Administrative and Medical By- · PDF file22.04 Attendance for Meetings of the Medical Staff...

Hamilton Health Sciences

Administrative and Medical By‐Laws

6/23/2011

Table of Contents

PREAMBLE 1

ARTICLE 1. DEFINITIONS AND INTERPRETATION 1

1.01 Definitions 1

1.02 Interpretation 4

ARTICLE 2. MEMBERSHIP IN THE CORPORATION 4

2.01 Members 4

2.02 Fees 5

2.03 Voting 5

ARTICLE 3. MEETINGS OF THE MEMBERS OF THE CORPORATION 5

3.01 Location of Meetings 5

3.02 Annual Meetings 5

3.03 Calling Meetings 5

3.04 Quorum 5

3.05 Notice 5

3.06 Votes 5

3.07 Chair of the Meeting 6

3.08 Adjourned Meeting 6

3.09 Notice of Adjourned Meeting 6

ARTICLE 4. BOARD OF DIRECTORS 6

4.01 Board Composition 6

4.02 Duties and Responsibilities 7

4.03 Qualification of Directors 7

4.04 Vacancy and Office 7

4.05 Removal 7

4.06 Election and Term 7

4.07 Nomination Procedure for Election of Directors 8

4.08 Maximum Terms 8

4.09 Filling Vacancies 8

4.10 Directors Remuneration 8

ARTICLE 5. MEETINGS OF DIRECTORS 8

5.01 Meetings of Directors 8

5.02 Regular Meetings 8

5.03 Notices 9

5.04 Quorum 9

5.05 First Meeting of New Board 9

5.06 Persons Entitled to be Present 9

5.07 Voting and Notice 9

5.08 Casting Vote 9

5.09 Polls 9

5.10 Adjournment of the Meeting 10

5.11 Notice of Adjourned Meeting 10

ARTICLE 6. INTEREST OF DIRECTORS IN CONTRACTS 10

ARTICLE 7. PROTECTION OF OFFICERS AND DIRECTORS 10

7.01 Protection of Directors, Officers and Committee Members 11

7.02 Indemnification of Directors and Others 11

7.03 Insurance 11

ARTICLE 8. COMMITTEES OF THE BOARD 12

8.01 Committees 12

8.02 Functions, Duties, Responsibilities and Powers of Committees 12

8.03 Committee Members, Chair 12

8.04 Quorum for Committees 12

8.05 Executive Committee 12

ARTICLE 9. OFFICERS 12

9.01 Officers 12

9.02 Terms of Office 13

ARTICLE 10. DUTIES OF OFFICERS 13

10.01 Chair of the Board 13

10.02 Vice Chair 13

10.03 President and Chief Executive Officer 13

10.04 Secretary / Treasurer 13

ARTICLE 11. ORGANIZATIONAL AND FINANCIAL 14

11.01 Seal 14

11.02 Signing Officers - 14

11.03 Banking Arrangements 14

11.04 Financial Year 14

11.05 Appointment of Auditor 14

11.06 Borrowing Power 14

11.07 Investments 14

ARTICLE 12. BOOKS AND RECORDS 15

ARTICLE 13. CONFIDENTIALITY 15

13.01 Confidentiality 15

13.02 Board Spokesperson 15

ARTICLE 14. PURPOSES OF PROFESSIONAL STAFF BY-LAWS, RULES, PLAN 15

14.01 Purposes of the Professional Staff By-Laws 15

14.02 Purposes of the Professional Staff Structure 16

14.03 Rules and Regulations 16

14.04 Medical/Professional Staff Human Resource Plan 16

ARTICLE 15. APPOINTMENT AND REAPPOINTMENT TO MEDICAL STAFF 16

15.01 Appointment and Revocation 16

15.02 Application for Appointment to the Medical Staff 17

15.03 Criteria for Appointment to the Medical Staff 20

15.04 Procedure for Processing Applications for Medical Staff Appointments 22

15.05 Reappointment to the Medical Staff 24

15.06 Dispute Resolution 25

15.07 Application for Change of Privileges 26

ARTICLE 16. CATEGORIES OF THE MEDICAL STAFF 26

16.01 Categories 26

16.02 Associate Staff 27

16.03 Active Staff 27

16.04 Honourary Staff 28

16.05 Courtesy Staff 28

16.06 Locum Staff 29

16.07 Clinical Assistants 29

16.08 Temporary Staff 30

16.09 Performance Reviews 30

ARTICLE 17. SUSPENSION REVOCATION 30

17.01 Monitoring Practices 30

17.02 Suspension/Revocation of Privileges 31

ARTICLE 18. MEDICAL STAFF DUTIES AND RESPONSIBILITIES 32

18.01 Collective Duties and Responsibilities 32

18.02 Individual Duties and Responsibilities 32

ARTICLE 19. DEPARTMENTS AND THEIR CHIEFS 33

19.01 Medical Staff Departments 33

19.02 Services in a Department 33

19.03 Appointment of Chiefs of Department 34

19.04 Duties of Chiefs of Department 35

19.05 Performance Evaluation of Chiefs of Department 36

19.06 Appointment of Deputy Chiefs of Departments/Site Leaders 37

19.07 Duties of Deputy Chiefs of Department/Site Leaders 37

19.08 Performance Evaluation Duties of Deputy Chiefs of Department/Site Leaders 37

19.09 Appointment of Heads of Service 37

19.10 Duties of Heads of Service 38

19.11 Performance Evaluation of Heads of Service 38

ARTICLE 20. MEDICAL ADVISORY COMMITTEE 38

20.01 Composition of Medical Advisory Committee 38

20.02 Accountability of Medical Advisory Committee 38

20.03 Medical Advisory Committee Duties and Responsibilities 39

20.04 Establishment of Committees of the Medical Advisory Committee 39

