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Medical Staff Bylaws and Policies and Shall Have Such Other Duties As Assigned by the HHCEB Through the CMO

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Medical Staff Bylaws and Policies and Shall Have Such Other Duties As Assigned by the HHCEB Through the CMO MEDICAL STAFF BYLAWS Revised 2011 University of Michigan Hospitals and Health Centers TABLE OF CONTENTS ARTICLE I. MISSION, PURPOSES, SCOPE AND RELATIONSHIP TO FGP ......................... 7 1.1. MISSION ......................................................................................................................... 7 1.2. PURPOSES ...................................................................................................................... 7 1.3. SCOPE ............................................................................................................................. 8 1.4. RELATIONSHIP TO FGP............................................................................................... 8 ARTICLE II. MEDICAL STAFF ADMINISTRATION AND OFFICIALS .............................. 11 2.1. CHIEF OF STAFF ......................................................................................................... 11 2.2. ASSOCIATE CHIEFS OF STAFF ................................................................................ 13 2.3. CHIEF MEDICAL OFFICER ........................................................................................ 13 2.4. PEDIATRICIAN-IN-CHIEF OF THE C.S. MOTT CHILDREN’S HOSPITAL ......... 14 2.5. SURGEON-IN-CHIEF OF THE C.S. MOTT CHILDREN’S HOSPITAL .................. 15 2.6. OBSTETRICIAN/GYNECOLOGIST-IN-CHIEF OF VON VOIGTLANDER WOMEN’S HOSPITAL ........................................................................................................... 18 2.7. OTHER MEDICAL-ADMINISTRATIVE OFFICIALS OF UMHHC......................... 19 2.8. DEPARTMENT CHAIR................................................................................................ 20 2.9. SERVICE CHIEF ........................................................................................................... 22 2.10. FACILITY MEDICAL DIRECTOR .......................................................................... 26 2.11. AMBULATORY CARE MEDICAL DIRECTOR .................................................... 26 2.12. TEMPORARY DISQUALIFICATION OF OFFICIALS .......................................... 26 ARTICLE III. MEDICAL STAFF MEMBERSHIP ................................................................... 27 3.1. MEMBERSHIP – A PRIVILEGE ................................................................................. 27 3.2. QUALIFICATIONS FOR MEMBERSHIP ................................................................... 27 3.3. BASIC REQUIREMENTS AND RESPONSIBILITIES FOR THOSE SEEKING OR HOLDING MEDICAL STAFF MEMBERSHIP ..................................................................... 27 i 3.4. INSTITUTIONAL FOCUSED CONSIDERATIONS FOR APPOINTMENTS .......... 31 3.5. SPECIAL RESPONSIBILITY REGARDING THE APPLICATION AND REAPPOINTMENT PROCESS – TIMELY ACTION AND MATERIAL INACCURACIES OR OMISSIONS ...................................................................................................................... 32 3.6. CONDITIONS AND DURATION OF APPOINTMENT ............................................. 32 ARTICLE IV. CATEGORIES AND DESIGNATIONS OF THE MEDICAL STAFF AND TRAINEES ................................................................................................................................... 34 4.1. THE MEDICAL STAFF CATEGORIES AND TITLES OF MEDICAL STAFF AND TRAINEES ............................................................................................................................... 34 4.2. THE ACTIVE STAFF ................................................................................................... 34 4.3. THE COURTESY STAFF ............................................................................................. 35 4.4. THE AFFILIATE STAFF .............................................................................................. 36 4.5. PROVISIONAL STATUS ............................................................................................. 37 4.6. THE HONORARY STAFF ........................................................................................... 38 4.7. THE VISITING STAFF ................................................................................................. 38 4.8. TRAINEES..................................................................................................................... 39 4.9. VISITING POST GRADUATE TRAINEE ................................................................... 41 ARTICLE V. PROCEDURE FOR APPOINTMENT AND REAPPOINTMENT ...................... 43 5.1. APPLICATION FOR APPOINTMENT OR REAPPOINTMENT ............................... 