.0 1.01)APPOINTMENT, REAPPOINTMENT, AND CLINICAL PRIVILEGESQualifications, Conditions, and ResponsibilitiesQualifications for Membership:GeneralAll persons practicing medicine, podiatry and dentistry at the Hospital, as well as all Regional Medical Staff Members providing patient care services in a Nemours Delaware Valley facility and all Affiliate Professionals performing certain independent services, unless excepted by specific provisions of these Bylaws, must first have been appointed as Members of the Medical Staff. Membership on the Medical Staff is a privilege that shall be extended only to professionally competent individuals who continuously meet the qualifications, standards, and requirements set forth in this Article and in such policies as are adopted from time to time by the Managers, the Medical Executive Committee, or designated committees. All processes described in this Article shall be subject to the confidentiality provisions described in Article 1.C.When determination to provide an application is based on the Hospital’s needs or its non-exclusive ability to provide the facilities, beds, and support staffing/services, consideration will be given, or as otherwise provided by law, to utilization patterns, and actual and planned allocations of physical, financial, and human resources, to general and specialized clinical and support services, and to the Hospital’s specific goals and objectives as reflected in the Hospital’s short and long-range plans. It is recognized that some patient-care services at the Hospital may be provided exclusively by a limited number of Practitioners selected by the Hospital who have been properly processed and granted Medical Staff membership and/or Clinical Privileges.Specific Eligibility Qualifications:Only Physicians, Podiatrists, Dentists, and Affiliate Professionals who satisfy all of the following conditions shall be qualified for membership on the Medical Staff and to be granted Clinical Privileges:Have a current unrestricted license to practice in the state which care is provided and have a Drug Enforcement Administration (DEA) license and a Delaware Controlled Dangerous Substance (CDS) registration, if requirements for the required Clinical Privileges (see also the criteria for membership on the Regional Medical Staff);Are able to provide continuous care to their patients or to arrange for other Members to provide care for patients in their absence;Possess current, valid professional liability insurance coverage in such form and in amounts satisfactory to the Hospital and in accordance with the requirements of the State in which care is provided and can demonstrate acceptable professional medical liability history;Have successfully completed an approved residency training program, or comparable training program for their specialty in the case of the Affiliate Professionals, in the specialty in which the applicant seeks Clinical Privileges (this requirement shall be applicable only to those individuals who apply for initial Medical Staff membership and Clinical Privileges on or after the date these Bylaws are adopted);Within six (6) years of joining Nemours, are certified by the appropriate specialty board, unless such requirement is waived by the Managers upon recommendation of the Chief Medical Officer in exceptional cases after considering the Hospital’s needs and the specific competence, training, and experience of the individual in question;Can document to the satisfaction of the Managers their:Background, experience, training, and current clinical competency including medical/clinical knowledge, technical and clinical skills, and clinical judgment, and an understanding of the contexts and systems within which care is provided, through peer references and former or current employer references;Adherence to the ethics of their profession, continuous professional development, and understanding of and sensitivity to diversity, and responsible attitude toward patients and their profession;Good reputation and character, including the ability to exercise the Clinical Privileges requested and to perform the duties and responsibilities of membership; andAbility to work harmoniously with others, including, but not limited to, interpersonal and communication skills sufficient to enable them to maintain professional relationships with patients, families and other members of health care teams, sufficiently to convince representatives of the Hospital, including, but not limited to (1) the Department Chairperson, (2) members of the Credentials Committee, and (3) members of the Medical Executive Committee, that all patients treated by them at the Hospital will receive quality care and that the Hospital will be able to operate in an orderly manner; andUnless waived by the Managers, in their sole discretion, have never been convicted of a felony or misdemeanor involving moral turpitude or excluded from participation in Medicare, Medicaid or any other government-sponsored reimbursement program, or any other private or public medical insurance program.Waiver of CriteriaA Division Chief or a Department Chairperson may recommend that certain criteria be waived. Such request for waiver shall be made to the Chief Medical Officer and shall include the rationale for such request. The Chief Medical Officer, if he concurs, shall make the request for waiver to the Credentials Committee, the Medical Executive Committee and the Board of Managers. Such waivers will be limited to exceptional circumstances. Review of a request for waiver shall include consideration of the specific qualifications of the individual in question, input from the relevant Department Chairperson or Division Chief, and the best interest of the Hospital and the communities it serves. No individual shall be entitled to a waiver or to a hearing if the Managers determine not to grant a waiver. A determination that an individual is not entitled to a waiver is not a “denial” of appointment or Clinical Privileges. The granting of a waiver in a particular case is not intended to set a precedent for any other individual or group of individuals.No Entitlement to MembershipNo individual shall be entitled to membership on the Medical Staff or to the exercise of particular Clinical Privileges merely by virtue of the fact that such individual:Is licensed to practice a profession in Delaware or any other state;Is a member of any particular professional organization;Has had in the past Medical Staff membership at the Hospital;Resides in the geographic service areas of the Hospital; orIs board certified by a specialty board.Nondiscrimination PolicyNo individual shall be denied membership on the basis of sex, race, religion, color or national origin, sexual orientation, or on the basis of any criteria unrelated to the delivery of quality patient care at the Hospital, to professional qualifications, or to the Hospital’s purposes, needs, and capabilities.(Joint Commission - Medical Staff Credentialing and Privileging MS: 06.01.01)Limitation of Privileges and MembershipNotwithstanding the foregoing and as set forth below, the Managers, in their sole discretion, shall have the authority to limit Medical Staff membership and privileges in any Division or Department in order to manage quality of care, patient safety, efficiency, or the effective operation of the Hospital.General Conditions of Appointment and ReappointmentBasic Responsibilities and Requirements for Applicants and MembersAs a condition of consideration of an application for Medical Staff membership, and as a condition of continued Medical Staff membership, if granted, every applicant and Member specifically agrees to the following:To provide appropriate continuous care and supervision to all patients within the Hospital for whom the individual has responsibility or arrange for coverage of such patients by Members with appropriate Clinical Privileges;To abide by all Bylaws, Medical Staff Rules and Regulations, and policies and procedures of the Medical Staff, Departments, Divisions and Hospital, as shall be in force during the time the individual is a Member of the Medical Staff;To accept committee assignments and such other reasonable Medical Staff duties and responsibilities as shall be assigned;To provide to the Credentials Department, with or without the need for request, new or updated information, as it arises, that is pertinent to any question on the application form;To attest that the applicant has had an opportunity to read copies of these Bylaws and the Policies and Procedures as are in force at the time of application and agrees to be bound by the terms hereof and thereof in all matters relating to consideration of the application without regard to whether or not membership to the Medical Staff and/or Clinical Privileges are granted;To appear, if requested, for personal interviews in regard to the application;That any misrepresentation or misstatement in or omission from the application, whether intentional or not, shall constitute cause for immediate cessation of the processing of the application and that no further processing shall occur until further clarification is received. In the event that a membership has been granted prior to the discovery of such misrepresentation, misstatement or omission, such discovery may be deemed by the Managers to constitute grounds for the automatic relinquishment of Clinical Privileges and Medical Staff membership. In either situation, there shall be no entitlement to hearing or appeal rights as set forth in these Bylaws;To use the Hospital and its facilities sufficiently for the category of Medical Staff membership or otherwise to allow the Hospital, through assessment by appropriate Medical Staff Committees and Departments, to evaluate in a continuing manner the current competence of the Member;Maintain an ethical practice by refraining from illegal fee splitting or other illegal inducements relating to patient referral;Maintain responsibility for the care of patients at all time and refrain from delegating responsibility for diagnosis or care of hospitalized patients to any individual who is not qualified to undertake this responsibility or who is not adequately supervised; To refrain from deceiving patients or their parents or guardians as to the identity of an operating surgeon or any other individual providing treatment or services;To seek consultation whenever necessary and as mandated by Medical Staff policy;To examine his/her inpatients on a daily basis and to document the same or his/her practitioner designee To notify promptly the Chief Executive Officer or his designee and the Chairperson of the Medical Executive Committee of any change in eligibility for payments by third-party payers or for participation in Medicare, Medicaid or any other government reimbursement program, including any sanctions imposed or recommended by the federal Department of Health and Human Services, and/or the receipt of a Quality Improvement Organization (QIO) citation and/or quality denial letter concerning alleged quality deficiencies in patient care;To abide by generally recognized ethical principles applicable to the applicant’s profession;To participate in monitoring and evaluation activities, as requested;To complete in a timely manner the medical and other required records (inpatient and outpatient) for all patients as required by the Bylaws, Rules and Regulations, Policies and Procedures, and other applicable policies of the Hospital;To complete a relevant history and physical examination upon each patient under his/her care. A medical history and physical examination (H& P) must be performed and documented by a Physician, Oral Surgeon, or other qualified licensed individual (as identified in State law and Medical Staff Policies and Procedures), no more than 30 days before or 24 hours after admission or registration for specific outpatient procedures as defined in the Medical Staff policies, but in all cases prior to surgery or a procedures requiring anesthesia services. If the H& P is performed within 30 days prior to the patient’s admission or registration for specific outpatient procedures, a physician, Oral Surgeon, or other qualified licensed individual must complete and document an updated examination of the patient, including any changes in the patient’s condition, with 24 hours after the patient’s admission or registration, but in all cases prior to surgery or a procedure requiring anesthesia services. To work cooperatively and professionally with Medical Staff members, Medical Staff leadership, nurses, and other Hospital personnel;To participate in appropriate continuing-education programs (both for his own benefit and for the benefit of other professionals and personnel);To satisfy appropriately the continuing medical education requirements for Medical Staff membership and licensure;To immediately notify the Chief Executive Officer or his designee of any reduction or change in malpractice insurance coverage;To authorize the release of all information necessary for an evaluation of the applicant’s qualifications for initial or continued membership, reappointment and/or Clinical Privileges;To exhaust all hearing and appeal procedure remedies set forth in these Bylaws with respect to any professional review action taken before resorting to legal action. If the individual takes legal action notwithstanding the provisions of these Bylaws and does not prevail, that person shall reimburse the Hospital, the Medical Staff and/or any Medical Staff members named in the action for all costs incurred in defending such legal action, including reasonable attorneys’ fees;To participate in the Hospital’s Compliance Program;To participate in “on-call” coverage as required by the Medical Staff Division or Department. To inform the Medical Executive Committee via the Medical Staff Affairs Office of any professional liability claims or suits, changes in medical staff membership (voluntarily or involuntarily) or privileges at any other hospital or health care organization, or any disciplinary action at any other hospital or health care organization at which the applicant has privileges; complaints to federal or state agencyTo satisfy such minimum standards for clinical activity at the Hospital as may be established for each category of Medical Staff membership by the Medical Executive Committee and approved by the Managers from time to time;To abide by all principles and codes pertinent to the applicant’s training, including, but not limited to, the Principles of Medical Ethics of the American Medical Association, the Code of Ethics of the American Dental Association, or the Code of Ethics of the American Board of Osteopathy, as well as all Hospital and Medical Staff Rules and Regulations and policies and all federal, state, and local laws, rules and regulations; andTo abide by any Medical Staff or Hospital policies regarding conduct and behavior.