Nemours/Alfred I. duPont Hospital for Children Medical ... · PDF fileNemours/Alfred I. duPont Hospital for Children Medical Staff Bylaws Adopted by Board of Managers: December 14,

Nemours/Alfred I. duPont Hospital for Children Medical Staff Bylaws

Adopted by Board of Managers: December 14, 2010


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I. GENERAL PROVISIONS ............................................................................................... 5 A. Purpose.......................................................................................................................... 5 B. Definitions..................................................................................................................... 5 C. Confidentiality and Peer Review Protections ............................................................... 7 D. Conflict of Interest Principles ....................................................................................... 7 E. Indemnification When Performing Credentialing and Peer Review Functions............ 8 F. Delegation of Functions................................................................................................ 8

II. GOVERNANCE AND STRUCTURE............................................................................. 8 A. Categories of the Medical Staff .................................................................................... 8

1. Active Employed Staff.............................................................................................. 9 2. Associate Employed Staff....................................................................................... 10 3. Affiliate Employed Staff......................................................................................... 11 4. Regional Medical Staff ........................................................................................... 12

5. Loss of Status …………………………………………………………………......12 6. Active Community Staff ......................................................................................... 13 7. Courtesy Community Staff ..................................................................................... 14 8. Consulting Community Staff .................................................................................. 15 10. Associate Community Staff .................................................................................... 16

B. Officers of the Medical Staff ...................................................................................... 17 1. Qualifications.......................................................................................................... 17 2. Term of Office ........................................................................................................ 18 3. Election of Officers................................................................................................. 18 4. Vacancies in Office:................................................................................................ 18 5. Duties of Officers.................................................................................................... 18 6. Removal of Elected Officers................................................................................... 19

C. Departments ................................................................................................................ 19 1. Organization............................................................................................................ 20 2. Department Chairpersons........................................................................................ 20 3. Divisions and Division Chiefs ................................................................................ 23

D. Medical Staff Committees and Functions................................................................... 24 1. Committees ............................................................................................................. 24 2. Standing Committees .............................................................................................. 24 3. Medical Executive Committee................................................................................ 24 4. Credentials Committee............................................................................................ 26 5. Nominating Committee........................................................................................... 27 6. Physician Health Team ........................................................................................... 27 7. Graduate Medical Education Committee................................................................ 28 8. Peer Review Committee ......................................................................................... 28 9. Special Committees ................................................................................................ 28

E. Meetings...................................................................................................................... 28 1. Medical Staff Year.................................................................................................. 29 2. Medical Staff Meetings........................................................................................... 29 3. Department, Division and Committee Meetings .................................................... 29

F. Provisions Common to All Meetings.......................................................................... 30


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1. Notice of Meetings.................................................................................................. 30 2. Quorum and voting ................................................................................................. 30 3. Agenda .................................................................................................................... 30 4. Rules of Order......................................................................................................... 30

III. APPOINTMENT, REAPPOINTMENT, AND CLINICAL PRIVILEGES............... 31 A. Qualifications, Conditions, and Responsibilities ........................................................ 31

1. Qualifications for Membership:.............................................................................. 31 2. Waiver of Criteria ................................................................................................... 33 3. No Entitlement to Membership............................................................................... 33 4. Nondiscrimination Policy ....................................................................................... 33 5. Limitation of Privileges and Membership .............................................................. 34

B. General Conditions of Appointment and Reappointment........................................... 34 1. Basic Responsibilities and Requirements for Applicants and Members ................ 34 2. Burden of Providing Information............................................................................ 37

C. Application.................................................................................................................. 38 1. Information ............................................................................................................. 38

D. Grant of Immunity and Authorization to Obtain/Release Information....................... 40 1. Immunity................................................................................................................. 40 2. Authorization to Obtain Information ...................................................................... 41 3. Authorization to Release Information..................................................................... 41

E. Procedure for Initial Appointment to the Medical Staff ............................................. 42 1. Pre-Credentialing Process. Request for Application ............................................. 42 2. Submission of Application...................................................................................... 43 3. Division Chief Procedure........................................................................................ 43 4. Department Chairperson Procedure........................................................................ 44 5. Hospital Medical Director Procedure ..................................................................... 44 6. Credentials Committee Procedure .......................................................................... 44 7. Medical Executive Committee Procedure .............................................................. 45 8. Managers Procedure................................................................................................ 46

F. Provisional Status........................................................................................................ 47 1. Nature of Provisional Status ................................................................................... 47 2. Focused Professional Practice Evaluation .............................................................. 47 3. Duration of Initial Provisional Membership ........................................................... 47 4. Duties of Provisional Members .............................................................................. 48

G. Clinical Privileges....................................................................................................... 48 1. Exercise of Privileges ............................................................................................. 48 2. Unavailable Clinical Privileges............................................................................... 49 3. Clinical Privileges for Dentists and Oral Surgeons ................................................ 49 4. Clinical Privileges for Podiatrists ........................................................................... 50 5. Clinical Privileges for New Procedures.................................................................. 50 6. Criteria for Clinical Privileges ................................................................................ 50 7. Physicians-in-Training............................................................................................ 51 8. Telemedicine Privileges.......................................................................................... 52 9. Emergency Clinical Privileges................................................................................ 52 10. Temporary Privileges.......................................................................................... 52 11. Disaster Privileges .............................................................................................. 52


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H. Procedures for reappointment ..................................................................................... 53 1. Applications for Reappointment ............................................................................. 53 2. Factors to Be Considered ........................................................................................ 53 3. Division Chief Procedures ...................................................................................... 55 4. Hospital Medical Director Procedure ..................................................................... 55 5. Credentials Committee Procedure .......................................................................... 55 6. Medical Executive Committee Procedure .............................................................. 56 7. Managers Procedure................................................................................................ 57

IV. PEER REVIEW AND FAIR HEARING PROCEDURES ........................................ 58 A. Questions Involving Medical Staff Members ............................................................. 58

1. Collegial Intervention/Informal Proceedings.......................................................... 58 2. Deemed Resignations: ............................................................................................ 59 3. Application for Medical Staff Membership After Resignation: ............................. 59 4. Ongoing and Focused Professional Practice Evaluations....................................... 60 5. Investigations .......................................................................................................... 60 6. Precautionary Suspension of Clinical Privileges .................................................... 63 7. Medical Executive Committee Procedure. ............................................................. 64 8. Automatic Relinquishment ..................................................................................... 65 9. Leaves of Absence .................................................................................................. 67

B. Hearings and Appeal Procedures ................................................................................ 68 1. Initiation of Hearing................................................................................................ 68 2. The Hearing ............................................................................................................ 69 3. Pre-Hearing and Hearing Procedure ....................................................................... 71 4. Hearing Conclusions, Deliberations, and Recommendations................................. 74 5. Appeal Procedure.................................................................................................... 75

V. AMENDMENTS, ADOPTION, AND MEDICAL STAFF RULES AND REGULATIONS AND POLICIES AND PROCEDURES................................................................................. 77

A. Amendments/Adoption............................................................................................... 77 B. Medical Staff Policies and Procedures ....................................................................... 78 C. Conflict Management Process .................................................................................... 79

I. GENERAL PROVISIONS 1

2 A. PURPOSE 3 The purposes of these Bylaws are to: 4

A. Establish the formal structure of the Medical Staff of the Alfred I. duPont 5 Hospital for Children; 6

B. Establish the requirements and processes for application for initial 7 appointment and periodic reappointment to membership on the Medical Staff, 8 for Clinical Privileges and for changes in status of membership on the Medical 9 Staff; 10

C. Establish the prerogatives and responsibilities of membership on the Medical 11 Staff; 12

D. Achieve a high level of professional performance by the Practitioners and 13 Affiliate Professionals authorized to practice in the Hospital through the 14 appropriate delineation of the Clinical Privileges that each Practitioner and 15 Affiliate Professional may exercise in the Hospital, and through an ongoing 16 review and evaluation of each Practitioner’s and Affiliate Professional’s 17 performance in the Hospital; 18

E. Provide a means whereby issues concerning the Medical Staff and the 19 Hospital may be discussed by the Medical Staff with the Managers and the 20 Administrator; and 21

F. Serve as a means for accountability to the Managers for the professional 22 performance and ethical conduct of the Members and to strive towards the 23 continual upgrading of the quality and efficiency of patient care delivered, 24 consistent with the state of the healing art and the resources locally available. 25 26

B. DEFINITIONS 27 The following definitions shall apply to terms used in these Bylaws: 28

A. “Administration” means those persons to whom the Administrator and/or the 29 Managers have delegated authority to carry our administrative responsibilities. 30

B. “Administrator” means the Chief Executive Officer or other individual 31 appointed to act in the overall administration of the Hospital. 32

C. “Affiliate Professional” means any licensed, independent health care provider 33 who is not a physician, dentist, or podiatrist, but who practices independently 34 within the scope of his or her license to provide patient care services at the 35 Hospital and who must be credentialed and granted Clinical Privileges 36 through existing Medical Staff mechanisms. Such individuals include, but are 37 not limited to, clinical psychologists, advanced practice nurses and physician 38 assistants. 39

D. “Bylaws” means these Medical Staff Bylaws of the Hospital. 40 E. “Clinical Privileges” means the permission granted to a Practitioner or 41

Affiliate Professional to render specific diagnostic, therapeutic, medical, 42 dental, or surgical services at the Hospital to inpatients and outpatients. 43

F. “Credentials Committee” means the Credentials Committee of the Medical 44 Staff. 45


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G. “Credentialing Department” means the Credentialing Department of Nemours. 1 H. “Dentist” means a person who holds a doctor of dental surgery or doctor of 2

dental medicine degree. 3 I. “Ex Officio” means a role or function being performed by a person due to the 4

person’s office or position held and, unless otherwise expressly provided, does 5 not limit voting rights. 6

J. “Hospital” means the Nemours/Alfred I. duPont Hospital for Children. 7 K. “Hospital Medical Director” means the physician appointed by the Physician-8

in-Chief and the Administrator who has certain delegated responsibilities 9 related to the Hospital and the Medical Staff and whose complete duties are 10 contained in the job description for that position. 11

L. “Managers” means the Board of Managers. 12 M. “Medical Executive Committee” means the Executive Committee of the 13

Medical Staff. 14 N. “Medical Staff” or “Staff” means the Medical Staff of the Hospital. 15 O. “Medical Staff Year” means the twelve-month period commencing on the first 16

day of January in each year. 17 P. “Member” or “Members” means a member or members of the Medical Staff. 18 Q. “Nemours” means The Nemours Foundation, a Florida non-profit corporation. 19 R. “Pediatrician-in-Chief” means a pediatrician in the Department of Pediatrics 20

appointed by the Physician-in-Chief. 21 S. “Physician Health Team” means the team consisting of the Hospital Medical 22

Director, the President of the Medical Staff and the Physician-in-Chief that 23 addresses concerns relating to impaired Members. 24

T. “Physician Health Committee” means the Physician Health Committee of the 25 Medical Society of Delaware or other Committee designated by the Delaware 26 State Board of Licensure and Discipline. 27

U. “Physician-in-Chief” means a physician appointed to perform the duties 28 described in these Bylaws. 29

V. “Physician” means a person who holds a doctor of medicine (M.D.) or doctor 30 of osteopathy (D.O.) degree. 31

W. “Podiatrist” means a person who holds a doctor of podiatric medicine 32 (D.P.M.) degree. 33

X. “Policies and Procedures,” unless otherwise specified, means the Policies and 34 Procedures of the Medical Staff. 35

Y. “Practitioner,” unless otherwise expressly limited, means any Physician, 36 Podiatrist, Dentist or Oral Surgeon applying for or holding privileges in the 37 Hospital. 38

Z. “Special Notice” means written notification sent by certified or registered 39 mail, return receipt requested. 40

AA. “Surgeon-in-Chief” means a surgeon in the Department of Surgery or 41 Orthopedics appointed by the Physician-in-Chief. 42

BB. “Peer Review Committee” means the group of Medical Staff Members 43 formally convened by the Medical Executive Committee to review and 44 evaluate the work of the Medical Staff. 45 46


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Words used in these Bylaws shall be read as the masculine or feminine gender, and as 1 the singular or plural, as the context requires. The captions and headings are for 2 convenience only and are not intended to limit or define the scope or effect of any 3 provision of these Bylaws. 4 5 C. CONDIFENTIALITY AND PEER REVIEW PROTECTIONS 6 Confidentiality: Actions taken and recommendations made pursuant to Article III 7 and Article IV shall be treated as confidential in accordance with applicable legal 8 requirements and such policies regarding confidentiality as may be adopted by the 9 Hospital and the Medical Staff. 10 11 Reporting: Reports of actions taken pursuant to Article III and Article IV shall be 12 made by the Administrator or designee to such governmental agencies as may be 13 required by law. The Nemours/Alfred I. duPont Hospital for Children shall disclose 14 reports of actions taken pursuant to that reporting requirement to other health care 15 organizations upon receipt of a formal request and authorization form to release the 16 information signed by the affected physician. 17 18 Records: All records and other information generated in connection with and/or as a 19 result of professional review activities shall be confidential, and each individual or 20 Committee member participating in such review activities shall make no disclosures 21 of any such information except as authorized, in writing, by the Administrator or 22 designee or by legal counsel for the Hospital or as required by applicable law. 23 24 Breach of Confidentiality: Any breach of confidentiality by an individual or 25 Committee member may result in a professional review action by the Medical Staff, 26 and/or may result in appropriate legal action to ensure that confidentiality is 27 preserved, including application to a court of law for injunctive or other relief. 28 29 Peer Review Protection: All minutes, reports, recommendations, communications, 30 and actions made or taken pursuant to Article III and Article IV are deemed to be 31 covered by the provisions of Title 24, Chapter 17 of the Delaware Code, or the 32 corresponding provisions of any subsequent federal or state statute providing 33 protection to peer review or related activities. Furthermore, the committees and/or 34 panels charged with making reports, findings, recommendations, or investigations 35 pursuant to Article IV shall be considered to be acting on behalf of the Hospital when 36 engaged in such professional review activities and thus shall be deemed to be 37 “professional review bodies” as that term is defined in the Health Care Quality 38 Improvement Act of 1986. All Members agree to execute such documentation to 39 confirm the confidential nature of the matters referred to in this section as may be 40 developed from time to time by the Medical Executive Committee and approved by 41 the Managers. 42 43 D. CONFLICT OF INTEREST PRINCIPLES 44 Members of the Medical Staff shall conduct themselves with integrity, honesty and 45 fairness to avoid any conflict between personal interests and the interests of 46


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Nemours/Alfred I. duPont Hospital for Children. Members shall not use their 1 position with Nemours and/or the Alfred I. duPont Hospital for Children to influence 2 decisions in which they know, or have reason to believe, that they have a financial 3 interest. 4 5 Members are required to file with the Medical Executive Committee a Conflict of 6 Interest Disclosure statement in circumstances that might reasonably be expected to 7 lead to a conflict of interest prior to engaging in any activity that could raise a 8 conflict. 9 10 E. INDEMNIFICATION WHEN PERFORMING CREDENTIALING 11 AND PEER REVIEW FUNCTIONS 12 Members of the Medical Executive Committee, Medical Staff Credentials 13 Committee, and Medical Staff Peer Review Committee will be immune under Title 14 24, Chapter 17, Section 1768 of the Delaware Code from any claim, suit, liability, 15 damages, or any other recourse, civil or criminal, arising from any Peer Review 16 Committee act, omission, proceeding, decision, or determination undertaken or 17 performed, or from any recommendation made, so long as the member and/or 18 Committee acted in good faith and without gross or wanton negligence in carrying 19 out the responsibility, authority, duties, powers, and privileges of the officers 20 conferred by law upon them. They and all Medical Staff members functioning as 21 their designees shall be indemnified by Nemours to the fullest extent permitted by 22 law. 23 24 F. DELEGATION OF FUNCTIONS 25 The Medical Staff of the Nemours/Alfred I. duPont Hospital for Children authorizes 26 the Medical Executive Committee to act on its behalf in the day-to-day matters 27 relating to: 28

Self-governance – policies, procedures, rules 29 Credentialing and Privileging 30 Graduate Medical Education 31 Peer Review 32 Strategic Planning 33

34 The Medical Executive Committee will advise the Medical Staff as to the actions 35 taken. 36 37

II. GOVERNANCE AND STRUCTURE 38 39

A. CATEGORIES OF THE MEDICAL STAFF 40 The Medical Staff shall be divided into the following categories: Active Employed, 41 Associate Employed, Affiliate Employed, Regional Medical Staff, Active 42 Community, Courtesy Community, Consultant Community, Associate Community, 43 and Affiliate Community. 44

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Medical Staff Members who have retired from practice shall have the designation of 1 “Retired.” 2 3 Medical Staff Members who have made outstanding contributions to the field of 4 medicine, the community or the Hospital shall have the designation “Emeritus” after 5 being nominated for and approved for such designation. 6 7

1. Active Employed Staff 8 Qualifications: 9 The Active Employed Staff shall be limited to those qualified Physicians, 10 Podiatrists, Dentists and oral surgeons who desire to practice actively at the 11 Hospital. Active Employed staff members must meet all of the following: 12

a) Meet the qualifications outlined in Article III.A; 13 b) Be employed by the Nemours Children’s Clinic, Delaware 14

Valley; 15 c) Be appointed to a specific Department; 16 d) Obtain board certification as required in Article III.A.1.e and 17

maintain such certification or recertification; and 18 e) Satisfy the requirement as set forth in Article III.A.1.f. 19

20 Prerogatives: 21 Members appointed to the Active Employed Staff shall be entitled to: 22

a) Admit and treat an unlimited number of patients within the 23 limits of their clinical privileges; 24

b) Hold office on the Medical Staff; 25 c) Be appointed to and serve on Medical Staff Committees and to 26

serve as the Chairperson of a Medical Staff Committee; and 27 d) Vote on matters voted upon by the Medical Staff. 28

29 Responsibilities: 30 By accepting membership to the Active Employed Staff category, each 31 Member agrees to assume all the following functions and responsibilities of 32 membership to the Active Employed Staff: 33

a) Attend Department meetings when possible. Attendance at 34 Department and Division meetings and participation in 35 teaching activities and committee work shall be considered by 36 the Department Chairperson at the biannual reappointment. 37 Excused absences will be permitted at the discretion of the 38 Chairperson of the Department; 39

b) Serve on Medical Staff Committees, as assigned; 40 c) Faithfully perform the duties of any office or position to which 41

the Member is elected or appointed; 42 d) Participate in quality assessment and monitoring activities as 43

may be assigned by the Department Chairperson, Division 44 Chief, or committee chairperson, including the evaluation of 45 provisional members; 46


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e) Complete teaching assignments as directed by the Department 1 Chairperson; 2

f) Provide care for unassigned patients, emergency service care, 3 and consultation according to the requirements of the 4 Member’s Division and/or Department and Medical Staff 5 Policy; and 6

g) Submit bi-annual reappointment applications. 7 8

2. Associate Employed Staff 9 Qualifications: 10 The Associate Employed Staff shall be limited to those practitioners who are 11 employed by the Nemours Children’s Clinic, Delaware Valley and who do not 12 provide patient care services or hold clinical privileges at the Nemours/Alfred 13 I. duPont Hospital for Children. This category includes Nemours employed 14 physicians in administrative roles. An Associate Employed Staff Member 15 must meet all of the following criteria: 16 17

a) Maintain employment with Nemours; 18 b) Maintain current licensure required by the state(s) in which the 19

Member works on behalf of Nemours; and 20 c) Obtain board certification as required in Article III.A.1.e and 21

maintain such certification or recertification. 22 23 Prerogatives and Responsibilities: 24 Associate Employed Staff Members: 25 26

a) May not admit patients to the Nemours/Alfred I. duPont 27 Hospital for Children; 28

b) Must maintain appropriate medical licenses, DEA registration, 29 CDS registrations (as necessary) and medical liability 30 insurance; 31

c) May be assigned to Medical Staff Committees; 32 d) Must fulfill attendance requirements for committees, if 33

assigned; 34 e) May vote on committee proceedings if assigned to a 35

committee; 36 f) Must cooperate with and participate in Medical Staff quality 37

assessment and monitoring activities; 38 g) Must submit bi-annual reappointment applications; and 39 h) May attend Medical Staff meetings and department meetings. 40

41 Physicians in Medico-Administrative Positions: 42 43

a) Administrative without clinical duties: Physicians, Dentists, 44 Podiatrists and psychologists employed by Nemours in a purely 45 administrative capacity with no clinical duties or responsibilities 46


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are subject to the regular Human Resources policies of Nemours 1 through their terms of employment; they need not be members of 2 the Medical Staff. If they choose Medical Staff membership, these 3 practitioners would be eligible for the Associate Employed Staff. 4

b) Administrative with clinical duties: 5 1) Medical Staff membership required: Physicians, Dentists, 6

Podiatrists and psychologists employed by Nemours, either 7 full or part-time, whose duties are medico-administrative in 8 nature and include clinical responsibilities or functions 9 involving their professional capabilities must be Members 10 of the Medical Staff. 11

