Board of Trustees Policy 1220.1
MEDICAL STAFF BYLAWS UAMS MEDICAL CENTER UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES
The original PDF version of this policy is linked from the revised date below.
UAMS Medical Center operates under State of Arkansas laws and regulations to achieve a defined mission. The mission is three-fold:
1. To provide high quality patient care;
2. To encourage the development of medical knowledge; and
3. To promote the education of physicians and allied health personnel.
The Medical Staff of UAMS Medical Center recognizes and accepts its delegated responsibility to promote the organizational mission. Execution of this responsibility entails cooperation with the Executive Director of UAMS Medical Center and accountability to the Medical Board and to the University of Arkansas Board of Trustees, the governing body. Therefore, the Medical Staff has resolved to adopt and conform to these Bylaws.
For the purpose of these Bylaws the following definitions apply:
"Appointees" is all Medical Staff appointees.
"Board of Trustees" means the Board of Trustees of the University of Arkansas.
"Chancellor" means the Chancellor of the University of Arkansas for Medical Sciences ("UAMS").
"Chief of Staff" means the individual elected by the Medical Board to act, along with the Medical Director, as the Medical Staff's chief administrative officers.
"Clinical Service" means the divisional organization of UAMS Medical Center by medical specialty.
"College of Medicine" means the College of Medicine, University of Arkansas for Medical Sciences.
"Dean, College of Medicine" means the individual appointed by the Chancellor to act on the Chancellor's behalf in the overall management of the College of Medicine.
"Disability" shall have the meaning set forth in the Americans with Disabilities Act.
"Executive Committee" means the group of Medical Board members defined under Article VIII of these Bylaws.
"Executive Director of UAMS Medical Center" or "Executive Director" means the individual appointed by the Chancellor to act on the Chancellor's behalf in the overall management of UAMS Medical Center.
"Faculty Appointment" means an appointment in the College of Medicine at a level of Instructor, Assistant Professor, Associate Professor, Professor, Distinguished Professor, University Professor, or one of the above titles modified by Clinical, Adjunct, Research, Visiting, or Emeritus.
"Hospital" or "University Hospital" means The University Hospital of Arkansas.
"Housestaff" means an intern, resident, or fellow who is not an appointee to the Active Staff (as defined in Paragraph 9.4) and who is receiving post-graduate training at UAMS.
"MCPG" or "Medical College Physicians Group" means the operating division of UAMS which administers the business aspects of the provision of physician services to patients of UAMS Medical Center, including billing, payment of service-related items, and other similar matters.
"Medical Board" means the group of individual Medical Staff appointees defined under Article V of the Bylaws.
"Medical Center" means UAMS Medical Center.
"Medical Director" means the individual responsible for the professional activities of UAMS Medical Center.
"Medical Staff" means all physicians and dentists granted privileges to attend patients.
"Reasonable accommodation," when used in connection with a disability, shall have the meaning ascribed to it in the Americans with Disabilities Act.
"UAMS Medical Center" means the Hospital and all clinics and other patient care facilities administered as part of the Medical Center.
Masculine and feminine word forms and pronouns may be used to mean either gender, and plural pronouns are sometimes used in the singular number, to avoid gender bias.
ARTICLE 1: NAME
The name of this document shall be the "Bylaws of the Medical Staff of UAMS Medical Center."
ARTICLE II: PURPOSE
2.1 The Medical Staff is organized to define and maintain the quality and appropriateness of care, education, and research through Rules and Regulations, performance standards, peer review, and cooperation. The Bylaws provide a structure in which the Medical Staff can perform its duties and functions.
2.2 The Medical Staff's goals are to:
a. Assure that optimum quality and appropriate health care services are rendered through UAMS Medical Center;
b. Assure appropriate professional performance and utilization of services, within the scope of defined clinical privileges, through systematic credentialing, review, appraisal, and improvement;
c. Provide an environment conducive to employment, education, and research;
d. Maintain a mechanism to address and resolve medical and administrative issues; and
e. Provide a plan for the Medical Staff's governance and accountability to the Board of Trustees.
ARTICLE III: CONDUCT OF MEETINGS
3.1 Quorum and Vote. Except as otherwise specified herein, one half of the voting membership present of the Medical Board, the Executive Committee or the Medical Board committees shall constitute a quorum for all actions. Except as otherwise specified herein, action on any matter shall be taken by a majority vote where a quorum is present.
3.2 Assignment of Right to Vote. Members of the Medical Board and Medical Board committees (with the exception of the Executive Committee) may assign their right to vote to another appointee to the Medical Staff (and of the same clinical service) provided that such assignment is in writing and presented to the person presiding at the meeting at or prior to the meeting. Such assignment may be a continuing one designating another appointee to the Medical Staff (and of the same clinical service) as an alternate with right to vote in the absence of the Board or Committee member.
3.3 Rules. Meetings shall be conducted by Robert's Rules of Order.
ARTICLE IV: CLINICAL SERVICES
4.1 Clinical Services Organization. The Medical Staff is organized into the following clinical services to provide patient service, education, and research effectively by grouping Medical Staff administrative units according to medical specialty:
Emergency Medicine Family and Community Medicine
Neurosurgery Obstetrics and Gynecology
Pediatrics Physical Medicine and Rehabilitation
4.2 Clinical Service Functions. Each clinical service shall have the following functions:
a. Organize services to provide patient care, education, and research specifically related to the clinical service;
b. Develop and implement a quality assurance and quality improvement program to continuously monitor, evaluate, and improve the quality and appropriateness of the care and treatment provided to patients, to include all major clinical activities of the service;
c. Schedule monthly staff meetings to: 1) consider findings from quality assurance and quality improvement activities; 2) provide peer assessment and recommendations for action; and 3) inform staff of policies, procedures, and current issues;
d. Record and maintain minutes, including Medical Staff attendance, of monthly meetings and report each month on quality assurance and quality improvement activities to the Quality Assurance Committee;
e. Assist the Medical Board in developing criteria for delineating clinical privileges and credentialing new staff; and
f. Conduct continuing education programs relevant to the service's specialty.
4.3 Duties of Members of Clinical Service. Each physician who is an Active Staff member of a clinical service shall:
a. Attend at least 50% of the regular meetings of the clinical service;
b. Participate in the service's quality assurance and quality improvement program;
c. Participate in the service's utilization review program; and
d. Perform such other duties as the Chief of Service may assign from time to time.
4.4 Qualifications of Chief of Service. To qualify for appointment, each Chief of Service shall be: 1) the concurrent Chair of the corresponding Department or Division in the College of Medicine, or 2) an individual recommended by the respective Department Chair of the College of Medicine. Appointees who are not Department Chairs shall be approved by the Medical Board and shall serve at the will of the Medical Board. A Department Chair may recommend the replacement of the Chief of Service for the Service which corresponds to such Department Chair's Department, subject to the approval of the Medical Board. If a Department Chair is replaced, the new Department Chair shall automatically become the Chief of Service.
4.5 Duties of the Chief of Service. Each Chief of Service is an administrative officer of UAMS Medical Center, responsible for the following duties:
a. Serving as a member of the Medical Board;
b. Planning and recommending goals and objectives for services to the Medical Director, Medical Board, and Executive Director;
c. Conducting all functions of a clinical service;
d. Monitoring and evaluating professional performance of all individuals within their defined clinical privileges in the service and assuring that appointees only provide services within the scope of privileges granted;
e. Taking primary responsibility to insure that the clinical service's quality assurance and quality improvement function is fulfilled;
f. Reviewing credentials of each prospective and current Medical Staff appointee and affiliated staff appointee and making recommendations to the Medical Board concerning appointments, reappointments, and clinical privileges;
g. Assisting the Medical Board in defining required credentials and the criteria for clinical privileges in the department;
h. Presiding at service meetings;
i. Enforcing Medical Staff Bylaws, Rules and Regulations, UAMS Medical Center's Policies and Procedures, and policies and procedures of UAMS as applicable to the service;
j. Working with appropriate administrators regarding fiscal affairs of the clinical service, including making recommendations concerning capital equipment which is needed to conduct clinical services;
k. Cooperating and coordinating activities with other services, the Executive Director, and the Medical Board; and
l. Recommending to the Medical Director persons to be appointed Physician Director of a clinical service.
ARTICLE V: MEDICAL BOARD AND EXECUTIVE COMMITTEE
5.1 Organization. The primary governing bodies for the Medical Staff are the Medical Board and the Executive Committee.
5.2 Purpose of Medical Board. The Medical Board is organized to: 1) allow representation and participation in any deliberations affecting the discharge of Medical Staff responsibilities; 2) assure the quality and appropriateness of patient care; and 3) establish a system of Medical Staff governance with accountability to the Board of Trustees. The Medical Board and its committees conduct the functions related to the Medical Staff's responsibilities.
5.3 Composition of Medical Board. The Medical Board is composed of the two officers of the Medical Staff and the Chief of Service from each clinical service. The following officials shall be non-voting, ex-officio members of the Medical Board: President, Chief Residents Council; Chancellor; Executive director; Medical Director; Director of Nursing; and Dean, College of Medicine.
5.4 Vacancies. Chief of Service vacancies shall be filled by an Acting Chief of Service. A vacancy in the office of the President, Chief Residents Council, shall be filled by the Vice President, Chief Residents Council.
