Presbyterian Hospital Medical Staff By-Laws 1995
MEDICAL STAFF BY-LAWS,
RULES AND REGULATIONS OF THE PRESBYTERIAN
HOSPITAL IN THE CITY OF NEW YORK
Revised January 18, 1995
PREAMBLE
The care of patients in The Presbyterian Hospital in the City of
New York is the responsibility of the Board of Trustees. The
medical care has been delegated, in so far as legally permissible,
to the Medical Board and through the Medical Board to the Medical
Staff.
For the purpose of these By-Laws, the words "Medical Staff" shall
be interpreted to include all Physicians and Dentists who are
privileged to attend patients in The Presbyterian Hospital in the
City of New York.
These By-Laws, Rules and Regulations shall be governed by the
provisions of the "By-Laws of The Presbyterian Hospital in the City
of New York," as the same may be revised and amended from time to
time, and by the provisions of the "Agreement between the Trustees
of Columbia University in the City of New York and The Presbyterian
Hospital in the City of New York dated February 10, 1921," revised
January 1, 1970, and as further revised and amended from time to
time.
Article I
NAME
The name of this organization shall be the "Medical Staff of The
Presbyterian Hospital in the City of New York."
Article II
PURPOSE
The purposes of this organization are:
1. To insure that all patients admitted to or treated in any of
the facilities, departments or services of the Hospital shall
receive the best possible care;
2. To insure a high level of professional performance of all
physicians and dentists authorized to practice in the Hospital
through appropriate delineation of the clinical privileges
that each physician or dentist may exercise in the Hospital
and through on-going review and evaluation of each physician's
or dentist's performance in the Hospital;
3. To make recommendations to the President and the Board of
Trustees for the establishment, maintenance and enforcement of
professional standards for the continuing improvement of the
quality of care rendered in the Hospital;
4. To initiate and maintain rules and regulations for the
professional conduct of the Medical Staff;
5. To insure the development and maintenance of high standards in
medical education programs, and to do so in cooperation with
the medical faculty of Columbia University's College of
Physicians and Surgeons.
Article III
MEMBERSHIP
Section 1. QUALIFICATIONS
Members of the Medical Staff shall be graduates of approved or
recognized medical, osteopathic or dental schools; shall be
licensed to practice medicine or dentistry in the State of New
York, except that members of the House Staff who are not eligible
for licensure by the State of New York may practice in the Hospital
in accordance with the provisions of the Education Law of the State
of New York; have, or have applied for, a narcotics license except
for members of the House Staff. Throughout the period of his/her
Medical Staff membership, each member of the Medical Staff shall
furnish protection against professional liability risk malpractice
either through statutory indemnity provisions or by obtaining
malpractice insurance coverage in amounts of not less than $2
million for each claimant and $6 million for all claimants, except
that the Hospital may waive this requirement with regard to
physicians and dentists whose duties are administrative in nature
and do not include clinical responsibilities or functions with the
Medical Staff involving their professional capacity as physicians
or dentists. Medical Staff members whose primary affiliation is
Presbyterian Hospital who have existing coverage of $1 million/$3
million may apply for the additional required $1 million/$3 million
of malpractice insurance coverage through the Hospital by
submitting a written request to the Hospital's Risk Management
Department.
Section 2. BASIC RESPONSIBILITIES OF STAFF MEMBERSHIP
Acceptance of appointment on the Medical Staff shall constitute the
Medical Staff appointee's agreement that he or she will strictly
abide by the principles of medical ethics of the American Medical
Association, the standards set by the American Osteopathic
Association, or the Code of Ethics of the American Dental
Association, whichever is applicable, and shall comply in all
respects with the applicable laws, rules and regulations of the
State and City of New York and of the Federal Government.
Members of the Medical Staff shall:
1. refrain from rebating a portion of a fee, or receiving other
inducements in exchange for patient referrals;
2. provide for continuous patient care; except that a physician
may inform a patient that he/she refuses to give advice with
respect to, or participate in, any induced termination of
pregnancy;
3. refrain from deceiving a patient as to the identity of an
operating surgeon or any other member of the Medical Staff
providing treatment or service;
4. refrain from delegating the responsibility for diagnosis or
care of patients to another member of the Medical Staff who is
not qualified to undertake this responsibility;
5. seek consultation whenever necessary;
6. abide by the Medical Staff By-Laws, Rules and Regulations,
Medical Board Policies and Procedures and all other standards,
policies and rules of the Hospital;
7. participate in continuing education commensurate with each
member's training, area of specialty and privileges granted;
8. carry out committee assignments as well as assigned staff and
service functions and participate in the Hospital's Quality
Assurance Program;
9. participate in the education of House Staff; and
10. prepare and complete in a timely manner the medical and other
required records for all patients he or she admits or for whom
he or she in any way provides care in the Hospital, as
provided in these Medical Staff By-Laws, Rules and
Regulations.
Section 3. TERMS OF APPOINTMENT
Subsection 1.
Recommendations for appointments to the Medical Staff shall be made
to the Medical Board of the Hospital by the Chairmen's Advisory
Committee to the Dean of the Faculty of Medicine of Columbia
University. Appointments to the Medical Staff shall be made by the
Board of Trustees of the Hospital from those recommended to the
Medical Board by the Trustees of Columbia University acting through
the Chairmen's Advisory Committee to the Dean of the Faculty of
Medicine, which Committee has been duly empowered by the Trustees
of Columbia University to make nominations to the Medical Staff of
the Hospital. Nominations for appointments to the Medical Staff
shall be acted upon by the Board of Trustees of the Hospital within
sixty days of receipt of the recommendations and supporting
documents from Columbia University. Appointments shall be for a
period not to exceed two years and will terminate on June 30th of
the applicable year.
The Board of Trustees of the Hospital, upon recommendation of the
Medical Board of the Hospital, which Board shall receive
recommendations from the Chairmen's Advisory Committee to the Dean
of the Faculty of Medicine of Columbia University, may reappoint
members of the Medical Staff for a further period not to exceed two
years.
Subsection 2.
Initial appointments to the Medical Staff shall be provisional
for a period of 180 days. During this provisional period the
applicant's performance and clinical competence shall be closely
observed by the Director of the Service to which the applicant has
been appointed.
Subsection 3.
Appointments to the Medical Staff shall confer on the appointee
only such privileges as are consistent with the Service or Services
to which such member of the Medical Staff is appointed.
Subsection 4.
No applicant shall be denied staff membership on the basis of
sex, race, creed, color or national origin. No applicant shall be
automatically excluded from membership on the Medical Staff or
denied exercise of any clinical privileges solely because of lack
of certification, fellowship or membership in a specialty body or
society. Membership on the Medical Staff is a privilege and only
applicants who can document their background, experience, training,
health status, and demonstrate competence, their adherence to the
ethics of their profession, their good reputation, and their
ability to work with others, shall be qualified for nomination for
membership on the Medical Staff.
Section 4. PROCEDURE FOR APPOINTMENT
Under the Alliance Agreement between the Trustees of Columbia
University and The Presbyterian Hospital in the City of New York,
dated February 10, 1921, revised January 1, 1970, "the professional
staffs of the Hospital are to be appointed by the Hospital on the
nomination of the University and are to consist of professors and
other members of the staff of the University Medical School and of
persons of comparable professional standing."
"Professional Staffs" consist of the Attending Staff, i.e.,
Consultants, Consultants Emeritus, Attending, Associate Attending,
Assistant Attending, Associate Physicians and Assistant Physicians
or Dentists; and the House Staff, i.e., Residents and Visiting
Fellows.