2) Procedure for appointment: Appointment to the Medical 12 Staff will be achieved through the same procedure as 13 provided for other Medical Staff Members. Privileges will 14 be delineated in terms of education, training, competence 15 and character, as well as the terms of employment. 16

c) Termination Review and Hearing Process: Termination of 17 employment of a Physician, Dentists, Podiatrist, or psychologist in 18 a medico-administrative position shall be subject to review 19 pursuant to Nemours employment policies and procedures. The 20 Credentials Committee of the Medical Staff shall review the reason 21 for the action, and determine whether either or both of his Medical 22 Staff membership and privileges should be affected. 23

1) Termination of Staff Privileges: when the reason for the 24 action is determined by the Credentials Committee to 25 involve the individual’s medical competence, which 26 includes his competence to supervise the professional 27 activities of practitioners under his direction, the Medical 28 Staff shall, if requested by the individual, provide for a 29 review of the decision, including the right to a hearing and 30 appeal, as stated in the Fair Hearing provisions of these 31 Bylaws (Article IV). The Medical Staff shall further 32 transmit a letter of recommendation to the Managers of any 33 such action proposed. 34

2) Termination of Administrative function: when the reason 35 for the action is determined by the Credentials Committee 36 to be purely administrative in nature and does not involve 37 the individual’s medical competency, Nemours shall follow 38 its usual personnel policies or the terms of the contract, if 39 there be one. 40

41 3. Affiliate Employed Staff 42

Qualifications: 43 The Affiliate Employed Staff shall be limited to persons who are Affiliate 44 Professionals, employed by the Nemours Children’s Clinic, Delaware Valley 45 or the Nemours/Alfred I. duPont Hospital for Children, licensed in Delaware 46


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and granted Clinical Privileges to provide specific independent patient care 1 services at the Hospital. An Affiliate Employed Staff Member must meet all 2 of the following criteria: 3

a) Maintain employment with Nemours; 4 b) Maintain active collaborative or supervisory agreement with a 5

Nemours-employed physician (as appropriate per licensure 6 requirements); 7

c) Maintain current licensure as required; 8 d) Obtain board certification as required in Article III.A.1.e and 9

maintain such certification or recertification; and 10 e) Satisfy the requirement set forth in Article III.A.1.f. 11

12 Prerogatives and Responsibilities: 13 Affiliated Employed Staff Members: 14

a) May not admit patients to their own service, but may facilitate 15 the admission of patients to their supervisor’s or collaborating 16 physician’s service; 17

b) May provide specific services within the scope of their 18 delineated clinical privileges; 19

c) May be assigned to Medical Staff committees; 20 d) May not vote or hold office on the Medical Staff, except that 21

Members of the Affiliate Employed Staff who are clinical 22 psychologists employed by the Hospital are eligible to vote on 23 all matters brought before the Medical Staff; 24

e) Must fulfill attendance requirements for committees, if 25 assigned; 26

f) May vote on committee proceedings if assigned to a 27 committee; 28

g) Must submit bi-annual reappointment applications; and 29 h) May attend Medical Staff meetings and Department meetings, 30

but are not required to do so. 31 4. Regional Medical Staff 32

Qualifications: 33 The Regional Medical Staff shall consist of those practitioners employed by 34 the Nemours Children’s Clinic, Delaware Valley who provide pediatric health 35 care at any of the Nemours health care facilities in Pennsylvania, New Jersey, 36 Maryland or Delaware who do not meet the criteria for the Active Employed 37 Medical Staff or are not otherwise members of the Active Employed Staff. 38 Regional Medical Staff members must meet all of the following criteria: 39

a) Maintain employment with Nemours; 40 b) Maintain current licensure required by the state(s) in which 41

they work on behalf of Nemours; 42 c) Obtain board certification as required in Article III.A.1.e and 43

maintain such certification or recertification; and 44 d) Satisfy the requirements set forth in Article III.A.1.f. 45

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Prerogatives and Responsibilities: 1 Regional Medical Staff Members: 2

a) May not admit patients to the Nemours/Alfred I. duPont 3 Hospital for Children; 4

b) Must maintain appropriate medical licenses, DEA registration 5 and CDS registrations and medical liability insurance as 6 required by the state(s) in which they provide patient care 7 services for Nemours; 8

c) May provide specific services within the scope of their 9 delineated clinical privileges at the Nemours health care 10 facilities at which they work; 11

d) Must maintain appropriate medical staff membership and 12 privileges at a local hospital in order to provide for inpatient 13 care of their patients; 14

e) May be assigned to Medical Staff committees; 15 f) Must fulfill attendance requirements for committees if 16

assigned; 17 g) May vote on committee proceedings if assigned to a 18

committee; 19 h) Must cooperate with and participate in Medical Staff quality 20

assessment and monitoring activities; 21 i) Must submit bi-annual reappointment applications; and 22 j) May attend Medical Staff meetings and Department meetings. 23

24 5. Loss of Status 25

Loss of Status-Regional Medical Staff: 26 In the event that any of the conditions set forth above are not met and 27 maintained, the practitioner shall automatically lose membership on the 28 Medical Staff of the Hospital and shall not be entitled to any hearing or 29 appeals proceedings in connection therewith. Otherwise, Members of the 30 Regional Medical Staff shall be subject to interventions as set forth in these 31 Bylaws. 32

33 Loss of Status – Employed Staff 34 If a Member of an employed staff category ceases employment with Nemours 35 or the Alfred I. duPont Hospital for Children, that individual’s Medical Staff 36 appointment and privileges shall end until such time as a request for change in 37 Medical Staff status is submitted, considered by the appropriate Division 38 Chief and/or Department Chair and approved by the Credentials Committee, 39 Medical Executive Committee and Board of Managers. 40 41

6. Active Community Staff 42 Qualifications: 43 The Active Community Staff shall be limited to those qualified Physicians, 44 Podiatrists, Dentists and oral surgeons who practice in the Delaware Valley 45


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community and desire to practice actively at the Hospital. Active 1 Community Staff Members must meet all of the following: 2

a) Meet the qualifications as outlined in Article III.A.1 3 (membership criteria); 4

b) Be appointed to a specific Department; 5 c) Obtain board certification as required in Article III.A.1.e and 6

maintain such certification or recertification; and 7 d) Satisfy the requirements set forth in Article III.A.1.f 8

9 Prerogatives 10 Members appointed to the Active Community Staff shall be entitled to: 11

a) Admit and treat an unlimited number of patients within the 12 scope and limits of their clinical privileges; 13

b) Hold office on the Medical Staff; 14 c) By appointed to and serve on Medical Staff committees and to 15

serve as the chairperson of a Medical Staff committee; and 16 d) Vote on matters voted upon by the Medical Staff. 17

18 Responsibilities: 19 By accepting membership to the Active Community Staff category, each 20 Member agrees to assume all the following functions and responsibilities of 21 membership on the Active Community Staff: 22

a) Attend Department meetings when possible. Attendance at 23 Department and Division meetings and participation in teaching 24 activities and committee work shall be considered by the 25 Department Chairperson at the bi-annual reappointments. Excused 26 absences will be permitted at the discretion of the Chairperson of 27 the Department; 28

b) Serve on Medical Staff Committees, as assigned; 29 c) Faithfully perform the duties of any office or position to which the 30

Member is elected or appointed; 31 d) Participate in quality assessment and monitoring activities as may 32

be assigned by the Department Chairperson, Division Chief, or 33 committee chairperson; 34

e) Complete teaching assignments as directed by the Department 35 Chairperson; 36

f) Provide care for unassigned patients, emergency service care, and 37 consultation according to the requirements of the Members’ 38 Division and/or Department, and Medical Staff Policy; and 39

g) Submit bi-annual reappointment applications. 40 41

7. Courtesy Community Staff 42 Qualifications: 43 The Courtesy Community Staff shall be limited to Physicians, Podiatrists, 44 Dentists, and oral surgeons who meet all the requirements for membership on 45 the Active Community Staff but are not Members of the Active Community 46


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Staff, but are qualified for Staff membership and only occasionally admit or 1 treat patients at the Hospital. 2 3 A Courtesy Community Staff Member may apply through the procedures 4 described in these Bylaws to be transferred to the Active Community Staff if 5 Hospital activity, as judged by such factors as the number of admissions, 6 procedures and patient contacts, is greater than the occasional activity 7 contemplated in Courtesy Community Staff membership. Conversely, an 8 Active Community Staff Member may apply to be transferred to the Courtesy 9 Community Staff if his activity at the Hospital and willingness to assume 10 Active Community Status committee assignments is below the level required 11 to constitute fulfillment of the responsibilities of Active Community Staff 12 Members. 13 14 Prerogatives: 15 Courtesy Community Staff Members shall: 16

a) Be entitled to admit no more than six (6) inpatients annually or 17 treat no more than six (6) outpatients annually within the limits of 18 their assigned clinical privileges; 19

b) Not be eligible to hold office on the Medical Staff; 20 c) Not be eligible to vote on matters voted upon by the Medical Staff; 21

and 22 d) May be appointed to and serve on Medical Staff Committees at the 23

discretion of the Chair of the Medical Executive Committee; when 24 such committee appointment is given, the Courtesy Community 25 Staff member may vote on all committee proceedings. 26

27 Responsibilities: 28 By accepting membership to the Courtesy Community Staff category, each 29 individual agrees to assume all the following functions and responsibilities of 30 membership to the Courtesy Community Staff: 31

a) Participate in quality assessment and monitoring activities as may 32 be assigned by the Department Chairperson, Division Chief or 33 committee chairperson, including the evaluation of provisional 34 Members; and 35

b) Submit bi-annual reappointment applications. 36 37

Responsibilities of the Courtesy Community Staff relating to consultation and 38 teaching assignment shall be specific to the Division and/or Department. 39 40

8. Consulting Community Staff 41 Qualifications: 42

The Consulting Community Staff shall be limited to specialists who are 43 appointed for the specific purposes of providing consultation in the diagnosis 44 and treatment of patients. Consulting Community Staff Members must meet 45 all of the following: 46


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a) Meet the qualifications for membership outlined in Article III.A.1; 1 b) Be appointed to a specific Department; 2 c) Obtain board certification as required in Article III.A.1.e and 3

maintain such certification or recertification; and 4 d) Satisfy the requirement set forth in Article III.A.1. 5

6 Prerogatives: 7 Consulting Community Staff Members: 8

a) May consult on and treat patients within the limits of their assigned 9 clinical privileges, in consultation with Active or Courtesy Staff 10 Member; 11

b) May not admit patients to the Hospital; 12 c) May be appointed to and serve on Medical Staff committees at the 13

discretion of the Chair of the Medical Executive Committee; when 14 such committee appointment is given, the Consulting Community 15 Staff Member may vote on all committee proceedings; 16

d) May attend Medical Staff meetings and Department meetings, but 17 are not required to do so; and 18

e) May not hold Medical Staff office or vote on matters being voted 19 upon by the Medical Staff. 20

21 Responsibilities: 22 Consulting Community Staff Members are responsible for: 23

a) Submitting bi-annual applications for reappointment; and 24 b) Cooperating with and participating in Medical Staff quality 25

assessment and monitoring activities. 26 27

9. Associate Community Staff 28 Qualifications: 29 The Associate Community Staff shall consist of those practitioners who meet 30 the qualifications for Active Community Staff but who have no clinical 31 privileges at the Nemours/Alfred I. duPont Hospital for Children. This 32 category shall also include those physicians who have retired from active 33 practice. Associate Community Staff Members must meet the qualifications 34 outlined in Article III.A.1 and be appointed to a specific Department. 35 36 Prerogatives: 37 Associate Community Staff Members: 38


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a) May not admit patients to their own service; 1 b) May not document in the Hospital medical records; 2 c) May not hold office on the Medical Staff; 3 d) May not vote on matters of the Medical Staff; 4 e) May serve on Committees of the Medical Staff at the discretion of 5

the Chairperson of the Medical Executive Committee and may 6 vote on all matters brought before such Committee; and 7

f) Are not required to submit bi-annual applications for 8 reappointment. 9

10 10. Affiliate Community Staff 11

Qualifications: 12 The Affiliate Community Staff shall be limited to persons who are Affiliate 13 Professionals licensed in Delaware and are granted Clinical Privileges to 14 provide specific independent patient care services for their collaborating or 15 supervising physicians at the Hospital. 16 17 Prerogatives and Responsibilities: 18 Affiliate Community Staff Members: 19

a) May not admit patients to their own service, but may facilitate the 20 admission of patients to the service of their collaborating or 21 supervising physicians; 22

b) May provide specific services to the patients of their supervising or 23 collaborating physicians within the scope of their delineated 24 clinical privileges; 25

c) May be assigned to Medical Staff committees; 26

d) May not vote or hold office on the Medical Staff; 27

e) Must fulfill attendance requirements for committees, if assigned; 28

f) May vote on committee proceedings if assigned to a committee; 29

g) Must submit bi-annual reappointment applications; and 30

h) May attend Medical Staff meetings and Department meetings, but 31 are not required to do so. 32

33 B. OFFICERS OF THE MEDICAL STAFF 34 The elected officers of the Medical Staff shall be the President and the President-35 Elect. 36

1. Qualifications 37

Only those Active Employed Staff and Active Community Staff Members 38 who satisfy all of the following criteria shall be eligible to serve as Medical 39 Staff officers: 40

a) Have been Members in good standing on the Active Employed 41 Staff or Active Community Staff and continue so during their 42 term of office; 43


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b) Meet the criteria for the office for which they are being 1 considered; 2

c) Are qualified by training, experience, or demonstrated ability 3 for the office; 4

d) Have no pending adverse recommendations concerning Staff 5 membership and/or clinical privileges; 6

e) Utilize the Hospital as one of their primary hospitals; 7 f) Are not serving as medical staff officers or department 8

chairpersons at another hospital or health care facility during 9 the term of office; 10

g) Are willing to discharge faithfully the duties and 11 responsibilities of the office to which the individual is elected; 12

h) Do not have an employment or other contractual arrangement 13 that may give rise to a conflict of interest with another entity; 14

i) Are knowledgeable concerning the duties of the office; and 15 j) Have constructively participated in Medical Staff affairs at the 16

Hospital, including peer review activity. 17 18

2. Term of Office 19 The President and President-Elect shall each serve a two-year term beginning 20 on the first of January immediately following their election. The President-21 Elect shall serve as President immediately upon the end of his two-year term 22 as President-Elect. The President may not be elected as President-Elect 23 immediately following the conclusion of his term as President. 24 25

3. Election of Officers 26 The President-Elect shall be elected by the Active Employed Staff and Active 27 Community Medical Staff Members as described in Article II.D.3. 28 29

4. Vacancies in Office 30 A vacancy in the office of President-Elect shall be filled by the Medical 31 Executive Committee. If there is a vacancy in the office of the President, the 32 President-Elect shall serve out the remaining term. Vacancies in both offices 33 of President and President-Elect shall be filled by a special vote of the 34 Medical Executive Committee. The terms of office for such special election 35 shall be to complete the remainder of the terms of the vacated offices. 36 37

5. Duties of Officers 38 President 39

The President shall: 40 a) Act in coordination and cooperate with the Physician-in-Chief 41

and the Hospital Medical Director in all matters of mutual 42 concern within the Hospital; 43

b) Call, preside at, and be responsible for the agenda of all 44 meetings of the Medical Staff; 45


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c) Serve on the Medical Executive Committee and act as its 1 Chairperson; 2

d) In conjunction with the Hospital Medical Director, be 3 responsible for the enforcement of these Bylaws and any 4 Policies and Procedures, for the implementation of sanctions 5 where these are indicated, and for the Medical Staff’s 6 compliance with procedural safeguards in all instances where 7 corrective actions have been imposed on a Member of the 8 Medical staff; 9

e) Appoint Members to all Medical Staff committees in 10 consultation with the Physician-in-Chief and the Hospital 11 Medical Director (except as otherwise stated in these Bylaws); 12

f) Represent the views, policies, needs, and grievances of the 13 Medical Staff to the Hospital Medical Director and the 14 Administrator and represent the Medical Staff to the Managers; 15

g) Receive and interpret for the Medical Staff the policies of the 16 Managers and report to the Managers with the Physician-in-17 Chief, Hospital Medical Director and Administrator on the 18 performance and maintenance of quality with respect to the 19 Medical Staff’s delegated responsibilities to provide medical 20 care; 21

h) Be the spokesperson for the Medical Staff; and 22 i) Be a member of the Physician Health Team. 23

24 President-Elect: 25 The President Elect shall automatically become President upon completion of 26 the President’s term of office. In the absence of the President, the President-27 Elect shall discharge all duties and authority of the President. The President-28 Elect shall be a member of the Medical Executive Committee and act as its 29 Vice Chairperson. He shall automatically succeed the President when the 30 latter fails to serve for any reason. The President-Elect shall serve as 31 Chairperson of the Medical Staff Policy Committee. The President-Elect shall 32 also assume such other duties as may be assigned to him from time to time by 33 the President of the Medical Staff. 34 35

6. Removal of Elected Officers 36 Elected officers of the Medical Staff may be removed from office only upon 37 good cause shown. Good cause shown shall mean that an officer has 38 performed his duties in an incompetent manner, has brought discredit upon the 39 Medical Staff or the Hospital, or is found to be unable to perform the duties of 40 the office. An elected officer may be removed from office only upon an 41 affirmative vote for removal of not less than two-thirds of the entire Medical 42 Executive Committee. 43 44

C. Departments 45 The Clinical Departments of the Medical Staff shall consist of the following: 46


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Anesthesiology and Critical Care 1 Medical Imaging 2 Orthopedic Surgery 3 Pathology/Clinical Laboratory 4 Pediatrics 5 Surgery 6 7

1. Organization 8 Departments shall be organized into Divisions as determined by the 9 Physician-in-Chief in consultation with the Department Chairperson. 10 Divisions are subdivisions of Departments. The Physician leadership for the 11 Departments and Divisions shall be responsible for performing the duties and 12 responsibilities set forth in these Bylaws. The descriptions of the Departments 13 and Divisions are attached to these Bylaws as Appendix A. Appendix A may 14 be modified or supplemented from time to time by action of the appropriate 15 Department Chairperson and the Physician-in-Chief, without the necessity of 16 amendment of this Article. 17 18

2. Department Chairpersons 19 Procedure for Appointment and Term 20 The appointment of all Department Chairpersons shall be made by the 21 Physician-in-Chief. 22 23

a) All Department Chairpersons shall be appropriately qualified 24 in the Department and shall serve at the pleasure of the 25 Physician-in-Chief. 26

b) In the event of a vacancy in an office of a Department 27 Chairperson for any reason other than a requested leave of 28 absence or retirement, an acting Chairperson shall be appointed 29 by the Physician-in-Chief until a permanent Chairperson is 30 appointed in accordance with this Article. 31

c) A Department Chairperson shall be certified by an appropriate 32 specialty board or have demonstrated affirmatively established 33 comparable competency through the credentialing process. 34

d) Only an individual who as an Active Employed Staff Member 35 shall be eligible to serve as a Department Chairperson. 36

e) At the sole discretion of the Physician-in-Chief, in lieu of a 37 Department Chairperson, one or more Members appointed by 38 the Physicians-in-Chief may serve as medico-administrative 39 directors in any Department with such duties as the Physician-40 in-Chief may assign. In such case, one of such Members shall 41 be assigned the duties of a Department Chairperson in the 42 appointment and reappointment to membership on the Medical 43 Staff and granting of Clinical Privileges and other duties 44 described in these Bylaws. 45

46


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Duties and Responsibilities 1 Each Department Chairperson shall be responsible for all of the following: 2 3


22

a) The clinically and administrative related activities of the 1 Department, and where applicable, for the teaching and any 2 research program within the Department; 3

b) Continuing surveillance of the professional performance of all 4 individuals in the Department who have delineated clinical 5 privileges; 6

c) Recommending the criteria for clinical privileges that are 7 relevant to the care provided in the Department; 8

d) Being a member of the Medical Executive Committee in 9 accordance with the composition of that Committee as 10 described in Article II.D.3; 11

e) Making an appraisal and recommendation regarding 12 individuals applying for Medical Staff membership and 13 Clinical Privileges in the Department and regarding 14 Department members applying for reappointment and Clinical 15 Privileges to the Credentials Committee; 16

f) Integrating the Department into the primary functions of the 17 Hospital and coordinating and integrating interdepartmental 18 and intradepartmental services; 19

g) Assessing and recommending off-site sources for needed 20 patient care services not provided by the Department or the 21 Hospital; 22

h) Developing and implementing Department policies and 23 procedures that guide and support the provision of services; 24

i) Recommending a sufficient number of qualified and competent 25 persons to provide care or service; 26

j) Determining the qualifications and competence of Department 27 or service personnel who are not licensed independent 28 practitioners and who provide patient care services; 29

k) Continually assessing and improving the quality of care and 30 services provided; 31

l) Maintaining quality control programs as appropriate; 32 m) Providing orientation and continuing education of all persons 33

in the Department; 34 n) Making recommendations for space and other resources needed 35

by the Department; and 36 o) Appointing a Department member, subject to the approval of 37

the Physician-in-Chief, to be responsible for Chairperson duties 38 in the event of the Chairperson’s absence for a period of time 39 of more than one month. In the event the Chairperson is 40 unable to perform his duties, the Physician-in-Chief shall 41 appoint a Departmental member to be responsible for the 42 Chairperson’s duties. 43

