The Semmelweis Society: Medical Credentials, Privileges, and Unbiased Peer-Review. Safe Practices.
Model By-Laws by R. Bard M.D., J.D. FACS
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4 Career Considerations
The Danger Is Immunity
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Semmelweis Services


SECTION 1: Grounds for action

A. 1. When a complaint occurs involving an individual with a current Medical staff appointment, this complaint should be filed with the immediate supervisor of the complainant. At this point, if the complaint is felt to have merit it will be forwarded the head of the department involved.

The Department Head will then have the obligation to make an informal investigation of this complaint which may involve discussion with the staff member involved. In all situations, if possible, it is preferable that the issues be resolved informally and promptly if possible. If the complaint has no merit a notation is to be made in the complainant's file and the Medical Executive Committee is to be notified that a baseless complaint was filed for future reference

If the issue cannot be resolved informally, then the matter will be referred to the Chief of Service of the affected physician. The Chief of service will then investigate the complaint before presentation to the service. This complaint will be handled in the executive session of the service committee and forwarded to the Executive Committee with a 1 through 4 recommendation as any other quality issue.

No permanent action can be taken that will result in any change of privileges or any permanent record in a members file unless the member expressly agrees in writing to waive the hearing procedure. If an action may be taken that would result in any kind of permanent record either in the minutes or a members file the member is to be immediately informed to allow the formal hearing process in Article IX.

2. An investigation may be requested by the Chief of staff, a majority vote of any committee, the chairman of any major service or by the Chairman of the Board. The chief executive officer may request an investigation by application in writing to the chief of staff who then shall determine if the investigation is indicated according to:

a. The person requesting the investigation must submit a written signed request to the Medical Executive Committee indicating the grounds for the investigation.

b. A majority vote of the executive committee is necessary to proceed with the investigation. The written request should be reviewed by the committee prior to this vote. The staff member for whom the investigation is requested does not have the right to be present at this vote.

c. A quality issue report forwarded by the appropriate service committee with a grade of a 3 or a 4 will for the purposes of this section be considered equivalent to a written request for an investigation addressed to the MEC.

3. An investigation may be requested whenever questions arise concerning an individual with a current medical staff appointment who:

a. fails to comply with the ethics of his/her profession or the bylaws, rules

and regulations of the medical staff pertaining to any aspect of his/her behavior or the policies of the hospital relating to the medical staff as approved by the medical staff; or

b. shows behavior or conduct is considered by the medical staff to be lower than the standards of the medical staff; or

c. is unable to work harmoniously with others with others to the extent

that it affects the orderly operation of the hospital or medical staff organization;

d. if there are questions as to his/her clinical competence; or his/her care or treatment of a patient.

4. All such requests or investigations shall be in writing, shall be made to the Medical

Executive Committee, and shall be supported by reference to the individuals

specific activity or conduct which constitutes the grounds for the request. Further, when informed of the investigation any allegations of the affected party are to be investigated with the same intensity and vigor as those made against the affected party.

B. No action of the type mentioned in this part may be taken without the right to a hearing and appeal unless these rights are specifically waived in writing by the member who may be subject to a permanent action. A member may be suspended without hearing for medical records violations in accordance with the rules and regulations. Suspension due to medical records violations is not a disciplinary action, however; if continued violations require additional action this additional action will be considered disciplinary.

C. Definitions:

1. Any letter temporarily placed in the educational file is not a permanent action falling under this section, but if this letter is used either as evidence resulting in a permanent action or is extended such that it is deemed permanent then the affected member may request the appropriate procedure for hearing an appeal be followed either in accordance with this part or Section IX.

2. The following are permanent disciplinary actions:

a. Issuance of a letter of reprimand. This letter must be clearly designated as a letter of reprimand and if not so designated will in every case be considered an educational action. A letter of reprimand may outline and contain, but is not limited to the following: To be a letter of reprimand the words "this is to be considered a letter of reprimand" must be somewhere in the letter.