(Joint Commission -Medical Staff Bylaws: MS 01.01.01, Medical Staff Oversight of Care, Treatment, and Services MS 03.01.01)Burden of Providing InformationIndividuals seeking appointment and reappointment have the burden of producing information deemed adequate by the Hospital for a proper evaluation of current competency, character, ethics, and other qualifications, and for resolving any doubts.Individuals seeing appointment and reappointment have the burden of providing evidence that all statements made and information given on the application are accurate and complete.An application shall be complete when all questions on the application form have been answered, all supporting documentation has been supplied, and all information has been verified from primary sources. An application shall become incomplete if the need arises for new, additional, or clarifying information at any time. Any application that continues to be incomplete sixty (60) days after the individual has been notified of additional information required shall automatically be deemed to have been withdrawn.The individual seeking appointment or reappointment is responsible for providing a complete application, including adequate responses from references. An incomplete application will not be processed.ApplicationInformationRequests for applications for membership on the Medical Staff shall be in writing to the Credentialing Department. Applications for membership shall be submitted on forms approved by the Credentialing Department. The application shall contain a request for specific Clinical Privileges desired by the applicant and shall contain detailed information concerning the applicant’s professional qualifications, including, but not limited to:The names and complete addresses of at least three (3) Physicians, Podiatrists, Dentists, or other health-care providers in the same discipline as appropriate, who have had recent extensive experience in observing and working with the applicant and who can provide adequate information pertaining to the applicant’s present professional competence and character. References may not be from individuals about to be associated with the applicant in professional practice or personally related to the applicant. At least one (1) reference shall be from the same specialty area as the applicant’s;The names and complete addresses of the chairperson/chief of each department/division of any and all hospitals or other institutions at which the applicant has ever worked or trained (i.e., the individuals who served as chairpersons/chiefs at the time the applicant worked in the particular department);Information as to whether the applicant’s medical staff membership or clinical privileges have ever been voluntarily or involuntarily relinquished, withdrawn, denied, revoked, suspended, subjected to probationary or other conditions, reduced, or not renewed at any other hospital or health care facility;Information as to whether the applicant has ever voluntarily or involuntarily withdrawn an application for membership, reappointment, or clinical privileges, or resigned from the medical staff before final decision on such application by a hospital’s or other health care facility’s governing body;Information as to whether the applicant’s license to practice any profession in any state or the applicant’s DEA license or Delaware CDS registration (if applicable) is or has ever been voluntarily or involuntarily suspended, modified, terminated, restricted, or had any previously successful or currently pending challenges. The submitted application shall include a list or copy of all the applicant’s current licenses to practice, as well as copies of the applicant’s DEA license and Delaware CDS registration (if applicable);Information as to whether the applicant has currently in force professional liability insurance coverage in accordance with the requirements of the State of Delaware or other states in which the applicant will practice on behalf of Nemours, the name of the insurance company, and the amount and classification of such coverage and whether said insurance covers the Clinical Privileges the applicant seeks to exercise at the Hospital;Information concerning the applicant’s present and past professional liability litigation experience, pending matters, litigation, final judgments, or settlements, including: (i) the substance of the allegations, (ii) the findings, (iii) the ultimate disposition, and (iv) and additional information concerning such proceedings or actions as the Credentials Committee or Managers may deem appropriate. The history of the applicant’s malpractice verdicts and the settlement of malpractice claims, as well as pending claims, will be evaluated as criteria for membership, reappointment, and the granting of Clinical Privileges. However, the mere presence or absence of verdicts, settlements, or claims shall not, in and of themselves, be sufficient to grant or deny membership or particular Clinical Privileges. The evaluation shall consider the extent to which verdicts, settlements or claims evidence a pattern of care that raises questions concerning the individual’s clinical competence, or whether a verdict, settlement, or claim, in and of itself, represents such deviation from standard medical practice as to raise overall questions regarding the applicant’s clinical competence, skill in the particular Clinical Privilege, or general behavior, or indicates that there is a substantial possibility that the applicant, if granted Clinical Privileges, could harm the reputation and standing of the Hospital or the Medical Staff;Information concerning any professional misconduct proceedings involving the applicant in Delaware or any other state, whether such proceedings are closed, in process, or still pending;Information concerning the suspension or termination for any period of time of the right or privilege to participate in Medicare, Medicaid, and any other government sponsored program, or any private or public medical insurance program, and information as to whether the applicant is currently under investigation by any such program;Current information regarding the applicant’s ability to exercise the Clinical Privileges requested and to perform the duties and responsibilities of Medical Staff membership with or without accommodation;Information as to whether the applicant has ever been named as a defendant in a criminal action and/or convicted of a felony or a misdemeanor involving moral turpitude, including details about any such instance;Information regarding any history of substance abuse or substance-related issues;A complete chronological listing of the applicant’s professional and education training, memberships, employment, and positions;Information on the citizenship and, if applicable, visa status of the applicant; andThe applicant’s signature and such other information as the Credentials Committee or the Managers may require.(Joint Commission - Medical Staff Credentialing and Privileging MS 06.01.03)Grant of Immunity and Authorization to Obtain/Release InformationThe following statements, which shall be included on the application form and which form a part of these Bylaws, are express conditions applicable to any Medical Staff applicant, any Member of the Medical Staff, and to all others having or seeking Clinical Privileges at the Hospital. By applying for membership, reappointment, or Clinical Privileges, the applicant or Member expressly accepts these conditions during the processing and consideration of the application, whether or not membership or Clinical Privileges are granted. This acceptance also applies during the time of any membership of reappointment.ImmunityTo the fullest extent permitted by applicable law, the applicant or Member releases from any and all liability, extends immunity to, and agrees not to sue the Hospital, its affiliated entities, the Medical Executive Committee, the Medical Staff, their authorized representatives (specifically including individual Medical Staff Members), the Chief Executive Officer, the Managers, and appropriate third parties, with respect to any acts, communications or documents, recommendations or disclosures involving the applicant or Member concerning the following:Applications for membership or Clinical Privileges, including temporary privileges;Evaluations concerning reappointment or changes in Clinical Privileges;Proceedings for suspension or reduction of Clinical Privileges or for revocation of Medical Staff membership, or any other disciplinary sanction;Precautionary suspension;Hearings and appellate reviews;Medical care evaluations;Utilization reviews;Other activities relating to the quality of patient care or professional conduct;Matters or inquiries concerning the applicant’s or Member’s professional qualifications, credentials, clinical competence, character, mental or emotional stability, physical condition, ethics or behavior; andAny other matter that might directly or indirectly relate to the applicant’s or Member’s competence or patient care, or to the orderly operation of the Hospital.Authorization to Obtain InformationThe applicant or Member specifically authorizes the Hospital, the Medical Staff and their authorized representatives to consult with any third party who may have information bearing on the individual’s professional qualifications, credentials, clinical competence, character, mental or emotional stability, physical condition, ethics, behavior, or any other matter reasonably having a bearing on the applicant’s or Member’s satisfaction of the criteria for initial and continued membership on the Medical Staff. The applicant or Member also specifically authorizes said third parties to release said information to the Hospital, the Medical Staff, and their authorized representatives upon request.Authorization to Release InformationThe applicant or Member specifically authorizes the hospital, the Medical Staff, and their authorized representatives to provide any requesting facilities with any and all information and documentation that the requesting facility may request regarding the applicant’s or Member’s professional qualifications. This authorization specifically includes, but is not limited to, any and all information and documentation relating to the clinical competency, professional conduct, and/or any peer review activities involving the applicant and/or Member during his tenure on the Medical Staff of the Hospital.The applicant or Member agrees to extend absolute immunity to, release from any and all liability, and agree not to sue the Hospital or any of its representatives for providing the above information and documentation, and for any action that may result from the provision of that information and documentation.Procedure for Initial Appointment to the Medical StaffThe Medical Staff through the Credentials Committee shall consider each application for appointment or reappointment to the Medical Staff and/or for Clinical Privileges and each request for modification of Medical Staff category or Clinical Privileges, utilizing resources of the Credentialing Department and Medical Staff Affairs Department to investigate and validate the contents of each application, before adopting and transmitting its recommendations to the Medical Executive Committee and the Board of Managers.Previously Denied or Terminated Applicants: Notwithstanding any other provision of these Bylaws, if an application is tendered by an applicant who has been previously denied Medical Staff membership and/or Clinical Privileges, or who has had Medical Staff membership and/or Clinical Privileges terminated, or whose prior application was deemed incomplete and withdrawn, and it appears that the application is based on substantially the same information as when previously denied, terminated, or deemed withdrawn, then the application shall be deemed insufficient by the Credentials Committee and returned to the applicant as unacceptable for processing. No such application shall be processed, and no right to hearing or appeal shall be available in connection with the return of such application. An individual who has previously resigned or voluntarily relinquished their privileges while under good standing from the medical staff or who has resigned or voluntary relinquished privileges for failure to complete proctoring and/or provisional status may reapply and will be subject to processing of the application as a new applicant and subject to the terms and conditions set forth in these Bylaws for new applicants.A Medical Staff Member may at any time request a change in Medical Staff category, Department affiliation or Clinical Privileges by submitting a written application to the Medical Staff Affairs Department. Such application shall be processed in substantially the same manner as an application for initial appointment.Pre-Credentialing Process. Request for ApplicationAn application form for membership to the Medical Staff shall only be sent upon request to those individuals (i) who are eligible to apply for membership and Clinical Privileges in a specialty area; (ii) who, according to these Bylaws and this Article are eligible for membership and Clinical Privileges because they meet the threshold criteria for membership and Clinical Privileges consideration; (iii) who desire to provide care and treatment to patients for conditions and diseases for which the Hospital has facilities and personnel; and (iv) who indicate an intention to utilize the Hospital as required by the Medical Staff category in which the applicant desires membership. (according to credentialing policy) Those individuals who meet the threshold criteria for consideration for membership on the Medical Staff and Clinical Privileges shall be given an application form. Individuals who fail to meet these criteria shall not be given an application form and shall be notified that they are ineligible to apply. Submission of ApplicationThe completed application for Medical Staff membership shall be submitted by the applicant to the Credentialing Department within thirty (30) days of the applicant’s receipt of the application form. After reviewing the application to determine that all questions have been answered, reviewing all references and other information or materials deemed pertinent, querying the national Practitioner Data Bank (NPDB) and such other information sources as may be legally required, and verifying the information with the primary sources, the Credentialing Department or its designee shall transmit the complete application and all supporting materials to the appropriate Division Chief. In the absence of a Division Chief, the application and all supporting materials will be transmitted to the appropriate Department Chairperson.An application shall be deemed to be complete when all questions on the application form have been answered in full, the application fee, if any, has been paid, all supporting documentation has been supplied, and all information verified from acceptable primary sources. An application shall become incomplete if the need arises for new, additional, or clarifying information any time during the evaluation. Any application that continues to be incomplete sixty (60) days after the applicant has been notified of the additional information or documentation required shall be deemed to have been withdrawn. It is the responsibility of the applicant to provide a complete application, including adequate responses from references. An incomplete application will not be processed.The applicant must immediately report to the Credentialing Department any change in the information in the application that occurs after the application has been submitted.If an applicant supplies information in the application process that contains any significant misrepresentation or omission, this may be grounds for denial of the application, or if membership or privileges have been granted, for automatic relinquishment per Section B.1.g of this Article. (According to Credentialing Policy) Division Chief ProcedureThe appropriate Division Chief shall evaluate the applicant’s education, training, and experience and may make inquiries to the applicant’s past or current department chairpersons or division chief(s), residency training director, or others who may have knowledge about the applicant’s education, training, experience, ability to exercise the privileges requested and ability to work with others if the documentation supporting the application is not sufficient. The Division Chief may interview the applicant and shall do so in any case where the Division Chief has any reservation as to whether the application should be approved.The appropriate Division Chief shall provide a written recommendation to the appropriate Department Chairperson within ten (10) business days of receipt of the application materials (or of the interview of the applicant, if conducted by the Division Chief) concerning the applicant’s qualifications for membership and requested Clinical Privileges.c) The Division Chief shall be available to the Credentials Committee to answer any questions that may be raised with respect to the Division Chief’s evaluation or recommendation.d) The Division Chief is responsible for investigating and resolving questions or concerns relative to the application, and support membership to the Department Chair, Credentials Committee, Medical Executive Committee and Managers. e) The Division Chief will cooperate with the Director of a Service Line to support an applicant who is being recruited for an appointment to the Medical Staff. Department Chairperson ProcedureThe completed application, request for Clinical Privileges, and the recommendation of the Division Chief shall be reviewed by the Department Chairperson. At any time during this process, the Department