What the Staff Medical Bylaws are.

Bylaws Sunny View Hospital Table of Contents PREAMBLE …… un DEFINITIONS …… ARTICLE 1.0: NAME AND DESCRIPTION OF MEDICAL STAFF ORGANIZATION ….14 4:.. 1.1: Name ……. 1.2: Relationship between Medical Staff, Medical Center and Medical School …… ARTICLE 2.0: PREROGATIVES AND PURPOSE .. ARTICLE 3.0: MEMBERSHIP AND/OR CLINICAL PRIVILEGES .. 10 3.1: Eligibility and General Responsibilities of Membership and/or Clinical Privileges ……… 10 3.2: General Requirements for Non-Physician Members ………………………. 11 3.3: General Requirements for Medical Staff and Non-Physician Members ……. 12 3.4: Waiver of Qualifications …….. 13 3.5: General Responsibilities of Membership ……………………. 13 3.6: Categories of Membership .. 14 3.7: Advanced Health Practitioners (AHP) ………. 16 3.8: Leave of Absence …… 18 3.9: Procedure for Appointment . 18 3.10: Term of Appointment ….. 24 3.11: Privileges ……. 24 3.12: Evaluation and Monitoring … 28 3.13: Standard of Conduct ….. 31 3.14: Termination or Suspension of Medical Staff Membership, Reduction of Clinical Privileges, and Other Corrective Action …. 32 3.15: Fair Hearing Plan … 41 3.16: Waiting Period After Adverse Action ……. 51 ARTICLE 4.0: ORGANIZATION .. 53 4.1: Departments …. 53 4.2: Department Chairs .. 53 ARTICLE 5.0: OFFICERS OF THE MEDICAL STAFF . 55 5.1: Officers and Their Duties . 55 5.2: Election and Tenure of Offices . 55 1 Page

Bylaws Sunny View Hospital ARTICLE 6.0: EXECUTIVE MEDICAL BOARD 56 6.1: Membership …. 56 6.2: Duties of the Executive Medical Board …………. 58 6.3: Meetings of the Executive Medical Board . 59 ARTICLE 7.0: COMMITTEES OF THE MEDICAL STAFF 59 7.1: Membership ……… 59 7.2: Meetings ….. 60 7.3: Authority and Responsibility ……………" 60 7.4: Standing Committees . 60 7.5: Special Committees ……" 64 ARTICLE 8.0: MEETINGS …….. 65 8.1: Annual Meeting …………. 65 8.2: Special Meetings….. 65 8.3: Department Meetings and Educational Conferences ……….. .4…….. 65 8.4: Voting ………. 65 ARTICLE 9.0: RULES AND REGULATIONS AND POLICIES ………..14 4.. 65 9.1: Rules and Regulations …………. 65 9.2: Policies…….. 66 9.3: Notices .. 67 9.4: Conflict Management ….. 67 ARTICLE 10.0: AMENDMENT OF BYLAWS …. 67 10.1: Amendment Procedure ….. 67 10.2: Interim Amendment of Bylaws ……….. …….4…1414181454 67 10.3: Technical and Editorial Amendments … 68 ARTICLE 11.0: ADOPTION OF BYLAWS . 68 ARTICLE 12.0: CONFIDENTIALITY ….. 68 12.1: General ….. 68 12.2: Breach of Confidentiality ………. 68 12.3: Immunity and Releases … 69 ARTICLE 13.0: OTHER RIGHTS AND RESPONSIBILITIES OF THE MEDICAL STAFF ……….. 70 13.1: Legal Counsel ….. 70 13.2: Disputes with the Governing Body .. 70 2| Page

1. Briefly explain what the Staff Medical Bylaws are. What is its main purpose?  Discuss how it relates to – the medical staff, the Board of Directors, and the CEO.

2. What is the relationship between the Medical Staff Bylaws and The Joint Commission?

3. Explain the process of credentialing and why you think there is a special committee in hospitals that oversees that process.

4. Explain the difference between Clinical Privileges and the process of Credentialing.