1) Reduction of clinical privileges.

2) Permanent suspension of any clinical privileges.

3) Revocation of staff appointment.

4) Probationary Term > 6 months

5) Mandatory consultation > 6 months

3. Ex parte means without the affected party present.

4. An educational action is any action taken by the Medical Executive Committee that is not a permanent disciplinary action as defined in this section.

5. Rights of the affected member in a permanent disciplinary action are as follows:

a. The accused has the right to question anyone who files a complaint against the member or causes a complaint to be filed.

b. If the accused is denied the right to question the person making the complaint above then he \she has the right to exclude the report in its entirety and it may not be considered as evidence in the issue at hand. If the excluded report is the only basis for a potential action the entire process is dismissed and terminated.

d. The affected member has a right to be present at all formal processes of the

Medical Executive Committee once it is determined the recommendation may be a permanent action.

e. The affected member has the right of appeal to the Board for any permanent disciplinary action, but not for educational actions.

f. The affected member can waive any or all of these rights in writing.

g. The waiver of a particular right does not waive any other rights and if there

is a question of which if any rights were waived the presumption is that the right was not waived.

h. Even if a right is waived the waiver may be rescinded by the affected party at any time until the final recommendation is made by the Medical Executive Committee.

i. Discussion of any issues regarding a possible permanent disciplinary action or educational action if the hospital employees involved become known to the accused member outside of the Medical Executive Committee meeting is

unprofessional behavior and may subject the member to further action.

This is meant to protect the employee from unwanted discussions outside of

the more formal committee process. The employee has the right to discuss

the issues with the involved member outside of the Executive Committee

but the choice is with the employee.

7. The chief of a major service is defined as the Chief of Medicine, OB/GYN, Pediatrics, Surgery, or Manchester Service.

SECTION 2: Investigative Procedure

A. If the request for the investigation or complaint contains information determined to be adequate for the Medical Executive Committee to make a recommendation

they may do so subject to the accused members right to a hearing and appeal if the action taken by the committee is permanent. Further, the accused has the right to request an investigation even if the Medical Executive Committee feels the original report is sufficient to render a recommendation. If this right to an investigation by the accused is waived it must be in writing and signed by the accused..

B. Once the Medical Executive Committee by majority vote determines that the initial request is adequate to proceed without investigation the accused party is to be notified and no further action or investigation is to be performed without the accused party being present. The accused party is to make time available to meet with the committee and repeated failures to be present at the time of any discussion regarding the request may result in loss of the right of the accused to be present and may result in action being taken by the committee ex parte.

C. If the Medical Executive Committee, by a majority vote, determines that the initial

request is inadequate to proceed without an investigation, the accused is to be notified of the nature of the complaint and that an investigation has been initiated. The accused party has the right to sit in on any interviews or formal proceedings of the Executive Committee in the course of the investigation. The accused member does not have the right to attend interviews or other evidence gathering of the investigative committee if one is appointed. Only the evidence presented at the formal meeting of the Medical Executive Committee will be considered in determining an action to finally be taken. The accused has the right during the meeting to question anyone who submits evidence to the executive committee or causes evidence to be submitted.

The Medical Executive Committee may investigate the matter in a body as a whole, or if it is deemed necessary, appoint an investigating committee. This committee shall consist of three members of the Medical Staff at least one of

whom must be a Medical Executive Committee member. The individual with respect to whom an investigation has been requested shall have an opportunity

to meet with the committee before it makes its report to the MEC.

At this meeting (but not as a matter of right in advance of it) he/she shall be informed of the general nature of the evidence supporting the investigation

requested 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 this bylaws

with respect to hearings shall apply. A summary of such interview including any remarks made by the accused at the informal meeting shall be made by the investigating committee. If a subcommittee or investigating committee was used,

the MEC may accept, modify, or reject the recommendation it receives from the

investigating committee. This decision is by a majority vote of the MEC with any

members of the MEC that were on the investigating committee not allowed to vote.