5.5 Duties. The Medical Board shall have the following duties. To:
a. Fulfill the Medical Staff's purposes as defined under Article II of these Bylaws;
b. Represent and act on behalf of the Medical Staff, subject to limitations imposed by these Bylaws;
c. Coordinate activities and general policies of various Medical Board committees and Clinical Services;
d. Receive and act upon minutes and reports from Medical Board committees and Clinical Services;
e. Formulate and implement Medical Staff policies within delegated authority;
f. Facilitate liaison among the Medical Staff; Dean, College of Medicine; Executive Director; and Board of Trustees;
g. Recommend action on medical/administrative issues to the Executive Director and the Board of Trustees;
h. Discharge responsibilities essential to maintaining accreditation and licensure;
i. Develop and implement an effective quality assurance and quality improvement program;
j. Enforce Medical Staff Bylaws, Rules and Regulations, as well as policies and procedures of UAMS Medical Center and UAMS;
k. Biannually review and revise as indicated the Medical Staff Bylaws, Rules and Regulations; submit revisions to the Board of Trustees for approval;
l. Plan, organize, implement, and monitor a program to grant Medical Staff appointment and reappointment, delineate clinical privileges, and assign members to clinical services; and
m. Reasonably ensure professional and ethical conduct as well as competent clinical performance by each Medical Staff member.
5.6 Term of Office of Members of Medical Board. Since the members of the Medical Board are either the chiefs of clinical services or are ex-officio members, the terms of office of members of the Medical Board shall be indefinite.
5.7 Composition of Executive Committee. Membership of the Executive Committee of the Medical Board is composed of the following: the two Medical Staff Officers; the three category representatives elected as specified in Article VI; and the following officials who shall be nonvoting, ex-officio members: Chancellor; Executive Director; Dean, College of Medicine; Medical Director; and Chair of the Quality Assurance Committee.
5.8 Duties of Executive Committee. The Executive Committee shall have the following duties:
a. Act on behalf of the Medical Board, subject to approval of action at the next Medical Board meeting;
b. Set agenda for Medical Board meetings;
c. Review recommendations of Credentials Committee as to credentials of all applicants and make recommendations to the Medical Board for Medical Staff appointment, reappointment, assignments to services, and delineation of clinical privileges;
d. Biannually review available information regarding the performance and clinical competence of Medical Staff members;
e. Report deliberations and actions taken to the Medical Board; and
f. Provide advisory and supervisory services in connection with appointing and granting clinical privileges to appointees to the Affiliated Health Professional Staff.
5.9 Meetings of Medical Board and Executive Committee. The Medical Board shall meet on the second Monday of each month. The Executive Committee shall meet monthly, one week prior to the meeting of the Medical Board. The Chief of Staff or the Chief of Staff-elect may call special meetings with reasonable notice. Minutes shall be kept and shall be maintained in the office of the Executive Director.
ARTICLE VI: ELECTION OF OFFICERS AND CATEGORY REPRESENTATIVES
6.1 Officers; Qualifications. The officers of the Medical Staff are the Chief of Staff, the Chief of Staff-elect, and the Secretary. Officers shall be Chiefs of Service at the time of election, and shall be Active appointees to the Medical Staff throughout their terms of office.
6.2 Categories of Clinical Services. For purposes of electing representatives to the Executive Committee, the clinical services are divided into three categories, as follows:
a. Category I:
b. Category II:
Obstetrics and Gynecology
c. Category III:
Physical Medicine and Rehabilitation
Effective July 1 of odd-numbered years, the Chiefs of Service of each category shall elect one of their number to serve on the Executive Committee for a two-year term.
6.3 Term of Office of Officers and Category Representatives. The term of office of officers and category representatives shall be two years beginning July 1 and ending June 30. Category representatives shall be elected in odd years. The Chief of Staff-elect and the Secretary shall be elected in even years. The Chief of Staff-elect, if duly elected, shall succeed the Chief of Staff at the end of the Chief of Staff's term of office. In the event there is no duly elected Chief of Staff-elect at the end of a Chief of Staff's term of office, there shall be an election for Chief of Staff at the same time as the election for Chief of Staff-elect.
6.4 Method of Election. The single--transferable--vote system is used for election of officers and category representatives. A ballot of eligible Chiefs of Service who have agreed to have their names submitted as a candidate for officer or category representative shall be proposed in May. Each Chief of Service shall vote on the officer(s) to be elected, and each Chief of Service shall be entitled to vote on the representative to be elected for the category in which his/her service is placed. Each Chief of Service will mark his/her first, second, third, and fourth choices on the ballot for the position for which he/she is entitled to vote.
Under this single--transferable--vote system, all the first choice votes are counted and placed in piles, one pile for each candidate. Then, if no candidate gets a majority of the total vote, the candidate having the smallest number of first choice votes is declared "out of the race" and his/her ballots are all re-counted in accordance with the second choice indicated on each ballot. If the addition of these second choice ballots does not give any candidate a majority of the total vote, the candidate with the lowest total on this second count is declared "out of the race" and his/her ballots are re-counted according to the next choice on each ballot. This system of dropping off the lowest candidate continues either until one candidate does get a majority of the total vote, or, failing that, until there is only one candidate remaining. In the event of a tie, the Chief of Staff will vote to determine the outcome.
6.5 Vacancies. Vacancies in the Medical Staff offices or in category representative positions shall be filled as follows:
a. Chief of Staff. The Chief of Staff-elect or Acting Chief of Staff-elect shall serve as Acting Chief of Staff for the remaining term. The Chief of Staff-elect shall then become Chief of Staff.
b. Chief of Staff-elect. The Executive Committee shall appoint one of their number who is an Active Medical Staff appointee to serve as the Acting Chief of Staff-elect for the remaining term. An Acting Chief of Staff-elect shall not succeed the Chief of Staff unless elected by the Medical Board at the election.
c. Vacancy in Both Offices. In the event of a vacancy in both offices, the Executive Director may appoint an Acting Chief of Staff until the Executive Committee appoints an Acting Chief of Staff and Acting Chief of Staff-elect to serve the remaining term.
d. Vacancy in Office of Secretary. In the event of a vacancy in the office of Secretary, the Executive Committee shall appoint one of their number to fill the remaining term.
e. Vacancy in Category Representative Position. In the event of a vacancy in the position of Category Representative, the Chiefs of Service within the category for which there is a vacancy shall elect one of their number to fill the unexpired term.
6.6 Removal from Office.
a. Reasons for Removal. An officer or a category representative may be removed for any of the following reasons:
(1) Failure to perform the duties of the office or position as described in these Bylaws;
(2) Failure to attend three scheduled meetings of the Medical Board in any one year without reasonable cause; in the case of members of the Executive Committee, failure to attend three scheduled meetings of such Committee without reasonable cause;
(3) Termination of Active Medical Staff membership; and
(4) In the case of a Chief of Staff-elect, notification of his/her intention of leaving UAMS.
b. Action of Executive Committee or Medical Board. Removal because of termination of Active Medical Staff membership or because of notification by a Chief of Staff-elect of intention to leave UAMS shall not require any action by the Medical Board. The Executive Committee shall declare a vacancy in the office. In the case of removal for some other cause, the Chief of Staff will notify the involved officer or representative of the allegations. If the involved individual is the Chief of Staff, the Chief of Staff-elect shall notify the Chief of Staff. The officer/representative may at that point decide to resign from his/her position. If the officer/representative disagrees with the allegations and wishes the Medical Board to consider the matter, the allegations against that officer/representative shall be presented to the Medical Board. The officer/representative involved shall be entitled to the following due process rights: notification in writing of the allegations and of the date of a hearing before the Medical Board and the right to be present at the Medical Board meeting where the allegations are presented; to confront his/her accusers; to ask them questions; and to present witnesses in his/her own defense.
c. Vote on Removal. An officer/representative may be removed from office by two-thirds vote of all members of the Medical Board who have voting rights. The officer/representative involved in removal proceedings may not vote. The Chief of Staff may vote to break a tie. If the Chief of Staff is the individual involved, the Chief of Staff-elect may vote to break a tie.
d. Finality of Medical Board Decision. The Medical Board decision shall be final and the involved officer/representative shall have no appeal rights.
ARTICLE VII. DUTIES OF OFFICERS, MEDICAL DIRECTOR, UNIT DIRECTORS
7.1 Chief of Staff. The Chief of Staff shall have the following duties:
a. Address issues and coordinate activities of mutual concern with the Medical Director and Executive Director;
b. Call and chair meetings of the Executive Committee, the Medical Board, and the Medical Staff; and
c. Appoint committee members.
7.2 Chief of Staff-elect. The Chief of Staff-elect shall have the following duties:
a. Act as Chief of Staff in absence of the Chief of Staff;
b. Serve as voting member of Executive Committee; and
c. Become Chief of Staff at the end of the previous Chief of Staff's term of office.
7.3 Secretary; Duties. The Secretary shall serve as an at-large member of the Executive Committee and shall have such other responsibilities as may be assigned from time to time by the Chief of Staff.
7.4 Medical Director; Qualifications and Appointment. The Medical Director will be an Active appointee of the Medical Staff. The Medical Director will be jointly appointed by the Dean of the College of Medicine and the Executive Director.