Chairperson may interview the applicant. The Department Chairperson shall provide a written recommendation to the Credentials Committee within ten (10) business days of the receipt of the material from the Division Chief (or of the interview of the applicant, if conducted by the Department Chairperson). The Department Chairperson shall be available to the Credentials Committee, Physician in Chief, and Hospital Medical Director to answer any questions that may be raised with respect to the Department Chairperson’s recommendation.Hospital Medical Director ProcedureThe Hospital Medical Director shall review the completed application, request for Clinical Privileges and the recommendations of the Division Chief and Department Chairperson. The Hospital Medical Director may interview the applicant at any time during this process and shall provide a written recommendation to the Credentials Committee within ten (10) business days of the receipt of the material from the Department Chairperson (or of the interview if conducted by the Hospital Medical Director). The Hospital Medical Director shall be available to the Credentials Committee and Medical Executive Committee to answer any questions that may be raised with respect to the Hospital Medical Director’s recommendation.Credentials Committee ProcedureThe Credentials Committee shall examine the completed application, the supporting information and materials, the recommendations of the Division Chief, the Department Chairperson, and the Hospital Medical Director, and any other information the committee determines it needs to review in order to make its recommendation.The Credentials Committee may request and require any additional information it determines it needs in order to make its decision and may use the expertise of the Division Chief, the Department Chairperson, the Hospital Medical Director, Director of a Service Line, and any member of the Department, or an outside information source, if additional information or documentation is deemed by the Credentials Committee to be necessary regarding the applicant’s qualifications.If the recommendation of the Credentials Committee to the Medical Executive Committee is delayed longer than ninety (90) days after receipt of the Hospital Medical Director’s recommendation, the Chairperson of the Credentials Committee shall send a letter to the applicant, with a copy to the Medical Executive Committee and Chief Executive Officer, explaining the reasons for the delay.Except as provided in Section E.6.c of this Article, not later than ninety (90) days from its receipt of the recommendation of the Hospital Medical Director, the Credentials Committee shall send its recommendation and written findings in support thereof to the Medical Executive Committee. The completed application, all supporting materials, and the recommendations of the Division Chief, the Department Chairperson and the Hospital Medical Director, shall accompany the Credentials Committee’s recommendations and findings. Each recommendation shall state one (1) of the following:That the applicant be appointed to the Medical Staff;That the applicant’s application be deferred for further consideration until any additional information or documentation the Committee deems necessary is provided; or That the application be rejected for Medical Staff membership.When the Credentials Committee recommends membership to the Medical Staff, it shall also make specific recommendation regarding the Clinical Privileges to be granted and any limitations or conditions on the membership or such privileges.The Chairperson of the Credentials Committee shall be available to the Hospital Medical Director, Medical Executive Committee, and to the Managers to answer any questions that may be raised with respect to the Credentials Committee’s recommendation.Medical Executive Committee ProcedureAt its next regular meeting after receipt of the written findings and recommendation of the Credentials Committee, the Medical Executive Committee shall recommend one of the following:That the applicant be appointed to the Medical Staff;That the applicant’s application be deferred for further consideration until any additional information or documentation the Medical Executive Committee deems necessary is provided; orThat the applicant be rejected for Medical Staff membership.The Medical Executive Committee may use the expertise of the Department Chairperson, any member of the Department, or an outside information source if additional information is deemed by the Committee to be necessary regarding the applicant’s qualifications.If the recommendation of the Medical Executive Committee is favorable to the applicant, it shall transmit to the Managers its recommendation together with the application and all supporting materials (which shall be available to the Managers at all times during the Managers’ consideration of the application, including specific recommendations of the Clinical Privileges to be granted, which may be qualified by any probationary or other conditions or restrictions relating to such privileges).If the recommendation of the Medical Executive Committee would entitle the applicant to request a hearing pursuant to Article IV of these Bylaws, the application, supporting materials, and recommendations shall be forwarded to the Chief Executive Officer who shall promptly notify the applicant in writing, certified mail, return receipt requested, of the Medical Executive Committee’s recommendation and of the applicant’s rights under Article IV. The Chief Executive Officer shall then hold the application until after the applicant has exercised or waived the right to a hearing as provided in these Bylaws or the time period for exercising such right has expired without the applicant’s exercise of such right, after which the Chief Executive Officer shall forward the recommendation of the Medical Executive Committee, together with the complete application and all supporting documentation, to the Managers for further action.(Joint Commission -Medical Staff Structure and Role of Medical Executive Committee MS 02.01.01)Managers ProcedureUpon receipt of a recommendation from the Medical Executive Committee, the Managers may:Favorable recommendation to grant membership and requested clinical privileges:Appoint the applicant and grant Clinical Privileges as recommended and notify the applicant of the appointment and the Clinical Privileges granted; orDetermine that the applicant’s application be deferred until any additional information or documentation the Managers deem necessary is provided by referring the matter back to the Medical Executive Committee, the Credentials Committee or the Department Chairperson for additional research or information. The Medical Executive Committee or Credentials Committee may elect to refer the matter to another source inside or outside the Hospital for additional research or information; or Determine to reject the application; in such case, that determination and the reasons in support thereof, shall be sent to the Chief Executive Officer, who shall promptly notify the applicant in writing of the Managers’ determination, certified mail, return receipt requested. The Managers shall make no final decision until the applicant has exercised or waived the right to a hearing and appeal as outlined in Article IV of these Bylaws, if applicable. If the decision of the Managers would entitle the applicant to request a hearing pursuant to Article IV of these Bylaws, the applicant shall be notified by the Chief Executive Officer of the applicant’s rights under Article IV.Unfavorable recommendation from the Medical Executive Committee followed by the applicant’s waiver of the rights to a hearing before the Medical Executive Committee as provided in these Bylaws or the expiration of the time period in which the applicant may exercise such right without the applicant’s exercise of such right:Determine that the applicant’s application be deferred until any additional information or documentation the Managers deem necessary is provided by referring the matter back to the Medical Executive Committee, the Credentials Committee or the Department Chairperson for additional research or information. The Medical Executive Committee or Credentials Committee may elect to refer the matter to another source inside or outside the Hospital for additional research or information; orDetermine to reject the application; in such case, that determination and the reasons in support thereof, shall be sent to the Chief Executive Officer, who shall promptly notify the applicant in writing of the Managers’ determination, certified mail, return receipt requested. The Managers shall make no final decision until the applicant has exercised or waived the right to a hearing and appeal as outlined in Article IV of these Bylaws, if applicable. If the decision of the Managers would entitle the applicant to request a hearing pursuant to Article IV of these Bylaws, the applicant shall be notified by the Chief Executive Officer of the applicant’s rights under Article IV.(Joint Commission Standard – Credentialing and Privileging: MS.06.0 1.01, MS 06.01.03, MS 06.01.05, MS 06.01.07, MS 06.01.09, MS 06.01.11, MS 06.01.13, and Appointment to Medical Staff: MS 07.01.01, MS 07.01.03)) (Joint Commission Standard – Medical Staff Credentialing and Privileging: MS.06.0 1.01, MS 06.01.03, MS 06.01.05, MS 06.01.07, MS 06.01.09, MS 06.01.11, MS 06.01.13, and Appointment to Medical Staff: MS 07.01.01, MS 07.01.03)Provisional StatusNature of Provisional StatusThe Medical Staff has designated the first twelve (12) months of an initial appointment and the initial granting of Clinical Privileges as a provisional period for the purpose of meeting its obligations to the Medical Staff, the Hospital and the community to ensure that practitioners appointed to the Medical Staff and/or Granted Clinical privileges are qualified and competent to provide same.Focused Professional Practice EvaluationEach newly appointed Practitioner, and each current Medical Staff Member who is granted new privileges, is subject to focused professional practice evaluation. This evaluation will be carried out by the Division Chief and/or Department Chairperson with the input of the Service Line Director during the twelve (12) months of the provisional appointment and will assess technical and clinical skills, clinical judgment, medical/clinical knowledge, interpersonal and communication skills, and professionalism. Focused professional practice evaluation may be carried out through any or a combination of the following methods: chart review, monitoring of clinical practice patterns, use of simulation, external peer review, multidisciplinary case discussions, and proctoring. Specific operational details shall be defined in the Medical Staff Policies and Procedures.The period of focused professional practice evaluation may be extended for one 12-month period at the request of the Division Chief and/or Department Chairperson with the input of the Service Line Director. Duration of Initial Provisional MembershipAll initial memberships to the Medical Staff (regardless of the category of the Staff to which the membership is made), and all initial granting of Clinical Privileges, shall be provisional for a period of twelve (12) months.During the term of this provisional membership, the Member shall be evaluated by the appropriate Department Chairperson, by the Chief of the Division and the Service Line Director to which the Member is assigned, and by the relevant committees of the Medical Staff as to the Member’s clinical competence and general behavior and conduct.Continued membership and/or Clinical Privileges after the provisional period shall be conditioned on an evaluation of the factors to be considered for reappointment as set for the Article III.H.Duties of Provisional MembersProvisional membership on the Medical Staff shall require that each Member assume such reasonable duties and responsibilities as the Medical Staff shall require.During the provisional period, a Member (i) must demonstrate all of the qualifications, (ii) may exercise all of the prerogatives, and (iii) must fulfill all of the responsibilities attendant to his Medical Staff category as outlined in Article II.A (Categories of the Medical Staff).During a Member’s provisional period, the Member shall satisfy any requirement for orientation and shall comply with any Medical Staff policy concerning orientation, as may exist from time to time.Each Member must arrange for, or cooperate in the arrangement for, the required numbers and types of cases to be reviewed/observed by proctors as designated by the appropriate Division Chief or Department Chairperson and Service Line Director. Failure of a provisional Member during the provisional period to admit, treat or attend to the number of patients designated by the appropriate Division Chief or Department Chairperson according to the Medical Staff membership category of the provisional Member (sufficient to permit observation and assessment), or failure of the Member during the provisional period to fulfill all requirements of membership related to meeting attendance, completion of medical records, and/or cooperation with monitoring or proctoring conditions, as outlined in this Article, shall render the provisional Member ineligible to apply for reappointment. In that event, at the expiration of the provisional membership period, all Clinical Privileges shall be relinquished and the individual shall be given written notice of such action and of the procedural right of a hearing as specified in these Bylaws. The Division Chief and/or the Department Chairperson, with consideration of any recommendation of the Service Line Director may request waiver of this section with the approval of the Department Chairperson and the Medical Director in those instances where the services of the provisional Member are necessary to support the mission of the Hospital but whose frequency of clinical activity does not lend itself to fulfillment of the requirements of this Section.