44 Removal of a Chairperson 45


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Failure of a Department Chairperson to maintain status as a Member of the 1 Active Employed Medical Staff shall immediately disqualify that person from 2 holding such position and shall be deemed to create a vacancy therein. A 3 Chairperson may be removed at any time, with or without cause, by the 4 Physician-in-Chief, in his sole discretion. Any such removal shall not, in and 5 of itself, entitle the Chairperson to the procedural rights afforded by the 6 hearing process in Article IV and shall not affect his Medical Staff 7 membership status or Clinical Privileges. 8 9

3. Divisions and Division Chiefs 10 Procedures for Appointment and Term 11 The appointment of all Division Chiefs shall be made by the Physician-in-12 Chief and the appropriate Department Chairpersons. 13

a) All Division Chiefs shall serve at the pleasure of the Physician-14 in-Chief. 15

b) Only an individual who is an Active Employed Staff or Active 16 Community Staff Member shall be eligible to serve as a 17 Division Chief. 18

c) In the event of a vacancy in an office of a Division Chief for 19 any reason other than a requested leave of absence or 20 retirement, an acting Division Chief shall be appointed by the 21 Physician-in-Chief in consultation with the Department 22 Chairperson until a permanent Division Chief has been 23 appointed in accordance with this Article. 24

25 Removal of a Division Chief 26 Failure of a Division Chief to maintain status as a Member of the Active 27 Employed Staff or Active Community Staff shall immediately disqualify that 28 person from holding such position and shall be deemed to create a vacancy 29 therein. A Division Chief may be removed, at any time, with or without 30 cause, by the Physician-in-Chief, in his sole discretion. Any such removal 31 shall not, in and of itself, entitle the Division Chief to the procedural rights 32 afforded by the hearing process in Article IV and shall not affect his Medical 33 Staff membership status or Clinical Privileges. 34 35 Creation of New Divisions or Elimination of Existing Divisions 36 The Department Chairperson may recommend to the Physician-in-Chief the 37 formation of additional Divisions within the Department or the elimination of 38 existing Divisions. The Physician-in-Chief may, at his sole discretion, create 39 a new Division or eliminate an existing Division. Criteria to be considered 40 when forming a new Division include: 41 42

a) Membership of the new Division shall consist of more than 43 three (3) Members, unless otherwise approved by the 44 Physician-in-Chief; and 45


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b) The function of the Members is significantly different than that 1 of the rest of the current Division assignments. 2

D. Medical Staff Committees and Functions 3

4 1. Committees 5

Committees of the Medical Staff shall be standing and special as approved by 6 the Medical Executive Committee. A quorum will consist of the presence of 7 at least three (3) Physician members of the committee, unless otherwise 8 specified in these Bylaws. All committee responsibility, quorum 9 requirements, composition, chairpersons, terms, election procedures, and other 10 committee rules not stated in these Bylaws shall be addressed in the Medical 11 Staff Policies and Procedures. 12 13 There may be Standing Committees and Ad Hoc Committees of the Medical 14 Staff. The Standing Committees shall be those described in these Bylaws. In 15 addition, the President of the Medical Staff may appoint Ad Hoc Committees 16 with the approval of the Medical Executive Committee for such purposes and 17 duration and with such composition as he deems appropriate. 18 19

2. Standing Committees 20 The Standing Committees shall be: 21

Medical Executive committee 22 Credentials Committee 23 Medical Staff Policy Committee 24 Nominating Committee 25 Graduate Medical Education Committee 26 Peer Review Committee 27 Physician Health Team 28 And others as may become necessary or desirable, as determined by 29 the Medical Executive Committee. 30

31 3. Medical Executive Committee 32

Quorum 33 A quorum for the Medical Executive Committee shall consist of the presence 34 of seven (7) of the members of the Medical Executive Committee, except for 35 an emergency meeting called by the Medical Staff President or the Physician-36 in-Chief when the presence of twenty percent (20%) of such Committee’s 37 members shall constitute a quorum. 38

39 Composition 40 The Medical Executive Committee shall consist of: 41

President of the Medical Staff 42 President-Elect of the Medical Staff 43 Hospital Medical Director 44 Physician-in-Chief or his Designee 45


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Administrator 1 Chief Operating Officer of the Hospital 2 Chief Nursing Executive of the Hospital 3 Five (5) at-large members (each serving a two-year term) 4

One (1) to be selected from among the Department 5 Chairpersons, by the Department Chairpersons; 6

One (1) to be elected from among the Division Chiefs 7 Three (3) to be elected from the Active Employed Medical 8

Staff or the Active Community Medical Staff 9 10

Term 11 Each member elected at-large shall serve for two years, after which time he 12 may be re-elected. 13 14 Chairperson and Vice Chairperson 15 The President of the Medical Staff shall serve as Chairperson of the Medical 16 Executive Committee. The President-Elect of the Medical Staff shall serve as 17 Vice Chairperson. If the Chairperson cannot preside due to incapacity or 18 absence, the Vice Chairperson shall conduct the meetings of the committee. 19 20 Election of Members 21 Officers and “at large” representatives (other than the at-large representative 22 selected by the Department Chairpersons) shall be elected by the Active 23 Community Staff and Active Employed Staff. Nominations shall be made by 24 the Nominating Committee at least ninety (90) days in advance of the Fall 25 meeting of the Medical Staff. The election shall occur via ballots sent by mail 26 to all Members of the Active Community Staff and Active Employed Staff at 27 least forty-five (45) days in advance of the Fall meeting of the Medical Staff. 28 Results of the election shall be announced at the Fall meeting. 29

30 Executive Session 31 The Committee may call an executive session for discussion and consideration 32 of peer review and other confidential information. Attendance at executive 33 sessions shall be limited to Members of the Medical Staff who are voting 34 and/or Ex Officio members of the Medical Executive Committee. The 35 Committee may invite others to an executive session where appropriate. 36 37 Duties: 38 The Committee shall be responsible for at least the following duties and for 39 recommendations to the Managers for governing-body approval. The Medical 40 Executive Committee shall be empowered to act for the Medical Staff in 41 intervals between Staff meetings. 42

a) Recommend Medical Staff Department structure; 43 b) Create such sub-committees as necessary to conduct its work; 44 c) Coordinate and oversee the clinical policies and activities of the 45

Medical Staff; 46


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d) Receive and act upon recommendations and reports from Medical 1 Staff Committees, Departments, and assigned activity groups; 2

e) Recommend standardized credentialing and recredentialing criteria 3 and processes for all applicants for Medical Staff membership; 4

f) Review and recommend applications for appointment and 5 reappointment to membership on the Medical Staff and delineated 6 Clinical Privileges for each eligible individual; 7

g) Establish standards for clinical competence and review periodically all 8 information available regarding Member performance against these 9 standards for patient care and clinical quality; 10

h) Monitor professional conduct to ensure all ethical standards are 11 complied with; 12

i) Authorize and implement remedial action when and if necessary; 13 j) Consider and recommend action to the Managers on matters of 14

medical administrative nature; 15 k) Report to the Managers on matters affecting Medical Staff 16

participants; 17 l) Report at each Medical Staff meeting; 18 m) Oversee Medical Staff participation in organized performance 19

improvement activities; 20 n) Oversee medical education programs and activities; and 21 o) Document its conclusions, recommendations, and actions taken. 22

23 Filling Vacancies 24 In the case of the death, resignation or disability of any elected or selected 25 member of the Committee, the Medical Staff President may appoint a 26 successor to fill the unexpired term. 27 28 Meetings 29 The Medical Executive Committee shall meet approximately monthly, but not 30 less than ten times annually. 31 32

4. Credentials Committee 33 Duties 34 The Credentials Committee shall investigate the qualifications of all 35 applicants for appointment or reappointment to membership on the Medical 36 Staff and Clinical Privileges in accordance with the provisions regarding 37 membership and Clinical Privileges set forth in Article III.A.1. 38 39 The Committee shall be responsible for the establishment of criteria for 40 Clinical Privileges in conjunction with the Department Chairpersons and 41 Division Chiefs. 42 43 The Credentials Committee shall also be responsible for evaluating requests 44 for new privileges and new technology to assure that appropriate criteria for 45 delineation of such privileges are developed and to assure that the Hospital 46


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possess appropriately trained staff and has the equipment available to support 1 such requests. 2 3 Chairperson 4 The Credentials Committee Chairperson shall be appointed by the Physician-5 in-Chief and shall: 6

a) Oversee the activities of the Credentials Committee and any sub-7 committees; 8

b) Prepare a report of the Credentials Committee actions for submission 9 to the Medical Executive Committee, which may include the report of 10 any sub-committees; 11

c) Select Chairpersons for any subcommittee meetings; and 12 d) Present the Credentials Committee recommendations and reports to the 13

Medical Executive Committee. 14 15 Composition 16 The Credentials Committee shall consist of at least one Member from three of 17 the Medical Staff Departments appointed by the Physician-in-Chief plus four 18 (4) additional Members appointed by the Physician-in-Chief, and the 19 Immediate Past President of the Medical Staff. Each Committee member 20 shall serve a two-year term and shall be eligible to be reappointed to the 21 Committee for additional terms. The Committee shall meet approximately 22 monthly. 23 24 Quorum 25 A quorum for the Credentials Committee shall consist of the presence of at 26 least four (4) of its members. 27 28

5. Nominating Committee 29 Composition 30 The Physician-in-Chief and the Medical Staff President shall jointly appoint a 31 Nominating Committee, with the approval of the Medical Executive 32 Committee, at least six (6) months prior to the annual general meeting of the 33 Medical Staff. The Nominating Committee shall consist of six (6) Physicians 34 who are members of the Active Community Staff and Active Employed Staff. 35 The Immediate Past President of the Medical Staff shall serve as Chairperson. 36 37 Duties 38 The Nominating Committee shall be responsible for nominating officers of the 39 Medical Staff and “at large” members of the Medical Executive Committee. 40 41

6. Physician Health Team 42 Composition 43 The Hospital Medical Director, the Physician-in-Chief, the President of the 44 Medical Staff, and the Administrator shall comprise the Physician Health 45 Team. The Hospital Medical Director shall chair the Physician Health Team. 46


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1 Duties 2 Pursuant to Medical Staff Policies and Procedures and these Bylaws, the 3 Physician Health Team shall address concerns about the actual or possible 4 impaired health or functioning of Medical Staff Members that threaten or may 5 threaten patient care. 6 7

7. Graduate Medical Education Committee 8 Composition 9 The Physician-in-Chief and the Medical Staff President shall jointly appoint 10 the members of the Graduate Medical Education Committee. The Director of 11 Graduate Medication Education at the Hospital shall serve as Chairperson. 12 13 Duties 14 The Graduate Medical Education Committee shall be responsible for 15 overseeing the graduate medical education programs at the Hospital, for 16 assuring compliance with residency review committee standards, and for 17 reporting to the Medical Executive Committee and the Board of Managers 18 about the safety and quality of patient care, treatment, and services provided 19 by, and the related educational and supervisory needs, of, the participants in 20 professional graduate education programs. 21 22

8. Peer Review Committee 23 Composition 24 The Peer Review Committee shall be composed of representatives from the 25 Medical Staff Departments. The Chairperson shall be appointed by the 26 Hospital Medical Director in consultation with the Medical Staff President 27 and the Physician-in-Chief. 28 29 Duties 30 The Peer Review Committee shall be responsible for overseeing the Medical 31 Staff peer review process, for reviewing and evaluating performance 32 improvement data, and for recommending actions to improve the quality of 33 care, treatment, and services provided by the Medical Staff and to improve 34 patient safety. The Peer Review Committee shall report its activities to the 35 Medical Executive Committee. 36 37

9. Special Committees 38 From time to time, the President of the Medical Staff may, in consultation 39 with the Physician-in-Chief, appoint special committees. In the event of the 40 appointment of a special committee, the purpose, composition, and any time 41 limitation on the existence of the committee shall be set forth in writing by the 42 President. 43 44

E. Meetings 45 46


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1. Medical Staff Year 1 The Medical Staff year is the calendar year – January 1 through December 31. 2 3

2. Medical Staff Meetings 4 Regular Meetings 5 Meeting Schedule – There shall be at least two regular Medical Staff meetings 6 held each year, one each in the fall and the spring on dates designated by the 7 Medical Executive Committee. 8 9 Annual General Meeting – The fall regular meeting shall be the annual 10 general meeting of the Medical Staff. At this meeting, elections shall be held 11 and a review of the year’s work presented. 12 13 Special Meetings 14 Special Meetings of the Medical Staff may be called at any time upon not less 15 than forty-eight (48) hours’ notice to all Members by the Physician-in-Chief, 16 the Hospital Medical Director, the President of the Medical Staff, or the 17 Medical Executive Committee and, upon like notice, shall be called at the 18 request of the Managers or at least twenty-five percent (25%) of the aggregate 19 Members of the Active Community Staff and the Active Employed Staff. The 20 notice to Members shall specify the reason for the meeting. At any special 21 meeting, no business shall be transacted except that stated in the notice calling 22 the meeting. 23 24

3. Department, Division and Committee Meetings 25 Regular Meetings 26 General 27 Each Department shall hold periodic meetings, the frequency of which to be 28 determined by the Department Chairperson. Written minutes shall be kept 29 and shall be submitted to the Medical Executive Committee. The purpose of 30 the meetings shall be to discuss Departmental business, to keep the members 31 of the Department informed of significant matters, and to review care 32 rendered to patients. At a minimum, each Department shall meet quarterly to 33 discuss quality issues. 34 35 Minutes 36 Minutes shall include the findings and conclusions of monitoring activities 37 within the Department and actions taken by the Department as a result of such 38 monitoring. If monthly Department meetings are not held, the Department 39 must document (a) the mechanisms in place to involve all members of the 40 Department in the monitoring and evaluation activities conducted by the 41 Department; (b) the periodic review of care provided by Department members 42 in order to draw conclusions, formulate recommendations, and initiate actions; 43 and (c) the mechanisms to communicate to members of the Department the 44 findings, conclusions, recommendations, and actions taken. 45 46


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1 2 Attendance 3 Members of the Active Employed Staff and Active Community Staff shall be 4 strongly encouraged to attend all regularly scheduled Departmental meetings. 5 Attendance at Department and Division meetings and participation in teaching 6 activities and committee work shall be considered by the Department 7 Chairperson at bi-annual reappointments. 8 9

F. Provisions Common to All Meetings 10 11

1. Notice of Meetings 12 Standing Meetings 13 The dates and times of standing Medical Staff meetings shall be set at the 14 beginning of the Medical Staff year and communicated at that time to Medical 15 Staff Members. Agendas for a specific standing meeting shall distributed at 16 least 1 week prior to such meeting. 17 18 Special Meetings 19 Notice of a special meeting shall be distributed at least 48 hours in advance of 20 the meeting. 21 22

2. Quorum and voting 23 Quorum 24 Those Members eligible to vote and who are present shall constitute a quorum 25 for all Medical Staff meetings, unless otherwise specified in these Bylaws. 26 27 Vote 28 A majority of the voting Staff present at any regular or special meeting shall 29 decide each question, unless otherwise specified in these Bylaws. 30 31

3. Agenda 32 The agendas for standing meetings shall be developed by the Chairperson and 33 distributed in advance of such meetings. 34 35 The agenda for a special meeting shall be determined by the individual or 36 group requesting such special meeting and shall be distributed at the time of 37 the notice of such meeting. 38 39

4. Rules of Order 40 Parliamentary Procedure 41 Robert’s Rules of Order shall not be binding at Medical Staff meetings or 42 elections, but may be used for reference in the discretion of the presiding 43 officer for the meeting. Rather, specific provisions of these Bylaws and 44 Medical Staff, Department or Committee custom shall prevail at all meetings, 45


31

and the Department or Committee Chairperson shall have the authority to rule 1 definitively on all matters of procedure. 2 3 Reports, Minutes, Recommendations 4 Minutes, reports and recommendations from Medical Staff meetings, 5 committee meetings and Department meetings shall be maintained in writing 6 in the Medical Staff Services Department. Periodic reports from Medical 7 Staff committees, Departments and other designated groups shall be submitted 8 to the Medical Executive Committee. 9 10 Attendance Requirements 11 Attendance by all Members at the regularly scheduled Medical Staff meetings 12 shall be strongly encouraged. 13 14

III. APPOINTMENT, REAPPOINTMENT, AND CLINICAL 15

PRIVILEGES 16 17

A. Qualifications, Conditions, and Responsibilities 18 19

1. Qualifications for Membership: 20 General 21 All persons practicing medicine, podiatry and dentistry at the Hospital, as well 22 as all Regional Medical Staff Members providing patient care services in a 23 Nemours Delaware Valley facility and all Affiliate Professionals performing 24 certain independent services, unless excepted by specific provisions of these 25 Bylaws, must first have been appointed as Members of the Medical Staff. 26 Membership on the Medical Staff is a privilege that shall be extended only to 27 professionally competent individuals who continuously meet the 28 qualifications, standards, and requirements set forth in this Article and in such 29 policies as are adopted from time to time by the Managers, the Medical 30 Executive Committee, or designated committees. All processes described in 31 this Article shall be subject to the confidentiality provisions described in 32 Article 1.C. 33 34 When determination to provide an application is based on the Hospital’s needs 35 or its non-exclusive ability to provide the facilities, beds, and support 36 staffing/services, consideration will be given, or as otherwise provided by law, 37 to utilization patterns, and actual and planned allocations of physical, 38 financial, and human resources, to general and specialized clinical and support 39 services, and to the Hospital’s specific goals and objectives as reflected in the 40 Hospital’s short and long-range plans. It is recognized that some patient-care 41 services at the Hospital may be provided exclusively by a limited number of 42 Practitioners selected by the Hospital who have been properly processed and 43 granted Medical Staff membership and/or Clinical Privileges. 44 45


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Specific Eligibility Qualifications: 1 Only Physicians, Podiatrists, Dentists, and Affiliate Professionals who satisfy 2 all of the following conditions shall be qualified for membership on the 3 Medical Staff and to be granted Clinical Privileges: 4

a) Have a current unrestricted license to practice in Delaware and have a 5 Drug Enforcement Administration (DEA) license and a Delaware 6 Controlled Dangerous Substance (CDS) registration, if requirements 7 for the required Clinical Privileges (see also the criteria for 8 membership on the Regional Medical Staff); 9

b) Are able to provide continuous care to their patients or to arrange for 10 other Members to provide care for patients in their absence; 11

c) Possess current, valid professional liability insurance coverage in such 12 form and in amounts satisfactory to the Hospital and in accordance 13 with the requirements of the State of Delaware and can demonstrate 14 acceptable professional medical liability history; 15

d) Have successfully completed an approved residency training program, 16 or comparable training program for their specialty in the case of the 17 Affiliate Professionals, in the specialty in which the applicant seeks 18 Clinical Privileges (this requirement shall be applicable only to those 19 individuals who apply for initial Medical Staff membership and 20 Clinical Privileges on or after the date these Bylaws are adopted); 21

e) Within six (6) years of joining Nemours, are certified by the 22 appropriate specialty board, unless such requirement is waived by the 23 Managers upon recommendation of the Physician-in-Chief in 24 exceptional cases after considering the Hospital’s needs and the 25 specific competence, training, and experience of the individual in 26 question; 27

f) Can document to the satisfaction of the Managers their: 28 1) Background, experience, training, and current clinical 29

competency including medical/clinical knowledge, technical 30 and clinical skills, and clinical judgment, and an 31 understanding of the contexts and systems within which care 32 is provided, through peer references and former or current 33 employer references; 34

2) Adherence to the ethics of their profession, continuous 35 professional development, and understanding of and 36 sensitivity to diversity, and responsible attitude toward 37 patients and their profession; 38

3) Good reputation and character, including the ability to 39 exercise the Clinical Privileges requested and to perform the 40 duties and responsibilities of membership; and 41

4) Ability to work harmoniously with others, including, but not 42 limited to, interpersonal and communication skills sufficient 43 to enable them to maintain professional relationships with 44 patients, families and other members of health care teams, 45 sufficiently to convince representatives of the Hospital, 46


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including, but not limited to (1) the Department Chairperson, 1 (2) members of the Credentials Committee, and (3) members 2 of the Medical Executive Committee, that all patients treated 3 by them at the Hospital will receive quality care and that the 4 Hospital will be able to operate in an orderly manner; and 5

g) Unless waived by the Managers, in their sole discretion, have 6 never been convicted of a felony or misdemeanor involving 7 moral turpitude or excluded from participation in Medicare, 8 Medicaid or any other government-sponsored reimbursement 9 program, or any other private or public medical insurance 10 program. 11