7.5 Medical Director; Duties. The primary responsibilities of the Medical Director are: 1) to be responsible to the Dean regarding UAMS faculty activities at UAMS Medical Center and its outpatient facilities, primarily involving coordination of clinical programs and maintaining and improving the quality of care; and 2) to serve as the primary contact person for physician outreach, institutional referral issues, and resolution of problems related to referral of patients to the physicians at UAMS Medical Center. Specific duties include:
a. Providing coordination of the various services in regard to professional activities of the Medical Center;
b. Representing the views, policies, and needs of the Medical Staff through the Executive Director, Dean, and Chancellor to the Board of Trustees;
c. Under the direction of the Board of Trustees and the Medical Board, providing overall supervision of the quality assurance and quality improvement programs of the Medical Staff;
d. Recommending to the Executive Director and Executive Committee appointment of a Unit Director in specialized patient care areas of the Medical Center requiring professional medical supervision, developing a written job description of this Unit Director's duties, responsibilities and qualifications and providing overall coordination and, in conjunction with the Chiefs of Service, direction to the various medical directors;
e. Serving as an ex-officio member of all Medical Staff Committees;
f. Communicating policies of the Board of Trustees and the Medical Board to the Medical Staff;
g. In conjunction with the Chiefs of Service and the Dean, being responsible for enforcing these Bylaws and the Medical Staff Rules and Regulations and for implementing sanctions where indicated;
h. In conjunction with the Chief of Staff and the Dean, serving as the spokesperson of the Medical Staff in its external professional and public affairs; and
i. Receiving and investigating complaints and concerns about patient care provided by the Medical Staff.
7.6 Units; Unit Directors. Units are as follows: ACRC, Audiologic Services, Cardiology Clinics, CVICU, CCU, Dermatology Clinics, Emergency Department, Endocrinology Clinics, Family and Community Medicine, Gastroenterology Clinics and Diagnostics, Gerontology Clinics, Hematology/Oncology Clinic, Infectious Disease Clinic, Initial Care Clinic, Internal Medicine Clinic, Labor and Delivery, MICU, NICU, Neurology Clinics, Neurosurgery Clinics, OB/GYN Clinic, Ophthalmology Clinic, Orthopedic Clinic, Otolaryngology Clinic, Outpatient Hemodialysis, Outpatient Psychiatry Services, Psychiatry Clinics, Recovery Room, Respiratory Services, Speech Therapy, Surgical Specialties, SICU, UPMG, University Women's Health, and Urology Clinics. Individuals who are selected as Unit Directors shall each have a job description which is developed by the Medical Director and approved by the Executive Director and the Medical Board. Each Unit Director shall be responsible for:
a. Overseeing the quality of medical care delivered in that unit;
b. Making recommendations to the Executive Committee concerning appropriate credentials necessary to perform procedures in the unit;
c. Working cooperatively with Administration to determine staff levels necessary to deliver appropriate care in the unit;
d. Assuring the operation of a facility which provides equal access to all individuals who have been appropriately designated through the credentialing process to perform procedures in the unit; and
e. In conjunction with Administration, determining need for new equipment to provide expected levels of care in the unit.
ARTICLE VIII. MEDICAL BOARD COMMITTEES
8.1 Committees. Medical Board standing committees have been formed to participate in discharging the duties of the Medical Board. These committees and the expected frequency of meetings are listed below. The Medical Board shall develop and approve a committee charge for each committee, designating the name, membership, suggested meeting frequency, and responsibilities. Committee charges shall be provided to Medical Staff members and practitioners with clinical privileges. Committee charges, meeting time, and appointments will be reviewed every two years. The meeting time shall be determined annually. Special meetings may be called by the Committee Chair.
8.2 Medical Board Standing Committees. The standing committees and the frequency of meetings are as follows:
Ambulatory Care Advisory Alternate Months
Bed Allocation Quarterly
Bylaws Alternate Years
Disaster On Call
Impaired Physician Quarterly
Infection Control Monthly
Intensive Care Units Alternate Months
Medical Ethics Quarterly/On Call
Medical Records Alternate Months
Laser On Call
Operating Room Management Alternate Months
Quality Assurance Monthly
Rehabilitation Services Alternate Months
Surgical Case Review Monthly
Trauma Alternate Months
Clinical Practice Management Monthly
8.3 Organization. Additional standing committees may be organized after: 1) presentation of proposal to the Medical Board, 2) approval by the Medical Board, and 3) amendment to these Bylaws. Ad hoc committees may be organized by the Chief of Staff: 1) after presentation of the proposal to the Medical Board and approval by the Medical Board, or 2) by designation by Chief of Staff and ratification by Medical Board at the next regular meeting. Upon completion of the assigned task, ad hoc committees shall be dissolved by the Medical Board.
8.4 Appointment of Committee Members. The Chief of Staff shall appoint members to all committees after consulting with the Chair of the Committee, the Medical Director, and the Executive Director. Appointments are subject to Medical Board approval. Members may be Medical Staff, other health professionals, or administrative staff of UAMS Medical Center. A majority of each committee shall be members of the Medical Staff. Unless the committee charge specifies that committee members who are not physicians are non-voting members, they shall be voting members. The Medical Director shall be an ex-officio member of all committees. Appointees may concurrently serve on more than one committee.
8.5 Term of Committee Members; Removal. Committee members are appointed for two-year terms, ending on June 30 of even years. Reappointments are encouraged in order to enhance continuity. An appointment shall automatically lapse if a member leaves UAMS Medical Center or resigns from the committee. The Chief of Staff shall remove from the committee any committee member who fails to participate in functions of the committee, misses more than half the meetings of the committee during any calendar year, or who misses more than three consecutive meetings without good cause. The Chair of each committee shall report to the Chief of Staff and the Medical Director in May of every year as to the attendance and performance of each committee member.
8.6 Vacancies in Committee Membership. Vacancies in committee membership shall be filled by the Chief of Staff. Appointments shall be for the remaining term of the vacancy. Medical Board approval of such appointments is not required.
8.7 Duties of Members. Committee members accept responsibility to:
a. Participate in committee functions;
b. Attend committee meetings;
c. Cooperate with committee members; and
d. Accept voting rights.
8.8 Chair. The Chief of Staff shall appoint the Chair of each committee. Committee Chairs shall be appointed to serve two-year terms, beginning July 1 of even-numbered years. Chairs shall not succeed themselves, unless the Chief of Staff and the Medical Director recommend an exception be made. In the event of a vacancy, the Chief of Staff shall appoint an interim Chair to serve out the unexpired term. Unless otherwise specified in the committee charge, each Chair must be a member of the Active Medical Staff. The Chair may delegate any duties to another committee member.
8.9 Duties. The duties of the committee chair are to:
a. Schedule, prepare agenda, notify members of meetings;
b. Conduct the committee's business to fulfill defined charge; and
c. Record minutes and attendance of meetings; distribute minutes.
8.10 Reporting. Minutes and attendance records of committee meetings shall be approved by its members and distributed to committee members, Medical Board, and Quality Assurance Department. Minutes and reports shall be maintained in the office of the Executive Director. Some committees may have other reporting requirements specified in their charge.
ARTICLE IX: MEDICAL STAFF RESPONSIBILITIES AND CATEGORIES
9.1 General. Only physicians who hold a Medical Staff appointment or temporary privileges (under Article X) are eligible to render medical care at UAMS Medical Center. Appointment to the Medical Staff is granted by the Board of Trustees through the appointment/reappointment process. Every person practicing the medical profession at UAMS Medical Center by virtue of Medical Staff appointment shall be entitled to exercise only those clinical privileges specifically granted to that person by the Board of Trustees, except in the case of temporary privileges.
9.2 Responsibilities of Appointment. By applying for and accepting a Medical Staff appointment, the applicant has agreed to:
a. Abide by Medical Staff Bylaws, Rules and Regulations, and policies;
b. Assist in educational and research activities;
c. Adhere to the American Medical Association's Principles of Medical Ethics, or the American Dental Association's Code of Ethics, and the American College of Surgeons' Principles of Financial Relations in the Professional Care of the Patient;
d. Provide patient care services consistent with delineated clinical privileges;
e. Participate in activities of the Medical Staff;
f. Participate in continuing education;
g. Participate in and cooperate with quality assurance, quality improvement, and utilization review activities;
h. Provide continuous patient care;
i. Abide by UAMS Medical Center Policies and Procedures; and
j. In the event an adverse recommendation or action is made with respect to staff status or clinical privileges, to exhaust any and all administrative remedies which may be available under these Bylaws before utilizing any other means of obtaining staff status and clinical privileges, including but not limited to legal action.
9.3 Categories. Medical Staff appointment shall consist of Active, Courtesy, and Honorary categories.
9.4 Active Medical Staff. To be eligible for appointment to the Active Medical Staff, individuals must be physicians duly licensed in Arkansas who either hold full-time faculty appointments in the College of Medicine, or hold part-time or voluntary faculty appointments and who regularly treat patients at the Medical Center, and who reside closely enough to the Medical Center to provide continuous care of their patients. Each appointee shall be assigned to a Clinical Service and shall have clinical privileges delineated. They shall be eligible to serve on Medical Board committees. Attendance at the annual meeting of the Medical Staff is required.