The procedure for appointment to the Professional Staffs shall be
as follows:
Subsection 1.
A physician or dentist applying for staff appointment shall
complete and sign a written application stating the applicant's
qualifications, references and the following additional
information:
1. The name of any hospital or facility with or at which the
applicant has or had any association, employment,
privileges or practice;
2. Whether any such association, employment, privilege or
practice was discontinued, and if so, the reason(s) it
was discontinued and, in particular, the reason(s) for
any adverse discontinuance;
3. Any pending professional medical or dental misconduct
proceedings or any pending medical malpractice actions in
this state or another state, the substance of the
allegations in such proceedings or actions, and any
additional information available concerning such
proceedings or actions; and
4. The substance of the findings in such proceedings or
actions and any additional information available
concerning such proceedings or actions.
The applicant's form shall contain the applicant's verification
that the information supplied is true and accurate, a waiver of
confidentiality with respect to such information, and specific
acknowledgment of every Medical Staff member's obligation to
provide continuous care and supervision of his or her patients, to
abide by the Medical Staff By-Laws, Rules and Regulations, to
accept committee assignments, to accept consultation assignments
and to accept such other reasonable service assignments from their
Director of Service, to observe all the ethical principles of his
or her profession, and furnish protection against professional
liability risk (malpractice).
Appointment to the Medical Staff shall require the appraisal of the
character, competence, training, experience, judgment, physical and
mental capabilities, and moral and ethical qualifications of each
applicant. By applying for appointment to the Medical Staff, each
applicant thereby agrees to provide and signifies their consent to
the Hospital's inspection of all records and documents that may be
material to the appraisal of any of the above listed qualifications
for staff membership and to the communication with any individual
or hospital having information about the same and to a personal
interview if requested. The Hospital shall request from any
hospital with or at which the applicant had or has privileges, was
associated, or was employed, the following information concerning
the applicant:
1. Any information regarding any pending professional
misconduct proceedings or any pending medical malpractice
actions;
2. Any judgments or settlements of malpractice actions and
any findings of professional misconduct in this or any
other state; and
3. Any information required to be reported by hospitals
concerning disciplinary actions against professional
licensees and possible physician professional misconduct.
All the specified documentation and information must be maintained
in a physician's or dentist's credentials file. Credentials files
are kept confidential and are located in the Office of the Senior
Vice President for Medical Affairs. Access to credentials files is
limited to a member's Director of Service, the Hospital's
President, the Hospital's Executive Vice President, Chief Medical
Officer, the Senior Vice President for Medical Affairs or his
designees, and others as required by law. It shall be the
responsibility of the Senior Vice President for Medical Affairs
and, when credentials files are in their possession, Directors of
Service to maintain the security and confidentiality of credentials
files.
Subsection 2.
A recommendation for appointment must be obtained from the Chairman
of the Department for submission to the Dean of the Faculty of
Medicine of Columbia University.
Subsection 3.
Recommendations for appointment shall be submitted to an advisory
committee, which acting pursuant to the power delegated to it by
the Board of Trustees of the Hospital and the Trustees of the
University shall review the recommendation and if approved,
determine whether such nomination shall include private admitting
privileges.
Subsection 4.
All nominations submitted by the Dean shall be considered at a
regular meeting of the Chairmen's Advisory Committee to the Dean of
the Faculty of Medicine. Nominations approved by the Chairmen's
Advisory Committee to the Dean are transmitted with a
recommendation of appointment or reappointment to the Medical Board
of the Hospital and must be received by the Medical Board of the
Hospital prior to the appointment date. All recommendations must
include a clear delineation of clinical privileges recommended.
The applicant's complete file shall accompany such recommendation
and shall be retained by the Senior Vice President for Medical
Affairs of the Hospital.
Subsection 5.
The Medical Board shall review all recommendations for appointment
and reappointment at a regular meeting of the Medical Board.
Recommendations of the Medical Board shall be transmitted with a
recommendation to the Board of Trustees of the Hospital. All
recommendations of appointment and reappointment shall include
delineation of clinical privileges to be extended.
Subsection 6.
The Board of Trustees of the Hospital, at a duly held meeting,
shall act upon all recommendations received from the Medical Board.
Appointments and reappointments made by the Board of Trustees shall
be recorded in the minutes of the Board of Trustees. The decision
of the Board shall be transmitted to the candidate for appointment
or reappointment.
Subsection 7.
A physician or dentist applying for staff reappointment shall
complete and sign a written application stating the applicant's
qualifications, and the following additional information:
1. The name of any hospital or facility with or at which the
applicant has or had any association, employment,
privileges or practice;
2. Whether any such association, employment, privilege or
practice was discontinued, and if so, the reason(s) it
was discontinued and, in particular, the reason(s) for
any adverse discontinuance;
3. Any pending professional medical or dental misconduct
proceedings or any pending medical malpractice actions in
this state or another state, the substance of the
allegations in such proceedings or actions, and any
additional information available concerning such
proceedings or actions; and
4. The substance of the findings in such proceedings or
actions and any additional information available
concerning such proceedings or actions.
The applicant's form shall contain the applicant's verification
that the information supplied is true and accurate, a waiver of
confidentiality with respect to such information, and specific
acknowledgment of every Medical Staff member's obligation to
provide continuous care and supervision of his or her patients, to
abide by the Medical Staff By-Laws, Rules and Regulations, to
accept committee assignments, to accept consultation assignments
and to accept such other reasonable service assignments from their
Director of Service, to observe all the ethical principles of his
or her profession, and furnish protection against professional
liability risk (malpractice).
Reappointment to the Medical Staff shall require appraisal of the
character, competence, training, experience, judgment, physical and
mental capabilities and past performance of each member of the
Medical Staff and shall include consideration by the Director of
Service of the following:
1. Credentials.
2. Professional and clinical performance.
3. Current privileges and the basis for any requested
modification.
4. Physical and mental health status (annual examination).
5. Completion of specialty medical or dental continuing
education requirements established by a member's Director
of Service.
6. Attendance at meetings of Committees of the Medical Board
and other Hospital Committees.
7. Service on Committees of the Medical Board and other
Hospital Committees.
8. Timely completion of medical records.
9. Annual acknowledgement form(s).
10. Verification of current licensure.
11. Compliance with applicable Hospital policies, Medical
Staff By-Laws, Rules and Regulations.
12. Continued protection against professional liability risk
(malpractice), either through insurance or statutory
indemnity provisions, in form and amount acceptable to
the Hospital.
13. Information related to involvement in any professional
liability action, previously successful or currently
pending challenges to any licensure or registration, and
loss of Medical Staff membership or clinical privileges
at another hospital.
14. Physician profiles.
15. All documents in the applicant's credentials or personnel
file.
Section 5. EMERGENCY AND TEMPORARY PRIVILEGES
Subsection 1.
Regardless of his or her Service or staff status, in case of
emergency the physician or dentist attending the patient shall be
permitted to do everything possible, within the scope of his/her
license, to save a patient's life or to save a patient from serious
harm, including the calling of such consultation as may be
available. When an emergency situation no longer exists, such
physician or dentist must request the privileges necessary to
continue to treat the patient. In the event such privileges are
denied or he or she does not desire to request privileges, the
patient shall be assigned to an appropriate member of the Medical
Staff. For the purpose of this section, an emergency is defined as
a condition in which the life of the patient is in immediate danger
and in which any delay in administering treatment would increase
the danger.