(Joint Commission Standard –Medical Staff Evaluation of Practitioners: MS.08.01.01, MS 08.01.03)Clinical PrivilegesExercise of Clinical PrivilegesEvery Practitioner providing direct clinical services, including, but not limited to, Telemedicine services, at the Hospital by virtue of Medical Staff membership or otherwise, shall, in connection with such practice, and except as provided in Sections 3 and 4 below, be entitled to exercise only those Clinical Privileges specifically granted to him by the Board of Managers. The inpatient privileges must be within the scope of the license authorizing the practitioner to provide care in Delaware. Regardless of the privileges granted, each Practitioner must obtain consultation when necessary for the safety of his patients or when required by these Bylaws, the Medical Staff and Department policies and procedures or other policies of the Medical Staff and the Hospital. Only those health care professionals with appropriate licenses and Clinical Privileges may evaluate the significance of medical histories, authenticate medical histories, perform and record physical examinations and prescribe treatments.The granting of Clinical Privileges shall carry with it acceptance of the obligations of such privileges, including obligations established by these Bylaws, , Medical Staff Policies and Procedures and Department requirements, if any are applicable, to fulfill the Hospital’s responsibilities under the Emergency Medical Treatment and Active Labor Act and/or other applicable requirements, laws, and standards.Clinical Privileges shall be voluntarily relinquished only in the manner that provides for the orderly transfer of such obligations.Practitioners requesting privileges at the Ambulatory Surgical Center must be appropriately licensed and credentialed. Unavailable Clinical PrivilegesNotwithstanding any other provisions of these Bylaws, to the extent that any requested Clinical Privileges are not available at the Hospital (whether because of a closed service, lack of facilities, policy decision of the Board of Managers, or otherwise), the request shall not be processed. Because such a determination is unrelated to the applicant’s qualifications, an applicant whose request is so rejected shall not be entitled to the hearing and appeal rights set forth in these Bylaws.Clinical Privileges for Dentists and Oral SurgeonsThe scope and extent of surgical procedures that a Dentist or an Oral Surgeon may perform at the Hospital shall be delineated and recommended in the same manner as other Clinical Privileges by the Chairperson of the Department of Surgery.Surgical procedures performed by Dentists or Oral Surgeons shall be under the overall supervision of the Chairperson of the Department of Surgery, or his designee. A medical history and physical examination of each patient shall be made and recorded by a Physician, other license independent practitioner or Oral Surgeon who holds membership on the Medical Staff before dental surgery may be performed, and a designated Physician, consulted by the Dentist or Oral Surgeon, shall be responsible for the medical care of the patient throughout the period of hospitalization. However, Oral Surgeons who admit patients without medical problems may perform the medical history and physical examination of those patients if they have such privileges and may assess the medical risks of the proposed operative and/or other invasive procedure.The Dentist or Oral Surgeon shall be responsible for the dental care of the patient, including the dental history and dental physical examination, as well as all appropriate elements of the patient’s record. Dentists and Oral Surgeons may write orders within the scope of their licenses and consistent with the Medical Staff Policies and Procedures, and in compliance with these Bylaws.Clinical Privileges for PodiatristsThe scope and extent of surgical procedures that a Podiatrist may perform at the Hospital shall be delineated and recommended in the same manner as other Clinical Privileges by the Chairperson of the Department of Orthopedic Surgery.Surgical procedures performed by Podiatrists shall be under the overall supervision of the Chairperson of the Department of Orthopedic Surgery. A medical history and physical examination should be made and recorded in the medical record by a Physician who holds membership, or other licensed independent practitioner on the Medical Staff before podiatric surgery shall be performed, and a designated Physician shall be responsible for the medical care of the patient throughout the period of hospitalization.The Podiatrist shall be responsible for the podiatric care of the patient, including the podiatric history and the podiatric physical examination, as well as all appropriate elements of the patient’s record. Podiatrists may write orders within the scope of their Clinical Privileges and licenses, consistent with the Medical Staff Policies and Procedures, and in compliance with these Bylaws.Clinical Privileges for New ProceduresRequests for Clinical Privileges for new procedures and/or the use of new technology shall be referred to the Credentials Committee, which shall evaluate the request according to the Committee’s operational guidelines.Criteria for Clinical PrivilegesClinical Privileges and the development of the criteria for granting such privileges shall follow the process outlined below:Each Department Chairperson shall recommend to the Medical Executive Committee written criteria for granting Clinical Privileges consistent with Medical Staff policies.The Clinical Privileges recommended by the Medical Executive Committee to the Managers shall be based upon consideration of the following:The applicant’s education, training, experience, demonstrated current clinical competence and judgment, including medical/clinical knowledge, technical and clinical skills, clinical judgment, interpersonal and communication skills, and professionalism with patients, families and other members of the health care team and peer evaluations related to the same, references, utilization patterns, and ability to perform privileges required;The applicant’s ability to meet all current criteria for the requested Clinical Privileges;Availability of qualified physicians or other appropriate Members to provide medical coverage for the applicant in case of the applicant’s illness or unavailability;Adequate levels of professional liability insurance coverage as required by the Hospital with respect to the Clinical Privileges requested;The Hospital’s available resources and personnel;Any previously successful or currently pending challenges to any licensure or registration, or the voluntary relinquishment of any such licensure or registration;Any information concerning professional review actions, voluntary or involuntary termination of medical staff membership, or voluntary or involuntary limitation, reduction, or loss of clinical privileges at another health care facility; andOther relevant information, including a written report and findings by the Chairperson of each of the Departments in which such privileges are sought.In recommending such criteria, the Department Chairperson and the Credentials Committee shall conduct any necessary research and may consult with experts, both those on the Medical Staff and those outside the Hospital, and develop recommendations regarding (i) the minimum education, training, and experience necessary to perform the privileges, and (ii) the extent of monitoring and supervision that should occur. The Department Chairperson and the Credentials Committee shall forward their recommends to the Medical Executive Committee. The Medical Executive Committee shall review the criteria and forward all recommendations to the Managers for final action.The Managers shall then approve, disapprove, or modify the minimum criteria and qualifications necessary to be able to perform the privileges.(Joint Commission -Medical Staff Medical Staff Oversight of Care, Treatment and Services MS 03.01.01)Physicians-in-TrainingResidents, in conjunction with their residency programs, shall not hold membership on the Medical Staff and shall not be granted specific Clinical Privileges. Rather, they shall be permitted to function clinically only in accordance with the written position descriptions as developed by the residency training program in conjunction with the Chief Medical Officer and the Chief Executive Officer.Chief Residents may be credentialed and granted membership and privileges as part of the progression of their training during the Chief Resident year.Clinical Fellows may be eligible for core privileges. Fellows may not be granted clinical privileges in the specialty for which they are receiving training. Telemedicine PrivilegesPhysicians who provide patient care services from remote locations via telemedicine modalities, such as radiologists, will be credentialed as outlined in these Bylaws. Emergency Clinical PrivilegesDefinition – for the purposes of this Section, an “emergency” is defined as a condition that could result in serious or permanent harm to a patient and in which any delay in administering treatments would add to that harm or danger.In an emergency, a Practitioner currently appointed to the Medical Staff may be permitted by the Hospital, as granted by the Chief Medical Officer or the Chief Executive Officer or his designee, in partnership with medical staff leadership, to exercise Clinical Privileges to the extent permitted by such Practitioner’s license, regardless of that Practitioner’s Department status or specific grant of Clinical Privileges. Similarly, in an emergency, any Practitioner who is not currently appointed to the Medical Staff may be permitted by the Hospital upon the approval of the Chief Medical Officer or the Chief Executive Officer or his designee to exercise Clinical Privileges to the extent permitted by such Practitioner’s license and subject to the verification requirements, if any, in the Medical Staff Policies and Procedures.Discontinuation of Emergency Privileges – when the emergency situation no longer exists, the patient shall be assigned by the Chief Medical Officer or his designee to a Member with appropriate Clinical Privileges. The wishes of the patient shall be considered in the selection of a substitute physician.Temporary PrivilegesThe Chief Medical Officer or Chief Executive Officer or his designee may grant temporary privileges to an applicant when the applicant’s application has been approved by the Credentials Committee but is pending review and recommendation by the Medical Executive Committee and approval by the Managers. Such temporary privileges shall terminate upon the earlier of (i) sixty days from the date temporary privileges were granted, or (ii) upon action on the applicant’s application by the Managers.Disaster PrivilegesDisaster privileges may be granted when an emergency management plan has been activated and the Hospital is unable to handle immediate patient needs. During a disaster in which an emergency management plan has been activated, the Chief Executive Officer, the Chief Medical Officer (as defined in the Hospital Disaster Plan), or the President of the Medical Staff or their respective designees shall have the option to grant disaster privileges within the parameters of the Medical Staff Policies and Procedures.Procedures for reappointmentAll terms, conditions, requirements, and procedures relating to initial membership shall apply to continued membership and Clinical Privileges and to reappointment.To be eligible to apply for renewal of Clinical Privileges, a Member must (i) satisfy any appropriate Hospital criteria for the exercise of Clinical Privileges as may be developed in accordance with Article III.G.6, and (ii) have performed sufficient procedures, treatments, or therapies in the current membership term to enable the appropriate Service Line Director, Division Chief, Department Chairperson and the Credentials Committee to assess the Member’s current clinical competence for the privileges requested.Applications for ReappointmentEach current Member who is eligible to be reappointed to the Medical Staff shall be responsible for completing a reappointment application form.The reappointment process will begin six months prior to the expiration of a Medical Staff membership. The reappointment application form shall be furnished to the Member 180 days prior to the membership expiration date. Failure to submit a complete application not later than 90 days prior to the membership expiration date will result in automatic expiration of the Member’s membership and Clinical Privileges at the end of the then current term of membership. Upon expiration, such Member may submit a new application for Medical Staff membership and Clinical Privileges. The applicant for reappointment shall produce any information and documentation that the Credentials Committee requests.Reappointment to the Medical Staff and the granting, renewal, or revision of Clinical Privileges are made for a period of no more than two years. The specific staggering of reappointments shall be in a manner established by the Hospital.In the previous two appointment periods, or the previous four years, each Member of the Active Employed, Active Community, Courtesy Community and Consulting Community staff status must have had at least one (1) inpatient admission, outpatient treatment, consultation, active participation on a committee, or teaching activity. The Chief Medical Officer and the Department Chairperson may agree to make exceptions to this requirement in special circumstances.Factors to Be ConsideredTo be eligible to apply for reappointment and renewal of Clinical Privileges, regardless of category, an individual must have, during the previous appointment term, had sufficient patient contacts to enable the assessment of currently clinical judgment and competence for the privileges requested. Any individual seeking reappointment who has minimal activity at the Hospital must submit such information as may be requested (such as a copy of his confidential quality profile from his primary hospital (if applicable), clinical information from the individual’s private office practice, and/or a quality profile from a managed care organization), before the application will be considered complete and processed further.Each recommendation concerning reappointment of an individual current appointed to the Medical Staff shall be based upon the Member’s continued completion of the specific eligibility criteria and upon such Member’s:Ethical behavior, clinical competence, and clinical judgment in the treatment of patients;Participate in Division, Department and Medical staff duties as appropriate;Compliance with Medical Staff Bylaws, Policies and Procedures and other Medical Staff requirements;Behavior at the Hospital, including compliance with the Medical Staff Policies on Standards of Physician Conduct;Use of the Hospital’s facilities for patients, taking into consideration the individual’s comparative utilization patterns;Current ability to perform Clinical Privileges;Capability to treat patients satisfactorily as indicated by the results of the Hospital’s quality improvement activities or other reasonable indicators of continuing qualifications, ongoing professional practice evaluations, and other peer review activities, taking into consideration practitioner-specific information compared to aggregate information concerning other individuals in the same or similar specialty (provided that other practitioners will not be identified) and any focused professional practice evaluations;Satisfactory completion of such continuing education requirements as may be imposed by law, the Hospital, the Department, the Division, these Bylaws or applicable certification or accreditation agencies;Current professional liability insurance status and explanation of current and pending malpractice challenges, including claims, lawsuits, judgments, and settlements;Current licensure, including previously successful or currently pending challenges to any licensure or registration, or the voluntary or involuntary relinquishment of such licensure or registration;Voluntary or involuntary termination of medical staff membership or voluntary or involuntary limitation, reduction, or loss of clinical privileges at another hospital or health care facility;Evaluation from the appropriate Service Line Director, Division Chief (if applicable) and Department Chairperson;Results of a query from the national Practitioner Data Bank (NPDB), all other sanction and background checks, or any other legally mandated reference database; andMaintenance of board and sub-specialty certification or continued satisfaction of Department or Division criteria for maintaining Clinical Privileges.