9.5 Courtesy Medical Staff. To be eligible for appointment to the Courtesy Medical Staff, individuals must be physicians or dentists duly licensed in Arkansas who practice in the community and hold part-time or voluntary faculty appointments in the College of Medicine, but who only occasionally treat patients at the Medical Center or act only as consultants. Each appointee shall be assigned to a Clinical Service and shall have clinical privileges delineated. Courtesy Staff members may serve as voting members of Medical Board committees, but are not eligible to hold office in the Medical Staff organization. Attendance at clinical service and annual staff meetings shall not be required, but Courtesy Staff appointees shall be responsible for knowing about any changes in policies and procedures applicable to the assigned clinical service and changes in Bylaws, Rules and Regulations.
9.6 Honorary Medical Staff. The Honorary Medical Staff shall consist of physicians and dentists who are not active in the Medical Center but are honored by emeritus positions. These may be physicians or dentists who have retired from active practice or who have achieved outstanding accomplishments and reputations and have contributed or can contribute to the development of UAMS Medical Center and UAMS. Honorary Staff appointments shall be initiated upon the applicable Chief of Service's invitation to the respective member. Honorary Staff appointees shall be assigned to a Clinical Service, but shall not have any clinical privileges other than such consulting privileges as may be delineated. They shall be eligible for membership and have the right to vote on Medical Board committees. If they have privileges to do so, they may render consultive care for patients under the care of another Medical Staff appointee. Attendance at Clinical Service and annual staff meetings shall not be required. To the extent necessary for them to exercise any consultative privileges they may have, Honorary Staff members shall be responsible for keeping current with changes in policies and procedures which are applicable to the assigned clinical service. Unless they have consulting privileges, Honorary Staff members are not subject to the appointment/reappointment process. If they have consulting privileges, they are subject to the appointment/reappointment process and delineation of privileges.
9.7 Housestaff. The housestaff shall consist of physicians who have been assigned clinical rotations at UAMS Medical Center because they have received an appointment in a UAMS medical training program or fellowship. They are eligible to serve on committees and to function in the clinical areas of UAMS Medical Center within the limitations of their appointments. The housestaff are not eligible to admit patients or to hold office, or to vote, except as members of committees. They are directly responsible to their respective Chief of Service, to the Chief of Staff, and to the Medical Director for clinical aspects of patient care and pertinent UAMS Medical Center policies. The Chiefs of Service shall establish patient care activities that can be carried out by housestaff. Within such parameters, members of the Active or Courtesy Medical Staff may delegate certain duties and responsibilities according to the house officer's capabilities and experience.
ARTICLE X: MEDICAL STAFF APPOINTMENT, REAPPOINTMENT, AND CLINICAL PRIVILEGES APPLICATION
10.1 General. All applications for Medical Staff appointment and clinical privileges shall be submitted in writing on forms obtained from the Executive Director upon request by persons eligible for appointment. The application process shall be designed to assure high quality patient care, and requires detailed, documented data about the applicant's qualifications, competence, and previous experiences.
10.2 Review Process.
a. Review by Executive Director. Applications for appointment, reappointment and clinical privileges shall be submitted to the Executive Director upon completion. After receipt of the application, office staff shall initially review the application for completeness and verify accuracy of data provided. Reasonable efforts to ensure completeness and verification of the application shall be accomplished within 30 calendar days following receipt. If the application is deemed incomplete the applicant shall be notified, and it shall be the applicant's burden to submit information necessary to complete the application. No further action shall be taken in the review process until the application is complete.
b. Review by Credentials Committee, Executive Committee, and Medical Board; Decision
Board of Trustees. The Credentials Committee reviews each application and reports on each application to the Executive Committee. The Executive Committee reviews each application and makes a recommendation to the Medical Board. It may defer action on an application one time and must take action on such application at its next regular meeting. If its recommendation is adverse (as defined in Article XIII), the applicant/appointee shall have the hearing and appeal rights set forth in Article XIII. The Medical Board reviews each application and makes a recommendation to the Board of Trustees. The Board of Trustees decides whether or not to grant the application. The review procedure is further set forth in Article XIII.
10.3 Eligibility. To be eligible for Medical Staff appointment an applicant shall be:
a. A graduate of an approved medical or dental school;
b. Licensed to practice medicine or dentistry in the State of Arkansas;
c. On the faculty of UAMS; and
d. A United States citizen, or a person with an appropriate visa.
Applications shall not be accepted from individuals who do not meet these eligibility criteria. On the other hand, meeting eligibility criteria does not guarantee appointment, reappointment, or granting of clinical privileges.
10.4 Application Requirements. A complete application includes the signed Application for Appointment to the Medical and Dental Staff and Delineation of Clinical Privileges forms with all requested data provided.
10.5 Submission of Application. Submission of the application signifies the applicant's:
a. Willingness to appear for interviews regarding the application;
b. Authorization for UAMS Medical Center representatives to consult the National Practitioner Data Bank and with other individuals and institutions and inspect all material records having information bearing on the applicant's experience, competence, character, ethics, and other qualifications for Medical Staff membership;
c. Release of UAMS Medical Center and its representatives from any liability for their acts or omissions, performed in good faith without malice, while evaluating the applicant's credentials and the applicant;
d. Release from liability of all individuals and institutions that provide information to UAMS Medical Center's representatives in good faith and without malice concerning the applicant's experience, competence, character, ethics, and other qualifications for Medical Staff appointment and clinical privileges, including otherwise privileged or confidential information;
e. Authorization and consent for UAMS Medical Center's representatives to provide other hospitals, medical associations, and other organizations concerned with provider performance and the quality and efficiency of patient care with any information UAMS' Medical Center may have concerning the applicant, and release of UAMS Medical Center and its representatives from liability for so doing, provided that furnishing such information is done in good faith and without malice;
f. Pledge to provide continuous care for the applicant's patients;
g. Receipt and understanding of Medical Staff Bylaws, Rules and Regulations, and agreement that the applicant's activities shall be bound by these documents;
h. Burden to produce adequate information for a proper evaluation of the applicant's experience, competence, character, ethics, and other qualifications and for resolving any doubts about such qualifications; and
i. Pledge to report notification of a professional liability action against the applicant.
10.6 Elements Considered in Application. During the application review process, the following elements shall be considered for appointment and clinical privileges delineation:
(1) Current licensure;
(2) Relevant experience/training;
(3) Current competence;
(4) If the applicant has indicated he or she has a disability, an evaluation of reasonable accommodations for such applicant;
(5) Quality assurance, quality improvement, and utilization review participation;
(6) Evidence of adverse action taken against the applicant by UAMS Medical Center or another health care institution;
(7) Category of Medical Staff membership;
(8) DEA registration;
(9) File with National Practitioner Data Bank.
b. UAMS Medical Center's ability to provide adequate facilities and support services for the applicant and the applicant's patients.
c. Health care needs of the patient population.
d. Peer review and recommendations.
e. Professional liability insurance coverage and claims experience (the applicant must furnish satisfactory evidence of at least $1,000,000 in professional liability coverage with an insurance company acceptable to UAMS Medical Center); and
f. UAMS Medical Center's current need for the expertise offered by the applicant.
Physicians and dentists shall not be entitled to Medical Staff appointment or have the right to exercise clinical privileges merely by virtue of the fact that they have: 1) fulfilled eligibility requirements; 2) practiced their profession in this or any other state; 3) been a member of any professional organization; or 4) been granted Medical Staff membership and/or clinical privileges at another institution. Sex, race, creed, disability or national origin are not used in making decisions regarding clinical privileges.
10.7 Leave of Absence and Returns to Staff.
a. Leave of Absence. A Medical Staff appointee may request a leave of absence of not more than one year. The Medical Board shall have authority to grant or deny requests for leaves of absence. During the leave of absence, unless otherwise specified by the Medical Board, the physician shall continue to be a Medical Staff appointee with full clinical privileges. If the time for reappointment occurs during the leave of absence, the physician shall not be required to go through the reappointment process until his/her return from leave of absence.
b. Physicians who wish to return to the staff after leaving the staff for a period of less than one year and who are eligible for Medical Staff appointment are not required to follow the procedure for initial staff appointment. They shall follow the procedure for reappointment, with appropriate modifications to ensure the disclosure of complete information concerning their practice and activities during the period when they were not on the Medical Staff of UAMS Medical Center. Physicians who wish to return to the staff after having left the staff for more than a year must complete the initial appointment procedure.
10.8 Reappointment Schedule.
a. Six-Month Review. Initial appointment to the Medical Staff and granting of clinical privileges shall be effective for a six-month period. At the end of the six-month appointment, the appointee may apply for a full appointment by completion of a six-month review form, the recommendation of the Chief of Service, the Credentials Committee, the Executive Committee, the Medical Board, and final approval of the Board of Trustees.
b. The initial full appointment shall end on the last day of the appointee's second birth month following the initial provisional appointment, at which time the appointee shall be eligible for reappointment. All reappointments shall be for a two-year term, with reappointment effective on the last day of the respective Medical Staff appointee's birth month.
c. One-Year Fellows. The six-month review shall not be required for physicians attending a one-year fellowship.
d. Two-Year Fellows. Reappointment is not required for physicians attending a two-year fellowship. If the stay of such a physician is extended beyond two years, a reappointment procedure must be completed before the end of the two-year period, preferably during the physician's birth month.