Subsection 2.
Physicians or dentists holding academic appointments in other
medical schools or of proven outstanding competence in their fields
may be granted temporary privileges in the Hospital with an
appropriate title, visiting pro tem, commensurate with
qualifications. Temporary appointments shall be made in the same
manner as provided for Professional Staff appointments under
Section 4 of this Article III. In the exercise of such privileges
he or she shall be under the direct supervision of the Director of
the Clinical Service. Under ordinary circumstances, these temporary
privileges shall not be extended for a period exceeding three
months.
Subsection 3.
Physicians who have been issued a limited permit to practice
medicine in New York State and who satisfy all Department of Health
requirements to practice at the Hospital may be granted temporary
privileges in the Hospital. Temporary appointments shall be made
in the same manner as provided for Professional Staff appointments
under Section 4 of this Article III. In the exercise of such
privileges a physician shall only practice under the supervision of
the Director of the Clinical Service to which he or she has been
appointed. Such temporary privileges may continue so long as the
physician has a valid limited permit.
Subsection 4.
When time is inadequate for normal processing of the appointment to
the Medical Staff and it is in the best interest of the Hospital to
grant temporary privileges, a fully qualified physician or dentist
may be granted temporary privileges at the Hospital, commensurate
with qualifications, by the Board of Trustees of the Hospital, upon
recommendation jointly made by the Dean of the Faculty of Medicine
of Columbia University and the Medical Director of the Hospital.
The recommendation shall be based on a review of the physician's or
dentist's application for appointment to the Medical Staff and all
other available information regarding his or her qualifications,
ability and judgment to exercise these temporary privileges. The
physician or dentist shall acknowledge that he or she has read and
agrees to be bound by the Medical Staff By-Laws, Rules and
Regulations and consents to the further investigation and
verification of information concerning his or her qualifications
and experience. There must be proof of protection against
professional liability risk (malpractice), either through insurance
or statutory indemnity provisions, in form and amount acceptable to
the Hospital. The temporary privileges shall not be extended for
a period exceeding three months, and the grant of the temporary
privileges shall be approved by the Dean's Committee on
Presbyterian Hospital Medical Staff Appointments within one month
of the date the temporary privileges are granted. Physicians or
dentists exercising temporary privileges granted under this
subsection shall be under the supervision of the Director of the
Clinical Service to which the physician or dentist is appointed.
Temporary privileges may be withdrawn at any time by the President
or Medical Director of the Hospital, in which event the patients of
the physician or dentist to whom temporary privileges have been
granted shall be assigned to appropriate members of the Medical
Staff by the responsible Director of Service. The wishes of the
patient shall be considered in the selection of the alternative
physician or dentist.
Subsection 5.
Practitioners from outside organ procurement organizations
designated by the Secretary of the U.S. Department of Health and
Human Services may engage in the harvesting of tissues and/or other
body parts for transplantation, therapy, research or educational
purposes pursuant to the Federal Anatomical Gift Act and the
requirements of 10 NYCRR 405.25 without obtaining medical staff
privileges at the Hospital.
Section 6. SUSPENSION
1. Corrective Action
a. Corrective action may be initiated by a Director of a
Clinical Service whenever such a Director has information
which, assuming the information were accurate, indicates
(a) that the activities or professional conduct of a
member of the Director's Service are detrimental to
patient safety or to the delivery of quality patient
care, or are disruptive to Hospital operations, or (b)
that restrictions should be placed on the medical or
dental practice of a member of the Director's Service.
Following receipt of any such information a Director may,
as he or she deems appropriate, take no action or,
without limitation, take one or more of the following
actions:
i. Issue a warning, a letter of admonition, or a
letter of reprimand.
ii. Require further clinical training or in-service
education in specified areas.
iii. Impose terms of probation, requirements of
consultation, or a specified level of clinical
supervision for particular or all cases.
iv. Recommend the reduction, suspension or revocation
of clinical privileges.
v. Recommend suspension or revocation of staff
membership.
b. In the event a Director issues a warning or a letter of
admonition or reprimand, such action shall constitute the
final action on the matter.
c. Any action taken by a Director pursuant to (ii) or (iii)
above, except when action taken pursuant to (iii) results
in a modification of the member's appointment, shall
entitle the member to the procedural rights provided in
Section 8 of this Article III concerning resolution of
intra-service disputes.
d. Any action by a Director pursuant to (iii), when such
action results in a modification of the member's
appointment, (iv) or (v) above, or any combination of
such actions, shall be considered a "professional review
action" within the meaning of the Health Care Quality
Improvement Act of 1986 and shall entitle the member to
the procedural rights provided in Section 7 of this
Article III, including a hearing before the Medical
Board.
2. Summary Suspension
a. Any one of the following, the President of the Medical
Board, the Director of a Clinical Service, the President
of the Hospital, the Chief of Staff, the Steering
Committee of the Medical Board and the Executive
Committee of the Board of Trustees, shall each have the
authority, whenever action must be taken immediately in
the best interest of patient care in the Hospital, to
summarily suspend all or any portion of the clinical
privileges of a physician or dentist.
b. A summary suspension may be imposed orally or in writing,
shall become effective immediately upon imposition and
shall be considered a "professional review action" within
the meaning of the Health Care Quality Improvement Act of
1986. The summary suspension shall not be lifted except
in accordance with its terms or upon removal following a
hearing in the matter as set forth in Section 7 of this
Article III.
c. A physician or dentist whose clinical privileges have
been summarily suspended may, within 30 days of receipt
of notice of the suspension, request a hearing on the
matter as set forth in Section 7 of this Article III, and
shall also be entitled to request that an expedited
hearing be held. If an expedited hearing is requested,
such hearing shall commence as soon as feasible, but no
later than 21 days after the receipt by the Hospital of
the practitioner's request for a hearing.
d. The hearing committee may modify, continue or terminate
the terms of the summary suspension. If, as a result of
such hearing, the hearing committee does not terminate
the summary suspension, with such termination to be
effective immediately, the practitioner shall be entitled
to the rights of appeal set forth in Section 7 of this
Article III.
e. Immediately upon the imposition of a summary suspension,
the President of the Medical Board or the responsible
Service Director shall have authority to provide for
alternative medical coverage for the suspended
practitioner's patients still in the Hospital at the time
of such suspension. The wishes of the patient shall be
considered in the selection of such alternative physician
or dentist.
3. Automatic Suspension
a. A temporary suspension in the form of a withdrawal of a
physician's or dentist's admitting privileges effective
until medical records are completed shall be imposed
automatically for failure to complete medical records as
specified in The Rules and Regulations, as the same may
be amended from time to time.
b. Action by New York State revoking or suspending a
physician's or dentist's license, or placing him or her
upon probation, shall automatically suspend all of his or
her Hospital privileges.
c. For failure to maintain the required amounts of
professional liability insurance, a physician's or
dentist's Hospital privileges shall be immediately
suspended.