(Joint Commission -Medical Staff Bylaws MS 01.01.01) Division Chief ProceduresPrior to the end of each Member’s current membership period, the Division Chief shall receive all necessary reappointment materials, as appropriate, for such Member who is applying for reappointment.The Division Chief will perform the reappointment evaluations of the Members assigned to his Division.No later than thirty (30) days after receipt of an application form and all required additional materials, the Division Chief shall prepare a written report concerning each individual seeking reappointment. In preparing the report, the Division Chief will consider the criteria in Section III.H.2 and any other relevant information. The Division Chief shall include in each written report, when applicable, the reasons for any changes recommended in Staff category, in Clinical Privileges, or for non-reappointment. In preparing the report, the Division Chief may meet with the individual. The Division Chief shall forward the report to the Department Chairperson for the Chairperson’s review and recommendation to the Credentials Committee. The Division Chief and the Department Chairperson shall be available to the Credentials Committee and Medical Executive Committee to answer any questions that may be raised with respect to any such recommendation.Hospital Medical Director ProcedureThe Hospital Medical Director shall review the completed application, request for Clinical Privileges and the recommendations of the Division Chief and Department Chairperson. The Hospital Medical Director shall provide a written recommendation to the Credentials Committee within ten (10) days of the receipt of the material from the Department Chairperson (or of the interview if required by the Hospital Medical Director). The Hospital Medical Director shall be available to the Credentials Committee to answer any questions that may be raised with respect to the Hospital Medical Director’s recommendations.Credentials Committee ProcedureNot later than ninety (90) days from its receipt of the recommendation of the Hospital Medical Director, the Credentials Committee shall send its recommendation and written findings in support thereof to the Medical Executive Committee. The completed application, all supporting materials, and the recommendations of the Division Chief, the Department Chairperson and the Hospital Medical Director shall accompany the Credentials Committee’s recommendations and findings. Each recommendation shall state one (1) of the following:That the applicant be reappointed to the Medical Staff;That the applicant’s application be deferred for further consideration until any additional information and documentation the Credentials Committee deems necessary or desirable is provided; orThat the application for continued Medical Staff membership be rejected.When the Credentials Committee recommends membership to the Medical Staff, it shall also make a specific recommendation regarding the Clinical Privileges to be granted and any limitations or conditions on the membership or such privileges.The Chairperson of the Credentials Committee shall be available to the Medical Executive Committee (and to the Managers) to answer any questions that may be raised with respect to the Credentials Committee recommendation.Medical Executive Committee ProcedureAt its next regular meeting after receipt of the written findings and recommendation of the Credentials Committee, the Medical Executive Committee shall recommend one of the following:That the applicant be reappointed to the Medical Staff;That the applicant’s application be deferred for further consideration until any additional information or documentation the Medical Executive Committee deems necessary is provided; orThat the applicant be rejected for continuing Medical Staff membership.The Medical Executive Committee may use the expertise of the Department Chairperson, Division Chief, any member of the Department, or an outside information source if additional information or documentation is deemed necessary or desirable regarding the applicant’s qualifications.If the recommendation of the Medical Executive Committee is favorable to the applicant, it shall transmit to the Managers its recommendation, together with the application and all supporting materials, including specific recommendation of the Clinical Privileges to be granted, which may be qualified by any probationary or other conditions or restrictions relating to such privileges.If the recommendation of the Medical Executive Committee would entitle the applicant to request a hearing pursuant to Article IV, the application, supporting materials, and recommendations shall be forwarded to the Chief Executive Officer who shall promptly notify the applicant in writing, certified mail, return receipt requested, of the Medical Executive Committee’s recommendation and of the applicant’s rights under Article IV. The Chief Executive Officer shall then hold the application until after the applicant has exercised or waived the right to a hearing as provided in these Bylaws or the time period for exercising such right has expired without exercise, after which the Chief Executive Officer shall forward the recommendation of the Medical Executive Committee, together with the complete application and all supporting documentation, to the Managers for further action.(Joint Commission-Medical Staff Structure and Role of Medical Executive Committee MS 02.01.01)Managers ProcedureUpon receipt of a favorable recommendation from the Medical Executive Committee that the applicant be granted reappointment and the requested Clinical Privileges or an unfavorable recommendation from the Medical Executive Committee followed by the applicant’s waiver of the right to a hearing as provided in these Bylaws or the expiration of the time period in which the applicant may exercise such right without the applicant’s exercise of such right, the Managers may:Appoint the applicant and grant Clinical Privileges as recommended and notify the applicant of the appointment and Clinical Privileges; orDetermine that the applicant’s application be deferred until any additional information or documentation the Managers deem necessary is provided by referring the matter back to the Medical Executive Committee, the Credentials Committee or the Department Chairperson for additional research or information. The Medical Executive Committee or Credentials Committee may elect to refer the matter to another source inside or outside the Hospital for additional research or information; orDetermine to reject the application; in such case, that determination and the reasons in support thereof, shall be sent to the Chief Executive Officer, who shall promptly notify the applicant in writing of the Managers’ determination, certified mail, return receipt requested. The Managers shall make no final decision until the applicant has exercised or waived the right to a hearing and appeal as outlined in Article IV, or the expiration of the time period in which the applicant may exercise such right without the applicant’s exercise of such right, if applicable. If the decision of the Managers would entitle the applicant to request a hearing pursuant to Article IV, the applicant shall be notified by the Chief Executive Officer of his rights under Article IV.(Joint Commission Standard – Medical Staff Credentialing and Privileging: MS.06.0 1.01, MS 06.01.03, MS 06.01.05, MS 06.01.07, MS 06.01.09, MS 06.01.11, MS 06.01.13, and Appointment to Medical Staff: MS 07.01.01, MS 07.01.03)PEER REVIEW AND FAIR HEARING PROCEDURESQuestions Involving Medical Staff membersCollegial Intervention/Informal ProceedingsNothing in this Article or these Bylaws shall preclude collegial, educational, and/or informal efforts to address questions or concerns relating to an individual's practice and conduct at the Hospital, and this Article specifically encourages voluntary structuring of Clinical Privileges to achieve a clinical practice mutually acceptable to the applicant or Member and the Division Chief, Department Chairperson, the Credentials Committee, the Medical Executive Committee, and the Managers. All efforts of the Hospital and the Medical Staff leaders in this regard are intended to be and are part of the Hospital’s quality improvement and professional review activities.These Bylaws encourage the use of progressive steps, beginning with collegial and educational efforts, to address questions relating to an individual’s clinical practice and/or professional conduct. Collegial intervention efforts involve reviewing and following up on questions raised about the clinical practice and/or conduct of Staff Members and pursuing counseling, education, and related steps, such as the following:Advising colleagues of all applicable policies, such as policies regarding appropriate behavior, emergency call obligations, and the timely and adequate completion of medical records;Proctoring, monitoring, consultation, and letters of guidance; andSharing comparative quality, utilization, and other relevant information, including any variations from clinical protocols or guidelines, in order to assist individuals to conform their practices to appropriate norms.The relevant Medical Staff leader(s) shall determine whether it is appropriate to include documentation of collegial intervention efforts in an individual’s confidential file. If documentation of collegial efforts is included in an individual’s file, the individual will have an opportunity to review it and respond in writing. The response will be maintained in that individual’s file along with the original documentation.Collegial intervention efforts are encouraged, but are not mandatory, except or unless mandated in other policies, and will be within the discretion of the appropriate Medical Staff leaders and Hospital management.Deemed ResignationsEmployed Members: The Medical Staff membership and Clinical Privileges of an employed Physician or health-care professional who ceases to be employed by the Hospital shall automatically and immediately be deemed to have been terminated, effective as of the date of such cessation. Members with Contracts: Membership and Clinical Privileges of Medical Staff Members who hold contracts shall automatically and immediately be deemed to have been terminated on either (1) the expiration or termination of the Medical Staff Member's contractual relationship with the Hospital or another Nemours facility/entity, or (2) the expiration or termination of the contractual relationship between the entity having a contractual relationship with the Hospital or another Nemours facility/entity. Procedural Rights: Medical Staff Members whose Medical Staff membership or Clinical Privileges are deemed to have been automatically terminated due to cessation of employment or contract shall not be entitled to a hearing or appeal as set forth in Article IV. If, however, the circumstances underlying the deemed termination of Medical Staff membership or Clinical Privileges reasonably constitute a surrender of privileges while under or in return for not conducting an investigation, such that the Hospital is required to make a report regarding the Member to the National Practitioner Data Bank or state licensing board or other governmental body, then the hearing and appeal rights set forth in Article IV shall not apply, but the individual shall be entitled to a hearing before a hearing officer appointed by the Hospital with respect to the basis of the professional review action to be reported. Application for Medical Staff Membership After Resignation:Voluntary Resignation: On a case-by-case basis, in the event that a physician employed by Nemours leaves the employment of Nemours voluntarily, the Chief Executive Officer or his designee, after consultation with the President of the Medical Staff and the applicable Department Chair ,Division Chie and Service line Coordinator, considering the need for the services, may invite the affected practitioner to submit a request for change in Medical Staff status if he desires to maintain Medical Staff membership (in a category other than Employed Active Staff) and privileges. If the physician voluntarily resigned from the Nemours Children's Clinic in good standing, with no outstanding issues involving clinical competence or professional conduct, the physician's Medical Staff membership will be subject to review to confirm continued satisfaction of qualifications for continued membership and privileges. The Division Chief and/or Department Chair will make a report on the request for change in Medical Staff status to the Credentials Committee, which will consider this report at its next scheduled meeting following receipt of the notice of resignation from the physician and make a recommendation to the Medical Executive Committee. Continued Medical Staff membership (with change in category) and Clinical Privileges shall commence following approval of the Board of Managers of the recommendation from the Medical Executive Committee to continue membership and privileges. Involuntary Resignation: A staff Member whose membership on the Medical Staff and Clinical Privileges have been deemed to have been automatically terminated due to an involuntary termination of employment or contract will not be eligible to reapply to the Medical Staff for a period of two (2) years unless invited to reapply by the Chief Executive Officer. An invitation to reapply may be offered by the Chief Executive Officer or his designee after consultation with the President of the Medical Staff and the applicable Department Chairperson, Division Chief and Service Line Director, considering the Hospital’s need for the individual's services. Any such reapplication will be processed as an initial application, except that the applicant will submit such additional information as may be required to demonstrate that the basis for the termination no longer exists. Conditions related to clinical performance improvement or behavior may be imposed. Ongoing and Focused Professional Practice Evaluations The Medical Staff shall conduct on-going evaluation of the professional practice of its Members and those individuals who are not Members of the Medical Staff but who hold Clinical Privileges. This on-going evaluation shall be conducted throughout the Practitioner’s current 2-year appointment cycle. Medical Staff Department Chairpersons and Division Chiefs will receive Practitioner-specific performance data for their evaluation. Medical Staff policy shall define the procedural elements of this process.Investigations Initial ProcedureWhenever a concern or question has been raised regarding:The clinical competence or clinical practice of any Member;The care or treatment of a patient or management of a case by any Member;The known or suspected violation by any Member of applicable ethical standards or the Bylaws, policies, or Rules and Regulations of the Medical Staff, including, but not limited to, the Hospital’s quality improvement, risk management, and utilization review programs; and/orBehavior or conduct on the part of any Member that is considered lower than the standards of the Medical Staff or is disruptive to the orderly operation of the Hospital or the Medical Staff, including the inability of the Member to work harmoniously with others;The Chairperson of the Medical Executive Committee, appropriate Department Chairperson, Chairperson of the Credentials Committee, Chief Medical Officer, or the Medical Director (or designee) shall make sufficient inquiry to determine to their satisfaction the possibility of a problem. In doing so, the persons listed in this Section shall consider any Medical Staff policy that may be in effect at the time regarding Member impairment. Initiation of InvestigationWhen a concern or question involving clinical competence or behavior/conduct has been referred to the Medical Executive Committee, that Committee shall determine either to discuss the matter with the Member concerned or to begin an investigation. An investigation shall begin only after a formal resolution of the Medical Executive Committee to that effect. The Medical Executive Committee may also, by formal resolution, initiate an investigation on its own.The Chairperson of the Medical Executive Committee shall promptly notify the Chief Medical Officer, the Hospital Medical Director, and the Chief Executive Officer in writing of all such discussions and investigations, and shall keep them fully informed of all actions taken in connection therewith. Investigative ProcedureUpon resolving to initiate an investigation, the Medical Executive Committee shall meet as soon as possible to consider the concern or question:If the Medical Executive Committee determines that it has enough information to conclude that action is needed or to make a recommendation to the Managers, it will make its recommendation, but only after offering an opportunity for a personal interview with the Member before making such recommendation.If the Medical Executive Committee determines that additional information is needed, it will appoint an investigative committee composed as follows:The President of the Medical Staff, the Chief Medical Officer, the Hospital Medical Director, and the Chief Executive Officer; orThe Credentials Committee; orAn ad hoc group of persons who may or may not hold membership on the Medical Staff.In no case may a person who is a partner, associate, or relative of the Member in question participate on the investigative committee. The Medical Executive Committee and the investigative committee shall have available to it the full resources of the Hospital and the Medical Staff, as well as the authority to use outside consultants or information sources, if it so desires. The investigative committee may also require a physical or mental examination of the Member being investigated by a physician or physicians and shall require that the results of such examination be made available for the investigative committee’s consideration.The Member being investigated shall have an opportunity to meet with the investigative committee before it makes its report. At least 72 hours prior