10.9 Criteria for Reappointment. Recommendations for reappointment and clinical privileges delineation shall be based on the following criteria:
a. Professional competence, performance and experience, utilizing results of quality assurance activities to assist in making determination;
b. Annual verification of licensure, registration, DEA registration or certification; pending challenges to any licensure or registration or the voluntary relinquishment of such licensure or registration;
c. Clinical judgment in the treatment of patients;
f. Attendance at Medical Staff committee and clinical service meetings;
g. Continuing education;
h. Accuracy, timeliness, and completion of medical records;
i. Compliance with the Medical Staff Bylaws, Rules and Regulations;
j. Compliance with policies and procedures of UAMS Medical Center;
k. Cooperation with personnel, patients, and other practitioners;
l. Utilization of resources;
m. Service and attendance on Medical Board committees;
n. Participation in quality assurance activities;
o. Peer recommendations;
p. Disabilities disclosed by the staff member (but no discrimination shall be based on a disability for which reasonable accommodation can be made);
q. Malpractice claims and lawsuits alleging medical injury; or
r. Canceled or refused professional liability insurance coverage.
10.10 Application for Reappointment.
a. At least two months prior to expiration of full appointment and clinical privileges, the Executive Director shall request the staff appointee to complete a portion of the Medical Staff Reappointment/Reappraisal form. Appointees shall return the completed form to the Medical Staff Coordinator no later than 30 days after it is sent to them. Information requested includes:
(1) Requested change in clinical privileges and justification;
(2) Continuing education activities;
(3) Whether the staff member is physically and mentally able to perform his/her responsibilities; and, if the staff member discloses a disability, whether reasonable accommodation can be made;
(4) Documented licensure, registration, or certification;
(5) Copy of current Drug Enforcement Administration (DEA) form;
(6) Appropriate evidence of current professional liability insurance coverage in an amount not less than $1,000,000 with an insurance carrier acceptable to UAMS Medical Center;
(7) Information concerning claims and lawsuits relating to the staff member;
(8) Information concerning the staff member's participation in quality assurance and utilization review activities; and
(9) Information concerning the staff member's admitting practices.
b. The Medical Staff Coordinator, for the Executive Director, shall also request reports from the National Practitioner Data Bank and from UAMS's Quality Assurance Department and shall seek such information from other sources as the Executive Director deems related to the reappointment application.
c. At least 30 days before expiration of a staff member's appointment, the staff member shall submit the completed form with requested documents to the Medical Staff Coordinator, who shall immediately forward the application to the respective Chief of Service. No less than 15 days prior to the expiration of the appointment, the Chief of Service shall submit a recommendation on the reappointment to the Executive Committee.
10.11 Clinical Privileges.
a. Appointees of the Medical Staff shall seek clinical privileges through the appointment/reappointment process defined in this Article.
b. Each staff appointee shall be entitled to exercise only those clinical privileges specifically granted to such appointee. Each Chief of Service shall have the responsibility to continually monitor and assure that all staff appointees with clinical privileges within the respective service shall provide only those services within the scope of privileges granted. The Medical Board shall have responsibility to assure the provision of the same level of quality patient care by all individuals with delineated clinical privileges within and across clinical services and among all Medical Staff appointees. The Medical Board shall conduct this responsibility through the established quality assurance program.
c. All appointees to the Active or Courtesy Medical Staff are automatically granted privileges to: 1) admit patients and treat inpatients and outpatients, with the exceptions of appointees in Anesthesiology, Radiology, and Pathology, unless individually approved; 2) order diagnostic and therapeutic services, except as noted in Medical Staff Bylaws, Rules and Regulations; 3) write orders and progress notes in the patient's medical record; 4) request consultation; 5) provide consultation within the scope of their privileges; 6) render any care, without regard to delineation of privileges, in a life-threatening emergency. Appointees to the Honorary Medical Staff shall only have the privileges which have been specifically delineated for a particular Honorary Staff member, and in no event shall have any privileges other than specifically delineated consulting privileges.
d. Every patient is under the care of a member of the Active or Courtesy Medical Staff, and the staff physicians cannot delegate the care of any patient to any person who is not a member of the Active or Courtesy Medical Staff.
10.12 Temporary Privileges.
a. General. There are three types of temporary privileges: temporary applicant's privileges for applicants who have substantially completed the appointment/reappointment process; temporary visiting privileges for physicians and dentists who are not seeking an appointment to the Medical Staff; and emergency transplant privileges. No person who has not substantially completed the appointment/reappointment process may practice medicine at UAMS Medical Center except under the direct supervision of a member of the Medical Staff.
b. Temporary Applicant's Privileges. Upon recommendation of the Medical Director, proof of a current license to practice medicine or dentistry, and proof of appropriate license to prescribe drugs, the Executive Director may grant applicants for Medical Staff appointment or reappointment temporary privileges after the substantial completion of their application for appointment or reappointment. "Substantially completed" means that the applicant has furnished all information required to be furnished, but that a minimal amount of data coming from third party sources has not arrived; or that the application is completed, but final approval of the Board of Trustees has not been obtained. Such applicant's temporary privileges shall be as follows:
(1) During the interim period between Medical Board recommendation on appointment and clinical privileges and Board of Trustees action, appointment and privileges shall be based on the Medical Board's recommendation.
(2) When the application review process for appointment or reappointment membership and clinical privileges has not progressed to the Medical Board review phase, reappointment, appointment and privileges shall be based on the recommendation of the applicable Chief of Service.
c. Temporary applicant's privileges shall terminate upon the first to happen of the following:
(1) Board of Trustees takes action on the appointment and granting of clinical privileges;
(2) Upon recommendation by the applicable Chief of Service, when the application review
process has not progressed to the Medical Board review phase. The
Executive Director shall notify the member of termination.
If an applicant for Medical Staff appointment has admitting privileges, and his/her temporary privileges are terminated, the termination shall take immediate effect as to admitting privileges. If it is determined that the life or health of the applicant's patients might be endangered by his/her continuing treatment, termination of all clinical privileges shall immediately take effect. The respective Chief of Service shall then assume responsibility for the care of such individual's patients until they are discharged from the hospital or the appointee's patients are transferred to the care of another staff appointee, after conferring with the patient on preference, to assure that medical care will not be interrupted.
d. Temporary Visiting Privileges. Physicians and dentists who are not applicants for the Medical Staff may be granted temporary visiting privileges. Such privileges may be granted at the request of a Chief of Service by the Executive Director or the Medical Director, or, in their absence, the Chief of Staff. Physicians with visiting privileges shall practice only under the direct supervision of the appropriate Chief of Service or his/her designee. They shall not have admitting privileges. Such privileges shall be based on the recommendation of the applicable Chief of Service for a defined period of time, not exceeding 91 days. Such privileges shall terminate at the end of such period of time, unless the Chief of Service terminates them sooner.
e. Emergency Transplant Privileges. A Chief of Service or the designee of a Chief of Service may grant privileges on an emergency basis for the sole purpose of allowing a physician to harvest organs or tissue from the body of a patient at The University Hospital. Such privileges shall be granted only upon proof of a current medical license in one of the United States, and may be subject to any requirements the Chief of Service (or designee) chooses to impose. At the time such privileges are granted, the Chief of Service shall notify the administrator on call.
ARTICLE XI: AUTOMATIC TERMINATION AND SUSPENSION
11.1 Termination of a member's clinical privileges and Medical Staff appointment shall automatically occur under the following circumstances:
a. Revocation, expiration or suspension of license to practice;
b. Termination of faculty status at the College of Medicine, in the case of an Active or Courtesy Medical Staff appointee; or
c. Conviction of a felony.
11.2 Automatic Suspension for Failure to Complete Medical Records. Staff appointment and privileges shall be automatically suspended for failure to complete medical records in accordance with the Rules and Regulations. The physician's appointment and privileges shall be reinstated following completion of all medical records; however, one or more automatic suspensions hereunder may constitute grounds for corrective action, including termination of staff appointment and privileges.
11.3 Summary Suspension.
a. Any two of the following: the Chief of Staff, a Chief of Service, the Medical Director, and the Executive Director--or the Executive Committee, shall have the authority, whenever action must be taken immediately in the best interest of patient care at UAMS Medical Center, to summarily suspend all or any portion of the clinical privileges of a Medical Staff member, and such summary suspension shall become effective immediately upon imposition.
b. If persons other than the Executive Committee impose such suspension, they shall notify the Executive Committee immediately of such action, and the Medical Staff member may request the Executive Committee to review such action at its next regular meeting, or, at the option of the Chief of Staff, at a special meeting held within ten days of the suspension if possible or as soon thereafter as practicable.
c. If clinical privileges necessary for quality patient care are removed, the respective Chief of Service to which the appointee is assigned must reassign the appointee's patients to other staff appointees, after conferring with the patient on preferences, to assure that medical care will not be interrupted.
11.4 Hearing and Appeal Rights. An appointee whose Medical Staff appointment has been terminated or suspended under Sections 11.1 and 11.2 shall not be entitled to a hearing or appeal; an appointee whose privileges have been summarily suspended under Section 11.3 shall be entitled to hearing and appeal rights set forth in Article XIII.