Section 7. GRIEVANCE PROCEDURE
a. A physician or dentist whose nomination for appointment
to the Medical Staff has not been approved by the Board
of Trustees of the Hospital, a physician or dentist whose
appointment will not be renewed, or a physician or
dentist who has had his or her appointment terminated or
otherwise restricted or modified, shall be notified in
writing within 14 days of such action. The notice shall
state: the particular action taken or proposed to be
taken against the practitioner; the reasons for the
action; that the practitioner has the right to request a
hearing on the action; the time limit within which the
practitioner may request the hearing; and a summary of
the practitioner's rights at the hearing under this
Section. Within 30 days after receipt of the notice, the
practitioner may request a hearing. Such request must be
in writing and be delivered to the President of the
Medical Board. Failure to request a hearing within the 30
day period after receipt of notice shall be deemed a
waiver by the practitioner of his or her right to a
hearing.
b. The hearing shall be conducted by a subcommittee of the
Medical Board and shall be scheduled to commence no less
than 30 days after the practitioner receives written
notice of the place, date and time of the hearing, except
that in cases of summary suspension the practitioner may
request that an expedited hearing be held. If an
expedited hearing is requested, such hearing shall
commence as soon as feasible, but no later than 21 days
after the receipt by the Hospital of the practitioner's
request for a hearing. Notice of the hearing shall
contain a list of witnesses (if any) expected to testify
at the hearing on behalf of the Hospital. The
subcommittee shall consist of three voting members of the
Medical Board, selected by the President of the Medical
Board. One member of the subcommittee shall be
designated its Chairman by the President of the Medical
Board.
c. In the event the Medical Board has made any adverse
recommendation, or taken any adverse action, concerning
the merits of the matter that is the subject of the
hearing, then the hearing committee shall be composed of
three members of the Active Staff of the Medical Staff
appointed by the President of the Hospital or his
designee from among those members of the Active Staff of
the Medical Staff who are not on the Medical Board.
d. The practitioner may challenge for cause the right of any
member of the hearing committee to sit at the hearing.
One ground for exclusion shall be that a member of the
hearing committee is in direct economic competition with
the practitioner. Such a challenge will be deemed waived
if not made prior to the presentation of evidence at the
hearing. The President of the Hospital shall consider
any challenge and make the final decision whether the
challenge should be sustained. If sustained, the
President of the Hospital shall appoint a member of the
Active Staff of the Medical Staff to sit in place of the
challenged hearing committee member.
e. A record of the hearing shall be made, by such method as
determined by the hearing committee. The expenses
incurred in creating a record of the hearing shall be
paid by the Hospital. Legal counsel for both the Hospital
and the practitioner may attend the hearing and may
introduce witnesses or evidence without adhering to
strict rules of evidence. The practitioner has the right:
to representation by an attorney or other person of his
or her choice; to call, examine and cross-examine
witnesses; to present evidence determined to be relevant
by the hearing committee regardless of its admissibility
in a court of law; and to submit a written closing
argument at the conclusion of the hearing. The Hospital
shall have the same rights as the practitioner at the
hearing. Prior to the scheduled date of the hearing,
both the practitioner and the Hospital may submit to the
members of the hearing committee documents intended to be
introduced in evidence at the hearing and a brief
statement of the matters in issue. Counsel for the
Hospital may act as legal advisor to the hearing
committee, provided that the attorney appointed to advise
the Committee is not the same attorney as the attorney
representing the Hospital before the Committee.
f. It shall be the obligation of counsel for the Hospital to
present, in the first instance, the adverse
recommendation or action taken and the supporting
reasons. In order to reverse the action taken, the
affected practitioner shall have the obligation to
persuade the hearing committee, by clear evidence, that
the supporting reasons lack any factual basis or that
such basis, or any action based thereon, is either
arbitrary, unreasonable or not in compliance with
applicable law.
g. Within 14 days of the completion of the hearing, the
hearing committee shall issue a decision either upholding
the adverse recommendation or action or terminating or
modifying such recommendation or action, and the hearing
committee shall forward copies of its decision to the
Board of Trustees, to the affected practitioner and to
counsel for the Hospital. Should the decision of the
hearing committee continue to be adverse to the
practitioner, the affected practitioner may request an
appellate review by written notice to the Board of
Trustees within 10 days after receipt of the adverse
decision of the hearing committee. The Hospital shall
also have the right to request an appellate review of an
adverse decision of the hearing committee. A written
request for appellate review shall include identification
of the grounds for the appeal and a clear and concise
statement of the reasons in support of the appeal. If a
request for appellate review is not made within such
period, the action of the hearing committee shall
constitute final action.
h. The Board of Trustees may sit as the Appellate Review
Committee or it may appoint such Committee, which shall
be composed of not less than three members of the Board
of Trustees. Knowledge of the matter involved shall not
preclude any person from serving as a member of the
Appellate Review Committee, so long as that person did
not take part in a prior hearing on the same matter. A
conflict of interest would preclude an individual from
serving as a member of the Appellate Review Committee.
For purposes of the appellate review, both parties shall
have access to the decision and record of the hearing
committee and all other material that was considered by
the hearing committee in making its decision, unless any
such material is otherwise exempt from disclosure by law.
i. The party appealing shall submit a written brief or
memorandum, i.e., a written statement setting
forth in full the grounds for appeal and the reasons in
support of the appeal. Unless the Appellate Review
Committee authorizes a different schedule, this
memorandum shall be submitted to the Appellate Review
Committee and to the opposing party within 20 days of the
date of receipt by the Board of Trustees of the request
for appellate review. The opposing party shall submit a
responsive memorandum within 20 days of receipt of the
appealing party's memorandum. After receiving both
memoranda, the Appellate Review Committee shall schedule
a date, time and place for the appellate review and shall
give written notice of the schedule to the parties. The
date of the appellate review shall not be more than 20
days from the date that the Appellate Review Committee
received the opposing party's memorandum.
j. The Appellate Review Committee shall review the record
created in the proceedings and the memoranda for the
purpose of determining whether the decision of the
hearing committee had a rational basis. The decision of
the hearing committee shall not be set aside unless it
could not reasonably have been made considering the
burden of proof and the facts and circumstances of the
case. The Appellate Review Committee may, in its sole
discretion, allow oral argument or accept additional
written evidence, subject to a foundational showing that
such evidence could not have been made available at the
hearing in the exercise of reasonable diligence. New or
additional matters not raised at the hearing, nor
otherwise reflected in the record, shall not be
introduced at the appellate review unless the Appellate
Review Committee, in its sole discretion, decides to
consider such new matters. Counsel for the Hospital may
act as legal advisor to the Committee, provided that the
attorney appointed to advise the Committee is not the
same as the attorney who represented the Hospital at the
hearing, or the attorney who represented the hearing
committee, or the attorney representing the Hospital on
the appeal.
k. Within 14 days after the conclusion of the appellate
review, the Appellate Review Committee shall render a
final decision in the matter, in writing, and shall
forward copies thereof to the Medical Board, to the
affected practitioner, and to counsel for the Hospital.
The Appellate Review Committee may affirm, modify, or
reverse the decision of the hearing committee or remand
the matter to the hearing committee for reconsideration.
l. No practitioner shall be entitled to more than one
evidentiary hearing and one appellate review on any
matter which shall have been the subject of adverse
action or recommendation. All proceedings shall be
considered confidential to the extent permitted by law
and subject to the reasonable needs of the Board of
Trustees and other persons who may be authorized from
time to time by the Board of Trustees to review the
proceedings.
m. Fair hearing and appellate review procedures set forth in
these By-Laws apply only to issues relating to the
Medical Staff. Columbia University has a separate
procedure for processing issues concerning faculty
status. The two processes are mutually exclusive. If a
member of the Medical Staff is not considered for
reappointment because of the lack of a faculty
appointment, all review shall be conducted under the
procedure provided by the University, and no review of
the matter is available under these By-Laws.