12 2. Waiver of Criteria 13

A Division Chief or a Department Chairperson may recommend that certain 14 criteria be waived. Such request for waiver shall be made to the Physician-in-15 Chief and shall include the rationale for such request. The Physician-in-Chief, 16 if he concurs, shall make the request for waiver to the Credentials Committee, 17 the Medical Executive Committee and the Board of Managers. Such waivers 18 will be limited to exceptional circumstances. Review of a request for waiver 19 shall include consideration of the specific qualifications of the individual in 20 question, input from the relevant Department Chairperson or Division Chief, 21 and the best interest of the Hospital and the communities it serves. No 22 individual shall be entitled to a waiver or to a hearing if the Managers 23 determine not to grant a waiver. A determination that an individual is not 24 entitled to a waiver is not a “denial” of appointment or Clinical Privileges. 25 The granting of a waiver in a particular case is not intended to set a precedent 26 for any other individual or group of individuals. 27 28

3. No Entitlement to Membership 29 No individual shall be entitled to membership on the Medical Staff or to the 30 exercise of particular Clinical Privileges merely by virtue of the fact that such 31 individual: 32

a) Is licensed to practice a profession in Delaware or any other state; 33 b) Is a member of any particular professional organization; 34 c) Has had in the past Medical Staff membership at the Hospital; 35 d) Resides in the geographic service areas of the Hospital; or 36 e) Is board certified by a specialty board. 37

38 4. Nondiscrimination Policy 39

No individual shall be denied membership on the basis of sex, race, religion, 40 color or national origin, sexual orientation, or on the basis of any criteria 41 unrelated to the delivery of quality patient care at the Hospital, to professional 42 qualifications, or to the Hospital’s purposes, needs, and capabilities. 43 44


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5. Limitation of Privileges and Membership 1 Notwithstanding the foregoing and as set forth below, the Managers, in their 2 sole discretion, shall have the authority to limit Medical Staff membership and 3 privileges in any Division or Department in order to manage quality of care, 4 patient safety, efficiency, or the effective operation of the Hospital. 5 6

B. General Conditions of Appointment and Reappointment 7 8 1. Basic Responsibilities and Requirements for Applicants and 9

Members 10 As a condition of consideration of an application for Medical Staff 11 membership, and as a condition of continued Medical Staff membership, if 12 granted, every applicant and Member specifically agrees to the following: 13

a) To provide appropriate continuous care and supervision to 14 all patients within the Hospital for whom the individual has 15 responsibility or arrange for coverage of such patients by 16 Members with appropriate Clinical Privileges; 17

b) To abide by all Bylaws, Medical Staff Rules and 18 Regulations, and policies and procedures of the Hospital, as 19 shall be in force during the time the individual is a Member 20 of the Medical Staff; 21

c) To accept committee assignments and such other 22 reasonable Medical Staff duties and responsibilities as shall 23 be assigned; 24

d) To provide to the Credentials Department, with or without 25 the need for request, new or updated information, as it 26 arises, that is pertinent to any question on the application 27 form; 28

e) To attest that the applicant has had an opportunity to read 29 copies of these Bylaws and the Policies and Procedures as 30 are in force at the time of application and agrees to be 31 bound by the terms hereof and thereof in all matters 32 relating to consideration of the application without regard 33 to whether or not membership to the Medical Staff and/or 34 Clinical Privileges are granted; 35

f) To appear, if requested, for personal interviews in regard to 36 the application; 37

g) That any misrepresentation or misstatement in or omission 38 from the application, whether intentional or not, shall 39 constitute cause for immediate cessation of the processing 40 of the application and that no further processing shall 41 occur. In the even that a membership has been granted 42 prior to the discovery of such misrepresentation, 43 misstatement or omission, such discovery may be deemed 44 by the Managers to constitute grounds for the automatic 45 relinquishment of Clinical Privileges and Medical Staff 46


35

membership. In either situation, there shall be no 1 entitlement to hearing or appeal rights as set forth in these 2 Bylaws; 3

h) To use the Hospital and its facilities sufficiently for the 4 category of Medical Staff membership or otherwise to 5 allow the Hospital, through assessment by appropriate 6 Medical Staff Committees and Departments, to evaluate in 7 a continuing manner the current competence of the 8 Member; 9

i) To refrain from illegal fee splitting or other illegal 10 inducements relating to patient referral; 11

j) To refrain from delegating responsibility for diagnosis or 12 care of hospitalized patients to any individual who is not 13 qualified to undertake this responsibility or who is not 14 adequately supervised; 15

k) To refrain from deceiving patients or their parents or 16 guardians as to the identity of an operating surgeon or any 17 other individual providing treatment or services; 18

l) To seek consultation whenever necessary and as mandated 19 by Medical Staff policy; 20

m) To examine his inpatients on a daily basis and to document 21 the same; 22

n) To notify promptly the Administrator or his designee and 23 the Chairperson of the Medical Executive Committee of 24 any change in eligibility for payments by third-party payers 25 or for participation in Medicare, Medicaid or any other 26 government reimbursement program, including any 27 sanctions imposed or recommended by the federal 28 Department of Health and Human Services, and/or the 29 receipt of a Quality Improvement Organization (QIO) 30 citation and/or quality denial letter concerning alleged 31 quality deficiencies in patient care; 32

o) To abide by generally recognized ethical principles 33 applicable to the applicant’s profession; 34

p) To participate in monitoring and evaluation activities, as 35 requested; 36

q) To complete in a timely manner the medical and other 37 required records (inpatient and outpatient) for all patients as 38 required by the Bylaws, Rules and Regulations, Policies 39 and Procedures, and other applicable policies of the 40 Hospital; 41

r) To complete a relevant history and physical examination 42 upon each patient under his care. The required contents of 43 history and physical examinations, as well as the time 44 frames required for completion, shall be set forth in 45 Medical Staff policy, History and physical examinations 46


36

may be completed up to 30 days prior to admission as long 1 as the history and physical is updated with any new 2 information upon admission, or within 24 hours of 3 admission; 4

s) To work cooperatively and professionally with Medical 5 Staff members, Medical Staff leadership, nurses, and other 6 Hospital personnel; 7

t) To participate in appropriate continuing-education 8 programs (both for his own benefit and for the benefit of 9 other professionals and personnel); 10

u) To satisfy appropriately the continuing medical education 11 requirements for Medical Staff membership and licensure; 12

v) To immediately notify the Administrator or his designee of 13 any reduction or change in malpractice insurance coverage; 14

w) To authorize the release of all information necessary for an 15 evaluation of the applicant’s qualifications for initial or 16 continued membership, reappointment and/or Clinical 17 Privileges; 18

x) To exhaust all hearing and appeal procedure remedies set 19 forth in these Bylaws with respect to any professional 20 review action taken before resorting to legal action. If the 21 individual takes legal action notwithstanding the provisions 22 of these Bylaws and does not prevail, that person shall 23 reimburse the Hospital, the Medical Staff and/or any 24 Medical Staff members named in the action for all costs 25 incurred in defending such legal action, including 26 reasonable attorneys’ fees; 27

y) To extend immunity to the Hospital, the Medical Staff, the 28 Managers and all individuals acting on their behalf for all 29 matters relating to membership, reappointment, and 30 Clinical Privileges or the applicant’s qualifications for the 31 same; 32

z) To participate in the Hospital’s Compliance Program; 33 aa) To participate in “on-call” coverage as required by the 34

Hospital; 35 bb) To inform the Medical Executive Committee via the 36

Medical Staff Affairs Office of any professional liability 37 claims or suits, changes in medical staff membership 38 (voluntarily or involuntarily) or privileges at any other 39 hospital or health care organization, or any disciplinary 40 action at any other hospital or health care organization at 41 which the applicant has privileges; 42

cc) To satisfy such minimum standards for clinical activity at 43 the Hospital as may be established for each category of 44 Medical Staff membership by the Medical Executive 45


37

Committee and approved by the Managers from time to 1 time; 2

dd) To abide by all principles and codes pertinent to the 3 applicant’s training, including, but not limited to, the 4 Principles of Medical Ethics of the American Medical 5 Association, the Code of Ethics of the American Dental 6 Association, or the Code of Ethics of the American Board 7 of Osteopathy, as well as all Hospital and Medical Staff 8 Rules and Regulations and policies and all federal, state, 9 and local laws, rules and regulations; and 10

ee) To abide by any Medical Staff or Hospital policies 11 regarding conduct and behavior. 12 13

2. Burden of Providing Information 14 Individuals seeking appointment and reappointment have the burden of 15 producing information deemed adequate by the Hospital for a proper 16 evaluation of current competency, character, ethics, and other qualifications, 17 and for resolving any doubts. 18 19 Individuals seeing appointment and reappointment have the burden of 20 providing evidence that all statements made and information given on the 21 application are accurate and complete. 22 23 An application shall be complete when all questions on the application form 24 have been answered, all supporting documentation has been supplied, and all 25 information has been verified from primary sources. An application shall 26 become incomplete if the need arises for new, additional, or clarifying 27 information at any time. Any application that continues to be incomplete 28 sixty (60) days after the individual has been notified of additional information 29 required shall automatically be deemed to have been withdrawn. 30 31 The individual seeking appointment or reappointment is responsible for 32 providing a complete application, including adequate responses from 33 references. An incomplete application will not be processed. 34


38

C. Application 1 1. Information 2

a) Requests for applications for membership on the Medical Staff shall be 3 in writing to the Credentialing Department. Applications for 4 membership shall be submitted on forms approved by the 5 Credentialing Department. 6

b) The application shall contain a request for specific Clinical Privileges 7 desired by the applicant and shall contain detailed information 8 concerning the applicant’s professional qualifications, including, but 9 not limited to: 10

1) The names and complete addresses of at least three (3) 11 Physicians, Podiatrists, Dentists, or other health-care providers 12 in the same discipline as appropriate, who have had recent 13 extensive experience in observing and working with the 14 applicant and who can provide adequate information pertaining 15 to the applicant’s present professional competence and 16 character. References may not be from individuals about to be 17 associated with the applicant in professional practice or 18 personally related to the applicant. At least one (1) reference 19 shall be from the same specialty area as the applicant’s; 20

2) The names and complete addresses of the chairperson/chief of 21 each department/division of any and all hospitals or other 22 institutions at which the applicant has ever worked or trained 23 (i.e., the individuals who served as chairpersons/chiefs at the 24 time the applicant worked in the particular department); 25

3) Information as to whether the applicant’s medical staff 26 membership or clinical privileges have ever been voluntarily or 27 involuntarily relinquished, withdrawn, denied, revoked, 28 suspended, subjected to probationary or other conditions, 29 reduced, or not renewed at any other hospital or health care 30 facility; 31

4) Information as to whether the applicant has ever voluntarily or 32 involuntarily withdrawn an application for membership, 33 reappointment, or clinical privileges, or resigned from the 34 medical staff before final decision on such application by a 35 hospital’s or other health care facility’s governing body; 36

5) Information as to whether the applicant’s license to practice any 37 profession in any state or the applicant’s DEA license or 38 Delaware CDS registration (if applicable) is or has ever been 39 voluntarily or involuntarily suspended, modified, terminated, 40 restricted, or had any previously successful or currently pending 41 challenges. The submitted application shall include a list or 42 copy of all the applicant’s current licenses to practice, as well as 43 copies of the applicant’s DEA license and Delaware CDS 44 registration (if applicable); 45


39

6) Information as to whether the applicant has currently in force 1 professional liability insurance coverage in accordance with the 2 requirements of the State of Delaware or other states in which 3 the applicant will practice on behalf of Nemours, the name of 4 the insurance company, and the amount and classification of 5 such coverage and whether said insurance covers the Clinical 6 Privileges the applicant seeks to exercise at the Hospital; 7

7) Information concerning the applicant’s present and past 8 professional liability litigation experience, pending matters, 9 litigation, final judgments, or settlements, including: (i) the 10 substance of the allegations, (ii) the findings, (iii) the ultimate 11 disposition, and (iv) and additional information concerning such 12 proceedings or actions as the Credentials Committee or 13 Managers may deem appropriate. The history of the applicant’s 14 malpractice verdicts and the settlement of malpractice claims, as 15 well as pending claims, will be evaluated as criteria for 16 membership, reappointment, and the granting of Clinical 17 Privileges. However, the mere presence or absence of verdicts, 18 settlements, or claims shall not, in and of themselves, be 19 sufficient to grant or deny membership or particular Clinical 20 Privileges. The evaluation shall consider the extent to which 21 verdicts, settlements or claims evidence a pattern of care that 22 raises questions concerning the individual’s clinical 23 competence, or whether a verdict, settlement, or claim, in and 24 off itself, represents such deviation from standard medical 25 practice as to raise overall questions regarding the applicant’s 26 clinical competence, skill in the particular Clinical Privilege, or 27 general behavior, or indicates that there is a substantial 28 possibility that the applicant, if granted Clinical Privileges, 29 could harm the reputation and standing of the Hospital or the 30 Medical Staff; 31

8) Information concerning any professional misconduct 32 proceedings involving the applicant in Delaware or any other 33 state, whether such proceedings are closed, in process, or still 34 pending; 35

9) Information concerning the suspension or termination for any 36 period of time of the right or privilege to participate in 37 Medicare, Medicaid, and any other government sponsored 38 program, or any private or public medical insurance program, 39 and information as to whether the applicant is currently under 40 investigation by any such program; 41

10) Current information regarding the applicant’s ability to exercise 42 the Clinical Privileges requested and to perform the duties and 43 responsibilities of Medical Staff membership with or without 44 accommodation; 45


40

11) Information as to whether the applicant has ever been named as 1 a defendant in a criminal action and/or convicted of a felony or 2 a misdemeanor involving moral turpitude, including details 3 about any such instance; 4

12) Information regarding any history of substance abuse or 5 substance-related issues; 6

13) A complete chronological listing of the applicant’s professional 7 and education training, memberships, employment, and 8 positions; 9

14) Information on the citizenship and, if applicable, visa status of 10 the applicant; and 11

15) The applicant’s signature and such other information as the 12 Credentials Committee or the Managers may require. 13

14 D. Grant of Immunity and Authorization to Obtain/Release 15

Information 16 17

The following statements, which shall be included on the application form and 18 which form a part of these Bylaws, are express conditions applicable to any 19 Medical Staff applicant, any Member of the Medical Staff, and to all others 20 having or seeking Clinical Privileges at the Hospital. By applying for 21 membership, reappointment, or Clinical Privileges, the applicant or Member 22 expressly accepts these conditions during the processing and consideration of the 23 application, whether or not membership or Clinical Privileges are granted. This 24 acceptance also applies during the time of any membership of reappointment. 25 26

1. Immunity 27 To the fullest extent permitted by applicable law, the applicant or Member 28 releases from any and all liability, extends immunity to, and agrees not to sue 29 the Hospital, its affiliated entities, the Medical Executive Committee, the 30 Medical Staff, their authorized representatives (specifically including 31 individual Medical Staff Members), the Administrator, the Managers, and 32 appropriate third parties, with respect to any acts, communications or 33 documents, recommendations or disclosures involving the applicant or 34 Member concerning the following: 35


41

a) Applications for membership or Clinical Privileges, including 1 temporary privileges; 2

b) Evaluations concerning reappointment or changes in Clinical 3 Privileges; 4

c) Proceedings for suspension or reduction of Clinical Privileges 5 or for revocation of Medical Staff membership, or any other 6 disciplinary sanction; 7

d) Precautionary suspension; 8 e) Hearings and appellate reviews; 9 f) Medical care evaluations; 10 g) Utilization reviews; 11 h) Other activities relating to the quality of patient care or 12

professional conduct; 13 i) Matters or inquiries concerning the applicant’s or Member’s 14

professional qualifications, credentials, clinical competence, 15 character, mental or emotional stability, physical condition, 16 ethics or behavior; and 17

j) Any other matter that might directly or indirectly relate to the 18 applicant’s or Member’s competence or patient care, or to the 19 orderly operation of the Hospital. 20

21 2. Authorization to Obtain Information 22

The applicant or Member specifically authorizes the Hospital, the Medical 23 Staff and their authorized representatives to consult with any third party who 24 may have information bearing on the individual’s professional qualifications, 25 credentials, clinical competence, character, mental or emotional stability, 26 physical condition, ethics, behavior, or any other matter reasonably having a 27 bearing on the applicant’s or Member’s satisfaction of the criteria for initial 28 and continued membership on the Medical Staff. The applicant or Member 29 also specifically authorizes said third parties to release said information to the 30 Hospital, the Medical Staff, and their authorized representatives upon request. 31 32

3. Authorization to Release Information 33 The applicant or Member specifically authorizes the hospital, the Medical 34 Staff, and their authorized representatives to provide any requesting facilities 35 with any and all information and documentation that the requesting facility 36 may request regarding the applicant’s or Member’s professional 37 qualifications. This authorization specifically includes, but is not limited to, 38 any and all information and documentation relating to the clinical 39 competency, professional conduct, and/or any peer review activities involving 40 the applicant and/or Member during his tenure on the Medical Staff of the 41 Hospital. 42 43 The applicant or Member agrees to extend absolute immunity to, release from 44 any and all liability, and agree not to sue the Hospital or any of its 45 representatives for providing the above information and documentation, and 46


42

for any action that may result from the provision of that information and 1 documentation. 2 3

E. Procedure for Initial Appointment to the Medical Staff 4 5

The Medical Staff through the Credentials Committee shall consider each 6 application for appointment or reappointment to the Medical Staff and/or for 7 Clinical Privileges and each request for modification of Medical Staff category 8 or Clinical Privileges, utilizing resources of the Credentialing Department and 9 Medical Staff Affairs Department to investigate and validate the contents of each 10 application, before adopting and transmitting its recommendations to the Medical 11 Executive Committee and the Board of Managers. 12 13 Previously Denied or Terminated Applicants: Notwithstanding any other 14 provision of these Bylaws, if an application is tendered by an applicant who has 15 been previously denied Medical Staff membership and/or Clinical Privileges, or 16 who has had Medical Staff membership and/or Clinical Privileges terminated, or 17 whose prior application was deemed incomplete and withdrawn, and it appears 18 that the application is based on substantially the same information as when 19 previously denied, terminated, or deemed withdrawn, then the application shall 20 be deemed insufficient by the Credentials Committee and returned to the 21 applicant as unacceptable for processing. No such application shall be 22 processed, and no right to hearing or appeal shall be available in connection with 23 the return of such application. An individual who has previously resigned or 24 voluntarily relinquished his privileges for failure to complete proctoring and/or 25 provisional status may reapply and will be subject to processing of the 26 application as a new applicant and subject to the terms and conditions set forth in 27 these Bylaws for new applicants. 28 29 A Medical Staff Member may at any time request a change in Medical Staff 30 category, Department affiliation or Clinical Privileges by submitting a written 31 application to the Medical Staff Affairs Department. Such application shall be 32 processed in substantially the same manner as an application for initial 33 appointment. 34

35 1. Pre-Credentialing Process. Request for Application 36

a) An application form for membership to the Medical Staff shall only be 37 sent upon request to those individuals (i) who are eligible to apply for 38 membership and Clinical Privileges in a specialty area; (ii) who, according 39 to these Bylaws and this Article are eligible for membership and Clinical 40 Privileges because they meet the threshold criteria for membership and 41 Clinical Privileges consideration; (iii) who desire to provide care and 42 treatment to patients for conditions and diseases for which the Hospital 43 has facilities and personnel; and (iv) who indicate an intention to utilize 44 the Hospital as required by the Medical Staff category in which the 45 applicant desires membership. 46


43

b) Those individuals who meet the threshold criteria for consideration for 1 membership on the Medical Staff and Clinical Privileges shall be given an 2 application form. Individuals who fail to meet these criteria shall not be 3 given an application form and shall be notified that they are ineligible to 4 apply. 5 6

2. Submission of Application 7 a) The completed application for Medical Staff membership shall be 8

submitted by the applicant to the Credentialing Department within thirty 9 (30) days of the applicant’s receipt of the application form. After 10 reviewing the application to determine that all questions have been 11 answered, reviewing all references and other information or materials 12 deemed pertinent, querying the national Practitioner Data Bank (NPDB) 13 and such other information sources as may be legally required, and 14 verifying the information with the primary sources, the Credentialing 15 Department or its designee shall transmit the complete application and all 16 supporting materials to the appropriate Division Chief. In the absence of a 17 Division Chief, the application and all supporting materials will be 18 transmitted to the appropriate Department Chairperson. 19

b) An application shall be deemed to be complete when all questions on the 20 application form have been answered in full, the application fee, if any, 21 has been paid, all supporting documentation has been supplied, and all 22 information verified from acceptable primary sources. An application 23 shall become incomplete if the need arises for new, additional, or 24 clarifying information any time during the evaluation. Any application 25 that continues to be incomplete sixty (60) days after the applicant has been 26 notified of the additional information or documentation required shall be 27 deemed to have been withdrawn. It is the responsibility of the applicant to 28 provide a complete application, including adequate responses from 29 references. An incomplete application will not be processed. 30

c) The applicant must immediately report to the Credentialing Department 31 any change in the information in the application that occurs after the 32 application has been submitted. 33

d) If an applicant supplies information in the application process that 34 contains any significant misrepresentation or omission, this may be 35 grounds for denial of the application, or if membership or privileges have 36 been granted, for automatic relinquishment per Section B.1.g of this 37 Article. 38