ARTICLE XII: CORRECTIVE ACTION
12.1 Reasons for Corrective Action. The Medical Staff organization shall assume responsibility for corrective action toward its appointees whenever the activities, professional conduct or physical or mental health status of any appointee:
a. Jeopardizes, or is likely to jeopardize, the safety or best interest of patient care; or
b. Is lower than the standards or aims of the Medical Staff; or
c. Is disruptive to operations of the Medical Center; or
d. Constitutes a willful disregard for Medical Staff Bylaws, Rules and Regulations or institutional policies and procedures; or
e. Causes inappropriate utilization of resources.
a. Corrective action due to any of the above reasons may be requested by any appointee of the Medical Staff, or the Executive Director. All requests for corrective action shall be in writing to the Medical Director. Requests shall be supported by specific, factual references that constitute the basis for initiating corrective action, including any relevant data necessary for investigation, such as patient number, date, specific acts of commission or omission.
b. Upon receipt of the request, the Medical Director shall notify in writing the appointee, appropriate Chief of Service, and Executive Director of the request and reasons for request.
c. The Medical Director may accept or reject the request for corrective action and shall notify in writing the aforementioned individuals of the acceptance or rejection and the reasons for rejection. On acceptance, the Medical Director shall forward the request for corrective action to the respective Chief of Service to whom the member is assigned.
d. Upon receipt, the Chief of Service shall investigate the request, and shall have the authority to inspect all material records and reports relevant to the case, interview individuals having knowledge of the case, and interview the involved member. Any or all of these investigative steps may be taken. All interviews shall be conducted informally without attendance of counsel, unless the member requests the attendance of counsel, and procedural rules for a formal hearing shall not apply. A record of any interviews shall be made.
e. Within 10 working days after receipt of the request for corrective action, the Chief of Service shall make a report of the investigation, including records of all interviews, to the Medical Director. The Medical Director shall review the case and shall make a determination as to whether the matter has been appropriately addressed, or whether further action is required. If further action is required, the matter will be presented to the Credentials Committee by the Medical Director.
f. At its next regularly scheduled meeting, or at a meeting called by the Chief of Staff, the Credentials Committee shall review the matter and, if appropriate, interview the involved member or other individuals having knowledge of the case. All interviews shall be conducted informally, without the attendance of counsel or the procedural rules for formal hearings, unless the member requests the attendance of counsel. A record of interviews conducted during the deliberations shall be made.
g. In the event the request for corrective action is against a Chief of Service, the Credentials Committee shall have authority to investigate the case and interview other individuals having knowledge of the case. Interviews shall be conducted informally without the attendance of counsel or the procedural rules for a formal hearing unless the Chief of Service requests the attendance of counsel. A record of any interviews shall be maintained.
h. The Credentials Committee shall have 10 working days after receipt of the request for corrective action to report its findings to the Executive Committee.
i. The Executive Committee shall consider the report of the Credentials Committee and shall recommend one of two actions to the Medical Board:
(1) Reject the request for corrective action on the grounds that the evidence supplied did not substantiate the charges; or
(2) Recommend sanctions:
(a) Issue a warning letter or reprimand or admonition;
(b) Place the individual on probation;
(c) Impose a consultation requirement;
(d) Reduce, suspend (partial or total), or revoke clinical privileges;
(e) Recommend that, in case of suspension, clinical privileges be terminated, modified or sustained;
(f) Reduce staff category or limit staff prerogatives relating to patient care; or
(g) Suspend or revoke staff appointment.
j. If clinical privileges necessary for quality patient care are removed, the respective Chief of Service to which the appointee is assigned must reassign the appointee's patients to other staff appointees, after conferring with the patient on preferences, to assure that medical care will not be interrupted.
12.3 Notification. The Executive Director shall immediately notify any affected appointee of action taken against him/her. The notification shall include an explanation of the exact nature of any infractions or charges against the appointee and, if the appointee is entitled to further hearing or appeal hereunder, shall state that he/she is entitled to request a hearing and appellate review as described hereinafter. The notification shall be in writing and delivered either in person or equivalent, return receipt requested. A copy of the notice shall be sent to the respective Chief of Service and Dean, College of Medicine.
ARTICLE XIII: DUE PROCESS RIGHTS
13.1 Due Process Defined. "Due process" means the various procedures set forth in these Bylaws to ensure fairness, such as the various investigations, interviews and reviews conducted hereunder. Individuals as to whom an "adverse action" is recommended shall also have the right to one hearing and one appellate review as part of their due process rights.
13.2 Adverse Action.
a. The term "adverse action," as used in this Article, shall mean:
(1) Denial of initial appointment to an applicant who is on the faculty of UAMS, is licensed to practice medicine or dentistry in Arkansas, and is a graduate of an approved medical or dental school (a "qualified applicant");
(2) Denial of reappointment to a "qualified applicant;"
(3) Certain restrictions of privileges, namely: (a) termination or suspension of privileges previously granted (except under Sections 11.1 and 11.2); (b) requirement of consultation or supervision; (c) refusal to grant privileges to a physician meeting the objective criteria for such privileges;
Provided, however, that the denial of privileges because of an administrative decision to limit the use of resources to a particular clinical service, or the imposition of consulting or other similar requirements generally imposed on other physicians exercising such privileges, is not an adverse action giving rise to hearing and appeal rights.
b. The following actions are not "adverse actions" entitling the affected person to hearing and appeal rights:
(1) Letter of warning or reprimand;
(2) Probation; and
(3) Automatic terminations or suspensions under Sections 11.1 and 11.2.
13.3 Medical Board Hearing.
a. Notification of Right to Hearing; Exercising Right. If the Executive Committee recommends an adverse action, it shall give the applicant/appointee written notification that the recommendation is adverse and the specific reasons for the adverse recommendation, that the applicant/appointee has a right to a Medical Board hearing, and that such right must be exercised by notification within 20 days. The applicant/appointee shall have 20 days from the date he/she receives such notification to notify the Executive Director of his/her desire for a Medical Board hearing. Failure to request a hearing within such time period shall be a waiver of the right to hearing and appellate review. Upon receipt of such notification, the Chief of Staff shall appoint an ad hoc hearing committee, which shall schedule a hearing within 30 days of receipt by the Executive Director of the request for hearing.
b. Composition of Hearing Committee. The hearing committee shall be comprised of five Medical Staff appointees. Each of the three categories in Article VI shall be represented by one appointee; one appointee shall be from the same clinical service as the individual requesting the hearing (if possible); and one appointee shall be from the Medical Staff at large. A staff member who actively participated in consideration of a previously adverse recommendation or who is in direct economic competition (i.e., within the same subspecialty) with the involved member shall not be appointed a member of the hearing committee. The Chief of Staff shall appoint one member of the ad hoc committee to serve as Chair of the committee.
c. Conduct of Hearing. The applicant/appointee shall have the right to be present, to present information supporting his/her position, and to question witnesses who are present. However, legal rules of evidence are not required to be followed. The applicant/appointee may have an attorney or other advisor present, but such advisor may be excluded or restricted from speaking if the advisor's behavior has a disruptive effect on the procedure. The hearing committee may also have an attorney present to advise it.
d. Action of Medical Board. The hearing committee shall promptly report its findings to the Medical Board, which shall recommend action based upon such findings. If the recommendation of the Medical Board is adverse (as defined above) to the applicant/appointee, such person has the right to appeal the decision.
13.4 Appeal of Adverse Action.
a. Notification of Adverse Action; Right to Appellate Review. When the recommendation of the Medical Board after such hearing is adverse to the applicant/appointee, the ExecutiveDirector shall promptly notify the applicant/appointee in writing either in person or by certified mail, return receipt requested. The applicant/appointee may then request reviewby the Board of Trustees. Such request for review must be in writing and delivered to the Executive Director within 10 days after the applicant/appointee received notification of the Medical Board's adverse determination.
b. Submission of Written Statements. Both the Medical Board and the applicant/appointee shall have 10 working days after receipt of the appellate review notification to submit written statements. The appellant shall present written documentation of alleged errors that occurred at the hearing level. The Medical Board shall present statements defending its decision or refuting the arguments of the appellant. Legal counsel may assist in preparation of the statements. The statements shall be sent to the Board of Trustees and to the Chancellor of UAMS.
c. Review by Chancellor. Within 20 days of his/her receipt of the written material submitted by the applicant/appointee and the Medical Board, the Chancellor shall have an opportunity to conduct a review of such material and, at the option of the Chancellor, may interview the applicant/appointee and the Chief of Staff concerning the adverse action recommendation. If the Chancellor does not recommend any change in the Medical Board's recommendation within 20 days of the Chancellor's receipt of such materials, the matter shall be promptly submitted to the Board of Trustees for appellate review. If the Chancellor recommends any changes in the recommendation of the Medical Board within such 20-day period, the Medical Board shall consider the Chancellor's recommendations at its next regular meeting. If, following such reconsideration, the recommendation of the Medical Board still constitutes "adverse action," the matter shall be promptly submitted to the Board of Trustees for appellate review.