Section 8. INTRA-SERVICE DISPUTES
If the type of corrective action taken pursuant to Section 6(1) of
this Article does not entitle the practitioner to the grievance
procedure set forth above in Section 7, the practitioner may invoke
the following procedure. This procedure also applies to disputes
and concerns within a Service that do not involve corrective
action.
If a clinical or administrative Service matter is of concern to a
member of a Service, he or she shall confer with the Director of
the Service with a view to reaching a mutually satisfactory
resolution.
If, after meeting with the Director of the Service, a member of the
Service believes that the matter has not been satisfactorily
resolved, the member may request, in writing to the President of
the Medical Board, that the matter be considered by the Steering
Committee of the Medical Board. A copy of the request shall also
be given to the Director of Service.
Upon notice to the Director of Service and the member, the Steering
Committee shall schedule a date to review the matter. The Director
of Service and the member shall be given the opportunity to be
heard at the meeting of the Steering Committee called to consider
the matter.
After consideration, the Steering Committee shall prepare a written
report, which report shall include its recommendations, if any, and
provide a copy to the Director of Service and the member of the
Service and, where appropriate, to the Administration of the
Hospital and/or to the Medical Board. Any recommendations shall be
non-binding and there shall be no right of appeal.
Article IV
CATEGORIES OF THE MEDICAL STAFF
Section 1. THE ATTENDING STAFF, HOUSE STAFF AND ALLIED HEALTH
PROFESSIONAL STAFF
The Attending Staff, the House Staff snd the Allied Health
Professional Staff shall together constitute the Medical Staff.
1. The Attending Staff shall be comprised of the following the
Consulting Staff, the Active Staff, the Clinical Assistiant
Physician Staff and the Doctoral Staff.
a. The Consulting Staff shall consist of physicians and
dentists of recognized professional ability who were
formerly members of the Active Staff and who have
accepted such appointment. Members of the Consulting
Staff shall not be eligible for admitting privileges;
instead they will see patients of Active Staff members in
a consultative capacity. Consulting Staff members who do
not have to fulfill any of the obligations of Active
Staff members except they agree to provide care to
patients as required by the By-Laws of their respective
Services. They shall have the right to attend meetings
of their respective Services and to vote therein.
b. The Active Staff shall consist of physicians and dentists
having appointments as Attending, Associate Attending,
Assistant Attending, Associate Physicians or Dentists,
and Assistant Physicians or Dentists, both full-time and
part-time, who, in addition to meeting the full
professional requirements for appointment established by
the Hospital, are active in the patient care, teaching
and research programs of the Hospital and the University.
Such staff members shall be expected to perform such
duties as may appropriately be assigned to them by their
respective Service Director in the patient care,
education and research programs of their respective
Service whether these duties relate to inpatients or
outpatients or both and, if they have admitting
privileges, to carry responsibility for the medical
treatment of their own patients. Such staff members shall
attend Medical Staff meetings of their respective
Services as required by their Service By-Laws. Such staff
members shall be eligible for appointment by the
President of the Medical Board to Committees of the
Medical Board and for appointment by the Board of
Trustees of the Hospital to the Medical Board. Members
of the Attending Staff shall have clinical privileges at
all divisions of the Hospital. Members of the Active
Staff may admit patients in accordance with the admitting
policies of the Hospital provided they have been granted
admitting privileges by the Board of Trustees of the
Hospital.
c. The Clinical Assistant Physician Staff shall consist of
Visiting Fellows who are in training in the Hospital and
who in addition perform duties as attending physicians in
specified areas of the Hospital. Such staff members shall
be licensed physicians, appropriately credentialed to
practice as Clinical Assistant Physicians and qualified
to provide care and supervise professional staff in a
specified area. The privileges of such Clinical Assistant
Physicians while assigned to specified areas shall be
delineated at the time of appointment. Such appointments
will only be in effect while such Clinical Assistant
Physicians are assigned to such specified areas.
d. The Doctoral Staff shall consist of psychologists and
doctoral scientists who are members of the faculty of
Columbia University's College of Physicians and Surgeons.
The procedure for appointment and reappointment of
psychologists and doctoral scientists to the Medical
Staff shall be same as set forth in Article III, Section
4, for physicians and dentists. Members of the Doctoral
Staff shall be assigned to an appropriate Clinical
Service. They shall have the right to attend meetings of
their respective Services and to vote therein. The
responsibilities and duties of members of the Doctoral
Staff shall not be eligible for admitting privileges.
The Grievance Procedure to which the Doctoral Staff is
entitled is set forth in Article III, Sections 7 and 8 of
these By-Laws.
2. The House Staff shall consist of Residents and Visiting
Fellows in the various Services of the Medical Staff as shall
be approved from time to time by the Board of Trustees of the
Hospital. House Staff appointments shall not exceed one year
and shall automatically terminate if the residency or
fellowship ends. Members of the House Staff must be graduates
of schools of medicine, osteopathy or dentistry accredited by
standard accrediting agencies. The responsibilities and
duties of the members of the House Staff shall be such as are
assigned by the Director of Service concerned and the
Administration of the Hospital. The Grievance Procedure to
which the House Staff is entitled is set forth in Article III,
Sections 7 and 8 of these By-Laws.
Section 2. EMPLOYED PHYSICIANS AND DENTISTS
Physicians and dentists employed part-time or full-time by the
Hospital, whose duties are medico-administrative in nature and
include clinical responsibilities or functions with the Medical
Staff involving their professional capacity as physicians or
dentists, must be members of the Medical Staff, achieving this
status by the same procedure provided for other Medical Staff
members in these By-Laws. Such physician may not have his or her
Medical Staff privileges terminated without recourse to the
Grievance Procedure specified in Section 7 of Article III of these
By-Laws without his or her written consent.
Section 3. EMERITUS STAFF
The Emeritus Staff shall consist of physicians and dentists of
outstanding reputation who were formerly Consultants who no longer
attend patients in the Hospital and whom the Hospital desires to
honor by this appointment. They shall have the right to attend
meetings of their respective Services but shall not have the right
to vote.
Article V
SERVICES OF THE MEDICAL STAFF
Section 1. SERVICES
To promote the care and treatment of patients, the Board of
Trustees of the Hospital may establish such Services as they may
deem advisable. Services of the Medical Staff shall include the
following clinical Services:
Anesthesiology
Dental
Dermatology
Family Medicine
Medicine
Neurological Surgery
Neurology
Obstetrics and Gynecology
Ophthalmology
Orthopedic Surgery
Otolaryngology
Pathology
Pediatrics
Psychiatry
Radiation Oncology
Radiology
Rehabilitation Medicine
Surgery
Urology
Members of the Medical Staff shall be assigned to a designated
Service.
Section 2. DIRECTORS OF SERVICES
Directors of Services shall be appointed by the Board of Trustees
of the Hospital in accordance with the provisions of the agreement
between the Hospital and Columbia University as the same may be
revised and amended from time to time. Each Director shall be in
charge of a specific Service and shall serve until his or her
successor has been appointed by the Board of Trustees. The
Directors of Service shall meet monthly as a body with the
President of the Hospital. The Directors of the Services shall:
1. Be accountable for all professional and administrative
activities within their Services.
2. Exercise general supervision over the work in the Hospital of
the members of the Medical Staff assigned to their respective
Services, including the treatment and care of private
patients, so that observance of the general rules, regulations
and standards of professional care of the Hospital shall be
maintained.
