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Medical Staff Bylaws

Definitions

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ADVERSE ACTION/RECOMMENDATION

means a professional review action as the term is used in the Health Care Quality Improvement Act of 1986 (HCQIA).


 

ALLIED HEALTH PROFESSIONAL (AHP)

means an individual other than a licensed physician, dentist, podiatrist or clinical psychologist who exercises independent judgment within the areas of his or her professional competence and who is qualified to render medical or surgical care under the supervision of a physician who has been accorded privileges to provide such care in the Hospital. The following are examples of categories of Allied Health Professionals: certified registered nurse anesthetists, certified nurse practitioners, certified nurse midwives, registered nurses, physician assistants, and doctoral scientists (PhD) other than clinical psychologists, and others as may be specified by the Medical Executive Committee and approved by the Board.


 

AUTHORIZED COMMUNICATIONS EQUIPMENT

means communications equipment to which both of the following apply:

  1. These Bylaws provide that use of such communications equipment is permissible for purpose of giving notice of meeting, or attending and participating in meetings
  2. The communications equipment in question provides a transmission, including, but not limited to, by telephone, telecopy, or any electronic means, from which it can be determined that the transmission was authorized by, and accurately reflects the intention of, the Member involved, and with respect to meetings, allows all Members participating to contemporaneously communicate with each other.

 

BOARD

means the governing board of the Hospital (i.e., its Board of Trustees or Directors) which shall have final responsibility for the affairs of the Medical Staff.


 

CLINICAL PRIVILEGES OR PRIVILEGES

means the rights granted to a Practitioner to provide those diagnostic, therapeutic, medical, surgical, dental or podiatric services specifically delineated to the Practitioner.


 

CREDENTIALING PLAN

means the credentialing plan described in Hospital's Medical Staff Credentialing Plan, contained in Section II of these Bylaws.


 

DENTIST

means an individual holding a doctoral degree in dentistry or oral surgery who is licensed to practice dentistry in the State of Ohio.


 

DEPARTMENT

means a clinical Department in the Hospital as determined by the Board from time to time.


 

DEPARTMENT DIRECTOR

means the person recommended by the Medical Executive Committee, voted on by a Majority of Active Staff Members of the Department, and approved by the Board.


 

DESIGNEE

means an individual acting officially in the absence of the named authority or formally designated by the named authority to act in his or her place.


 

HOSPITAL PRESIDENT & CEO

means the individual bearing that title, or a like title, who is appointed to act on the Hospital’s behalf in the overall administrative management of the Hospital.


 

EX OFFICIO

means service as an appointee of a body or committee, typically by virtue of holding a particular office or position. An Ex Officio appointee, unless otherwise expressly provided, serves without the right to vote on matters coming before such body or committee.


 

FAIR HEARING PLAN

means the hearing plan describing certain procedural rights afforded a Practitioner where a corrective action against the Practitioner is contemplated, recommended or implemented. The Fair Hearing Plan is contained in Section III of these Bylaws.


 

GOOD STANDING

means that the Medical Staff Member has met the attendance requirements during the previous Medical Staff year, is not under suspension or other restriction of clinical privileges at the Hospital, and is otherwise compliant with the requirements of the medical staff.


 

INFORMATION

means a record of proceedings, minutes, interviews, records, reports, forms, memoranda, statements, recommendations, findings, evaluations, opinions, conclusions, actions, data and other disclosures or communications whatever in written form.


 

MAJORITY

means over half of the votes cast by Members eligible to vote on a matter at a legal meeting at which a Quorum is present, ignoring blanks and abstentions.


 

HOSPITAL

means Your Hospital, Your, Ohio.


 

HOSPITAL POLICES

shall mean the policies and procedures adopted by the Hospital from time to time.


 

MEDICAL EXECUTIVE COMMITTEE

means the group of Medical Staff Members and Ex Officio representatives chosen to represent and coordinate the overall activities and policies of the Medical Staff and its subdivisions.


 

MEDICAL STAFF or STAFF

means the formal organization created by the Board, composed of Practitioners who have been appointed by the Board to assist the Hospital in carrying out certain assigned functions.


 

MEDICAL STAFF BYLAWS or BYLAWS

shall mean the bylaws of the Your Hospital Medical Staff, including but not limited Section I: Medical Staff Bylaws, Section II: Medical Staff Credentialing Plan, Section III: Fair Hearing Plan, and Section IV: Rules and Regulations.


 

MEDICAL STAFF POLICIES

shall mean the policies and procedures adopted by the Medical Staff, and approved by the Medical Executive Committee and the Board, from time to time. These shall include these Medical Staff Bylaws, the Credentialing Plan, the Fair Hearing Plan, the Rules and Regulations and any other policy deemed necessary and appropriate to carry out the duties and responsibilities of the Medical Staff delegated by the Board.


 

MEMBER

means a Practitioner who has been granted clinical privileges through one or more Departments of the Hospital.


 

ORAL SURGEON

means a licensed dentist with advanced training qualifying him or her for board certification by the American Board of Oral & Maxillofacial Surgery.


 

ORGANIZATION & FUNCTIONS MANUAL

describes the current organization of the Medical Staff and defines the mechanisms by which the Medical Staff will accomplish its purposes and responsibilities.


 

PHYSICIAN

means an individual with an MD or DO degree that is licensed by the applicable board to practice medicine in the State of Ohio.


 

PODIATRIST

means an individual holding a degree in podiatric medicine and licensed to practice podiatry in the State of Ohio.


 

PRACTITIONER

means, unless otherwise expressly provided, any licensed Physician, Dentist, Podiatrist or Psychologist applying for, exercising clinical privileges, or providing other diagnostic, therapeutic, teaching or research services in or with respect to patients of the Hospital.


 

PREROGATIVE

means a participatory right granted by virtue of Staff category or otherwise, to a Medical Staff appointee or Allied Health Professional and exercisable subject to the conditions and limitations imposed in these Bylaws and in other Hospital and Medical Staff Policies.


 

PRIMARY DEPARTMENT

means the principal Department in which a Practitioner obtains clinical privileges.


 

PSYCHOLOGIST

means an individual holding a doctoral degree in psychology or its equivalent and licensed to practice psychology in the State of Ohio.


 

QUORUM

shall mean, unless otherwise specified in these Bylaws or Medical Staff Policy, the presence of one-fourth of the members eligible to vote of the Medical Staff, committee, Department or other applicable decision-making body, present at any regular meeting, unless the Chairperson, Hospital President and CEO, or Department Director, with such capacity shall determine that a higher percentage of voting members is appropriate to constitute quorum.


 

REPRESENTATIVE

means the Board and any director, trustee or committee thereof; the Hospital President and CEO, or the Hospital President and CEO’s designee; any employees of other organizations; a Medical Staff organization or any committee of the Medical Staff or the Board, and any individual authorized by any of the foregoing

performing specific information gathering, analysis, use or disseminating functions, which relate to any Professional Review Activity (as that term is defined under HCQIA).


 

RULES & REGULATIONS

mean those rules and regulations applicable to the Medical Staff adopted pursuant to Article IX of these Bylaws. The Rules and Regulations are contained in Section IV of these Bylaws.


 

SELF GOVERNANCE

means the duty of the officers, committees and Departments of the Medical Staff to initiate and carry out the functions delegated by the Board and to fulfill the obligations provided for in these bylaws.


 

SPECIAL NOTICE

means written notification sent by certified or registered mail, return receipt requested.


 

THIRD PARTIES

means both individuals and organizations providing information and representatives.

 
 
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