to any such interview, the individual shall be informed by specific notice of the general supporting evidence and the general nature of the subject being investigated and shall be invited to discuss, explain, or refute it. This interview shall not constitute a hearing, and none of the procedural rules provided in Article IV with respect to hearings shall apply. A summary of such interview shall be made by the investigative committee and included with its report to the Medical Executive Committee. After completing its investigation, the investigative committee shall make a report and recommendation to the Medical Executive Committee. Procedure ThereafterAfter receiving the report and recommendation of the investigative committee, the Medical Executive Committee shall make its determination at its next MEC meeting on the matter.If the Medical Executive Committee determines that no change in Medical Staff membership or Clinical Privileges is needed, no further action will take place and the Member in question shall be so advised. If the Medical Executive Committee determines that a change of Medical Staff membership or Clinical Privileges is not needed, but that precautionary action is needed, it may issue a written warning, issue a letter of reprimand, impose terms of probation, or such other precautionary action as it deems appropriate.If the Medical Executive Committee determines that a change in Medical Staff membership or Clinical Privileges is needed, it will make a recommendation to the Managers. Such change may be a change in or suspension of Clinical Privileges, a suspension or revocation of Medical Staff membership, or other action affecting Clinical Privileges or Medical Staff membership.Any recommendation by the Medical Executive Committee that would entitle the Member being investigated to the procedural rights provided in Article IV shall be forwarded to the Chief Executive Officer, who shall promptly notify the affected Member of the Medical Executive Committee recommendation and the Member’s rights under Article IV by certified mail, return receipt requested. The Chief Executive Officer shall then hold the recommendation until after the individual has exercised or has waived the right to a hearing, or the time for exercising such right has expired without exercise, after which the Chief Executive Officer shall forward the recommendation of the Medical Executive Committee, together with all supporting information, to the Managers.If the action of the Medical Executive Committee does not entitle the Member to a hearing, the action shall take effect immediately without action of the Managers and without a right of appeal to the Managers. A report of the action taken and reasons therefore shall be made to the Managers through the Chief Medical Officer and the Chief Executive Officer, and the action shall stand unless modified by the Managers.In the event the Managers determine to consider modification of the action of the Medical Executive Committee and such modification would entitle the Member to a hearing in accordance with Article IV of these Bylaws, it shall so notify the affected Member, through the Chief Executive Officer, and shall take no final action thereon until the Member has had an opportunity to exercise the right to a hearing and appeal as provided in Article IV.After the procedures of Article IV have taken place or have been waived by the Member, the Managers shall determine to approve, disapprove, or modify the recommendation of the Medical Executive Committee.(Joint Commission Standards-Medical Staff Acting on Reported Concerns about a Practitioner: MS.09.01.01)Precautionary Suspension of Clinical Privileges Grounds for Precautionary SuspensionThe Chairperson of the Medical Executive Committee, the Chairperson of a clinical Department, the Hospital Medical Director (or his designee), the Chief Medical Officer and the Chief Executive Officer shall each have the authority to suspend all or any portion of the Clinical Privileges of a Medical Staff Member whenever failure to take such action may result in an imminent danger to the health and/or safety of any individual or to the continued effective operation of the Hospital. Such precautionary suspension shall be deemed an interim precautionary step in the professional review activity related to the ultimate professional review action that may be taken with respect to the suspended individual, but is not a complete professional review action in and of itself. It shall not imply any final finding of responsibility for the situation that caused the suspension and shall not entitle the Member to any right to a hearing.Such precautionary suspension shall become effective immediately upon imposition, shall be communicated to the Member by special notice, shall immediately be reported in writing to the Chief Executive Officer, the Chief Medical Officer, the Hospital Medical Director, the Chairperson of the Medical Executive Committee, and the Department Chairperson, and shall remain in effect unless or until modified by the Medical Executive Committee.(Joint Commission-Medical Staff Bylaws MS 01.01.01)Medical Executive Committee ProcedureA review of a matter resulting in precautionary suspension of a Member shall be completed within fourteen (14) days or reasons for the delay shall be transmitted to the Chief Medical Officer and the Chief Executive Officer so that they and the Medical Executive Committee may consider whether the suspension should be lifted. In any event, the Medical Executive Committee shall take such further action as is required in the manner specified under Section IV.A.5. As part of this review, the Member shall be invited to meet with the Medical Executive Committee or a subset thereof determined by the President of the Medical Executive Committee. In advance of the meeting, the Member may submit a written statement and other information to the Medical Executive Committee. At the meeting, the Member may provide information to the Medical Executive Committee and should respond to questions that may be raised by committee members. The Member may also propose ways, other than precautionary suspension, to protect patients, employees or others while an investigation is conducted.After considering the reasons for the suspension and the Member’s response, if any, the Medical Executive Committee shall determine whether the precautionary suspension should be continued, modified, or lifted. The Medical Executive Committee shall also determine whether to begin an investigation.If the Medical Executive Committee decides to continue the suspension, it will send the Member written notice of its decision, including the basis for it and that suspensions lasting longer than 30 days must be reported to the National Practitioner Data Bank.There is no right to a hearing based on the imposition or continuation of a precautionary suspension. Care of Suspended Member’s PatientsImmediately upon the imposition of a precautionary suspension of a Member, the appropriate Department Chairperson or, if unavailable, the Chief Medical Officer or the Hospital Medical Director, shall assign to another Member with appropriate Clinical Privileges responsibility for care of the suspended Member’s patients still under care at the Hospital as either inpatients or outpatients. The assignment shall be effective until such time as the patients are discharged or the suspension has been lifted by the Medical Executive Committee. The wishes of the patient shall be considered in the selection of the assigned Member.It shall be the duty of all Medical Staff Members to cooperate in enforcing all suspensions.Automatic RelinquishmentExcept as specifically provided otherwise, the automatic relinquishment of a Member’s Medical Staff appointment and privileges described in this Section A.8 shall occur only after the Chairperson of the Medical Executive Committee or Hospital Medical Director has confirmed one or more of the following underlying facts contributing to such actions:Failure to Complete Medical Records. The admitting and Clinical Privileges (elective and emergency), including the permission to perform outpatient surgeries or procedures, of any Member shall be deemed to be automatically relinquished for failure to complete medical records in accordance with applicable policies governing the same, after notification by the Hospital Medical Director or his designee to the Member in question. Medical-record delinquency shall be handled according to Medical Staff policy. Failure to complete the medical records that caused relinquishment of Clinical Privileges within sixty (60) days from the relinquishment of such privileges shall constitute an automatic relinquishment of all Clinical Privileges and resignation from the Medical Staff. At the formal written request of the Member involved, extenuating circumstances (illness, disability, etc.) may be taken into consideration by the Medical Executive Committee, in its discretion.Action by State Licensing Agency. Action by an applicable state licensing board or agency revoking or suspending a Member’s professional license, DEA license or CDS registration, or loss or lapse of a state license to practice for any reason, shall result in automatic relinquishment of Medical Staff membership and all Clinical Privileges as of that date, unless and until the matter is resolved, and an application for reinstatement of membership and privileges has been approved by the Managers. In the event the individual's license is only partially restricted, the Clinical Privileges that would be affected by the license restriction shall be similarly restricted.Failure to be Adequately Insured. If at any time a Member's professional liability insurance coverage lapses, falls below the required minimum, is terminated or otherwise ceases to be in effect (in whole or in part), the Member must notify the Chief Executive Officer or designee of such a change and the Member's Clinical Privileges that would be affected shall be automatically relinquished or restricted as applicable as of that date unless and until the matter is resolved and the required professional liability insurance coverage has been restored.Failure to Provide Requested Information. If at any time a Member fails to provide required information or documentation pursuant to a formal request by the Credentials Committee, the Medical Executive Committee, the Hospital Medical Director, the Chief Medical Officer, the Chief Executive Officer, or the Managers, the Member's Clinical Privileges shall be automatically relinquished until the required information is provided to the satisfaction of the requesting party. For purposes of this section, "required information or documentation" shall refer to (1)?physical or mental examinations as specified elsewhere in this Article; (2)?information or documentation necessary to explain an investigation, professional review action, or resignation from another facility or agency; (3) information pertaining to professional liability actions involving the Member; or (4) any other information or documentation relative to the Member’s qualifications for membership or professional practice, or exercise of Clinical Privileges.Criminal Activity. Any Member who has been convicted of any felony, or of any misdemeanor involving violations of law pertaining to controlled substances, illegal drugs, Medicare or Medicaid violations, or insurance fraud or abuse, or any Member who pleads guilty or nolo contendere to charges pertaining to the same, shall automatically relinquish his Medical Staff membership and all Clinical Privileges, unless waived by the Managers.Medicare and Medicaid Participation. Any Member whose participation in the Medicare or Medicaid programs is terminated by either the Centers for Medicare and Medicaid Services (CMS) or the Delaware Department of Health and Social Services (DHSS), or who is otherwise excluded or precluded from participation in either or both of those programs by CMS or DHSS, shall be subject to the actions specified under Section A.5 of this Article. It shall be the duty of all Members to promptly inform the Chief Executive Officer of any action taken by either such program in this regard.Misrepresentation, Misstatement or Omission of Information in the Application or Reapplication Process. In accordance with Section III.B.1 (g), any membership that has been granted prior to the discovery of misrepresentation, misstatement or omission of information, whether intentional or unintentional, may be deemed by the Managers, after recommendation of the Medical Executive Committee, to constitute grounds for automatic relinquishment of Clinical Privileges and Medical Staff membership.Failure to Request Reappointment. In accordance with Section III.H, failure to request reappointment by means of timely submitting a complete application, including the application fee, if any, within the required time frame shall result in automatic expiration of the Member's membership and Clinical Privileges at the end of the then current term of membership. Failure to attend Special Conference. If at any time a Member fails to appear at a special conference pursuant to a formal request by the Credentials Committee, the Medical Executive Committee, the Hospital Medical Director, the Chief Medical Officer, the Chief Executive Officer, or the Managers, the Member's Clinical Privileges shall be automatically relinquished until the Member appears before the special conference to the satisfaction of the requesting party. (Joint Commission - Medical Staff Bylaws MS 01.01.01)Leaves of AbsenceReasons for Leaves of Absence - Leaves of absence, not to exceed one year, may be granted by the applicable Department Chairperson for the following reasons: health, maternity leave, medical education, military duty, charity work or such other reasons as may be approved by the applicable Department Chairperson for just cause shown. Requests - Requests for leaves of absence shall be made to the Member’s Department Chairperson and shall state the beginning and ending dates of the requested leave and the reasons for the requested leave.Prerogatives and Responsibilities While on Leave of Absence. Any Member granted a leave of absence shall relinquish the prerogatives of membership and shall not be required to fulfill the responsibilities of membership, including payment of dues, attendance at meetings or any of the regular Medical Staff duties while on such leave. A Member who is on leave of absence cannot admit patients to or treat patients at the Hospital.Reinstatement from a Leave of Absence - At the conclusion of the leave of absence, the Member may apply to be reinstated by submitting to the Credentials Committee current license, DEA and CDS certificates, proof of professional liability coverage, and documentation of current competence. Reinstatement from the leave of absence shall be effective only upon approval by the Managers. The Member shall also provide such other information or documentation as may be requested by the Credentials Committee at that time. If the leave of absence was for medical reasons, the Member must submit a report from his attending Physician to Medical Staff Member Referral Team at the Hospital indicating that the Member is physically and mentally capable of resuming professional practice and exercising the Clinical Privileges requested. The Hospital may require a second opinion by a Physician of its choice as to the Member’s health. Medical Staff Member Referral Team shall evaluate the report and any second opinion and provide a recommendation to the Credentials Committee. After considering all relevant information, the Credentials Committee and the Medical Executive Committee shall then make a recommendation to the Managers for final action. In acting upon the request for reinstatement, the Managers may approve reinstatement either to the same or a different Medical Staff category, and may limit or modify the Clinical Privileges to be extended to the Member upon reinstatement. Failure to receive reinstatement, limitation, or modification of Clinical Privileges constitutes grounds for a hearing under Section IV.B.Hearings and Appeal Procedures Initiation of Hearing Grounds For HearingAn applicant for a Member holding a Medical Staff membership shall be entitled to request a hearing whenever