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1215.2 UAMS Medical Staff Bylaws

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1215.2 UAMS Medical Staff Bylaws MEDICAL STAFF BYLAWS RULES & REGULATIONS UAMS MEDICAL CENTER LITTLE ROCK, ARKANSAS Amended September 2016 TABLE OF CONTENTS PREAMBLE .......................................................................................................................... 2 DEFINITIONS ....................................................................................................................... 3 ARTICLE I: NAME ................................................................................................................ 6 ARTICLE II: PURPOSE ......................................................................................................... 6 ARTICLE III: CONDUCT OF MEETINGS ............................................................................... 6 3.1 QUORUM AND VOTE........................................................................................ 6 3.2 ASSIGNMENT OF RIGHT TO VOTE .................................................................... 6 3.3 RULES ............................................................................................................... 7 ARTICLE IV: SERVICE LINES ................................................................................................ 7 4.1 SERVICE LINE ORGANIZATION .......................................................................... 7 4.2 SERVICE LINE FUNCTIONS ................................................................................ 7 4.3 DUTIES OF SERVICE LINE MEMBERS· ............................................................... 7 4.4 SERVICE LINE DIRECTOR QUALIFICATIONS ...................................................... 7 4.5 DUTIES OF SERVICE LINE DIRECTOR ................................................................. 8 ARTICLE V: MEDICAL BOARD AND EXECUTIVE COMMITTEE ........................................... 9 5.1 ORGANIZATION ................................................................................................ 9 5.2 PURPOSE OF MEDICAL BOARD ........................................................................ 9 5.3 COMPOSITION OF MEDICAL BOARD .............................................................. 10 5.4 VACANCIES ..................................................................................................... 10 5.5 DUTIES ............................................................................................................ 10 5.6 TERM OF OFFICE OF MEMBERS OF MEDICAL BOARD ................................... 11 5.7 COMPOSITION OF EXECUTIVE COMMITTEE .................................................. 11 5.8 DUTIES OF EXECUTIVE COMMITTEE .............................................................. 12 5.9 MEETINGS OF MEDICAL BOARD AND EXECUTIVE COMMITTEE .................... 12 ARTICLE VI: ELECTION OF OFFICERS ................................................................................ 12 6.1 OFFICERS QUALIFICATIONS ............................................................................ 12 6.2 TERM OF OFFICE OF OFFICERS ....................................................................... 12 6.3 METHOD OF ELECTION .................................................................................. 12 6.4 VACANCIES ..................................................................................................... 13 6.5 REMOVAL FROM OFFICE ................................................................................ 13 ARTICLE VII: DUTIES OF OFFICERS, ICE CLINICAL OFFICERS AND UNIT DIRECTORS ...... 14 7.1 CHIEF OF STAFF .............................................................................................. 14 7.2 CHIEF OF STAFF-ELECT ................................................................................... 14 7.3 ICE CLINICAL OFFICERS: QUALIFICATIONS AND APPOINTMENT .................. 14 7.4 ICE CLINICAL OFFICERS: DUTIES .................................................................... 15 i 7.5 SERVICE LINE LEADERSHIP AND CLINIC PRACTICE DIRECTORS ...................... 18 ARTICLE VIII: MEDICAL BOARD COUNCILS AND COMMITTEES ...................................... 19 8.1 COUNCILS AND COMMITTEES ........................................................................ 19 8.2 APPOINTMENT OF COUNCIL AND COMMITTEE MEMBERS........................... 19 8.3 TERM AND REMOVAL .................................................................................... 19 8.4 VACANCIES ..................................................................................................... 20 8.5 DUTIES OF MEMBERS ..................................................................................... 20 8.6 CHAIR ............................................................................................................. 20 8.7 DUTIES OF THE CHAIR .................................................................................... 20 8.10 REPORTING ................................................................................................... 20 ARTICLE IX: THE CREDENTIALS COMMITTEE .................................................................. 21 9.1 ORGANIZATION AND PURPOSE ..................................................................... 21 9.2 COMPOSITION OF CREDENTIALS COMMITTEE .............................................. 21 9.3 COMMITTEE RESPONSIBILITIES ..................................................................... 21 9.4 MEETINGS OF CREDENTIALS COMMITTEE ..................................................... 21 ARTICLE X: MEDICAL STAFF RESPONSIBILITIES AND CATEGORIES ................................ 22 10.1 GENERAL ...................................................................................................... 22 10.2 RESPONSIBILITIES OF APPOINTMENT .......................................................... 22 10.3 CATEGORIES ................................................................................................. 24 10.4 ACTIVE MEDICAL STAFF ............................................................................... 24 10.5 COURTESY MEDICAL STAFF .......................................................................... 24 10.6 HONORARY MEDICAL STAFF ........................................................................ 25 10.7 ADVANCED PRACTICE STAFF ........................................................................ 25 ARTICLE XI: MEDICAL STAFF APPOINTMENT, REAPPOINTMENT AND CLINICAL PRIVILEGES APPLICATION ................................................................................................ 26 11.1 GENERAL ...................................................................................................... 26 11.2 ELIGIBILITY .................................................................................................... 26 11.3 APPLICATION REQUIREMENTS ..................................................................... 27 11.4 SUBMISSION OF APPLICATION .................................................................... 28 11.5 REVIEW PROCESS ......................................................................................... 28 11.6 ELEMENTS CONSIDERED IN APPLICATION ................................................... 30 11.7 INITIAL APPOINTMENT/SIX (6) MONTH REVIEWS ....................................... 32 11.8 REAPPOINTMENT ......................................................................................... 32 11.9 CLINICAL PRIVILEGES ................................................................................... 35 11.10 TEMPORARY PRIVILEGES ............................................................................ 36 11.11 LEAVE OF ABSENCE ..................................................................................... 37 11.12 CHANGE IN PRIVILEGES ............................................................................... 38 11.13 DISASTER PRIVILEGES .................................................................................. 38 ii ARTICLE XII: AUTOMATIC TERMINATION AND SUSPENSION ........................................ 39 12.1 AUTOMATIC TERMINATION ......................................................................... 39 12.2 AUTOMATIC ADMINISTRATIVE SUSPENSION .............................................. 40 12.3 SUMMARY SUSPENSION .............................................................................. 41 12.4 PATIENT REASSIGNMENT............................................................................. 41 ARTICLE XIII: PROFESSIONAL CORRECTIVE ACTION ....................................................... 41 13.1 BASIS FOR PROFESSIONAL REVIEW ACTION ................................................ 41 13.2 EXAMPLES OF PROFESSIONAL REVIEW ACTION .......................................... 42 13.3 INVESTIGATIONS .......................................................................................... 43 13.4 PROFESSIONAL REVIEW ACTIONS ................................................................ 44 ARTICLE XIV: HEARING AND APPEAL .............................................................................. 44 14.1 GROUNDS FOR HEARING ............................................................................. 44 14.2 REQUEST FOR HEARING ............................................................................... 44 14.3 CONDUCT FOR HEARING ............................................................................. 45 14.4 ACTION OF HEARING COMMITTEE .............................................................. 46 14.5 APPEAL OF PROFESSIONAL REVIEW ACTION ............................................... 46 ARTICLE XV: HOUSESTAFF ..............................................................................................
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