3. Assure that the quality and appropriateness of patient care
provided within the Service are monitored and evaluated and
make specific recommendations and suggestions.
4. Maintain continuing review of the professional performance of
all physicians or dentists with clinical privileges in his or
her Service and report thereon to the Medical Board.
5. Be responsible for enforcement of the Hospital By-Laws and of
the Medical Staff By-Laws, Rules and Regulations within his or
her Service.
6. Be responsible for implementation within his or her Service of
actions taken by the Medical Board.
7. Transmit to the Medical Board his or her Service's
recommendations concerning the staff qualification,
reappointment and delineation of clinical privileges for all
physicians or dentists in his or her Service.
8. Transmit his or her Service's recommendation concerning the
granting of private admitting privileges for his or her
Service. In reaching a recommendation, a Director shall
consider the category of appointment, the duties of the
applicant (for instance, research, education, patient care or
Administration), the interests of patient care and the needs
of the particular Service, including the availability of
appropriate beds and office space.
9. Be responsible for all special care units in his or her
Service.
10. Be responsible for the teaching, educational and research
programs in his or her Service and for terminating the
employment of any resident or fellow when, in the opinion of
the Director, such is in the best interests of the Service.
11. Participate in every phase of administration of his or her
Service through cooperation with the Nursing Service and the
Hospital Administration in matters affecting patient care,
including personnel, supplies, special regulations, standing
orders and techniques.
12. Assist in the preparation of such annual reports, including
budgetary planning pertaining to his or her Service as may be
required by the Medical Board, the Administration of the
Hospital or the Board of Trustees of the Hospital.
13. Update on an ongoing basis physician profiles of each member
of their Service. At a minimum, such updating shall be
reviewed at the time of reappointment. Physician profiles,
which shall be kept in the personnel or credentials file of
each member of the Medical Staff, shall be compiled from at
least the following data sources, if applicable:
a. morbidity and mortality review
b. tissue review
c. blood utilization review
d. medical record review
e. infection control review
f. incident report review
g. utilization review
h. complaints
i. liability claims data
j. PRO quality review data
k. prescription review
l. safety committee review
m. surgical case review
n. medical case review
o. any medical care evaluations performed
p. continuing education programs and other training
Each Director of Service shall be responsible for tracking the
quality assurance reviews of members of his or her Service and
determining what actions, if any, must be taken based on the
reviews.
14. Physicians, surgeons or dentists in charge of divisions or
sub-services shall be responsible to the appropriate Director
of their Service for the care and treatment of patients in
their respective division or sub-service.
Section 3. SERVICE BY-LAWS
Each Service shall adopt By-Laws which shall govern the operation
of the internal affairs of the Service and which shall provide for
regular monthly meetings of members of such Service, regular review
of the clinical work of members of Service and review of findings
from the ongoing monitoring and evaluation of the quality and
appropriateness of the care and treatment provided to patients.
Such By-Laws shall be subject to the approval of the Medical Board.
Article VI
MEDICAL BOARD
Section 1. MEMBERSHIP
The members of the Medical Board shall be appointed annually by the
Board of Trustees of The Presbyterian Hospital. Voting members
shall be members of the Active or House Staff of the Hospital.
The Directors of the Clinical Services, and their successors,
shall, by virtue of their respective positions, be voting members
of the Medical Board. A Director may be represented at any meeting
of the Medical Board by an alternate of his or her designation.
The alternate may both participate in discussion and vote.
The Chairman of the Staff Committee, the Chairman of the Allen
Pavilion Clinical Services Committee and the President of The
Society of Practitioners shall be voting members of the Medical
Board.
One member of the House Staff shall be a voting member of the
Medical Board. The House Staff member shall be chosen annually by
the Board of Trustees upon recommendation of the Steering Committee
of the Medical Board from among three nominees to be submitted by
the House Staff Committee.
Three members of the Active Staff who are not already members of
the Medical Board shall also be voting members of the Medical
Board. Such three members shall be chosen annually by the Board of
Trustees upon recommendation of the Medical Board Nominating
Committee who shall solicit nominations for candidates from the
members of the Active Staff.
The immediate past president of the Medical Board, if not already
a member of the Medical Board and if still a member of the Active
Staff, shall be a voting member of the Medical Board.
The President, Chief of Staff, Senior Vice President for Medical
Affairs, Chief Operating Officer and Chief Nursing Officer of the
Hospital and the Vice President for Health Sciences and Dean of the
Faculty of Medicine, the Dean of the School of Public Health, the
Dean of the Dental School and the Dean of the Nursing School of
Columbia University shall be members of the Medical Board without
vote.
Each of the following may attend Medical Board meetings when a
topic of interest to him or her is on the agenda and shall receive
a copy of the agenda and the minutes of all meetings of the Medical
Board: the Executive Vice President for Corporate and Legal
Affairs; the Deputy to the President; the Senior Vice
President/Milstein - Harkness; the Senior Vice President/Babies-
Sloane; the Senior Vice President/Allen Pavilion; the Senior Vice
President/Ambulatory Services; the Medical Director, Allen
Pavilion; the Medical Director, ACNC; the Director, Quality
Assurance; the Director, Emergency Services; the Director, Social
Work Services; and the Director, Clinical Information Systems.
Subsection 1.
Any person who has served on the Medical Board may, by action
of the Medical Board and approval of such action by the Board of
Trustees to The Presbyterian Hospital, be appointed an honorary
member of the Medical Board. Honorary members shall have the right
to be present at all meetings of the Medical Board but shall not be
entitled to vote.
Section 2. DUTIES OF THE MEDICAL BOARD
1. The Medical Board shall be responsible to the Board of
Trustees for the professional care and treatment of patients
in accordance with the highest standard of medical science.
2. The Medical Board shall be responsible to see that the
purposes of the Medical Staff organization as set forth in
Article II of these By-Laws are fulfilled by the Medical
Staff.
3. The Medical Board shall keep the Board of Trustees advised
concerning all matters pertaining to the health and well-being
of the patients and shall make suggestions and recommendations
tending to improve such professional care and to enhance the
usefulness of the Hospital.
4. The Medical Board, as directed by the Board of Trustees
through the President of Presbyterian Hospital, shall be
responsible for the implementation and monitoring of the
responsibilities of the Medical Staff under the Quality
Assurance Program as described in the Quality Assurance
Program Plan.
5. The Medical Board shall review the minutes of the Steering
Committee of the Medical Board, of the Standing Committees,
subcommittees and ad hoc committees of the Medical Board and
of the meetings of the various services of the Hospital.
6. The Medical Board shall recommend to the Board of Trustees the
Residents who are to be granted diplomas and certificates.
7. In fulfilling its responsibilities under Article III, Section
4 of these By-Laws, the Medical Board shall review the
recommendations for appointment and reappointment submitted by
the Chairmen's Advisory Committee to the Dean of the Faculty
of Medicine of Columbia University.
8. The Medical Board shall have such other duties as may, from
time to time, be assigned to it by the Board of Trustees.
Section 3. OFFICERS
Subsection 1.
At its regular meeting in June, the Medical Board shall elect from
among its voting members a President and a Vice-President to serve
for one (1) year or until their successors are elected. An officer
may be reelected to no more than two (2) additional consecutive one
(1) year terms.
Subsection 2.
The President shall preside at all meetings of the Medical Board
and of the Steering Committee. He or she shall perform such other
duties as required by these By-Laws and shall be a member without
vote of the Board of Trustees.
Subsection 3.