3. Division Chief Procedure 39 a) The appropriate Division Chief shall evaluate the applicant’s education, 40

training, and experience and may make inquiries to the applicant’s past or 41 current department chairpersons or division chief(s), residency training 42 director, or others who may have knowledge about the applicant’s 43 education, training, experience, ability to exercise the privileges requested 44 and ability to work with others if the documentation supporting the 45 application is not sufficient. The Division Chief may interview the 46


44

applicant and shall do so in any case where the Division Chief has any 1 reservation as to whether the application should be approved. 2

b) The appropriate Division Chief shall provide a written recommendation to 3 the appropriate Department Chairperson within ten (10) business days of 4 receipt of the application materials (or of the interview of the applicant, if 5 conducted by the Division Chief) concerning the applicant’s qualifications 6 for membership and requested Clinical Privileges. 7

c) The Division Chief shall be available to the Credentials Committee to 8 answer any questions that may be raised with respect to the Division 9 Chief’s evaluation or recommendation. 10

11 4. Department Chairperson Procedure 12

The completed application, request for Clinical Privileges, and the 13 recommendation of the Division Chief shall be reviewed by the Department 14 Chairperson. At any time during this process, the Department Chairperson 15 may interview the applicant. The Department Chairperson shall provide a 16 written recommendation to the Credentials Committee within ten (10) 17 business days of the receipt of the material from the Division Chief (or of the 18 interview of the applicant, if conducted by the Department Chairperson). The 19 Department Chairperson shall be available to the Credentials Committee to 20 answer any questions that may be raised with respect to the Department 21 Chairperson’s recommendation. 22 23

5. Hospital Medical Director Procedure 24 The Hospital Medical Director shall review the completed application, request 25 for Clinical Privileges and the recommendations of the Division Chief and 26 Department Chairperson. The Hospital Medical Director may interview the 27 applicant at any time during this process and shall provide a written 28 recommendation to the Credentials Committee within ten (10) business days 29 of the receipt of the material from the Department Chairperson (or of the 30 interview if conducted by the Hospital Medical Director). The Hospital 31 Medical Director shall be available to the Credentials Committee to answer 32 any questions that may be raised with respect to the Hospital Medical 33 Director’s recommendation. 34

35 6. Credentials Committee Procedure 36

a) The Credentials Committee shall examine the completed application, the 37 supporting information and materials, the recommendations of the 38 Division Chief, the Department Chairperson, and the Hospital Medical 39 Director, and any other information it determines it needs to review in 40 order to make its recommendation. 41

b) The Credentials Committee may request and require any additional 42 information it determines it needs in order to make its decision and may 43 use the expertise of the Division Chief, the Department Chairperson, the 44 Hospital Medical Director, any member of the Department, or an outside 45 information source, if additional information or documentation is deemed 46


45

by the Credentials Committee to be necessary regarding the applicant’s 1 qualifications. 2

c) If the recommendation of the Credentials Committee to the Medical 3 Executive Committee is delayed longer than ninety (90) days after receipt 4 of the Hospital Medical Director’s recommendation, the Chairperson of 5 the Credentials Committee shall send a letter to the applicant, with a copy 6 to the Medical Executive Committee and Administrator, explaining the 7 reasons for the delay. 8

d) Except as provided in Section E.6.c of this Article, not later than ninety 9 (90) days from its receipt of the recommendation of the Hospital Medical 10 Director, the Credentials Committee shall send its recommendation and 11 written findings in support thereof to the Medical Executive Committee. 12 The completed application, all supporting materials, and the 13 recommendations of the Division Chief, the Department Chairperson and 14 the Hospital Medical Director, shall accompany the Credentials 15 Committee’s recommendations and findings. Each recommendation shall 16 state one (1) of the following: 17 1) That the applicant be appointed to the Medical Staff; 18 2) That the applicant’s application be deferred for further consideration 19

until any additional information or documentation the Committee 20 deems necessary is provided; or 21

3) That the application be rejected for Medical Staff membership. 22 e) When the Credentials Committee recommends membership to the Medical 23

Staff, it shall also make specific recommendation regarding the Clinical 24 Privileges to be granted and any limitations or conditions on the 25 membership or such privileges. 26

f) The Chairperson of the Credentials Committee shall be available to the 27 Medical Executive Committee (and to the Managers) to answer any 28 questions that may be raised with respect to the Credentials Committee’s 29 recommendation. 30 31

7. Medical Executive Committee Procedure 32 a) At its next regular meeting after receipt of the written findings and 33

recommendation of the Credentials Committee, the Medical Executive 34 Committee shall recommend one of the following: 35 1) That the applicant be appointed to the Medical Staff; 36 2) That the applicant’s application be deferred for further consideration 37

until any additional information or documentation the Medical 38 Executive Committee deems necessary is provided; or 39

3) That the applicant be rejected for Medical Staff membership. 40 b) The Medical Executive Committee may use the expertise of the 41

Department Chairperson, any member of the Department, or an outside 42 information source if additional information is deemed by the Committee 43 to be necessary regarding the applicant’s qualifications. 44

c) If the recommendation of the Medical Executive Committee is favorable 45 to the applicant, it shall transmit to the Managers its recommendation 46


46

together with the application and all supporting materials (which shall be 1 available to the Managers at all times during the Managers’ consideration 2 of the application, including specific recommendations of the Clinical 3 Privileges to be granted, which may be qualified by any probationary or 4 other conditions or restrictions relating to such privileges). 5

d) If the recommendation of the Medical Executive Committee would entitle 6 the applicant to request a hearing pursuant to Article IV of these Bylaws, 7 the application, supporting materials, and recommendations shall be 8 forwarded to the Administrator who shall promptly notify the applicant in 9 writing, certified mail, return receipt requested, of the Medical Executive 10 Committee’s recommendation and of the applicant’s rights under Article 11 IV. The Administrator shall then hold the application until after the 12 applicant has exercised or waived the right to a hearing as provided in 13 these Bylaws or the time period for exercising such right has expired 14 without the applicant’s exercise of such right, after which the 15 Administrator shall forward the recommendation of the Medical Executive 16 Committee, together with the complete application and all supporting 17 documentation, to the Managers for further action. 18

19 8. Managers Procedure 20

Upon receipt of a favorable recommendation from the Medical Executive 21 Committee that the applicant be granted membership and the requested 22 Clinical Privileges or an unfavorable recommendation from the Medical 23 Executive Committee followed by the applicant’s waiver of the right to a 24 hearing as provided in these Bylaws or the expiration of the time period in 25 which the applicant may exercise such right without the applicant’s exercise 26 of such right, the Managers may: 27

28 29

a) Appoint the applicant and grant Clinical Privileges as recommended 30 and notify the applicant of the appointment and the Clinical Privileges 31 granted; or 32

b) Determine that the applicant’s application be deferred until any 33 additional information or documentation the Managers deem necessary 34 is provided by referring the matter back to the Medical Executive 35 Committee, the Credentials Committee or the Department Chairperson 36 for additional research or information. The Medical Executive 37 Committee or Credentials Committee may elect to refer the matter to 38 another source inside or outside the Hospital for additional research or 39 information; or 40

c) Determine to reject the application; in such case, that determination 41 and the reasons in support thereof, shall be sent to the Administrator, 42 who shall promptly notify the applicant in writing of the Managers’ 43 determination, certified mail, return receipt requested. The Managers 44 shall make no final decision until the applicant has exercised or 45 waived the right to a hearing and appeal as outlined in Article IV of 46


47

these Bylaws, if applicable. If the decision of the Managers would 1 entitle the applicant to request a hearing pursuant to Article IV of these 2 Bylaws, the applicant shall be notified by the Administrator of the 3 applicant’s rights under Article IV. 4

5

F. Provisional Status 6

7 1. Nature of Provisional Status 8

The Medical Staff has designated the first twelve (12) months of an initial 9 appointment and the initial granting of Clinical Privileges as a provisional 10 period for the purpose of meeting its obligations to the Medical Staff, the 11 Hospital and the community to ensure that practitioners appointed to the 12 Medical Staff and/or Granted Clinical privileges are qualified and competent 13 to provide same. 14 15

2. Focused Professional Practice Evaluation 16 Each newly appointed Practitioner, and each current Medical Staff Member 17 who is granted new privileges, is subject to focused professional practice 18 evaluation. This evaluation will be carried out by the Division Chief and/or 19 Department Chairperson during the twelve (12) months of the provisional 20 appointment and will assess technical and clinical skills, clinical judgment, 21 medical/clinical knowledge, interpersonal and communication skills, and 22 professionalism. Focused professional practice evaluation may be carried out 23 through any or a combination of the following methods: chart review, 24 monitoring of clinical practice patterns, use of simulation, external peer 25 review, multidisciplinary case discussions, and proctoring. Specific 26 operational details shall be defined in the Medical Staff Policies and 27 Procedures. 28 29 The period of focused professional practice evaluation may be extended for 30 one 12-month period at the request of the Division Chief and/or Department 31 Chairperson. 32 33

3. Duration of Initial Provisional Membership 34 All initial memberships to the Medical Staff (regardless of the category of the 35 Staff to which the membership is made), and all initial granting of Clinical 36 Privileges, shall be provisional for a period of twelve (12) months. 37 38 During the term of this provisional membership, the Member shall be 39 evaluated by the appropriate Department Chairperson, by the Chief of the 40 Division to which the Member is assigned, and by the relevant committees of 41 the Medical Staff as to the Member’s clinical competence and general 42 behavior and conduct. 43 44


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Continued membership and/or Clinical Privileges after the provisional period 1 shall be conditioned on an evaluation of the factors to be considered for 2 reappointment as set for the Article III.H. 3 4

4. Duties of Provisional Members 5 Provisional membership on the Medical Staff shall require that each Member 6 assume such reasonable duties and responsibilities as the Medical Staff shall 7 require. 8

a) During the provisional period, a Member (i) must demonstrate all of 9 the qualifications, (ii) may exercise all of the prerogatives, and (iii) 10 must fulfill all of the responsibilities attendant to his Medical Staff 11 category as outlined in Article II.A (Categories of the Medical Staff). 12

b) During a Member’s provisional period, the Member shall satisfy any 13 requirement for orientation and shall comply with any Medical Staff 14 policy concerning orientation, as may exist from time to time. 15

c) Each Member must arrange for, or cooperate in the arrangement for, 16 the required numbers and types of cases to be reviewed/observed by 17 proctors as designated by the appropriate Division Chief or 18 Department Chairperson. 19

d) Failure of a provisional Member during the provisional period to 20 admit, treat or attend to the number of patients designated by the 21 appropriate Division Chief or Department Chairperson according to 22 the Medical Staff membership category of the provisional Member 23 (sufficient to permit observation and assessment), or failure of the 24 Member during the provisional period to fulfill all requirements of 25 membership related to meeting attendance, completion of medical 26 records, and/or cooperation with monitoring or proctoring conditions, 27 as outlined in this Article, shall render the provisional Member 28 ineligible to apply for reappointment. In that event, at the expiration 29 of the provisional membership period, all Clinical Privileges shall be 30 relinquished and the individual shall be given written notice of such 31 action and of the procedural right of a hearing as specified in these 32 Bylaws. The Division Chief and/or the Department Chairperson may 33 request waiver of this section with the approval of the Department 34 Chairperson and the Medical Director in those instances where the 35 services of the provisional Member are necessary to support the 36 mission of the Hospital but whose frequency of clinical activity does 37 not lend itself to fulfillment of the requirements of this Section. 38

39 G. Clinical Privileges 40

41 1. Exercise of Privileges 42

a) Every Practitioner providing direct clinical services, including, but not 43 limited to, Telemedicine services, at the Hospital by virtue of Medical 44 Staff membership or otherwise, shall, in connection with such practice, 45 and except as provided in Sections 3 and 4 below, be entitled to exercise 46


49

only those Clinical Privileges specifically granted to him by the Board of 1 Managers. The privileges must be within the scope of the license 2 authorizing the Practitioner to practice in Delaware. Regardless of the 3 privileges granted, each Practitioner must obtain consultation when 4 necessary for the safety of his patients or when required by these Bylaws, 5 the Medical Staff and Department policies and procedures or other 6 policies of the Medical Staff and the Hospital. Only those health care 7 professionals with appropriate licenses and Clinical Privileges may 8 evaluate the significance of medical histories, authenticate medical 9 histories, perform and record physical examinations and prescribe 10 treatments. 11

b) The granting of Clinical Privileges shall carry with it acceptance of the 12 obligations of such privileges, including obligations established by these 13 Bylaws, Medical Staff rules and regulations, Medical Staff Policies and 14 Procedures and Department requirements, if any are applicable, to fulfill 15 the Hospital’s responsibilities under the Emergency Medical Treatment 16 and Active Labor Act and/or other applicable requirements, laws, and 17 standards. 18

c) Clinical Privileges shall be voluntarily relinquished only in the manner 19 that provides for the orderly transfer of such obligations. 20 21

2. Unavailable Clinical Privileges 22 Notwithstanding any other provisions of these Bylaws, to the extent that any 23 requested Clinical Privileges are not available at the Hospital (whether 24 because of a closed service, lack of facilities, policy decision of the Board of 25 Managers, or otherwise), the request shall not be processed. Because such a 26 determination is unrelated to the applicant’s qualifications, an applicant whose 27 request is so rejected shall not be entitled to the hearing and appeal rights set 28 forth in these Bylaws. 29 30

3. Clinical Privileges for Dentists and Oral Surgeons 31 a) The scope and extent of surgical procedures that a Dentist or an Oral 32

Surgeon may perform at the Hospital shall be delineated and 33 recommended in the same manner as other Clinical Privileges by the 34 Chairperson of the Department of Surgery. 35

b) Surgical procedures performed by Dentists or Oral Surgeons shall be 36 under the overall supervision of the Chairperson of the Department of 37 Surgery, or his designee. A medical history and physical examination of 38 each patient shall be made and recorded by a Physician or qualified Oral 39 Surgeon who holds membership on the Medical Staff before dental 40 surgery may be performed, and a designated Physician, consulted by the 41 Dentist or Oral Surgeon, shall be responsible for the medical care of the 42 patient throughout the period of hospitalization. However, qualified Oral 43 Surgeons who admit patients without medical problems may perform the 44 medical history and physical examination of those patients if they have 45


50

such privileges and may assess the medical risks of the proposed operative 1 and/or other invasive procedure. 2

c) The Dentist or Oral Surgeon shall be responsible for the dental care of the 3 patient, including the dental history and dental physical examination, as 4 well as all appropriate elements of the patient’s record. Dentists and Oral 5 Surgeons may write orders within the scope of their licenses and 6 consistent with the Medical Staff Policies and Procedures, and in 7 compliance with these Bylaws. 8

9 4. Clinical Privileges for Podiatrists 10

a) The scope and extent of surgical procedures that a Podiatrist may perform 11 at the Hospital shall be delineated and recommended in the same manner 12 as other Clinical Privileges by the Chairperson of the Department of 13 Orthopedic Surgery. 14

b) Surgical procedures performed by Podiatrists shall be under the overall 15 supervision of the Chairperson of the Department of Orthopedic Surgery. 16 A medical history and physical examination of each patient shall be made 17 and recorded in the medical record by a Physician who holds membership 18 on the Medical Staff before podiatric surgery shall be performed, and a 19 designated Physician shall be responsible for the medical care of the 20 patient throughout the period of hospitalization. 21

c) The Podiatrist shall be responsible for the podiatric care of the patient, 22 including the podiatric history and the podiatric physical examination, as 23 well as all appropriate elements of the patient’s record. Podiatrists may 24 write orders within the scope of their Clinical Privileges and licenses, 25 consistent with the Medical Staff Policies and Procedures, and in 26 compliance with these Bylaws. 27

28 5. Clinical Privileges for New Procedures 29

Requests for Clinical Privileges for new procedures and/or the use of new 30 technology shall be referred to the Credentials Committee, which shall 31 evaluate the request according to the Committee’s operational guidelines. 32 33

6. Criteria for Clinical Privileges 34 Clinical Privileges and the development of the criteria for granting such 35 privileges shall follow the process outlined below: 36

a) Each Department Chairperson shall recommend to the Medical 37 Executive Committee written criteria for granting Clinical Privileges 38 consistent with Medical Staff policies. 39

b) The Clinical Privileges recommended by the Medical Executive 40 Committee to the Managers shall be based upon consideration of the 41 following: 42

1) The applicant’s education, training, experience, demonstrated 43 current clinical competence and judgment, including 44 medical/clinical knowledge, technical and clinical skills, 45 clinical judgment, interpersonal and communication skills, and 46


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professionalism with patients, families and other members of 1 the health care team and peer evaluations related to the same, 2 references, utilization patterns, and ability to perform 3 privileges required; 4

2) The applicant’s ability to meet all current criteria for the 5 requested Clinical Privileges; 6

3) Availability of qualified physicians or other appropriate 7 Members to provide medical coverage for the applicant in case 8 of the applicant’s illness or unavailability; 9

4) Adequate levels of professional liability insurance coverage as 10 required by the Hospital with respect to the Clinical Privileges 11 requested; 12

5) The Hospital’s available resources and personnel; 13 6) Any previously successful or currently pending challenges to 14

any licensure or registration, or the voluntary relinquishment of 15 any such licensure or registration; 16

7) Any information concerning professional review actions, 17 voluntary or involuntary termination of medical staff 18 membership, or voluntary or involuntary limitation, reduction, 19 or loss of clinical privileges at another health care facility; and 20

8) Other relevant information, including a written report and 21 findings by the Chairperson of each of the Departments in 22 which such privileges are sought. 23

c) In recommending such criteria, the Department Chairperson and the 24 Credentials Committee shall conduct any necessary research and may 25 consult with experts, both those on the Medical Staff and those outside 26 the Hospital, and develop recommendations regarding (i) the minimum 27 education, training, and experience necessary to perform the privileges, 28 and (ii) the extent of monitoring and supervision that should occur. The 29 Department Chairperson and the Credentials Committee shall forward 30 their recommends to the Medical Executive Committee. The Medical 31 Executive Committee shall review the criteria and forward all 32 recommendations to the Managers for final action. 33

d) The Managers shall then approve, disapprove, or modify the minimum 34 criteria and qualifications necessary to be able to perform the 35 privileges. 36

37 7. Physicians-in-Training 38

Residents, in conjunction with their residency programs, shall not hold 39 membership on the Medical Staff and shall not be granted specific Clinical 40 Privileges. Rather, they shall be permitted to function clinically only in 41 accordance with the written position descriptions as developed by the 42 residency training program in conjunction with the Physician-in-Chief and the 43 Administrator. 44 45


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Chief Residents may be credentialed and granted membership and privileges 1 as part of the progression of their training during the Chief Resident year. 2

8. Telemedicine Privileges 3 Physicians who provide patient care services from remote locations via 4 telemedicine modalities, such as radiologists, will be credentialed as outlined 5 in these Bylaws. 6 7

9. Emergency Clinical Privileges 8 a) Definition – for the purposes of this Section, an “emergency” is defined as 9

a condition that could result in serious or permanent harm to a patient and 10 in which any delay in administering treatments would add to that harm or 11 danger. 12

b) In an emergency, a Practitioner currently appointed to the Medical Staff 13 may be permitted by the Hospital, as granted by the Physician-in-Chief or 14 the Administrator or his designee, to exercise Clinical Privileges to the 15 extent permitted by such Practitioner’s license, regardless of that 16 Practitioner’s Department status or specific grant of Clinical Privileges. 17 Similarly, in an emergency, any Practitioner who is not currently 18 appointed to the Medical Staff may be permitted by the Hospital upon the 19 approval of the Physician-in-Chief or the Administrator or his designee to 20 exercise Clinical Privileges to the extent permitted by such Practitioner’s 21 license and subject to the verification requirements, if any, in the Medical 22 Staff Policies and Procedures. 23

c) Discontinuation of Emergency Privileges – when the emergency situation 24 no longer exists, the patient shall be assigned by the Physician-in-Chief or 25 his designee to a Member with appropriate Clinical Privileges. The wishes 26 of the patient shall be considered in the selection of a substitute physician. 27

28 10. Temporary Privileges 29

The Physician-in-Chief or Administrator or his designee may grant temporary 30 privileges to an applicant when the applicant’s application has been approved 31 by the Credentials Committee but is pending review and recommendation by 32 the Medical Executive Committee and approval by the Managers. Such 33 temporary privileges shall terminate upon the earlier of (i) sixty days from the 34 date temporary privileges were granted, or (ii) upon action on the applicant’s 35 application by the Managers. 36 37