The accused member has the right to be present when the investigating committee makes its report to the MEC. Further, the accused member may, if the action at this time is determined to possibly be permanent, present his/her own evidence at the meeting of the MEC and to also question any of the witnesses that have provided evidence against him/her. Failure of a witness to allow this questioning

for any reason will cause their previous testimony or evidence to be completely stricken. This information may then not be used by the MEC to reach its decision.

At any time during the investigation, if it is determined that there is a reasonable good faith belief that there is a significant safety issue involving either patient care or the hospital staff, the Medical Executive Committee may suspend all or any part

of the clinical privileges of the member individual being investigated. This suspension shall be administrative in nature, for the protection of the patients and/or staff. It shall remain in effect during the investigation only, shall not indicate the validity of the charges, and shall remain in force without appeal during the course of the investigation. If any suspension is placed in effect, the investigation

must be completed in 7 days or the reasons for the delay shall be transmitted to the Governing Board within 8 days of the suspension so it may consider whether the suspension should be lifted. The Governing Board must make a recommendation

as to whether to continue or lift the suspension within 48 hours of notification of the delay from the MEC. If there is failure to follow any step delineated above

regarding administrative suspension, then the suspension is automatically lifted

without any further action by either the Governing Board or the MEC. If no suspension is involved, then the investigative process should be completed within 30 days. .

SECTION 3: Procedure Thereafter

A. In acting after the investigation and hearing, the Medical Executive Committee may:

1. Dismiss the complaint if the investigation has not supported the allegations,

2. Issue an educational action which is not a permanent action and may consist of,

but is not limited to the following:

a. Continuing Medical Education

b. Requirement for Consultation

c. Requirement for Proctoring

d. Other educational activity as might be defined by the MEC.

3. An educational action is to be placed in the members educational file and completely purged at the end of the period determined by the Medical

Executive Committee to be the term of the action if successfully completed

by the affected member. This period shall in no case exceed 6 months.

4. A permanent disciplinary action is placed in the members permanent file.

B. The transfer of an educational action to the permanent file or use of any of

the materials in the educational file for determination of a permanent action

will allow the application of all rights of the affected member regarding any

of the materials used. This will be treated as a new action.

C. Any recommendation by the Medical Executive Committee for a Letter of Reprimand associated with a permanent disciplinary action shall automatically trigger the procedural rights provided in Article IX: Hearing and Appeal Procedures. Such a recommendation shall be forwarded to the Chief of Staff who shall promptly notify the affected individual by certified mail, return receipt requested.

D. If the action of the Medical Executive Committee results in an educational action such as that described above it will take effect immediately and without right of appeal to the Board. However, if the action of the Medical Executive Committee results in any action that would be considered a permanent disciplinary action, limited to the actions delineated in Section 1, D 2. above there is an absolute right of Appeal under Article IX. Any member of the Medical Executive Committee who participated in the decision to recommend a permanent action, or any partner or associate of either the accused member or a member of the Medical Executive Committee who also sits on the Board will not be permitted to participate in the appeal determination. Any action recommended by the Medical Executive Committee is held in abeyance until the Board affirms the action of the Medical Executive Committee. The Board shall have the right to conduct their own investigation or may evaluate the case on the record. If the Board decides to use the record no additional evidence may be presented by the Medical Executive Committee. The accused member has the right to attend any Board meetings in which his case is discussed. The Board may recommend the action be carried

out in its entirety, may dismiss the action entirely, or may modify the action.

E. The chairman of the Medical Executive Committee shall promptly notify the chief executive officer in writing of all requests for action regarding a practitioner currently appointed to the medical staff received by the Medical Executive Committee if there is determined to be merit in the request as described above and keep the chief executive officer fully informed of all action taken in connection therewith.