In the event of a vacancy in the office of the President, or during
his or her absence or inability to act, his or her duties shall
devolve upon the Vice-President.
Subsection 4.
The Hospital's Senior Vice President for Medical Affairs shall be
the Secretary of the Medical Board. The Secretary shall keep a
careful record of the proceedings of the meetings of the Medical
Board and of the Steering Committee, shall give notice of all
meetings of the Medical Board and of the Steering Committee to
members and shall perform such other duties as may be assigned from
time to time by the Medical Board. The Secretary shall be entitled
to attend all meetings of the Medical Board and the Steering
Committee.
Subsection 5.
Any officer may resign at any time by giving written notice to the
President or the Secretary of the Medical Board. Unless otherwise
specified in the notice, the resignation shall take effect upon
delivery, and acceptance of the resignation shall not be necessary
to make it effective.
Subsection 6.
Elected Medical Board officers may be removed for cause by the
Medical Board, acting on a two-thirds (2/3) vote by secret ballot
of the members of the Medical Board.
Permissible bases for removal of such Medical Board officers
include, without limitation:
1. failure to perform the duties of the position held in a
timely and appropriate manner;
2. failure to continuously satisfy the qualifications for
the position.
Section 4. MEETINGS
Subsection 1.
The Medical Board shall hold regular monthly meetings. Eight (8)
members of the Board shall constitute a quorum. All meetings of
the Medical Board shall be held at the Hospital.
Subsection 2.
Upon at least one (1) days notice, special meetings of the Medical
Board may be called by the President and shall be called by the
President at the request of the Board of Trustees, or upon the
written request of three (3) members of the Medical Board, stating
the purpose for which the meeting is called. Special meetings
called by request must be held within ten (10) days of the receipt
of such request.
Subsection 3.
At all meetings of the Medical Board, the Secretary shall make a
record of the minutes of such meetings, including any
recommendations approving or disapproving appointment or
reappointment to the Medical Staff and scope of privileges
extended, and a copy of these minutes shall be sent to all members
of the Medical Board and to all members of the Board of Trustees.
Section 5. STEERING COMMITTEE
Subsection 1.
There shall be a Steering Committee of the Medical Board which
shall set the agenda for Medical Board meetings and which may, in
an emergency when there is not sufficient time to call a meeting of
the full Medical Board, exercise all the power of the Medical
Board. The voting members of the Steering Committee shall be the
President and Vice-President of the Medical Board, and the
immediate past president of the Medical Board, if still a member of
the Medical Board. If the immediate past president of the Medical
Board is no longer a member of the Medical Board, the Medical Board
may appoint a replacement from among the voting members of the
Medical Board. The Secretary of the Medical Board shall be a
member of the Steering Committee without vote.
Subsection 2.
The Steering Committee shall hold regular meetings at least once
each month. Two (2) members shall constitute a quorum. All meetings
of the Steering Committee shall be held at the Hospital.
Section 6. STANDING AND AD HOC COMMITTEES
There shall be Standing Committees of the Medical Board in such
number as determined by the Medical Board to be advisable or
appropriate.
The Medical Board shall appoint a chairman of each Committee.
Additional members of each Committee shall be appointed by the
Medical Board on the recommendation of the Committee chairman.
Each Committee chairman may create any subcommittee necessary to
allow the Committee to perform its function. The chairman and
members of any such subcommittee must be approved by the Medical
Board.
The Medical Board may appoint such ad hoc committees as it may deem
advisable or appropriate to assist the Medical Board in performing
its duties. Ad hoc committee chairmen and members shall be
appointed by the Medical Board.
A record of the minutes of the Standing Committees, sub-committees
and ad hoc committees shall be made and a copy sent to the Medical
Board.
Section 7. WAIVER OF NOTICE
Notice of any meeting of the Medical Board or of the Steering
Committee may be waived in writing at any time, either before or
after the meeting by any person entitled to such notice.
Section 8. RULES AND REGULATIONS
The Medical Board shall adopt, from time to time, rules and
regulations for the proper conduct of the work of the Medical
Staff. Such rules and regulations shall be reviewed at least once
in each three year period and may be amended or revised, from time
to time, by a two-thirds vote of the members of the Medical Board
present and voting at any meeting. Such amendment or revision by
the Medical Board shall become effective only when approved by the
Board of Trustees of the Hospital.
The Medical Board may, from time to time, issue policies and
procedures for the proper conduct of the work of the Medical Staff.
All policies and procedures issued by the Medical Board shall be
reviewed at least once in each three-year period.
Section 9. MEDICAL DIRECTOR
The Chief of Staff shall be the Medical Director of the Hospital
and shall be appointed by the Board of Trustees in consultation
with the Medical Board. Such officer shall be responsible for
directing the organization and conduct of the medical staff as the
designated Medical Director.
Article VII
MEETINGS
Subsection 1.
Robert's Rules of Order (latest revision) shall govern meetings
under these By-Laws in all cases in which they are applicable and
in which they are not inconsistent with these By-Laws. Voting must
be in person; no proxies will be recognized.
Subsection 2.
Absence by a member of any Committee provided for under these
By-Laws from more than 50% of the meetings in any calendar year,
unless excused by the Chairman of the Committee for just cause,
shall be grounds for removal of such member from the Committee and
shall be considered at the time of the member's reappointment to
the Professional Staff.
Article VIII
IMMUNITY FROM LIABILITY
The following shall be expressed conditions to any physician's or
dentist's application for membership on the Professional Staff of
The Presbyterian Hospital in the City of New York and his or her
continuation as a member thereof:
1. There shall be absolute immunity from civil liability arising
out of any act, communication, report, recommendations or
disclosure with respect to any physician's or dentist's
performance made in good faith without malice and at the
request of any authorized representative of this or any other
health care facility for the purpose of achieving and
maintaining quality patient care in this or any other health
care facility or the Department of Health of the State of New
York and in connection with any provision of these Medical
Staff By-Laws.
2. This absolute immunity from civil liability shall extend to
the Hospital, the Board of Trustees of the Hospital, the
President of the Hospital, members of the Hospital's Medical
Staff, and all other employees, agents and representatives of
the Hospital as well as to third parties who furnish
information to any of the foregoing.
3. This absolute immunity from civil liability shall apply to all
acts, communications, reports, recommendations or disclosures
performed or made in connection with this or any other health
care activity related but not limited to:
a. applications for appointment or clinical privileges;
b. periodic reappraisals for reappointment or clinical
privileges;
c. corrective action, including summary suspension;
d. hearings;
e. medical care evaluation;
f. utilization reviews;
g. other Hospital Service or committee activities related to
quality patient care, professional conduct or other
provisions of these Medical Staff By-Laws.
4. The acts, communications, reports, recommendations or
disclosures referred to herein may relate to the physician's
or dentist's qualifications, clinical competency, character,
mental or emotional stability, physical condition, ethics, or
any other matter that might be relevant in connection with his
or her appointment to the Professional Staff.
5. That in furtherance of the foregoing, each physician and
dentist shall upon request of the Hospital execute releases in
accordance with the tenor and import of this Article VIII in
favor of the individuals and organizations specified in
paragraph 2.
Article IX
AMENDMENTS
These By-Laws shall be reviewed at least once in each three year
period and may be amended as follows:
Subsection 1.
By the Board of Trustees of the Hospital, or
Subsection 2.