an unfavorable recommendation has been made by the Medical Executive Committee to the Managers regarding the following:Denial of initial Medical Staff membership appointment;Denial of Medical Staff membership reappointment;Revocation of Medical Staff membership;Denial of requested initial Clinical Privileges;Denial of requested additional Clinical Privileges;Decrease in Clinical Privileges;Suspension of Clinical Privileges (other than precautionary suspension);Restriction of Clinical Privileges (e.g., required formal concurring consultations with other Members prior to proceeding with a specified course of treatment); or Denial of request for reactivation of privileges, or limitation or modification of such privileges, after a leave of absence.No other recommendations or actions except those enumerated in (a) of this Section 4.B.1 shall entitle an applicant or Member to request a hearing. The affected individual shall also be entitled to request a hearing before the Managers enter a final decision, in the event the Managers should determine, without a similar recommendation from the Medical Executive Committee, to take any action set forth in (a) of this Section IV.B.1.The hearing shall be conducted in as informal a manner as possible, subject to the rules and procedures set forth in this Article.Actions Not Grounds for Hearing.None of the following actions shall constitute grounds for a hearing, and such actions shall take effect without hearing or appeal:The issue of a letter of warning, a letter of admonition, or a letter of reprimand;The imposition of terms of probation, monitoring, or a general consultation requirement;The termination of any temporary privileges;The automatic relinquishment of Clinical Privileges as provided in Section IV.A.8; orThe imposition of a requirement for additional training or continuing education.THE HEARINGNotice of RecommendationWhen a recommendation to the Managers is made by the Medical Executive Committee or a determination is made by the Managers that, according to Section IV.B.1 (a), entitles an individual to a hearing prior to a final decision by the Managers, the affected individual shall promptly be given notice of such recommendation by the Chief Executive Officer, in writing, certified mail, return receipt requested. The Chief Executive Officer shall provide such notice to the individual within ten (10) days from the date the recommendation was made. The notice shall contain:A statement of the recommendation or determination made and the general reasons for it;Notice that the individual has the right to request a hearing on the recommendation within thirty (30) days of receipt of such notice; and A copy of this Article outlining the rights in the hearing as provided for in this Article.Request for Hearing.An individual shall have thirty (30) days following the date of the receipt of the notice described above within which to request a hearing. The request shall be in writing to the Chief Executive Officer. In the event the individual does not request a hearing within the time and in the manner required by this Article, the individual shall be deemed to have waived the right to the hearing and to have accepted the action involved. That action shall become effective immediately upon final action by the Managers.Notice of Hearing and Statement of ReasonsIf a hearing is requested in accordance with this Article, the Chief Executive Officer shall schedule the hearing and shall give written notice, certified mail, return receipt requested, to the individual who requested the hearing. The notice shall include:The time, place, and date of the hearing;The names of the Hearing Panel members appointed in accordance with this Section and the Hearing Panel Chairperson, if known; A statement of the specific reasons for the recommendation or determination, as well as a list of patient records and information supporting the recommendation or determination (the “Statement of Reasons”). The Statement of Reasons and the list of supporting patient record numbers and other supporting information and documentation may be revised or amended at any time, even during the hearing, so long as the additional material is relevant to the continued membership or Clinical Privileges of the individual requesting the hearing. The individual and their counsel, if any, shall have sufficient time, up to thirty (30) days, to study this additional information and documentation and attempt to rebut it; andA proposed list of witnesses, as known at that time, but which may be modified, who will give testimony or present evidence at the hearing in support of the Medical Executive Committee recommendation or the Managers’ determination.The individual requesting the hearing shall have up to thirty (30) days from the date of receipt of notice of the hearing to register any objections to any of the matters set forth in the Statement of Reasons. Failure to do so within the specified time frame shall be deemed to constitute a waiver of any objections.The hearing shall begin as soon as practicable, but no sooner than thirty (30) days after the notice of the hearing unless an earlier hearing date has been specifically agreed to in writing by the individual and the Hospital.Witness ListWithin ten (10) days after receiving notice of the hearing, the individual requesting the hearing shall provide a written list of the names, addresses, and telephone numbers of any individuals expected to offer testimony or present evidence on his behalf.The affected individual's witness list, as well as the witness list of the Medical Executive Committee, shall include a brief summary of the nature of the anticipated testimony. Both lists shall be finalized, to the extent possible, at the time of a pre-hearing conference. However, the witness list of either party may thereafter, in the discretion of the Hearing Panel Chairperson, be supplemented or amended at any time during the course of the hearing, provided that notice of the change is given to the other party. The Hearing Panel Chairperson shall have the authority to limit the number of witnesses, especially character witnesses or witnesses whose testimony is merely cumulative, as set forth in Section IV.B.3.Hearing Panel and Hearing Panel ChairpersonHearing PanelWhen a hearing is requested, the Chief Executive Officer, after considering the recommendations of the Chairperson of the Medical Executive Committee, shall appoint a Hearing Panel that shall be composed of not fewer than three (3) persons. The Hearing Panel shall be composed of a majority of members that are peers to the affected physician and who are Medical Staff Members who shall not have actively participated in the consideration of the matter involved at any previous level, or of physicians or laypersons not connected with the Hospital, or any combination of such persons. In all cases, the Hearing Panel shall include at least two (2) physicians. Knowledge of the matter involved shall not preclude any individual from serving as a member of the Hearing Panel.The Hearing Panel shall not include any individual with the potential conflict of interest. The Chief Executive Officer shall appoint one (1) member of the Hearing Panel as the Hearing Panel Chairperson.Hearing Panel ChairpersonThe Hearing Panel Chairperson, in addition to chairing the hearing, shall:Act to assure that all participants in the hearing have a reasonable opportunity to be heard and to present oral and documentary evidence, subject to reasonable limits on the number of witnesses and duration of direct and cross examination, applicable to both sides, as may be necessary to avoid cumulative, repetitive, or irrelevant testimony or to prevent abuse of the hearing process;Prohibit conduct or presentation of evidence that is cumulative, repetitive, excessive, irrelevant, abusive, or that causes undue delay;Maintain decorum throughout the hearing;Determine the order of procedure throughout the hearing;Have the authority and discretion, in accordance with this Article, to make rulings on all questions that pertain to matters of procedure and to the admissibility of evidence; Act in such a way that all information relevant to the membership or Clinical Privileges of the individual requesting the hearing is considered by the Hearing Panel in formulating its recommendations; andEntertain argument by counsel on procedural points outside the presence of the Hearing Panel unless the Hearing Panel wishes to be present. The Hearing Panel Chairperson may be advised by legal counsel to the Hospital.Pre-Hearing and Hearing Procedure Discovery/Provision of Relevant InformationThere is no right to discovery in connection with the hearing. However, the individual requesting the hearing shall be entitled, upon specific request, to the following documents, subject to a stipulation signed by both parties that such documents shall be maintained as confidential and shall not be disclosed or used for any purpose outside of the hearing, except as required by applicable law:Copies at the individual’s expense of, or reasonable access to, all patient medical records referred to in the Statement of Reasons;Copies at the individual’s expense of, or reasonable access to, reports of experts relied upon by the Medical Executive Committee or the Managers;Redacted copies of relevant Committee or Department minutes (such provision does not constitute a waiver of the state peer review protection statute); andCopies at the individual’s expense of, or reasonable access to, any other documents relied upon by the Medical Executive Committee or the Managers.Prior to the hearing, by a date set by the Hearing Panel Chairperson or agreed upon by both parties, each party shall provide the other party with the party's proposed exhibits. All objections to documents or witnesses to the extent then reasonably known shall be submitted in writing to the Hearing Panel Chairperson in advance of the hearing. The Hearing Panel Chairperson shall not entertain subsequent objections unless the party offering the objection demonstrates good cause.Neither the affected individual, nor his or her attorney, nor any other person acting on behalf of the affected individual, shall contact Hospital employees appearing on the Hospital’s witness list concerning the subject matter of the hearing, unless specifically agreed upon by counsel for the Hospital.Pre-Hearing ConferenceThe Hearing Panel Chairperson shall require the parties or counsel for the individual and for the Hospital to participate in a pre-hearing conference conducted by the Hearing Panel Chairperson for purposes of resolving, to the extent possible, all procedural questions in advance of the hearing. The Hearing Panel Chairperson may specifically require that:All documentary evidence/exhibits to be submitted by the parties be presented to each other prior to this conference and that any objections regarding the documents be made at this conference and be resolved by the Hearing Panel Chairperson;Evidence unrelated to the reasons for the unfavorable recommendation or determination or unrelated to the individual's qualifications for membership or the relevant Clinical Privileges be excluded;The names of all witnesses and a brief statement of their anticipated testimony be exchanged by the parties prior to this conference, and that any objections regarding witnesses be made at this conference and be resolved by the Hearing Panel Chairperson;The time granted to each witness' testimony and cross-examination be agreed upon, or determined by the Hearing Panel Chairperson, in advance; andWitnesses and documentation not provided and agreed upon in advance of the hearing may be excluded from the hearing.Failure to AppearFailure, without good cause, of the individual requesting the hearing to appear and proceed at the pre-hearing conference or at the hearing shall be deemed to constitute voluntary acceptance of the pending recommended or determined actions, which shall then be forwarded to the Managers for final decision.Record of HearingThe Hearing Panel shall maintain a record of the hearing by a stenographic reporter present to make a record of the hearing or a recording of the proceedings. The cost of such reporter shall be borne by the Hospital, but copies of the transcript shall be provided to the individual requesting the hearing at that individual's expense. Oral evidence shall be taken only on oath or affirmation administered by any person designated by the Hearing Panel. Rights of Both Sides and the Hearing Panel at the HearingAt a hearing, both parties shall have the following rights, subject to reasonable limits determined by the Hearing Panel Chairperson:To call and examine witnesses to the extent available;To introduce exhibits;To cross-examine any witness on any matter relevant to the issues and to rebut any evidence;Representation by counsel who may call, examine, and cross-examine witnesses and present the case. Both parties shall notify the other of the name of that counsel at least ten (10) days prior to the pre-hearing conference; andTo make an oral statement or submit a written statement at the close of the hearing.Any individual requesting a hearing who does not testify in his own behalf may be called and examined as if under cross-examination.The Hearing Panel may question the witnesses, call additional witnesses, engage consultants, and/or request documentary evidence.Admissibility of Evidence.The pre-hearing conference and the hearing shall not be conducted according to rules of evidence that apply in courts of law. Hearsay evidence shall not be excluded merely because it constitutes hearsay. Any relevant evidence shall be admitted if it is the sort of evidence on which responsible persons are accustomed to rely in the conduct of serious affairs, regardless of the admissibility of such evidence in a court of law. Post-Hearing Memoranda of Points and Authorities.The Hearing Panel shall have the right to request, in its discretion, that each party submit a memorandum of points and authorities following the close of the hearing. The Hearing Panel Chairperson, after consultation with all parties, shall establish time frames within which any such post-hearing memoranda must be submitted.Official Notice.The Hearing Panel Chairperson shall have the discretion to take official notice of any matters, either technical or scientific, relating to the issues under consideration that could have been judicially noticed by the courts of Delaware. Participants in the hearing shall be informed of the matters to be officially noticed and such matters shall be noted in the record of the hearing. Either party shall have the opportunity to request that a matter be officially noticed or to refute the noticed matter by evidence or by written or oral presentation of authority. Reasonable additional time shall be granted, if requested, to present written rebuttal of any evidence admitted on official notice.Postponements and Extensions.Postponements and extensions of time beyond any time limit set forth in this Article may be requested by anyone but shall be permitted only by the Hearing Panel Chairperson after a showing of good cause.Hearing Conclusion, Deliberation, & Recommendation Order of PresentationThe Hospital shall first present evidence in support of the Medical Executive Committee’s recommendation or the Managers’ determination. Thereafter, the burden to present evidence shall shift to the individual who requested the hearing.Basis of DecisionThe Hearing Panel shall recommend in favor of the Hospital unless it finds that the individual who requested the hearing has established by a preponderance of the evidence that the recommendation or determination that prompted the hearing was arbitrary, capricious, or not supported by substantial evidence.The decision of the Hearing Panel shall be based on the evidence produced at the hearing. This evidence may consist of the following:Oral testimony of witnesses;Memorandum of points and authorities presented in connection with the hearing;Any information regarding the individual who requested the hearing so long as that information has been admitted into evidence at the hearing and the person who requested the hearing has had the opportunity to comment on and, by other evidence, refute it;Any and all applications, references, and accompanying documents;Other documented