d. Conduct of Appellate Review. A quorum of the Board of Trustees shall be present
to proceed with the review. All members shall have full voting rights and voting by
proxy shall not be allowed. An accurate record of the review shall be recorded by
any of the following means: court reporter, electronic recording equipment, transcription,
or minutes. The Chairman of the Board of Trustees shall be responsible for ensuring
the review is recorded. Postponement of the scheduled review shall be made only upon
the Board of Trustees' approval and for reasonable cause. The Board of Trustees shall
review the records and shall consider the written statements submitted by both parties
for the purpose of determining whether the adverse recommendation or decision was
argument may be part of the review procedure if requested. The individual requesting the review shall be given the opportunity to be present at the review, shall be permitted to speak against the adverse recommendation or decision, and shall answer questions addressed to him/her by any member of the Board of Trustees. A representative of the Medical Board shall also be permitted to speak in favor of the adverse decision and shall answer questions addressed to him/her by the Board of Trustees. New or additional matters not raised during the hearing or its report, nor otherwise reflected in the record, shall only be introduced at the appellate review under unusual circumstances, and the Board of Trustees shall have sole discretion in determining whether such new matters shall be accepted.
e. Action of Board of Trustees. Within 10 working days after the appellate review,
the Board of Trustees shall make a decision to affirm, modify, or reject the previous
decision. The decision of the Board of Trustees shall be final and shall take immediate
effect. At its next regular meeting, the Board of Trustees or its duly authorized
committee shall act on the matter. The Board of Trustees' decision shall be conclusive,
except that the Board may defer final determination by referring the matter back to
the Medical Board for further reconsideration. Any such referral back shall state
the reasons therefore, shall set a time limit within which a subsequent recommendation
to the Board of Trustees shall be made, and may include a directive that an additional
hearing be conducted to clarify issues which
are in doubt. At its next regular meeting after receipt of such subsequent recommendation, and new evidence in the matter, if any, the Board shall make a decision which shall be final.
f. Notice of Appellate Review Decision. The Board of Trustees shall send notice of its decision to the appellant and Chief of Staff to be presented to the Medical Board. Copies of the decision shall also be sent to the respective Chief of Service; Executive Director; Medical Director; and Dean, College of Medicine.
ARTICLE XIV: ANNUAL MEETING
14.1 The annual meeting of the Medical Staff shall be held in the Spring. The Chief of Staff shall preside. Attendance at the annual meeting is required for Active Staff.
ARTICLE XV: AFFILIATED HEALTH PROFESSIONAL STAFF
a. Affiliated Health Professional Staff appointees shall be health professionals who: 1) hold advanced degrees and have proven skill in the area of their specialty, or 2) are performing clinical duties and patient services under the supervision of a member of the Medical Staff who is responsible for their clinical performance. Affiliated Staff appointees must be employees of UAMS, Arkansas Children's Hospital, or a Veteran's Administration facility located in Pulaski County.
b. The Affiliated Health Professional Staff is a separate staff from the Medical Staff. Affiliated Staff appointees are not members of the Medical Staff, and no Affiliated Staff appointee shall be eligible to hold office or vote as a Medical Staff member.
c. Affiliated Staff appointees shall not have admitting privileges, and shall render patient services under the overall supervision of the Medical Staff member responsible for the patient concerned.
d. Affiliated Staff appointees shall attend at least 50% of all regularly-scheduled meetings of the clinical service to which they are assigned, and shall not miss more than three consecutive meetings without good cause.
e. The Affiliated Staff is divided into Consulting Scientist and Allied Health Personnel.
f. Each Affiliated Staff appointee shall have a "sponsoring physician" who shall be a member of the Active or Consulting Medical Staff. In the case of Consulting Scientists, the sponsoring physician will ordinarily be the Chief of Service to which the Consulting Scientist is assigned. In the case of Allied Health Personnel, the sponsoring physician may be the Chief of Service or the physician who is directly responsible for their supervision.
15.2 Consulting Scientists. Consulting Scientists are doctoral-level scientists and licensed health professionals with doctoral degrees such as psychologists, who 1) by their licensure act (or other comparable certification), are permitted to provide patient care services without direction or supervision, and 2) are graduates of a doctoral program in a profession accredited by a nationally recognized accrediting body approved by the U.S. Office of Education. While they may not admit patients, Consulting Scientists may have privileges to consult in relation to patients to whom their special consulting scientist skills may be useful and in activities of education and research.
15.3 Allied Health Personnel. Allied Health Personnel shall be licensed health professionals such as Registered Nurses and Respiratory Therapists, and highly-trained health professionals for whom licensure is not available in Arkansas, who: 1) are not licensed to practice independently, and 2) are performing clinical duties and patient services under the supervision of an appointee to the Medical Staff who is responsible for their clinical performance.
15.4 Clinical Privileges. Each Affiliated Health Professional shall be assigned to a clinical service and shall have clinical privileges and definitive lines of supervision and level of supervision delineated in writing. Clinical privileges shall be granted to Affiliates consistent with their profession, licensure, experience, and competence.
15.5 Appointment Process.
a. Affiliated Health Professionals shall make application for privileges to the Executive Director pursuant to a procedure established by the Executive Director and approved by the Executive Committee. The complete application shall consist of:
(1) An application completed and signed by the applicant;
(2) Verified current Arkansas license/certification;
(3) Documentation of training to perform clinical activities, which shall be verified through written statement of the sponsoring physician;
(4) At least one outside reference letter and two additional reference letters;
(5) If the applicant is not an employee of the State of Arkansas, the applicant must also provide proof of professional liability insurance coverage reasonably satisfactory to the Executive Director or proof that the applicant's employer's insurance policy will cover the applicant's acts or omissions at UAMS Medical Center; and
(6) In the case of an applicant for Allied Staff privileges or a Consulting Scientist who is obtaining privileges for the purpose of assisting a particular physician, the applicant must also provide a letter from his/her supervising physician whereby the physician agrees to accept responsibility and accountability for the conduct of the applicant within the Medical Center.
b. The Executive Director shall obtain the recommendation of the appropriate Clinical Service and, in the case of Registered Nurses, the recommendation of the Director of Nursing, as to the applicant's privileges, lines of supervision, and level of supervision.
c. The Executive Director shall grant or deny Affiliated Health Professional status and privileges to applicants in accordance with guidelines established by the Executive Committee and shall report actions approving or disapproving Affiliated Health Professional Staff status to the Credentials Committee at the next regular meeting of the Credentials Committee. The report shall state: 1) the name of the applicant, 2) the name of the sponsoring physician, and 3) the privileges, lines of supervision, and level of supervision of the applicant. The Credentials Committee shall review such report and make a report thereon to the Executive Committee. The Credentials Committee and the Executive Committee shall have the authority to request additional information concerning the applicant.
d. Initial appointment shall be for a six-month provisional period. At the end of the provisional period the applicant may be converted to full appointment through the reappointment process.
e. If an Affiliate Staff appointee was granted clinical privileges for the purpose of assisting a particular supervising physician, his/her privileges shall terminate automatically upon the termination of privileges of the supervising physician unless he/she is reassigned to another supervision physician.
15.6 Reappointment Process.
a. Reappointments shall be for a two-year period and shall begin and end on the last day of the Affiliated Health Professional's birth month.
b. At least two months prior to termination of provisional or full appointment and clinical privileges, the Executive Director of University Hospital shall request the staff appointee to complete a portion of the Affiliated Health Professional Staff Reappointment/Reappraisal form. Information requested includes:
(1) Requested clinical privileges and justification;
(2) Continuing education activities;
(3) Health status; and
(4) Documented licensure, registration or certification.
The Staff appointee shall submit the form to the respective Chief of Service who shall evaluate the appointee, complete the form, and submit a recommendation for reappointment/non-reappointment and clinical privilege delineation to the Executive Director.
c. The Executive Director shall review the recommendation within 30 days and notify the Credentials Committee that the application has been: 1) granted, and the applicant has been reappointed with clinical privileges delineated, or 2) denied, or 3) deferred for further consideration, with the reasons for deferral clearly stated. When the Executive Director defers consideration of the applicant to obtain further information, the Executive Director shall continue the review and, within an additional 30 days, shall report to the Credentials Committee that the applicant has been: 1) reappointed with privileges delineated, or 2) not reappointed. The report shall state: 1) the name of the applicant, 2) the name of the sponsoring physician, and 3) the privileges, lines of supervision, and level of supervision of the applicant. The Credentials Committee shall review such report and make a report thereon to the Executive Committee. The Credentials Committee and the Executive Committee shall have the authority to request additional information concerning the applicant/appointee.
15.7 Suspension and Termination of Privileges. With or without cause, the privileges of an Affiliated Staff appointee may be suspended, terminated, or subjected to conditions, by the appointee's supervising physician, the Chief of Service of the service to which the appointee has been assigned, the Executive Director, or the Executive Committee. However, such action may not be taken as a means of discriminating against the appointee on a prohibited basis, such as race, religion, gender, disability, or age. The appointee shall have no right of hearing or appeal on account of such action.
ARTICLE XVI: RULES AND REGULATIONS
16.1 The Medical Staff may adopt Rules and Regulations as may be necessary to implement these Bylaws, subject to approval by the Board of Trustees. These rules and regulations shall relate to the proper conduct of Medical Staff organizational activities as well as specify the level of practice required of each member.