By the Medical Board after notice given at any regular meeting of
the Medical Board. Such notice shall be referred to a Special
Committee of the Medical Board, which shall report at the next
regular meeting of the Medical Board. Amendments shall require a
two-third's majority vote of those Medical Board members present
for adoption. Amendments so made shall be effective only when
approved by the Board of Trustees of the Hospital.
RULES AND REGULATIONS
1. Meetings shall be held as provided in the By-Laws of the
Medical Staff of The Presbyterian Hospital in the City of New
York.
2. Except in an emergency, no patient shall be admitted by the
Hospital until a provisional diagnosis has been stated. In
case of emergency, the provisional diagnosis shall be stated
as soon as possible after admission.
3. Physicians or dentists requesting admission of patients shall
be held responsible for giving such information as may be
necessary to assure the protection of other patients from
those who are a source of danger from any cause whatsoever, or
to assure protection of the patient from self harm.
4. Patients shall be admitted to that Service of the Hospital
appropriate for the treatment of the condition presented by
the patient. In as far as possible, admission of all patients
will be arranged in accordance with the urgency of their need
for care. Private patients shall be the responsibility of and
be attended by their own physicians or dentists. All patients
shall be made available for participation in medical student
and house staff education programs, unless any such patient is
excluded by his or her attending physician or dentist.
5. The Directors of the various Services and their designated
assistants shall be responsible for the care of all patients
admitted to the Hospital.
6. All orders for treatment shall be in writing. An order shall
be considered to be in writing if dictated to a registered
professional nurse or licensed practical nurse and signed by
the physician or dentist responsible for the patient. Orders
dictated over the telephone shall be used sparingly and shall
be given only to a registered professional nurse and signed by
the person to whom dictated with the name of the physician or
dentist per his or her own name. The physician or dentist
responsible for the patient shall sign such orders within 24
hours.
7. Drugs shall be U.S. Pharmacopeia, National Formulary, and New
and Non-official Remedies, with the exception of drugs
approved by the Institutional Review Board.
8. A complete medical record shall be created for each patient,
and the attending physician and dentist concerned shall be
responsible for seeing that this is done. The physician and
dentist responsible for each individual patient shall record
in the medical record notes of his or her own examination,
opinion and recommended treatment. A complete medical record
shall include identification data; complaint; personal and
family history; history of present illness; physical
examinations; provisional diagnosis; special examinations such
as clinical laboratory, X-ray and other examinations;
consultation notes; provisional or working diagnosis; medical,
surgical or dental treatment; gross and microscopic findings;
progress notes; and where applicable, date alternate care
required; final diagnosis; condition on discharge; follow-up
and in case of death and autopsy, autopsy findings; discharge
summary. No medical record shall be filed until it is
complete except on order of the Medical Records Committee.
9. A complete history and physical examination shall, in all
cases, be performed within 24 hours before or after admission
of the patient and recorded in the medical record within 24
hours after admission.
10. When such history and physical examination are not recorded
before the time stated for operation, the operation shall be
cancelled unless the attending surgeon states in writing that
such delay would constitute a hazard to the patient.
11. The Director of each Service or his or her deputy in
conjunction with House Staff shall review regularly medical
records on all discharged patients in the respective Service
in order to be certain that the records are complete within 30
days following discharge and that the diagnosis in each case
is properly recorded in a prominent place in the record at the
time of discharge.
12. All records are the property of the Hospital and shall not be
taken away except by court order, subpoena or other
requirements of law. In case of readmission of a patient, all
previous records shall be available for the use of the
physician or dentist responsible for the patient. This shall
apply whether the patient is attended by the same physician or
dentist or by another.
13. An operation shall be performed only on written informed
consent of the patient and/or his or her legal representative,
as required by law, except in emergencies. Policies shall be
issued from time to time, setting forth the legal requirements
for consent.
14 All operations performed shall be fully described by the
operating surgeon. A brief operative note must be written
immediately in the medical record. A complete operative
report must be written or dictated within 24 hours following
surgery and the report promptly signed by the surgeon and made
part of the patient's current medical record. As a general
rule, all tissues removed at operation shall be sent to the
Hospital pathologist who shall make such examination as he or
she may consider necessary to arrive at a pathological
diagnosis and he or she shall sign the report. The report
shall be filed with the medical record. The Medical Staff, in
consultation with the pathologist, may create exceptions to
such general rule. Exceptions shall only be made when the
quality of care has not been compromised by the exception,
when another suitable means of verification of the removal has
been routinely used, and when there is an authenticated
operative or other official report that documents the removal.
15. Except in an emergency, consultation is required in the
following cases:
a. Cases on all Services in which according to the judgment
of the physician or the Director of Service:
i. The patient is not a good medical or surgical risk.
ii. The diagnosis is obscure.
iii. There is doubt as to the best therapeutic measures
to be utilized.
b. For other conditions as recommended by the Bureau of
Maternal and Child Health of the State Department of
Health or otherwise required by law.
Consultant
A consultant must be well qualified on the basis of
training, experience and competence to give an opinion in
the field in which his or her opinion is sought. A
written opinion, signed by the consultant, must be
included in the medical record. When operative
procedures are involved, the consultation note, except in
emergency, shall be recorded prior to the operation.
16. Patients shall be discharged only on written order of a staff
physician or dentist. The attending physician or dentist
shall see that the record is complete, state his or her final
diagnosis and sign the record attestation.
17. Staff discussions at meetings held as provided for under
Number 1 of these Rules and Regulations shall constitute a
thorough review and analysis of the clinical work done in the
Hospital, including consideration of deaths, unimproved cases,
infections, complications, diagnostic problems, and results of
treatment from among significant cases in the Hospital at the
time of the meeting and significant cases discharged since the
last meeting, and analysis of clinical reports from each
Service and reports of committees of the active Medical Staff.
18. Every member of the Medical Staff is expected to be actively
interested in securing autopsies. No autopsy shall be
performed without written consent of a relative or legally
authorized agent. All autopsies shall be performed by the
Hospital pathologist or by a physician delegated this
responsibility.
19. The Hospital shall accept for admission patients suffering
from all types of diseases. Patients may be treated only by
physicians or dentists who have been duly appointed to
membership on the Medical Staff.
20. Surgeons must be in the operating room and ready to commence
operation at the time scheduled.
21. Medical Staff Disaster Assignments shall be in accordance with
"Emergency Operation Procedures for Columbia-Presbyterian
Medical Center", as amended and revised from time to time.
22. Free access to all medical records of all patients shall be
afforded to staff physicians or dentists in good standing for
bona fide study and research, consistent with preserving the
confidentiality of personal information concerning the
individual patient. Subject to the discretion of the
President, former members of the Medical Staff shall be
permitted free access to information from the medical records
of their patients covering all periods during which they
attended such patients in the Hospital.
23. The Directors of Services shall be responsible for research
programs in their respective Services. Such research programs
shall receive the prior approval of the Director of Service or
his or her designated representative. Research performed on
or involving patients shall have prior approval of the
Institutional Review Board.
24. Patients requiring dental services shall be admitted and
discharged from the Dental Service by dental members of the
Medical Staff. The patient's dental problem shall be the
responsibility of the Director of the Dental Service. A
complete dental history and dental examination shall be made
by a dental member of the Medical Staff. A complete medical
history and physical examination shall be made by a physician
member of the Medical Staff or by a member of the Oral and
Maxillofacial Surgery sub-service of the Dental Service who
has been credentialed to perform medical histories and
physical examinations. A physician member of the Medical
Staff shall be responsible for the care of any medical
problems during hospitalization.
![[help]](/images/buttons/help.gif)