11. Disaster Privileges 38 Disaster privileges may be granted when an emergency management plan has 39 been activated and the Hospital is unable to handle immediate patient needs. 40 During a disaster in which an emergency management plan has been 41 activated, the Chief Executive Officer, the Chief Medical Officer (as defined 42 in the Hospital Disaster Plan), or the President of the Medical Staff or their 43 respective designees shall have the option to grant disaster privileges within 44 the parameters of the Medical Staff Policies and Procedures. 45 46


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H. Procedures for reappointment 1 2

All terms, conditions, requirements, and procedures relating to initial membership 3 shall apply to continued membership and Clinical Privileges and to 4 reappointment. 5

6 To be eligible to apply for renewal of Clinical Privileges, a Member must (i) 7 satisfy any appropriate Hospital criteria for the exercise of Clinical Privileges as 8 may be developed in accordance with Article III.G.6, and (ii) have performed 9 sufficient procedures, treatments, or therapies in the current membership term to 10 enable the appropriate Department Chairperson and the Credentials Committee to 11 assess the Member’s current clinical competence for the privileges requested. 12 13

14 1. Applications for Reappointment 15

a) Each current Member who is eligible to be reappointed to the Medical 16 Staff shall be responsible for completing a reappointment application 17 form. 18

b) The reappointment process will begin six months prior to the expiration 19 of a Medical Staff membership. The reappointment application form 20 shall be furnished to the Member 180 days prior to the membership 21 expiration date. Failure to submit a complete application not later than 22 90 days prior to the membership expiration date will result in automatic 23 expiration of the Member’s membership and Clinical Privileges at the 24 end of the then current term of membership. Upon expiration, such 25 Member may submit a new application for Medical Staff membership 26 and Clinical Privileges. The applicant for reappointment shall produce 27 any information and documentation that the Credentials Committee 28 requests. 29

c) Reappointment to the Medical Staff and the granting, renewal, or revision 30 of Clinical Privileges are made for a period of no more than two years. 31 The specific staggering of reappointments shall be in a manner 32 established by the Hospital. 33

d) In the previous two appointment periods, or the previous four years, each 34 Member of the Active Employed, Active Community, Courtesy 35 Community and Consulting Community staff status must have had at 36 least one (1) inpatient admission, outpatient treatment, consultation, 37 active participation on a committee, or teaching activity. The Physician-38 in-Chief and the Department Chairperson may agree to make exceptions 39 to this requirement in special circumstances. 40

41 2. Factors to Be Considered 42

To be eligible to apply for reappointment and renewal of Clinical Privileges, 43 regardless of category, an individual must have, during the previous 44 appointment term, had sufficient patient contacts to enable the assessment of 45 currently clinical judgment and competence for the privileges requested. Any 46


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individual seeking reappointment who has minimal activity at the Hospital 1 must submit such information as may be requested (such as a copy of his 2 confidential quality profile from his primary hospital (if applicable, clinical 3 information from the individual’s private office practice, and/or a quality 4 profile from a managed care organization), before the application will be 5 considered complete and processed further. 6 7 Each recommendation concerning reappointment of an individual currently 8 appointed to the Medical Staff shall be based upon the Member’s continued 9 completion of the specific eligibility criteria and upon such Member’s: 10 a) Ethical behavior, clinical competence, and clinical judgment in the 11

treatment of patients; 12 b) Attendance at Medical Staff, Department, Division and committee 13

meetings, and participation in staff duties; 14 c) Compliance with Medical Staff Bylaws, Policies and Procedures and 15

other Medical Staff requirements; 16 d) Behavior at the Hospital, including compliance with the Medical Staff 17

Policies on Standards of Physician Conduct; 18 e) Use of the Hospital’s facilities for patients, taking into consideration the 19

individual’s comparative utilization patterns; 20 f) Current ability to perform Clinical Privileges; 21 g) Capability to treat patients satisfactorily as indicated by the results of the 22

Hospital’s quality improvement activities or other reasonable indicators 23 of continuing qualifications, ongoing professional practice evaluations, 24 and other peer review activities, taking into consideration practitioner-25 specific information compared to aggregate information concerning other 26 individuals in the same or similar specialty (provided that other 27 practitioners will not be identified) and any focused professional practice 28 evaluations; 29

h) Satisfactory completion of such continuing education requirements as 30 may be imposed by law, the Hospital, the Department, the Division, these 31 Bylaws or applicable certification or accreditation agencies; 32

i) Current professional liability insurance status and explanation of current 33 and pending malpractice challenges, including claims, lawsuits, 34 judgments, and settlements; 35

j) Current licensure, including previously successful or currently pending 36 challenges to any licensure or registration, or the voluntary or involuntary 37 relinquishment of such licensure or registration; 38

k) Voluntary or involuntary termination of medical staff membership or 39 voluntary or involuntary limitation, reduction, or loss of clinical 40 privileges at another hospital or health care facility; 41

l) Evaluation from the appropriate Division Chief (if applicable) and 42 Department Chairperson; 43

m) Results of a query from the national Practitioner Data Bank (NPDB), all 44 other sanction and background checks, or any other legally mandated 45 reference database; and 46


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n) Maintenance of board and sub-specialty certification or continued 1 satisfaction of Department or Division criteria for maintaining Clinical 2 Privileges. 3 4

3. Division Chief Procedures 5 a) Prior to the end of each Member’s current membership period, the 6

Division Chief shall receive all necessary reappointment materials, as 7 appropriate, for such Member if he is applying for reappointment. 8

b) The Division Chief will perform the reappointment evaluations of the 9 Members assigned to his Division. 10

c) No later than thirty (30) days after receipt of an application form and all 11 required additional materials, the Division Chief shall prepare a written 12 report concerning each individual seeking reappointment. In preparing 13 the report, the Division Chief will consider the criteria in Section III.H.2 14 and any other relevant information. The Division Chief shall include in 15 each written report, when applicable, the reasons for any changes 16 recommended in Staff category, in Clinical Privileges, or for non-17 reappointment. In preparing the report, the Division Chief may meet 18 with the individual. The Division Chief shall forward the report to the 19 Department Chairperson for the Chairperson’s review and 20 recommendation to the Credentials Committee. The Division Chief and 21 the Department Chairperson shall be available to the Credentials 22 Committee to answer any questions that may be raised with respect to 23 any such recommendation. 24

4. Hospital Medical Director Procedure 25

The Hospital Medical Director shall review the completed application, request 26 for Clinical Privileges and the recommendations of the Division Chief and 27 Department Chairperson. The Hospital Medical Director shall provide a 28 written recommendation to the Credentials Committee within ten (10) days of 29 the receipt of the material from the Department Chairperson (or of the 30 interview if required by the Hospital Medical Director). The Hospital Medical 31 Director shall be available to the Credentials Committee to answer any 32 questions that may be raised with respect to the Hospital Medical Director’s 33 recommendations. 34 35

5. Credentials Committee Procedure 36 a) Not later than ninety (90) days from its receipt of the recommendation of 37

the Hospital Medical Director, the Credentials Committee shall send its 38 recommendation and written findings in support thereof to the Medical 39 Executive Committee. The completed application, all supporting 40 materials, and the recommendations of the Division Chief, the Department 41 Chairperson and the Hospital Medical Director shall accompany the 42 Credentials Committee’s recommendations and findings. Each 43 recommendation shall state one (1) of the following: 44 1) That the applicant be reappointed to the Medical Staff; 45


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2) That the applicant’s application be deferred for further consideration 1 until any additional information and documentation the Credentials 2 Committee deems necessary or desirable is provided; or 3

3) That the application for continued Medical Staff membership be 4 rejected. 5

b) When the Credentials Committee recommends membership to the Medical 6 Staff, it shall also make a specific recommendation regarding the Clinical 7 Privileges to be granted and any limitations or conditions on the 8 membership or such privileges. 9

c) The Chairperson of the Credentials Committee shall be available to the 10 Medical Executive Committee (and to the Managers) to answer any 11 questions that may be raised with respect to the Credentials Committee 12 recommendation. 13

14 6. Medical Executive Committee Procedure 15

a) At its next regular meeting after receipt of the written findings and 16 recommendation of the Credentials Committee, the Medical Executive 17 Committee shall recommend one of the following: 18 1) That the applicant be reappointed to the Medical Staff; 19 2) That the applicant’s application be deferred for further consideration 20

until any additional information or documentation the Medical 21 Executive Committee deems necessary is provided; or 22

3) That the applicant be rejected for continuing Medical Staff 23 membership. 24


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b) The Medical Executive Committee may use the expertise of the 1 Department Chairperson, any member of the Department, or an outside 2 information source if additional information or documentation is deemed 3 necessary or desirable regarding the applicant’s qualifications. 4

c) If the recommendation of the Medical Executive Committee is favorable 5 to the applicant, it shall transmit to the Managers its recommendation, 6 together with the application and all supporting materials, including 7 specific recommendation of the Clinical Privileges to be granted, which 8 may be qualified by any probationary or other conditions or restrictions 9 relating to such privileges. 10

d) If the recommendation of the Medical Executive Committee would entitle 11 the applicant to request a hearing pursuant to Article IV, the application, 12 supporting materials, and recommendations shall be forwarded to the 13 Administrator who shall promptly notify the applicant in writing, certified 14 mail, return receipt requested, of the Medical Executive Committee’s 15 recommendation and of the applicant’s rights under Article IV. The 16 Administrator shall then hold the application until after the applicant has 17 exercised or waived the right to a hearing as provided in these Bylaws or 18 the time period for exercising such right has expired without exercise, 19 after which the Administrator shall forward the recommendation of the 20 Medical Executive Committee, together with the complete application and 21 all supporting documentation, to the Managers for further action. 22

23 7. Managers Procedure 24

Upon receipt of a favorable recommendation from the Medical Executive 25 Committee that the applicant be granted reappointment and the requested 26 Clinical Privileges or an unfavorable recommendation from the Medical 27 Executive Committee followed by the applicant’s waiver of the right to a 28 hearing as provided in these Bylaws or the expiration of the time period in 29 which the applicant may exercise such right without the applicant’s exercise 30 of such right, the Managers may: 31

a) Appoint the applicant and grant Clinical Privileges as recommended 32 and notify the applicant of the appointment and Clinical Privileges; or 33

b) Determine that the applicant’s application be deferred until any 34 additional information or documentation the Managers deem necessary 35 is provided by referring the matter back to the Medical Executive 36 Committee, the Credentials Committee or the Department Chairperson 37 for additional research or information. The Medical Executive 38 Committee or Credentials Committee may elect to refer the matter to 39 another source inside or outside the Hospital for additional research or 40 information; or 41

c) Determine to reject the application; in such case, that determination 42 and the reasons in support thereof, shall be sent to the Administrator, 43 who shall promptly notify the applicant in writing of the Managers’ 44 determination, certified mail, return receipt requested. The Managers 45 shall make no final decision until the applicant has exercised or 46


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waived the right to a hearing and appeal as outlined in Article IV, or 1 the expiration of the time period in which the applicant may exercise 2 such right without the applicant’s exercise of such right, if applicable. 3 If the decision of the Managers would entitle the applicant to request a 4 hearing pursuant to Article IV, the applicant shall be notified by the 5 Administrator of his rights under Article IV. 6

7

IV. PEER REVIEW AND FAIR HEARING PROCEDURES 8 9

A. Questions Involving Medical Staff members 10 11

1. Collegial Intervention/Informal Proceedings 12 13

Nothing in this Article or these Bylaws shall preclude collegial, educational, 14 and/or informal efforts to address questions or concerns relating to an 15 individual's practice and conduct at the Hospital, and this Article specifically 16 encourages voluntary structuring of Clinical Privileges to achieve a clinical 17 practice mutually acceptable to the applicant or Member and the Division 18 Chief, Department Chairperson, the Credentials Committee, the Medical 19 Executive Committee, and the Managers. All efforts of the Hospital and the 20 Medical Staff leaders in this regard are intended to be and are part of the 21 Hospital’s quality improvement and professional review activities. 22

a) These Bylaws encourage the use of progressive steps, beginning with 23 collegial and educational efforts, to address questions relating to an 24 individual’s clinical practice and/or professional conduct. Collegial 25 intervention efforts involve reviewing and following up on questions 26 raised about the clinical practice and/or conduct of Staff Members and 27 pursuing counseling, education, and related steps, such as the 28 following: 29 1) Advising colleagues of all applicable policies, such as policies 30

regarding appropriate behavior, emergency call obligations, and 31 the timely and adequate completion of medical records; 32

2) Proctoring, monitoring, consultation, and letters of guidance; and 33 3) Sharing comparative quality, utilization, and other relevant 34

information, including any variations from clinical protocols or 35 guidelines, in order to assist individuals to conform their practices 36 to appropriate norms. 37


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b) The relevant Medical Staff leader(s) shall determine whether it is 1 appropriate to include documentation of collegial intervention efforts 2 in an individual’s confidential file. If documentation of collegial 3 efforts is included in an individual’s file, the individual will have an 4 opportunity to review it and respond in writing. The response will be 5 maintained in that individual’s file along with the original 6 documentation. 7

c) Collegial intervention efforts are encouraged, but are not mandatory, 8 except or unless mandated in other policies, and will be within the 9 discretion of the appropriate Medical Staff leaders and Hospital 10 management. 11

12 2. Deemed Resignations 13

a) Employed Members: The Medical Staff membership and Clinical 14 Privileges of an employed Physician or health-care professional who 15 ceases to be employed by the Hospital shall automatically and 16 immediately be deemed to have been terminated, effective as of the 17 date of such cessation. 18

b) Members with Contracts: Membership and Clinical Privileges of 19 Medical Staff Members who hold contracts shall automatically and 20 immediately be deemed to have been terminated on either (1) the 21 expiration or termination of the Medical Staff Member's contractual 22 relationship with the Hospital or another Nemours facility/entity, or (2) 23 the expiration or termination of the contractual relationship between 24 the entity having a contractual relationship with the Hospital or 25 another Nemours facility/entity. 26

c) Procedural Rights: Medical Staff Members whose Medical Staff 27 membership or Clinical Privileges are deemed to have been 28 automatically terminated due to cessation of employment or contract 29 shall not be entitled to a hearing or appeal as set forth in Article IV. If, 30 however, the circumstances underlying the deemed termination of 31 Medical Staff membership or Clinical Privileges reasonably constitute 32 a surrender of privileges while under or in return for not conducting an 33 investigation, such that the Hospital is required to make a report 34 regarding the Member to the National Practitioner Data Bank or state 35 licensing board or other governmental body, then the hearing and 36 appeal rights set forth in Article IV shall not apply, but the individual 37 shall be entitled to a hearing before a hearing officer appointed by the 38 Hospital with respect to the basis of the professional review action to 39 be reported. 40

41 3. Application for Medical Staff Membership After Resignation: 42

a) Voluntary Resignation: On a case-by-case basis, in the event that a 43 physician employed by Nemours leaves the employment of Nemours 44 voluntarily, the Administrator or his designee, after consultation with 45 the President of the Medical Staff and the applicable Department Chair 46


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and Division Chief, considering the need for the services, may invite 1 the affected practitioner to submit a request for change in Medical 2 Staff status if he desires to maintain Medical Staff membership (in a 3 category other than Employed Active Staff) and privileges. If the 4 physician voluntarily resigned from the Nemours Children's Clinic in 5 good standing, with no outstanding issues involving clinical 6 competence or professional conduct, the physician's Medical Staff 7 membership will be subject to review to confirm continued satisfaction 8 of qualifications for continued membership and privileges. The 9 Division Chief and/or Department Chair will make a report on the 10 request for change in Medical Staff status to the Credentials 11 Committee, which will consider this report at its next scheduled 12 meeting following receipt of the notice of resignation from the 13 physician and make a recommendation to the Medical Executive 14 Committee. Continued Medical Staff membership (with change in 15 category) and Clinical Privileges shall commence following approval 16 of the Board of Managers of the recommendation from the Medical 17 Executive Committee to continue membership and privileges. 18

b) Involuntary Resignation: A staff Member whose membership on the 19 Medical Staff and Clinical Privileges have been deemed to have been 20 automatically terminated due to an involuntary termination of 21 employment or contract will not be eligible to reapply to the Medical 22 Staff for a period of two (2) years unless invited to reapply by the 23 Administrator. An invitation to reapply may be offered by the 24 Administrator or his designee after consultation with the President of 25 the Medical Staff and the applicable Department Chairperson and 26 Division Chief, considering the Hospital’s need for the individual's 27 services. Any such reapplication will be processed as an initial 28 application, except that the applicant will submit such additional 29 information as may be required to demonstrate that the basis for the 30 termination no longer exists. Conditions related to clinical 31 performance improvement or behavior may be imposed. 32

33 4. Ongoing and Focused Professional Practice Evaluations 34

The Medical Staff shall conduct on-going evaluation of the professional 35 practice of its Members and those individuals who are not Members of the 36 Medical Staff but who hold Clinical Privileges. This on-going evaluation shall 37 be conducted throughout the Practitioner’s current 2-year appointment cycle. 38 Medical Staff Department Chairpersons and Division Chiefs will receive 39 Practitioner-specific performance data for their evaluation. Medical Staff 40 policy shall define the procedural elements of this process. 41

42 5. Investigations 43

Initial Procedure 44 Whenever a concern or question has been raised regarding: 45


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a) The clinical competence or clinical practice of any Member; 1 b) The care or treatment of a patient or management of a case by any 2

Member; 3 c) The known or suspected violation by any Member of applicable ethical 4

standards or the Bylaws, policies, or Rules and Regulations of the 5 Medical Staff, including, but not limited to, the Hospital’s quality 6 improvement, risk management, and utilization review programs; 7 and/or 8

d) Behavior or conduct on the part of any Member that is considered 9 lower than the standards of the Medical Staff or is disruptive to the 10 orderly operation of the Hospital or the Medical Staff, including the 11 inability of the Member to work harmoniously with others; 12

13 The Chairperson of the Medical Executive Committee, appropriate 14 Department Chairperson, Chairperson of the Credentials Committee, 15 Physician-in-Chief, or the Medical Director (or designee) shall make 16 sufficient inquiry to determine to his satisfaction the possibility of a problem. 17 In doing so, the persons listed in this Section shall consider any Medical Staff 18 policy that may be in effect at the time regarding Member impairment. 19

20 Initiation of Investigation 21

a) When a concern or question involving clinical competence or 22 behavior/conduct has been referred to the Medical Executive 23 Committee, that Committee shall determine either to discuss the matter 24 with the Member concerned or to begin an investigation. An 25 investigation shall begin only after a formal resolution of the Medical 26 Executive Committee to that effect. The Medical Executive 27 Committee may also, by formal resolution, initiate an investigation on 28 its own. 29

b) The Chairperson of the Medical Executive Committee shall promptly 30 notify the Physician-in-Chief, the Hospital Medical Director, and the 31 Administrator in writing of all such discussions and investigations, and 32 shall keep them fully informed of all actions taken in connection 33 therewith. 34

35 Investigative Procedure 36 Upon resolving to initiate an investigation, the Medical Executive Committee 37 shall meet as soon as possible to consider the concern or question: 38


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a) If the Medical Executive Committee determines that it has enough 1 information to conclude that action is needed or to make a 2 recommendation to the Managers, it will make its recommendation, 3 but only after offering an opportunity for a personal interview with the 4 Member before making such recommendation. 5

b) If the Medical Executive Committee determines that additional 6 information is needed, it will appoint an investigative committee 7 composed as follows: 8 1) The Chairperson of the Medical Executive Committee, the 9

Physician-in-Chief, the Hospital Medical Director, and the 10 Administrator; or 11

2) The Credentials Committee; or 12 3) An ad hoc group of persons who may or may not hold membership 13

on the Medical Staff. 14 c) In no case may a person who is a partner, associate, or relative of the 15

Member in question participate on the investigative committee. 16 d) The Medical Executive Committee and the investigative committee 17

shall have available to it the full resources of the Hospital and the 18 Medical Staff, as well as the authority to use outside consultants or 19 information sources, if it so desires. The investigative committee may 20 also require a physical or mental examination of the Member being 21 investigated by a physician or physicians and shall require that the 22 results of such examination be made available for the investigative 23 committee’s consideration. 24

e) The Member being investigated shall have an opportunity to meet with 25 the investigative committee before it makes its report. At least 72 26 hours prior to any such interview, the individual shall be informed by 27 specific notice of the general supporting evidence and the general 28 nature of the subject being investigated and shall be invited to discuss, 29 explain, or refute it. This interview shall not constitute a hearing, and 30 none of the procedural rules provided in Article IV with respect to 31 hearings shall apply. A summary of such interview shall be made by 32 the investigative committee and included with its report to the Medical 33 Executive Committee. 34

f) After completing its investigation, the investigative committee shall 35 make a report and recommendation to the Medical Executive 36 Committee. 37