16.2 The rules and regulations shall be a supplement to these Bylaws, except that they may be amended or repealed at a regular or special meeting of the Medical Board, where a quorum is present, by a two-thirds vote of those members present and eligible to vote. Amendments to the Rules and Regulations shall become effective upon Medical Board approval, subject to approval by the Board of Trustees.
ARTICLE XVII: ADOPTION
17.1 The Medical Staff Bylaws of The UAMS Medical Center of Arkansas, including Rules and Regulations, shall be adopted at any regular or special meeting of the Medical Board by two-thirds vote of those present and eligible to vote. Upon adoption, the Bylaws shall replace any previous Bylaws of the Medical Staff. These Bylaws shall become effective when approved by the Board of Trustees.
ARTICLE XVIII: AMENDMENTS
18.1 The Medical Board shall biannually review these Bylaws and propose amendments when necessary to reflect current and future practices with respect to Medical Staff organization and functions.
18.2 Proposed amendments shall be presented to the Medical Board at a regular or special
meeting of the Medical Board where a quorum is present. An amendment shall require
a two-thirds vote of members present and eligible to vote. Amendments shall become
effective when approved by the Board of Trustees.
June 1, 1993 (Revised)
January 25, 1991 (Revised)
July 22, 1957 (Adopted)
The University Hospital of Arkansas
RULES AND REGULATIONS
1. ADMISSION OF PATIENTS BY STAFF APPOINTEES ONLY.
Active and Courtesy Medical Staff may admit patients to the hospital, treat inpatients and outpatients, assume responsibility for continuous care of their patients, and, where appropriate, provide emergency service care and appropriate consultations.
Patients may be admitted in this hospital only by Staff appointees who have filed written application, submitted proper credentials, and have been duly recommended for appointment to the Staff by the Hospital Medical Board and approved in accordance with the provisions of ARTICLE IX, of the Medical Staff Bylaws.
2. PROVISIONAL DIAGNOSIS NECESSARY FOR ADMISSION.
Except in emergencies as determined by a physician appointee to the Medical Staff, no patient shall be admitted to the Hospital until a provisional diagnosis has been stated, and the consent of the Hospital secured through the Admitting Office. In case of an emergency, the provisional diagnosis shall be stated as soon after admission as possible.
3. STANDING ORDERS.
Standing orders may be formulated and specifically approved for each clinical service by the Medical Staff and Hospital Administration. Standing orders are those affecting all patients treated in a specific medical service or all patients with a particular diagnosis or planned surgery. Standing procedures may be instituted by the nursing staff unless otherwise ordered by the physician. All standing orders shall be reviewed when initiated or revised by the Chief of Service and the Quality Assurance Committee. Existing standing procedures will be reviewed annually by the appropriate medical service staff and the Quality Assurance Committee.
4. CARE OF PATIENTS IN THE EMERGENCY ROOM.
Patients applying for admission or treatment in the Emergency Room who have no attending physician or allege no attending physician shall be assigned to appointees to the Active Medical Staff on duty in the service to which the illness of the patient indicates assignment and from a rotational roster as determined by the Chief of Service and the Active Staff members of the service. The responsibility for the care of patients in the Emergency Room shall be limited to members of the Housestaff and Medical Staff.
5. CARE OF PATIENT IN THE OUTPATIENT CENTERS.
The responsibility for the medical care of outpatients shall be limited to appointees of the Housestaff and Medical Staff. Housestaff will provide patient care under the guidance of the edical Staff. Medical Staff direction for each outpatient center, including Medical Staff coverage, will be established by the Medical Director for each clinical service. It is the duty of the Medical Staff to provide routine clinical specialty consultation upon request.
6. STAFF MEMBER RESPONSIBILITY FOR AUTOPSIES.
Each appointee to the Medical Staff is expected to be actively interested in securing autopsies. No autopsy shall be performed without written authorization of the next-of-kin or other legally authorized agent. All autopsies shall be performed by the Hospital Pathologist or by a physician to whom he/she may delegate the duty.
7. STAFF MEMBERS TO REVIEW OF CLINICAL WORK.
The medical discussions and meetings held as provided in ARTICLE V of the Medical Staff Bylaws shall constitute a thorough review and analysis of the clinical work done in the hospital, including consideration of deaths, unimproved cases, infectious complications, errors in diagnosis and results of treatment from selected cases in the hospital at the time of the meeting; selected cases discharged since the last meeting; analysis of clinical reports from each such department; and reports of the committees of the Active Medical and Dental Staff at the regular Staff meetings.
8. HOUSESTAFF SUPERVISION.
Each clinical service has specific rules and regulations that specify the mechanisms by which Housestaff are supervised by appointees to the Medical Staff in carrying out their patient care responsibilities.
9. MEDICAL STAFF HOSPITAL POLICIES.
A Medical Staff hospital policy may be recommended by any Medical Board Committee. The Medical Board must approve all Medical Staff Hospital policies. These policies will be reviewed at least every two years.
10. MEDICAL RECORDS - PREPARATION.
While appointees to the Medical Staff share the responsibility for ongoing preparation of medical records, the final obligation for completion of the record rests with the responsible physician. "Responsible physician" is defined as a member of the Active or Courtesy Medical Staff and does not include any resident or intern of The University Hospital regardless of any other title by which he/she is designated. The patient's medical record should be complete at the time of discharge including the signed, completed code sheet, history and physical, progress notes, and orders. The first physician order must be signed with a complete legal signature. All other physician orders may be initialed.
11. MEDICAL RECORDS - COMPLETION.
Medical records shall be completed within 30 days following discharge, to include the signature of the attending physician on the following:
A. Discharge Summary;
B. Operative Note (if indicated); and
C. Attestation Statement (if Medicare patient).
The operative report is considered delinquent if it is not completed within 24 hours. All physicians involved in the surgical case will lose their operating room privileges until the operative report is completed.
Any medical record incomplete after 30 days shall be considered delinquent. The physician responsible for completion of a delinquent chart available in the Medical Record Department shall be so notified by weekly notice through the department mailing system. For purposes of this section dealing with the completion of medical records, a responsible physician shall be deemed to include a resident.
Medical Records Department shall notify departments weekly, on Thursdays, of the responsible physicians on the preceding week's list who have not yet completed their records. Medical Records shall prepare on Friday a list of responsible physicians who have not completed their delinquent records during the preceding 7 days. Residents shall be notified by certified mail of their suspension for delinquent records.
The Medical Records Department shall hold through the weekend the list of delinquent responsible physicians and deliver it the following Monday morning to department chairmen. The weekend shall be considered a grace period during which responsible physicians may continue to complete delinquent records. Responsible physicians who have not completed records within the specified time frames: 1) shall have operating room privileges suspended until all of their delinquent operative reports are dictated; 2) shall be suspended, with Medical Staff losing the privilege to admit patients and residents being suspended without pay (at the rate of 8 hours pay for every day suspended) until all available records are completed. Medical Records management will contact responsible physicians by phone prior to suspension to confirm their knowledge of delinquent status and of their pending suspension.
Residents shall not be sanctioned for:
A. Records not available at the time of visit to the Medical Records Department;
B. Vacation, travel, or sick days reported to the Medical Records Department at extension 66038. Residents are expected to complete all available records prior to leaving on a planned absence.
The Director of Medical Records (extension 66082) shall have the authority to resolve minor issues that may arise in the administration of the record completion system. Any issues not resolved to a physician's satisfaction by the Medical Records Department shall be reviewed by the Hospital Medical Board in consultation with the respective medical department chairman.
12. PROTECTION OF MEDICAL RECORDS.
The original medical record may not be removed from the Hospital except in the custody of the Director of Medical Records or his/her designee upon a court order or subpoena. (Incomplete medical records can only be checked out of the Medical Record Department for direct patient care.) Medical records shall be checked out for one working day only to all areas with the exception of approved research projects (one week), autopsy (48 hours), and inpatient care (until discharge). The location of the medical record must be known by the Medical Records Department at all times. The medical record shall not be removed from an inpatient unit until after discharge except by Medical Records personnel. Medical records shall be checked out to an individual who shall be responsible for the record while it is out of the Department and return of the record if needed for patient care.
13. PROTECTION OF MEDICAL RECORD INFORMATION.
All requests by a patient or other party to view or receive a copy of a medical record shall be coordinated through the Medical Record Information Services Department and accompanied by the patient's written authorization. The physician may write an order in the record that a copy of the chart may be released to the patient or that certain portions should not be released to the patient or that certain portions should not be released for a specified reason at the time of a patient's discharge. A physician will be given 48 hours to respond to a patient's request to see his/her medical record if there are medical contra-indications. Recommendations to limit or deny medical record information to the patient require a physician's written justification. All referring physicians should receive a copy of the discharge summary. Information in the charts is privileged and may not be divulged to any third party without proper authority. In case of readmission of a patient, all previous records shall be available for the use of the attending physician. This rule shall apply to all patients, whether the patient is attended by the same physician or by another.
14. CONTINUING MEDICAL EDUCATION.
Appointees of the Active and Courtesy Staff shall have 20 hours of continuing medical education at the time of reappointment. Consulting Staff shall have 10 hours of continuing education. The Chief of Service shall determine if appointees with less than the required hours have enough relevant continuing education to warrant reappointment on an exception basis.