evidence, including, but not limited to, medical records; andAny other evidence that has been admitted.Adjournment and Conclusion.The Hearing Panel Chairperson may, without special notice, adjourn the hearing and reconvene the same at the convenience and with the agreement of the participants. Upon conclusion of the presentation of evidence by the parties and/or questions by the Hearing Panel, the hearing shall be closed.Deliberations and Recommendation of the Hearing Panel.Within twenty (20) days after final adjournment of the hearing (which may be designated as the time the Hearing Panel receives the hearing transcript), the Hearing Panel shall conduct its deliberations outside the presence of any other person except the Hospital’s counsel, and shall render a recommendation to the Managers, accompanied by a report, which shall contain a concise statement of the basis for the Hearing Panel's recommendation.Disposition of Hearing Panel Report.The Hearing Panel shall deliver its report and recommendation to the Chief Executive Officer who shall forward it, along with all supporting documentation, to the Chairperson of the Managers. The Chief Executive Officer shall also send a copy of the report and recommendation, certified mail, return receipt requested, to the individual who requested the hearing. The Chief Executive Officer shall also provide an information copy to the Medical Executive Committee.APPEAL PROCEDURETime for Appeal.Within ten (10) days after receiving notice of the Hearing Panel's recommendation, either party may request an appellate review. The request shall be in writing, and shall be delivered to the Chief Executive Officer either in person or by certified mail, return receipt requested, and shall include a statement of the reasons for appeal and the specific facts or circumstances that justify further review based upon the grounds set forth in this Section. If such appellate review is not requested within ten (10) days as provided herein, both parties shall be deemed to have waived appellate review, and the Hearing Panel's report shall be forwarded by the Chairperson of the Managers to the Managers for final decision.Grounds for AppealThe grounds for appeal shall be limited to the following:There was substantial failure to comply with this Article and/or these Bylaws during or prior to the hearing, so as to deny a fair hearing; orThe recommendations of the Hearing Panel were made arbitrarily, capriciously, or with prejudice; orThe recommendations of the Hearing Panel were not supported by substantial evidence.Time, Place and NoticeWhenever an appeal is requested as set forth in this Section IV.B.5, the Chairperson of the Managers shall, within ten (10) days after receipt of such request, schedule and arrange for an appellate review. The affected individual and the Hospital shall each be given notice of the time, place, and date of the appellate review. The date of appellate review shall be not less than ten (10) days, nor more than thirty (30) days, from the date of receipt of the request for appellate review; provided, however, that when a request for appellate review is from a Member who is under a suspension then in effect, the appellate review shall be held as soon as the arrangements may reasonably be made. The time for appellate review may be extended by the Chairperson of the Managers for good cause.Nature of Appellate ReviewThe Chairperson of the Managers shall appoint a Review Panel composed of not fewer than three (3) persons, at least two (2) of whom shall be physicians, who may, but shall not be required to, include reputable physicians outside the Hospital, to consider the record upon which the recommendation was made. The Review Panel shall not include any member of the Hearing Panel or any person who would be disqualified from being a member of the Hearing Panel pursuant to Section IV.B.2, but may include one or more of the Managers.The Review Panel may in its discretion accept additional oral or written evidence subject to the same rights of cross-examination or confrontation provided at the Hearing Panel proceedings. Such additional evidence shall be accepted only if the party seeking to admit it can demonstrate that it is new, relevant evidence or that an opportunity to admit it at the hearing was improperly denied.Each party shall have the right to present a written statement in support of its position on appeal. In its sole discretion, the Review Panel may allow each party or its representative to appear personally and make oral argument not to exceed thirty?(30) minutes. The Review Panel shall recommend final action to the Managers.The Managers may affirm, modify, or reverse the recommendation of the Review Panel or, in its discretion, refer the matter to the Review Panel for further review and recommendation, or make its own decision. In the event the Managers determine to modify or reverse the recommendation of the Review Panel in such a manner that the action would entitle the affected individual to another hearing in accordance with this Article, it shall so notify the affected individual through the Chief Executive Officer, and shall take no final action thereon until the individual has exercised or has waived the procedural rights provided in this Article.Final Decision of the ManagersWithin thirty (30) days after receipt of the recommendation of the Hearing Panel or the Review Panel, as the case may be, the Managers shall render a final decision in writing, including specific reasons, and shall deliver a copy thereof to the affected individual by certified mail, return receipt requested. A copy shall also be delivered to the Medical Executive Committee and the Chief Executive Officer.Further Review.Except where the matter is referred for further review and recommendation in accordance with this Section IV.B.5 (Nature of Appellate Review (d)), the decision of the Managers following an appeal shall be final effective immediately and shall not be subject to further review. If the matter is referred pursuant to Section IV.B.5 (Nature of Appellate Review (d)) for further review and recommendation, such recommendation shall be promptly made to the Managers in accordance with its instructions. This further review process and the report back to the Managers shall in no event exceed thirty (30) days except as the parties may otherwise agree.Right to One Hearing and One Appeal Only.No applicant or Medical Staff Member shall be entitled to more than one (1) hearing and one (1) appellate review on any matter that may be the subject of an appeal. If the Managers determine to deny initial Medical Staff membership or reappointment to an applicant, or to revoke or terminate the Medical Staff membership and/or Clinical Privileges of a current Member, that individual may not apply for Staff membership or for those Clinical Privileges at the Hospital for a period of five (5) years unless the Managers specifically determine otherwise.(Joint Commission Standard- Medical Staff Bylaws: MS 01.01.01 and Fair Hearing and Appeal Process: MS.10.01.01)AMENDMENTS, ADOPTION, AND MEDICAL STAFF RULES AND REGULATIONS AND POLICIES AND PROCEDURESAmendments / AdoptionsAmendments to these Bylaws may be proposed to the Managers by the Medical Staff following approval by the Medical Executive Committee, communication of the proposed amendment to the Members at least thirty (30) days prior to the Members' vote, and approval by a majority of the Active Staff Members voting either in person, by mail, or by electronic mail. Amendments shall be effective only when approved by majority vote of the Managers. Amendments may also be proposed directly to the Managers by majority vote of the Active Staff Members, following a petition signed by 25% of the voting Staff. Neither the Managers nor the Medical Staff may unilaterally amend these Bylaws, except when necessary to comply with changes in applicable federal or state laws.In circumstances where the Medical Executive Committee or the Managers determine that an amendment to these Bylaws is required to comply with changes in applicable federal or state laws, requirements imposed by insurance carriers, state licensure requirements, Joint Commission accreditation standards, and/or Medicare/Medicaid Conditions of Participation for Hospitals, the review and revision process for such amendments shall be expedited to the fullest extent possible. The Medical Executive Committee, with the concurrence of the Chief Medical Officer and the Chief Executive Officer, shall have the power to adopt such amendments to the Bylaws as are, in the Medical Executive Committee’s judgment, solely technical or legal modifications or clarifications, reorganization or renumbering, or amendments made necessary because of punctuation, spelling, or other errors of grammar or expression. Such amendments shall be effective immediately and shall be remain in force if not disapproved by the Medical Staff or the Managers within sixty (60) days of adoption by the Medical Executive Committee. The action to amend may be taken by a motion acted upon in the same manner as any other motion before the Medical Executive Committee. Immediately upon adoption, such amendments shall be sent to the Chief Executive Officer and the Managers and posted for the Medical Staff. Members of the Medical Staff shall be notified about the changes using the most efficient means of communication.(Joint Commission Medical Staff Bylaws MS 01.01.01)Medical Staff Policies and Procedures Policies and ProceduresThe Medical Staff shall adopt such Policies and Procedures as it may deem necessary or desirable upon approval by the Medical Executive Committee, the Chief Medical Officer, and the Chief Executive Officer. If required by regulatory or accrediting organizations, specific individual policies also require approval by the Managers. Subject to review by the Medical Executive Committee, Departments, Divisions, and identified programs may develop policies and procedures specific to a named Medical Staff service, program, Department or Division separate from general Medical Staff Policies and Procedures that are applicable to all Members. AmendmentAll Medical Staff Policies and Procedures may be amended by vote of the Medical Executive Committee and approval of the Chief Medical Officer and the Chief Executive Officer. The Medical Executive Committee and the Managers shall have the power to provisionally adopt urgent amendments to the Policies and Procedures that are needed in order to comply with a law or regulation, without providing prior notice of the proposed amendments to the Medical Staff. Notice of all provisionally adopted amendments shall be provided to each Member of the Medical Staff as soon as possible. The Medical Staff shall have 14 days to review and provide comments on the provisional amendments to the Medical Executive Committee. If there is no conflict between the Medical Staff and the Medical Executive Committee, the provisional amendments shall stand. If there is conflict over the provisional amendments, then the process for resolving conflicts set forth below shall be implemented.ReviewMedical Staff Policies and Procedures shall be reviewed by the Medical Staff, principally by the Medical Staff Policy Committee, at least every two (2) years, and the Medical Staff Policy Committee shall forward its recommendations for amendments to the Policies and Procedures to the Medical Executive Committee.Conflict management Process When there is a conflict between the Medical Staff and the Medical Executive Committee, as set forth in a petition signed by 25% of voting Members, with regard to:Proposed amendments to the Medical Staff Rules and Regulations;A new policy proposed by the Medical Executive Committee; orProposed amendments to an existing policy that is under the authority of the Medical Executive Committee;a special meeting of the Medical Staff shall be called. The agenda for that meeting shall be limited to the amendment(s) or policy at issue. The purpose of the meeting shall be solely to attempt to resolve the differences that exist with respect to Medical Staff Rules and Regulations or policies.If the differences cannot be resolved at the meeting, the Medical Executive Committee shall forward its recommendations, along with the proposed recommendations pertaining to the Medical Staff Rules and Regulations or policies offered by the voting members of the Medical Staff, to the Managers for final action.This conflict management process section is limited to the matters noted above. It is not to be used to address any other issue, including, but not limited to, professional review actions concerning individual Members of the Medical Staff.(Joint Commission Standards-Medical Staff Bylaws: MS.01.01.01, MS.01.01.03 and Acting on Reported Concerns about a Practitioner: MS.09.01.01)Approved by the Medical Executive Committee: October 18, 2010Ratified by the Medical Staff: November 22, 2010Approved by the Board of Managers – December 14, 2010Revised and approved by the Board of Managers – March 13, 2012Revised and approved by Medical Executive Committee: March 18, 2013Revised and approved by Board of Managers- June 18, 2013APPENDICES:APPENDIX “A”DESCRIPTION OF DEPARTMENTS AND DIVISIONSDEPARTMENTSThe Medical Staff shall be organized into six Departments: Department of Anesthesiology and Critical CareDepartment of Medical ImagingDepartment of Pathology/Clinical Laboratory Department of PediatricsDepartment of Orthopedic SurgeryDepartment of Surgery The purposes of departmentalization are:To provide a structured mechanism for the review and evaluation of the quality of care and the assessment of the clinical performance of the members of the Departments;To provide a forum for discussion and action on mutual concerns; andTo provide broad educational opportunities for members of the Departments.DIVISIONSDepartment of Surgery:The Department of Surgery shall include the following Divisions:CardiothoracicOtorhinolaryngologyDental SurgeryPlastic SurgeryGeneral SurgerySolid Organ TransplantationNeurosurgeryOphthalmologyUrologyDepartment of Orthopedic Surgery:The Department of Orthopedic Surgery shall include the following Division:OrthopedicsDepartment of Pediatrics:The Department of Pediatrics shall include the following Divisions:Behavioral HealthHematology/OncologyBlood and Bone Marrow TransplantInfectious DiseaseAllergy/ImmunologyNeonatologyCardiologyNephrologyDermatologyNeurologyDevelopmental MedicinePulmonaryEmergency MedicineGeneral Pediatrics - InpatientEndocrinologyRehabilitation MedicineGastroenterology and NutritionRheumatologyGeneticsDiagnostic ReferralExternal Primary Care (employed)External Specialty Pediatrics (employed)Transition of CarePalliative Care Weight Management Department of Medical Imaging:The Department of Medical Imaging shall include the following Divisions:Computerized Axial Tomography/Magnetic Resonance ImagingNuclear MedicineRadiologyUltrasoundNeuroradiologyDepartment of Anesthesiology and Critical Care:The Department of Anesthesiology and Critical Care shall include the following Divisions:Cardiac Critical CareCardiac Anesthesiology Intensive/Critical CareSurgical AnesthesiaDepartment of Pathology/Clinical Laboratory:The Department of Pathology/Clinical Laboratory shall include the following Divisions:Anatomic PathologyBlood BankClinical LaboratoryAPPENDIX BThe Nemours Board has determined the following Departments, Divisions or Service lines as closed services for the purposes of providing high quality, efficient patient care. Only physicians employed by or under contract with Nemours are eligible for membership and clinical privileges in these specialty areas:AnesthesiologyCritical Care – including pediatric critical care, neonatology, and cardiac critical careEmergency MedicinePathologyMedical ImagingHospitalist ServiceNemours Cardiac Center – including cardiology, cardio-thoracic surgery, cardiac anesthesiology, and cardiac catheterization laboratoryAPPENDIX CDescription of current Service LinesNemours Cardiac Center Nemours Neuroscience CenterNemours Cancer and Blood Disorders CenterNemours Orthopedics References: Joint Commission Standards for Medical Staff Services can be found on Team share under Medical and Professional Staff Services. CMS Regulations website: ................
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