38 Procedure Thereafter 39 After receiving the report and recommendation of the investigative committee, 40 the Medical Executive Committee shall make its determination on the matter. 41

a) If the Medical Executive Committee determines that no change in 42 Medical Staff membership or Clinical Privileges is needed, no further 43 action will take place and the Member in question shall be so advised. 44

b) If the Medical Executive Committee determines that a change of 45 Medical Staff membership or Clinical Privileges is not needed, but that 46


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precautionary action is needed, it may issue a written warning, issue a 1 letter of reprimand, impose terms of probation, or such other 2 precautionary action as it deems appropriate. 3

c) If the Medical Executive Committee determines that a change in 4 Medical Staff membership or Clinical Privileges is needed, it will 5 make a recommendation to the Managers. Such change may be a 6 change in or suspension of Clinical Privileges, a suspension or 7 revocation of Medical Staff membership, or other action affecting 8 Clinical Privileges or Medical Staff membership. 9

d) Any recommendation by the Medical Executive Committee that would 10 entitle the Member being investigated to the procedural rights 11 provided in Article IV shall be forwarded to the Administrator, who 12 shall promptly notify the affected Member of the Medical Executive 13 Committee recommendation and the Member’s rights under Article IV 14 by certified mail, return receipt requested. The Administrator shall 15 then hold the recommendation until after the individual has exercised 16 or has waived the right to a hearing, or the time for exercising such 17 right has expired without exercise, after which the Administrator shall 18 forward the recommendation of the Medical Executive Committee, 19 together with all supporting information, to the Managers. 20

e) If the action of the Medical Executive Committee does not entitle the 21 Member to a hearing, the action shall take effect immediately without 22 action of the Managers and without a right of appeal to the Managers. 23 A report of the action taken and reasons therefore shall be made to the 24 Managers through the Physician-in-Chief and the Administrator, and 25 the action shall stand unless modified by the Managers. 26

f) In the event the Managers determine to consider modification of the 27 action of the Medical Executive Committee and such modification 28 would entitle the Member to a hearing in accordance with Article IV 29 of these Bylaws, it shall so notify the affected Member, through the 30 Administrator, and shall take no final action thereon until the Member 31 has had an opportunity to exercise the right to a hearing and appeal as 32 provided in Article IV. 33

g) After the procedures of Article IV have taken place or have been 34 waived by the Member, the Managers shall determine to approve, 35 disapprove, or modify the recommendation of the Medical Executive 36 Committee. 37

38 6. Precautionary Suspension of Clinical Privileges 39

Grounds for Precautionary Suspension 40 a) The Chairperson of the Medical Executive Committee, the 41

Chairperson of a clinical Department, the Hospital Medical Director 42 (or his designee), the Physician-in-Chief and the Administrator shall 43 each have the authority to suspend all or any portion of the Clinical 44 Privileges of a Medical Staff Member whenever failure to take such 45 action may result in an imminent danger to the health and/or safety of 46


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any individual or to the continued effective operation of the Hospital. 1 Such precautionary suspension shall be deemed an interim 2 precautionary step in the professional review activity related to the 3 ultimate professional review action that may be taken with respect to 4 the suspended individual, but is not a complete professional review 5 action in and of itself. It shall not imply any final finding of 6 responsibility for the situation that caused the suspension and shall not 7 entitle the Member to any right to a hearing. 8

b) Such precautionary suspension shall become effective immediately 9 upon imposition, shall be communicated to the Member by special 10 notice, shall immediately be reported in writing to the Administrator, 11 the Physician-in-Chief, the Hospital Medical Director, the Chairperson 12 of the Medical Executive Committee, and the Department 13 Chairperson, and shall remain in effect unless or until modified by the 14 Medical Executive Committee. 15

16 7. Medical Executive Committee Procedure 17

a) A review of a matter resulting in precautionary suspension of a Member 18 shall be completed within fourteen (14) days or reasons for the delay shall 19 be transmitted to the Physician-in-Chief and the Administrator so that they 20 and the Medical Executive Committee may consider whether the 21 suspension should be lifted. In any event, the Medical Executive 22 Committee shall take such further action as is required in the manner 23 specified under Section IV.A.5. 24

b) As part of this review, the Member shall be invited to meet with the 25 Medical Executive Committee or a subset thereof determined by the 26 Chairman of the Medical Executive Committee. In advance of the 27 meeting, the Member may submit a written statement and other 28 information to the Medical Executive Committee. At the meeting, the 29 Member may provide information to the Medical Executive Committee 30 and should respond to questions that may be raised by committee 31 members. The Member may also propose ways, other than precautionary 32 suspension, to protect patients, employees or others while an investigation 33 is conducted. 34

c) After considering the reasons for the suspension and the Member’s 35 response, if any, the Medical Executive Committee shall determine 36 whether the precautionary suspension should be continued, modified, or 37 lifted. The Medical Executive Committee shall also determine whether to 38 begin an investigation. 39

d) If the Medical Executive Committee decides to continue the suspension, it 40 will send the Member written notice of its decision, including the basis for 41 it and that suspensions lasting longer than 30 days must be reported to the 42 National Practitioner Data Bank. 43

e) There is no right to a hearing based on the imposition or continuation of a 44 precautionary suspension. 45

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Care of Suspended Member’s Patients 1 a) Immediately upon the imposition of a precautionary suspension of a 2

Member, the appropriate Department Chairperson or, if unavailable, the 3 Physician-in-Chief or the Hospital Medical Director, shall assign to 4 another Member with appropriate Clinical Privileges responsibility for 5 care of the suspended Member’s patients still under care at the Hospital as 6 either inpatients or outpatients. The assignment shall be effective until 7 such time as the patients are discharged or the suspension has been lifted 8 by the Medical Executive Committee. The wishes of the patient shall be 9 considered in the selection of the assigned Member. 10

b) It shall be the duty of all Medical Staff Members to cooperate in enforcing 11 all suspensions. 12

13 8. Automatic Relinquishment 14

Except as specifically provided otherwise, the automatic relinquishment of a 15 Member’s Medical Staff appointment and privileges described in this Section 16 A.8 shall occur only after the Chairperson of the Medical Executive 17 Committee has confirmed one or more of the following underlying facts 18 contributing to such actions: 19 a) Failure to Complete Medical Records. The admitting and Clinical 20

Privileges (elective and emergency), including the permission to perform 21 outpatient surgeries or procedures, of any Member shall be deemed to be 22 automatically relinquished for failure to complete medical records in 23 accordance with applicable policies governing the same, after notification 24 by the Hospital Medical Director or his designee to the Member in 25 question. Medical-record delinquency shall be handled according to 26 Medical Staff policy. Such relinquishment shall continue until all the 27 records of the Member’s patients are no longer delinquent. Failure to 28 complete the medical records that caused relinquishment of Clinical 29 Privileges within sixty (60) days from the relinquishment of such 30 privileges shall constitute an automatic relinquishment of all Clinical 31 Privileges and resignation from the Medical Staff. At the formal written 32 request of the Member involved, extenuating circumstances (illness, 33 disability, etc.) may be taken into consideration by the Medical Executive 34 Committee, in its discretion. 35

b) Action by State Licensing Agency. Action by an applicable state licensing 36 board or agency revoking or suspending a Member’s professional license, 37 DEA license or CDS registration, or loss or lapse of a state license to 38 practice for any reason, shall result in automatic relinquishment of 39 Medical Staff membership and all Clinical Privileges as of that date, 40 unless and until the matter is resolved, and an application for reinstatement 41 of membership and privileges has been approved by the Managers. In the 42 event the individual's license is only partially restricted, the Clinical 43 Privileges that would be affected by the license restriction shall be 44 similarly restricted. 45


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c) Failure to be Adequately Insured. If at any time a Member's professional 1 liability insurance coverage lapses, falls below the required minimum, is 2 terminated or otherwise ceases to be in effect (in whole or in part), the 3 Member must notify the Administrator or designee of such a change and 4 the Member's Clinical Privileges that would be affected shall be 5 automatically relinquished or restricted as applicable as of that date unless 6 and until the matter is resolved and the required professional liability 7 insurance coverage has been restored. 8

d) Failure to Provide Requested Information. If at any time a Member fails to 9 provide required information or documentation pursuant to a formal 10 request by the Credentials Committee, the Medical Executive Committee, 11 the Hospital Medical Director, the Physician-in-Chief, the Administrator, 12 or the Managers, the Member's Clinical Privileges shall be automatically 13 relinquished until the required information is provided to the satisfaction 14 of the requesting party. For purposes of this section, "required 15 information or documentation" shall refer to (1) physical or mental 16 examinations as specified elsewhere in this Article; (2) information or 17 documentation necessary to explain an investigation, professional review 18 action, or resignation from another facility or agency; (3) information 19 pertaining to professional liability actions involving the Member; or (4) 20 any other information or documentation relative to the Member’s 21 qualifications for membership or professional practice, or exercise of 22 Clinical Privileges. 23

e) Criminal Activity. Any Member who has been convicted of any felony or 24 of any misdemeanor involving violations of law pertaining to controlled 25 substances, illegal drugs, Medicare or Medicaid violations, or insurance 26 fraud or abuse, or any Member who pleads guilty or nolo contendere to 27 charges pertaining to the same, shall automatically relinquish his Medical 28 Staff membership and all Clinical Privileges, unless waived by the 29 Managers. 30

f) Medicare and Medicaid Participation. Any Member whose participation in 31 the Medicare or Medicaid programs is terminated by either the Centers for 32 Medicare and Medicaid Services (CMS) or the Delaware Department of 33 Health and Social Services (DHSS), or who is otherwise excluded or 34 precluded from participation in either or both of those programs by CMS 35 or DHSS, shall be subject to the actions specified under Section A.5 of 36 this Article. It shall be the duty of all Members to promptly inform the 37 Administrator of any action taken by either such program in this regard. 38

g) Misrepresentation, Misstatement or Omission of Information in the 39 Application or Reapplication Process. In accordance with Section III.B.1 40 (g), any membership that has been granted prior to the discovery of 41 misrepresentation, misstatement or omission of information, whether 42 intentional or unintentional, may be deemed by the Managers, after 43 recommendation of the Medical Executive Committee, to constitute 44 grounds for automatic relinquishment of Clinical Privileges and Medical 45 Staff membership. 46


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h) Failure to Request Reappointment. In accordance with Section III.H, 1 failure to request reappointment by means of timely submitting a complete 2 application, including the application fee, if any, within the required time 3 frame shall result in automatic expiration of the Member's membership 4 and Clinical Privileges at the end of the then current term of membership. 5

i) Failure to attend Special Conference. If at any time a Member fails to 6 appear at a special conference pursuant to a formal request by the 7 Credentials Committee, the Medical Executive Committee, the Hospital 8 Medical Director, the Physician-in-Chief, the Administrator, or the 9 Managers, the Member's Clinical Privileges shall be automatically 10 relinquished until the Member appears before the special conference to the 11 satisfaction of the requesting party. 12 13

9. Leaves of Absence 14 a) Reasons for Leaves of Absence - Leaves of absence, not to exceed one 15

year, may be granted by the applicable Department Chairperson for the 16 following reasons: health, maternity leave, medical education, military 17 leave, charity work or such other reasons as may be approved by the 18 applicable Department Chairperson for just cause shown. 19

b) Requests - Requests for leaves of absence shall be made to the Member’s 20 Department Chairperson and shall state the beginning and ending dates of 21 the requested leave and the reasons for the requested leave. 22

c) Prerogatives and Responsibilities While on Leave of Absence. Any 23 Member granted a leave of absence shall relinquish the prerogatives of 24 membership and shall not be required to fulfill the responsibilities of 25 membership, including payment of dues, attendance at meetings or any of 26 the regular Medical Staff duties while on such leave. A Member who is 27 on leave of absence cannot admit patients to or treat patients at the 28 Hospital. 29

d) Reinstatement from a Leave of Absence - At the conclusion of the leave of 30 absence, the Member may apply to be reinstated by submitting to the 31 Credentials Committee current license, DEA and CDS certificates, proof 32 of professional liability coverage, and documentation of current 33 competence. Reinstatement from the leave of absence shall be effective 34 only upon approval by the Managers. The Member shall also provide such 35 other information or documentation as may be requested by the 36 Credentials Committee at that time. If the leave of absence was for 37 medical reasons, the Member must submit a report from his attending 38 Physician to the Physician Health Team at the Hospital indicating that the 39 Member is physically and mentally capable of resuming professional 40 practice and exercising the Clinical Privileges requested. The Hospital 41 may require a second opinion by a Physician of its choice as to the 42 Member’s health. The Physician Health Team shall evaluate the report 43 and any second opinion and provide a recommendation to the Credentials 44 Committee. After considering all relevant information, the Credentials 45 Committee and the Medical Executive Committee shall then make a 46


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recommendation to the Managers for final action. In acting upon the 1 request for reinstatement, the Managers may approve reinstatement either 2 to the same or a different Medical Staff category, and may limit or modify 3 the Clinical Privileges to be extended to the Member upon reinstatement. 4 Failure to receive reinstatement, limitation, or modification of Clinical 5 Privileges constitutes grounds for a hearing under Section IV.B. 6

7 B. Hearings and Appeal Procedures 8

9 1. Initiation of Hearing 10

Grounds For Hearing 11 a) An applicant for a Member holding a Medical Staff membership shall be 12

entitled to request a hearing whenever an unfavorable recommendation 13 has been made by the Medical Executive Committee to the Managers 14 regarding the following: 15 1) Denial of initial Medical Staff membership appointment; 16 2) Denial of Medical Staff membership reappointment; 17 3) Revocation of Medical Staff membership; 18 4) Denial of requested initial Clinical Privileges; 19 5) Denial of requested additional Clinical Privileges; 20 6) Decrease in Clinical Privileges; 21 7) Suspension of Clinical Privileges (other than precautionary 22

suspension); 23 8) Restriction of Clinical Privileges (e.g., required formal concurring 24

consultations with other Members prior to proceeding with a specified 25 course of treatment); or 26

9) Denial of request for reactivation of privileges, or limitation or 27 modification of such privileges, after a leave of absence. 28

b) No other recommendations or actions except those enumerated in (a) of 29 this Section 4.B.1 shall entitle an applicant or Member to request a 30 hearing. 31

c) The affected individual shall also be entitled to request a hearing before 32 the Managers enter a final decision, in the event the Managers should 33 determine, without a similar recommendation from the Medical Executive 34 Committee, to take any action set forth in (a) of this Section IV.B.1. 35

d) The hearing shall be conducted in as informal a manner as possible, 36 subject to the rules and procedures set forth in this Article. 37

38 Actions Not Grounds for Hearing. 39 None of the following actions shall constitute grounds for a hearing, and such 40 actions shall take effect without hearing or appeal: 41 a) The issue of a letter of warning, a letter of admonition, or a letter of 42

reprimand; 43 b) The imposition of terms of probation, monitoring, or a general 44

consultation requirement; 45 c) The termination of any temporary privileges; 46


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d) The automatic relinquishment of Clinical Privileges as provided in Section 1 IV.A.8; or 2

e) The imposition of a requirement for additional training or continuing 3 education. 4

5 2. THE HEARING 6

Notice of Recommendation 7 When a recommendation to the Managers is made by the Medical Executive 8 Committee or a determination is made by the Managers that, according to 9 Section IV.B.1 (a), entitles an individual to a hearing prior to a final decision 10 by the Managers, the affected individual shall promptly be given notice of 11 such recommendation by the Administrator, in writing, certified mail, return 12 receipt requested. The Administrator shall provide such notice to the 13 individual within ten (10) days from the date the recommendation was made. 14 The notice shall contain: 15 a) A statement of the recommendation or determination made and the general 16

reasons for it; 17 b) Notice that the individual has the right to request a hearing on the 18

recommendation within thirty (30) days of receipt of such notice; and 19 c) A copy of this Article outlining the rights in the hearing as provided for in 20

this Article. 21 22

Request for Hearing. 23 An individual shall have thirty (30) days following the date of the receipt of 24 the notice described above within which to request a hearing. The request 25 shall be in writing to the Administrator. In the event the individual does not 26 request a hearing within the time and in the manner required by this Article, 27 the individual shall be deemed to have waived the right to the hearing and to 28 have accepted the action involved. That action shall become effective 29 immediately upon final action by the Managers. 30

31 Notice of Hearing and Statement of Reasons 32 a) If a hearing is requested in accordance with this Article, the Administrator 33

shall schedule the hearing and shall give written notice, certified mail, 34 return receipt requested, to the individual who requested the hearing. The 35 notice shall include: 36

1) The time, place, and date of the hearing; 37 2) The names of the Hearing Panel members appointed in accordance with 38

this Section and the Hearing Panel Chairperson, if known; 39 3) A statement of the specific reasons for the recommendation or 40

determination, as well as a list of patient records and information 41 supporting the recommendation or determination (the “Statement of 42 Reasons”). The Statement of Reasons and the list of supporting patient 43 record numbers and other supporting information and documentation 44 may be revised or amended at any time, even during the hearing, so 45 long as the additional material is relevant to the continued membership 46


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or Clinical Privileges of the individual requesting the hearing. The 1 individual and his or her counsel, if any, shall have sufficient time, up 2 to thirty (30) days, to study this additional information and 3 documentation and attempt to rebut it; and 4

4) A proposed list of witnesses, as known at that time, but which may be 5 modified, who will give testimony or present evidence at the hearing in 6 support of the Medical Executive Committee recommendation or the 7 Managers’ determination. 8

b) The individual requesting the hearing shall have up to thirty (30) days 9 from the date of receipt of notice of the hearing to register any objections 10 to any of the matters set forth in the Statement of Reasons. Failure to do 11 so within the specified time frame shall be deemed to constitute a waiver 12 of any objections. 13

c) The hearing shall begin as soon as practicable, but no sooner than thirty 14 (30) days after the notice of the hearing unless an earlier hearing date has 15 been specifically agreed to in writing by the individual and the Hospital. 16

17 Witness List 18 a) Within ten (10) days after receiving notice of the hearing, the individual 19

requesting the hearing shall provide a written list of the names, addresses, 20 and telephone numbers of any individuals expected to offer testimony or 21 present evidence on his behalf. 22

b) The affected individual's witness list, as well as the witness list of the 23 Medical Executive Committee, shall include a brief summary of the nature 24 of the anticipated testimony. Both lists shall be finalized, to the extent 25 possible, at the time of a pre-hearing conference. However, the witness 26 list of either party may thereafter, in the discretion of the Hearing Panel 27 Chairperson, be supplemented or amended at any time during the course 28 of the hearing, provided that notice of the change is given to the other 29 party. The Hearing Panel Chairperson shall have the authority to limit the 30 number of witnesses, especially character witnesses or witnesses whose 31 testimony is merely cumulative, as set forth in Section IV.B.3. 32

33 Hearing Panel and Hearing Panel Chairperson 34 a) Hearing Panel 35

1) When a hearing is requested, the Administrator, after considering the 36 recommendations of the Chairperson of the Medical Executive 37 Committee, shall appoint a Hearing Panel that shall be composed of 38 not fewer than three (3) persons. The Hearing Panel shall be 39 composed of Medical Staff Members who shall not have actively 40 participated in the consideration of the matter involved at any previous 41 level, or of physicians or laypersons not connected with the Hospital, 42 or any combination of such persons. In all cases, the Hearing Panel 43 shall include at least two (2) physicians. Knowledge of the matter 44 involved shall not preclude any individual from serving as a member 45 of the Hearing Panel. 46


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2) The Hearing Panel shall not include any individual who is in economic 1 competition with the affected person or any individual having 2 economic interests in common, directly or indirectly, with the affected 3 person. 4

3) The Administrator shall appoint one (1) member of the Hearing Panel 5 as the Hearing Panel Chairperson. 6

b) Hearing Panel Chairperson 7 1) The Hearing Panel Chairperson, in addition to chairing the hearing, 8

shall: 9 i. Act to assure that all participants in the hearing have a reasonable 10

opportunity to be heard and to present oral and documentary 11 evidence, subject to reasonable limits on the number of witnesses 12 and duration of direct and cross examination, applicable to both 13 sides, as may be necessary to avoid cumulative, repetitive, or 14 irrelevant testimony or to prevent abuse of the hearing process; 15

ii. Prohibit conduct or presentation of evidence that is cumulative, 16 repetitive, excessive, irrelevant, abusive, or that causes undue 17 delay; 18

iii. Maintain decorum throughout the hearing; 19 iv. Determine the order of procedure throughout the hearing; 20 v. Have the authority and discretion, in accordance with this Article, 21

to make rulings on all questions that pertain to matters of 22 procedure and to the admissibility of evidence; 23

vi. Act in such a way that all information relevant to the membership 24 or Clinical Privileges of the individual requesting the hearing is 25 considered by the Hearing Panel in formulating its 26 recommendations; and 27

vii. Entertain argument by counsel on procedural points outside the 28 presence of the Hearing Panel unless the Hearing Panel wishes to 29 be present. 30

2) The Hearing Panel Chairperson may be advised by legal counsel to the 31 Hospital. 32