43 5.2. APPOINTMENT PROCESS ......................................................................................... 44 5.3. REAPPOINTMENT PROCESS .................................................................................... 46 ARTICLE VI. SPECIFIED PROFESSIONAL PERSONNEL ................................................... 50 6.1. PREROGATIVES .......................................................................................................... 50 6.2. PROCEDURE FOR GRANTING CLINICAL PRIVILEGES ...................................... 50 6.3. HEARING PROCEDURES APPLICABLE TO SPPs .................................................. 51 ii ARTICLE VII. CLINICAL PRIVILEGES ................................................................................. 52 7.1. CLINICAL PRIVILEGES ............................................................................................. 52 7.2. TEMPORARY PRIVILEGES ....................................................................................... 55 7.3. SPECIAL EMERGENCY AND DISASTER PRIVILEGES FOR MEMBERS ........... 56 7.4. SPECIAL EMERGENCY AND DISASTER PRIVILEGES FOR NON-MEMBERS . 56 ARTICLE VIII. PERFORMANCE IMPROVEMENT AND CORRECTIVE ACTION ........... 57 8.1. SPECIAL PROFESSIONAL REVIEW AT DEPARTMENT OR SERVICE LEVEL . 57 8.2. ROUTINE CORRECTIVE ACTION ............................................................................ 57 8.3. SUMMARY ACTION ................................................................................................... 61 8.4. AUTOMATIC ACTION ................................................................................................ 62 8.5. ADMINISTRATIVE ACTION...................................................................................... 63 8.6. ALTERNATIVE ACTION ............................................................................................ 66 8.7. PRECAUTIONARY SUSPENSION OR RESTRICTION ........................................... 67 ARTICLE IX. HEARING AND APPELLATE REVIEW .......................................................... 70 9.1. HEARINGS AND APPELLATE REVIEW .................................................................. 70 9.2. TERMINATION OF CONTRACT ............................................................................... 70 ARTICLE X. COMMUNICATION AND RESOLUTION OF DIFFERENCES ....................... 71 ARTICLE XI. REPRESENTATIVE OF MEDICAL STAFF ON HHCEB ................................ 72 11.1. REPRESENTATIVES OF MEDICAL STAFF ON HHCEB .................................... 72 11.2. ELECTION OF MEDICAL STAFF CANDIDATES ................................................ 72 11.3. APPOINTMENT OF MEDICAL STAFF REPRESENTATIVES TO THE HHCEB .................................................................................................................................... 72 11.4. TERM OF OFFICE .................................................................................................... 72 11.5. VACANCIES ............................................................................................................. 72 11.6. MEMBERSHIP ON EXECUTIVE COMMITTEE ON CLINICAL AFFAIRS ....... 72 iii ARTICLE XII. ORGANIZATIONAL UNITS OF THE MEDICAL STAFF ............................. 73 12.1. GENERAL PURPOSE AND DUTIES OF SERVICES AND COMMITTEES ....... 73 12.2. DEPARTMENTS AND SERVICES ......................................................................... 74 12.3. COMMITTEES .......................................................................................................... 76 12.4. PROFESSIONAL REVIEW COMMITTEES ........................................................... 77 12.5. EXECUTIVE COMMITTEE ON CLINICAL AFFAIRS ......................................... 78 12.6. CREDENTIALING AND PRIVILEGING COMMITTEE ....................................... 83 12.7. MEDICAL LIABILITY REVIEW COMMITTEE .................................................... 84 12.8. MEDICAL STAFF QUALITY COMMITTEE ......................................................... 86 12.9. PROFESSIONAL REVIEW ADVISORY COMMITTEE ........................................ 88 12.10. OTHER MEDICAL STAFF COMMITTEES ............................................................ 89 12.11. RECORD MAINTENANCE AND ACCESSIBILITY ............................................. 90 12.12. UMHHC AND UMHS COMMITTEES .................................................................... 90 ARTICLE XIII. MEDICAL STAFF MEETINGS ...................................................................... 91 13.1. REGULAR MEETINGS OF THE MEDICAL STAFF ............................................. 91 13.2. THE ANNUAL MEETING OF THE MEDICAL STAFF ........................................ 91 13.3. SPECIAL MEETINGS OF THE MEDICAL STAFF ................................................ 91 13.4. QUORUM .................................................................................................................. 91 ARTICLE
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