Section 4: Summary Suspension

A. Any one of the following: The Chairman of the Medical Executive Committee, the Chief of any major Service, the Chairman of the Board, the Chief Executive Officer and the Medical Executive Committee of either the medical staff or the governing body, shall each have the authority whenever action must be taken immediately in the interest of patient or personnel safety in the hospital, to summarily suspend all or any portion of the clinical privileges of a practitioner, and such summary suspension shall become effective immediately upon imposition.

B. A practitioner whose clinical privileges have been summarily suspended shall be entitled to request that the Medical Executive Committee hold a hearing on the

matter within 7 days. 5 days. If the MEC investigation supports maintaining

summary suspension, the affected individual then has the right to request that his

rights for a hearing in accordance with Article IX be completed within a 21 day

time frame. This is the only instance in which the standard time frame of Article

IX proceedings may be modified.

C. The Medical Executive Committee may recommend modifications, continuance or termination of the terms of the summary suspension. If, as a result of such hearing, the Executive Committee does not recommend immediate termination of the summary suspension, the affected practitioner shall, also in accordance with Article IX, be entitled to request appellate review by the governing body, but the terms of the summary suspension as sustained or as modified by the Executive Committee shall remain in effect pending a final decision thereon by the governing body. If the affected party selects the appeal process under this part, appeal to the

board shall be convened within 7 days after the hearing of the Medical Executive

Committee is completed. The hearing in the Medical Executive Committee is limited to 2 days. Thus, the entire process under this part should be completed

in approximately 20 days from the time of the initial summary suspension.

C. Immediately upon the imposition of a summary suspension, the chairman of the Medical Executive Committee or responsible Chief of Service shall have authority to provide for alternate medical coverage for the patients of the suspended practitioner still in the hospital at the time of such suspension. The wishes of the patients shall be considered in the selection of such alternative practitioner. If no coverage can be found the ultimate responsibility and liability for patient care is the Chief of Staffs and the Chief Executive Officers.

Section 5: Automatic Suspension

A. Action by the applicable state professional licensing board revoking, suspending, or otherwise resulting in termination of a practitioners license, or placing him on probation, shall automatically suspend all of his hospital privileges. (revised 2/93)

B. Failure of a practitioner to maintain adequate professional liability insurance coverage, as required by these bylaws, or to provide documentation of his license or DEA certificate, shall automatically suspend all of his hospital privileges. (revised 2/93)

C. It shall be the duty of the Chief of the Medical staff to cooperate with the Chief Executive Officer in enforcing all automatic suspensions. Nevertheless, as automatic suspensions of any staff member is a physician matter the final authority for this action lies with the chief of the medical staff.

Section 6: Effects of Bylaws Change

A. A check is to be made of each medical staff members permanent file by the hospital personnel assigned to this task. Anything in this file that does not fall

into one of the permanent disciplinary actions listed in this part (for example

a warning letter) is to be moved to that members educational file. An educational

file is to be maintained on every member of the medical staff.

B. If the Medical Executive Committee decides to change the status of what under this section would be an educational action to a permanent disciplinary action then the rights of the affected member are triggered and the action is treated as a new action. An example would be to take a letter not delineated as a letter of reprimand such as a warning letter and change it to a letter of reprimand.

C. Each member of the medical staff may request a copy of their permanent or educational file at any time and it should be provided in a timely basis (30 days).

D. Any action previously taken that is dated more than 6 months prior to the passage of this part of the Bylaws which is not a permanent disciplinary action is to be

purged from the permanent file and not placed in the educational file. Nevertheless, the Medical Executive Committee may request that an older action be maintained in the educational file for the first 6 months if there is a written explanation for this.



Section 1: Initiation of the Hearing

An applicant or practitioner holding a medical staff appointment shall be entitled to a formal hearing whenever a recommendation unfavorable to him has been made by the

Medical Executive Committee (MEC) regarding the matters enumerated in Section 2B

of this Article or any other action by the MEC considered or delineated as a permanent

action under Article VIII of these bylaws.

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