3. Pre-Hearing and Hearing Procedure 33

Discovery/Provision of Relevant Information 34 a) There is no right to discovery in connection with the hearing. However, 35

the individual requesting the hearing shall be entitled, upon specific 36 request, to the following documents, subject to a stipulation signed by 37 both parties that such documents shall be maintained as confidential and 38 shall not be disclosed or used for any purpose outside of the hearing, 39 except as required by applicable law: 40 1) Copies at the individual’s expense of, or reasonable access to, all 41

patient medical records referred to in the Statement of Reasons; 42 2) Copies at the individual’s expense of, or reasonable access to, reports 43

of experts relied upon by the Medical Executive Committee or the 44 Managers; 45


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3) Redacted copies of relevant Committee or Department minutes (such 1 provision does not constitute a waiver of the state peer review 2 protection statute); and 3

4) Copies at the individual’s expense of, or reasonable access to, any 4 other documents relied upon by the Medical Executive Committee or 5 the Managers. 6

b) Prior to the hearing, by a date set by the Hearing Panel Chairperson or 7 agreed upon by both parties, each party shall provide the other party with 8 the party's proposed exhibits. All objections to documents or witnesses to 9 the extent then reasonably known shall be submitted in writing to the 10 Hearing Panel Chairperson in advance of the hearing. The Hearing Panel 11 Chairperson shall not entertain subsequent objections unless the party 12 offering the objection demonstrates good cause. 13

c) Neither the affected individual, nor his or her attorney, nor any other 14 person acting on behalf of the affected individual, shall contact Hospital 15 employees appearing on the Hospital’s witness list concerning the subject 16 matter of the hearing, unless specifically agreed upon by counsel for the 17 Hospital. 18

19 Pre-Hearing Conference 20 The Hearing Panel Chairperson shall require the parties or counsel for the 21 individual and for the Hospital to participate in a pre-hearing conference 22 conducted by the Hearing Panel Chairperson for purposes of resolving, to the 23 extent possible, all procedural questions in advance of the hearing. The 24 Hearing Panel Chairperson may specifically require that: 25 a) All documentary evidence/exhibits to be submitted by the parties be 26

presented to each other prior to this conference and that any objections 27 regarding the documents be made at this conference and be resolved by 28 the Hearing Panel Chairperson; 29

b) Evidence unrelated to the reasons for the unfavorable recommendation or 30 determination or unrelated to the individual's qualifications for 31 membership or the relevant Clinical Privileges be excluded; 32

c) The names of all witnesses and a brief statement of their anticipated 33 testimony be exchanged by the parties prior to this conference, and that 34 any objections regarding witnesses be made at this conference and be 35 resolved by the Hearing Panel Chairperson; 36

d) The time granted to each witness' testimony and cross-examination be 37 agreed upon, or determined by the Hearing Panel Chairperson, in 38 advance; and 39

e) Witnesses and documentation not provided and agreed upon in advance 40 of the hearing may be excluded from the hearing. 41

42 Failure to Appear 43 Failure, without good cause, of the individual requesting the hearing to appear 44 and proceed at the pre-hearing conference or at the hearing shall be deemed to 45


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constitute voluntary acceptance of the pending recommended or determined 1 actions, which shall then be forwarded to the Managers for final decision. 2 3 Record of Hearing 4 The Hearing Panel shall maintain a record of the hearing by a stenographic 5 reporter present to make a record of the hearing or a recording of the 6 proceedings. The cost of such reporter shall be borne by the Hospital, but 7 copies of the transcript shall be provided to the individual requesting the 8 hearing at that individual's expense. Oral evidence shall be taken only on oath 9 or affirmation administered by any person designated by the Hearing Panel. 10 11 Rights of Both Sides and the Hearing Panel at the Hearing 12 a) At a hearing, both parties shall have the following rights, subject to 13

reasonable limits determined by the Hearing Panel Chairperson: 14 1) To call and examine witnesses to the extent available; 15 2) To introduce exhibits; 16 3) To cross-examine any witness on any matter relevant to the issues 17

and to rebut any evidence; 18 4) Representation by counsel who may call, examine, and cross-19

examine witnesses and present the case. Both parties shall notify the 20 other of the name of that counsel at least ten (10) days prior to the 21 pre-hearing conference; and 22

5) To make an oral statement or submit a written statement at the close 23 of the hearing. 24

b) Any individual requesting a hearing who does not testify in his own 25 behalf may be called and examined as if under cross-examination. 26

c) The Hearing Panel may question the witnesses, call additional witnesses, 27 engage consultants, and/or request documentary evidence. 28

29 Admissibility of Evidence. 30 The pre-hearing conference and the hearing shall not be conducted according 31 to rules of evidence that apply in courts of law. Hearsay evidence shall not be 32 excluded merely because it constitutes hearsay. Any relevant evidence shall 33 be admitted if it is the sort of evidence on which responsible persons are 34 accustomed to rely in the conduct of serious affairs, regardless of the 35 admissibility of such evidence in a court of law. 36 37 Post-Hearing Memoranda of Points and Authorities. 38 The Hearing Panel shall have the right to request, in its discretion, that each 39 party submit a memorandum of points and authorities following the close of 40 the hearing. The Hearing Panel Chairperson, after consultation with all 41 parties, shall establish time frames within which any such post-hearing 42 memoranda must be submitted. 43 44 Official Notice. 45


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The Hearing Panel Chairperson shall have the discretion to take official notice 1 of any matters, either technical or scientific, relating to the issues under 2 consideration that could have been judicially noticed by the courts of 3 Delaware. Participants in the hearing shall be informed of the matters to be 4 officially noticed and such matters shall be noted in the record of the hearing. 5 Either party shall have the opportunity to request that a matter be officially 6 noticed or to refute the noticed matter by evidence or by written or oral 7 presentation of authority. Reasonable additional time shall be granted, if 8 requested, to present written rebuttal of any evidence admitted on official 9 notice. 10 11 Postponements and Extensions. 12 Postponements and extensions of time beyond any time limit set forth in this 13 Article may be requested by anyone but shall be permitted only by the 14 Hearing Panel Chairperson on a showing of good cause. 15

4. Hearing Conclusion, Deliberation, & Recommendation 16

Order of Presentation 17 The Hospital shall first present evidence in support of the Medical Executive 18 Committee’s recommendation or the Managers’ determination. Thereafter, 19 the burden to present evidence shall shift to the individual who requested the 20 hearing. 21 22 Basis of Decision 23 a) The Hearing Panel shall recommend in favor of the Hospital unless it finds 24

that the individual who requested the hearing has established by a 25 preponderance of the evidence that the recommendation or determination 26 that prompted the hearing was arbitrary, capricious, or not supported by 27 substantial evidence. 28

29 b) The decision of the Hearing Panel shall be based on the evidence produced 30

at the hearing. This evidence may consist of the following: 31 1) Oral testimony of witnesses; 32 2) Memorandum of points and authorities presented in connection with 33

the hearing; 34 3) Any information regarding the individual who requested the hearing so 35

long as that information has been admitted into evidence at the hearing 36 and the person who requested the hearing has had the opportunity to 37 comment on and, by other evidence, refute it; 38

4) Any and all applications, references, and accompanying documents; 39 5) Other documented evidence, including, but not limited to, medical 40

records; and 41 6) Any other evidence that has been admitted. 42

43 Adjournment and Conclusion. 44


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The Hearing Panel Chairperson may, without special notice, adjourn the 1 hearing and reconvene the same at the convenience and with the agreement of 2 the participants. Upon conclusion of the presentation of evidence by the 3 parties and/or questions by the Hearing Panel, the hearing shall be closed. 4 5 Deliberations and Recommendation of the Hearing Panel. 6 Within twenty (20) days after final adjournment of the hearing (which may be 7 designated as the time the Hearing Panel receives the hearing transcript), the 8 Hearing Panel shall conduct its deliberations outside the presence of any other 9 person except the Hospital’s counsel, and shall render a recommendation to 10 the Managers, accompanied by a report, which shall contain a concise 11 statement of the basis for the Hearing Panel's recommendation. 12 13 Disposition of Hearing Panel Report. 14 The Hearing Panel shall deliver its report and recommendation to the 15 Administrator who shall forward it, along with all supporting documentation, 16 to the Chairperson of the Managers. The Administrator shall also send a copy 17 of the report and recommendation, certified mail, return receipt requested, to 18 the individual who requested the hearing. The Administrator shall also 19 provide an information copy to the Medical Executive Committee. 20 21

5. APPEAL PROCEDURE 22 Time for Appeal. 23 Within ten (10) days after receiving notice of the Hearing Panel's 24 recommendation, either party may request an appellate review. The request 25 shall be in writing, and shall be delivered to the Administrator either in person 26 or by certified mail, return receipt requested, and shall include a statement of 27 the reasons for appeal and the specific facts or circumstances that justify 28 further review based upon the grounds set forth in this Section. If such 29 appellate review is not requested within ten (10) days as provided herein, both 30 parties shall be deemed to have waived appellate review, and the Hearing 31 Panel's report shall be forwarded by the Chairperson of the Managers to the 32 Managers for final decision. 33 34 Grounds for Appeal 35 The grounds for appeal shall be limited to the following: 36 a) There was substantial failure to comply with this Article and/or these 37

Bylaws during or prior to the hearing, so as to deny a fair hearing; or 38 b) The recommendations of the Hearing Panel were made arbitrarily, 39

capriciously, or with prejudice; or 40 c) The recommendations of the Hearing Panel were not supported by 41

substantial evidence. 42 43

Time, Place and Notice 44 Whenever an appeal is requested as set forth in this Section IV.B.5, the 45 Chairperson of the Managers shall, within ten (10) days after receipt of such 46


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request, schedule and arrange for an appellate review. The affected individual 1 and the Hospital shall each be given notice of the time, place, and date of the 2 appellate review. The date of appellate review shall be not less than ten (10) 3 days, nor more than thirty (30) days, from the date of receipt of the request for 4 appellate review; provided, however, that when a request for appellate review 5 is from a Member who is under a suspension then in effect, the appellate 6 review shall be held as soon as the arrangements may reasonably be made. 7 The time for appellate review may be extended by the Chairperson of the 8 Managers for good cause. 9 10 Nature of Appellate Review 11 a) The Chairperson of the Managers shall appoint a Review Panel composed 12

of not fewer than three (3) persons, at least two (2) of whom shall be 13 physicians, who may, but shall not be required to, include reputable 14 physicians outside the Hospital, to consider the record upon which the 15 recommendation was made. The Review Panel shall not include any 16 member of the Hearing Panel or any person who would be disqualified 17 from being a member of the Hearing Panel pursuant to Section IV.B.2, but 18 may include one or more of the Managers. 19

b) The Review Panel may in its discretion accept additional oral or written 20 evidence subject to the same rights of cross-examination or confrontation 21 provided at the Hearing Panel proceedings. Such additional evidence shall 22 be accepted only if the party seeking to admit it can demonstrate that it is 23 new, relevant evidence or that an opportunity to admit it at the hearing was 24 improperly denied. 25

c) Each party shall have the right to present a written statement in support of 26 its position on appeal. In its sole discretion, the Review Panel may allow 27 each party or its representative to appear personally and make oral 28 argument not to exceed thirty (30) minutes. The Review Panel shall 29 recommend final action to the Managers. 30

d) The Managers may affirm, modify, or reverse the recommendation of the 31 Review Panel or, in its discretion, refer the matter to the Review Panel for 32 further review and recommendation, or make its own decision. In the 33 event the Managers determine to modify or reverse the recommendation of 34 the Review Panel in such a manner that the action would entitle the 35 affected individual to another hearing in accordance with this Article, it 36 shall so notify the affected individual through the Administrator, and shall 37 take no final action thereon until the individual has exercised or has 38 waived the procedural rights provided in this Article. 39

40 Final Decision of the Managers 41 Within thirty (30) days after receipt of the recommendation of the Hearing 42 Panel or the Review Panel, as the case may be, the Managers shall render a 43 final decision in writing, including specific reasons, and shall deliver a copy 44 thereof to the affected individual by certified mail, return receipt requested. A 45


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copy shall also be delivered to the Medical Executive Committee and the 1 Administrator. 2 3 Further Review. 4 Except where the matter is referred for further review and recommendation in 5 accordance with this Section IV.B.5 (Nature of Appellate Review (d)), the 6 decision of the Managers following an appeal shall be final effective 7 immediately and shall not be subject to further review. If the matter is 8 referred pursuant to Section IV.B.5 (Nature of Appellate Review (d)) for 9 further review and recommendation, such recommendation shall be promptly 10 made to the Managers in accordance with its instructions. This further review 11 process and the report back to the Managers shall in no event exceed thirty 12 (30) days except as the parties may otherwise agree. 13 14 Right to One Hearing and One Appeal Only. 15 No applicant or Medical Staff Member shall be entitled to more than one (1) 16 hearing and one (1) appellate review on any matter that may be the subject of 17 an appeal. If the Managers determine to deny initial Medical Staff 18 membership or reappointment to an applicant, or to revoke or terminate the 19 Medical Staff membership and/or Clinical Privileges of a current Member, 20 that individual may not apply for Staff membership or for those Clinical 21 Privileges at the Hospital for a period of five (5) years unless the Managers 22 specifically determine otherwise. 23 24

V. AMENDMENTS, ADOPTION, AND MEDICAL STAFF 25

RULES AND REGULATIONS AND POLICIES AND 26

PROCEDURES 27 28

A. Amendments / Adoptions 29 30

Amendments to these Bylaws may be proposed to the Managers by the Medical 31 Staff following approval by the Medical Executive Committee, communication of 32 the proposed amendment to the Members at least thirty (30) days prior to the 33 Members' vote, and approval by a majority of the Active Staff Members voting 34 either in person, by mail, or by electronic mail. Amendments shall be effective 35 only when approved by majority vote of the Managers. Amendments may also be 36 proposed directly to the Managers by majority vote of the Active Staff Members, 37 following a petition signed by 25% of the voting Staff. Neither the Managers nor 38 the Medical Staff may unilaterally amend these Bylaws, except when necessary to 39 comply with changes in applicable federal or state laws. 40 41 In circumstances where the Medical Executive Committee or the Managers 42 determine that an amendment to these Bylaws is required to comply with changes 43 in applicable federal or state laws, requirements imposed by insurance carriers, 44 state licensure requirements, Joint Commission accreditation standards, and/or 45


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Medicare/Medicaid Conditions of Participation for Hospitals, the review and 1 revision process for such amendments shall be expedited to the fullest extent 2 possible. 3 4 The Medical Executive Committee, with the concurrence of the Physician-in-5 Chief and the Administrator, shall have the power to adopt such amendments to 6 the Bylaws as are, in the Medical Executive Committee’s judgment, solely 7 technical or legal modifications or clarifications, reorganization or renumbering, 8 or amendments made necessary because of punctuation, spelling, or other errors 9 of grammar or expression. Such amendments shall be effective immediately and 10 shall be remain in force if not disapproved by the Medical Staff or the Managers 11 within sixty (60) days of adoption by the Medical Executive Committee. The 12 action to amend may be taken by a motion acted upon in the same manner as any 13 other motion before the Medical Executive Committee. Immediately upon 14 adoption, such amendments shall be sent to the Administrator and the Managers 15 and posted for the Medical Staff. Members of the Medical Staff shall be notified 16 about the changes using the most efficient means of communication. 17

18 B. Medical Staff Policies and Procedures 19

Policies and Procedures 20 The Medical Staff shall adopt such Policies and Procedures as it may deem 21 necessary or desirable upon approval by the Medical Executive Committee, the 22 Physician-in-Chief, and the Administrator. If required by regulatory or accrediting 23 organizations, specific individual policies also require approval by the Managers. 24 Subject to review by the Medical Executive Committee, Departments, Divisions, 25 and identified programs may develop policies and procedures specific to a named 26 Medical Staff service, program, Department or Division separate from general 27 Medical Staff Policies and Procedures that are applicable to all Members. 28 29 Amendment 30 All Medical Staff Policies and Procedures may be amended by vote of the 31 Medical Executive Committee and approval of the Physician-in-Chief and the 32 Administrator. 33 34 The Medical Executive Committee and the Managers shall have the power to 35 provisionally adopt urgent amendments to the Policies and Procedures that are 36 needed in order to comply with a law or regulation, without providing prior notice 37 of the proposed amendments to the Medical Staff. Notice of all provisionally 38 adopted amendments shall be provided to each Member of the Medical Staff as 39 soon as possible. The Medical Staff shall have 14 days to review and provide 40 comments on the provisional amendments to the Medical Executive Committee. 41 If there is no conflict between the Medical Staff and the Medical Executive 42 Committee, the provisional amendments shall stand. If there is conflict over the 43 provisional amendments, then the process for resolving conflicts set forth below 44 shall be implemented. 45 46


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Review 1 Medical Staff Policies and Procedures shall be reviewed by the Medical Staff, 2 principally by the Medical Staff Policy Committee, at least every two (2) years, 3 and the Medical Staff Policy Committee shall forward its recommendations for 4 amendments to the Policies and Procedures to the Medical Executive Committee. 5 6

C. Conflict management Process 7 8

1) When there is a conflict between the Medical Staff and the Medical Executive 9 Committee, as set forth in a petition signed by 25% of voting Members, with 10 regard to: 11 a) Proposed amendments to the Medical Staff Rules and Regulations; 12 b) A new policy proposed by the Medical Executive Committee; or 13 c) Proposed amendments to an existing policy that is under the authority of 14

the Medical Executive Committee; 15 a special meeting of the Medical Staff shall be called. The agenda for that 16 meeting shall be limited to the amendment(s) or policy at issue. The purpose 17 of the meeting shall be solely to attempt to resolve the differences that exist 18 with respect to Medical Staff Rules and Regulations or policies. 19

2) If the differences cannot be resolved at the meeting, the Medical Executive 20 Committee shall forward its recommendations, along with the proposed 21 recommendations pertaining to the Medical Staff Rules and Regulations or 22 policies offered by the voting members of the Medical Staff, to the Managers 23 for final action. 24

3) This conflict management process section is limited to the matters noted 25 above. It is not to be used to address any other issue, including, but not 26 limited to, professional review actions concerning individual Members of the 27 Medical Staff. 28

29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46


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1 2 Approved by the Medical Executive Committee: October 18, 2010 3 Ratified by the Medical Staff: November 22, 2010 4 Approved by the Board of Managers – December 14, 2010 5


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APPENDICES: 1 2

APPENDIX “A” 3 4

DESCRIPTION OF DEPARTMENTS AND DIVISIONS 5 6 DEPARTMENTS 7 8 The Medical Staff shall be organized into six Departments: 9 10 Department of Anesthesiology and Critical Care 11 Department of Medical Imaging 12 Department of Pathology/Clinical Laboratory 13 Department of Pediatrics 14 Department of Orthopedic Surgery 15 Department of Surgery 16 17 The purposes of departmentalization are: 18 19

a) To provide a structured mechanism for the review and evaluation of the quality of 20 care and the assessment of the clinical performance of the members of the 21 Departments; 22

b) To provide a forum for discussion and action on mutual concerns; and 23 c) To provide broad educational opportunities for members of the Departments. 24

25 DIVISIONS 26 27 Department of Surgery: 28 29 The Department of Surgery shall include the following Divisions: 30 31 Cardiothoracic Otorhinolaryngology 32 Dental Surgery Plastic Surgery 33 General Surgery Solid Organ Transplantation 34 Neurosurgery Ophthalmology 35 Urology 36 37 Department of Orthopedic Surgery: 38 39 The Department of Orthopedic Surgery shall include the following Division: 40 41 Orthopedics 42 43 Department of Pediatrics: 44 45

The Department of Pediatrics shall include the following Divisions: 46


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1 Behavioral Health Hematology/Oncology 2 Blood and Bone Marrow Transplant Infectious Disease 3 Allergy/Immunology Neonatology 4 Cardiology Nephrology 5 Dermatology Neurology 6 Developmental Medicine Pulmonary 7 Emergency Medicine General Pediatrics - Inpatient 8 Endocrinology Rehabilitation Medicine 9 Gastroenterology and Nutrition Rheumatology 10 Genetics Diagnostic Referral 11 External Primary Care (employed) External Specialty Pediatrics (employed) 12 Transition of Care 13

14 Department of Medical Imaging: 15 16 The Department of Medical Imaging shall include the following Divisions: 17 18

Computerized Axial Tomography/Magnetic Resonance Imaging 19 Nuclear Medicine 20 Radiology 21 Ultrasound 22 Neuroradiology 23 24 Department of Anesthesiology and Critical Care: 25 26

The Department of Anesthesiology and Critical Care shall include the following 27 Divisions: 28

29 Intensive/Critical Care 30 Surgical Anesthesia 31 32 Department of Pathology/Clinical Laboratory: 33 34

The Department of Pathology/Clinical Laboratory shall include the following 35 Divisions: 36

37 Anatomic Pathology 38 Blood Bank 39 Clinical Laboratory 40

Nemours/Alfred I. duPont Hospital for Children Medical ... · PDF fileNemours/Alfred I. duPont Hospital for Children Medical Staff Bylaws Adopted by Board of Managers: December 14,

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