20.05 Composition of Executive Committee of the Medical Advisory Committee 39

20.06 The Executive Committee of the Medical Advisory Committee Duties and Responsibilities 40

ARTICLE 21. CHAIR OF MAC 40

21.01 Appointment of Chair of MAC 40

21.02 Term of Office 40

21.03 Role of Chair of MAC 40

21.04 Responsibilities and Duties of Chair of MAC 41

21.05 Vice Chair, Medical Advisory Committee 41

21.06 Appointment of Vice-President, Medical 42

21.07 Responsibilities and Duties of the Vice President, Medical 42

ARTICLE 22. MEETINGS OF THE MEDICAL STAFF ASSOCIATION 42

22.01 Meetings of the Medical Staff Association 42

22.02 Special Meetings of the Medical Staff Association 43

22.03 Quorum 43

22.04 Attendance for Meetings of the Medical Staff Association and Medical Staff Association Dues 43

ARTICLE 23. OFFICERS OF THE MEDICAL STAFF ASSOCIATION 43

23.01 Officers of the Medical Staff 43

23.02 Eligibility for Office 44

23.03 President of the Medical Staff 44

23.04 The Vice-President of the Medical Staff 44

23.05 The Secretary/Treasurer of the Medical Staff 44

23.06 Election Procedures of Officers of the Medical Staff Association 44

23.07 Vacancies 45

ARTICLE 24. DENTAL STAFF/SERVICE 45

24.01 Preamble 45

24.02 Dental Service 46

24.03 Appointment 46

24.04 Admitting Privileges 46

24.05 Head of the Dental Service 46

24.06 Dental Clinical Resource Plan 46

24.07 Meetings 46

ARTICLE 25. MIDWIFERY STAFF 47

25.01 Preamble 47

25.02 Midwifery Service 47


25.04 Criteria For Appointment to the Midwifery Staff 47

25.05 Categories of the Midwifery Staff 48

25.06 Associate Staff 48

25.07 Active Staff 49

25.08 Courtesy Staff 50

25.09 Locum Midwifery Staff: 50

25.10 Director of the Midwifery Service 51

25.11 Duties Of Director of the Midwifery Service 51

ARTICLE 26. EXTENDED CLASS NURSES 52


ARTICLE 27. SPECIAL PROFESSIONAL STAFF 52

27.01 Special Professional Staff 52

27.02 Duties 52

27.03 Application of Clinical Plan 52

27.04 Criteria 53

27.05 Dispute Resolution 53

ARTICLE 28. AMENDMENTS 53

28.01 Amendments to Medical Staff By-Laws 53

ARTICLE 29. MATTERS REQUIRED BY THE PUBLIC HOSPITALS ACT 54

29.01 Committees and Programs Required by the Public Hospitals Act 54

29.02 Fiscal Advisory Committee 54

29.03 Chief Nursing Executive 54

29.04 Nurses and other Staff and Professionals on Committee 54

29.05 Retention of Written Statements 54

29.06 Occupational Health and Safety Program 54

29.07 Health Surveillance Program 55

29.08 Organ Donation 55

ARTICLE 30. RULES AND POLICIES 55

30.01 Rules of Order 55

30.02 Policies 55

ARTICLE 31. NOTICES 55

31.01 Computation of Time 56

31.02 Omissions and Errors 56

31.03 Waiver of Notice 56

ARTICLE 32. AMENDMENT TO THE BY-LAWS 56

32.01 Amendment 57

32.02 Effect of Amendment 57

32.03 Member Approval 57

32.04 Amendments to the Professional Staff By-law 57

BY-LAWS OF HAMILTON HEALTH SCIENCES CORPORATION

(hereinafter referred to as the “Corporation”)

PREAMBLE WHEREAS it is the purpose of the Corporation to serve the community in accordance with the objects of the Corporation as provided in the letters patent of amalgamation, and with the mission and vision of the Corporation, as established by the Board from time to time; AND WHEREAS the objects of the Corporation are as follows: (a) To operate, maintain and manage a hospital or hospitals at one or more sites consistent

with the highest standards of treatment, care and comfort of persons suffering from illness or disability.

(b) To promote and carry on teaching and scientific research activities of the Faculty of Health Sciences of McMaster University, the Health Sciences Programs of Mohawk College of Applied Arts and Technology and other educational institutions related to the care of the sick and injured insofar as such teaching and research can be carried on in, or in connection with, the Corporation.

(c) To equip, maintain and operate laboratories and all other services incidental to a hospital. (d) To undertake research programs in connection with the prevention, treatment or

rehabilitation of any sickness, injury or disease. (e) To operate programmes for the treatment and care of aged and infirm persons as well as

programmes and services for the chronically ill and those requiring complex continuing care or palliative care services, including in-patient, community-based and out-patient programmes.”

(f) To operate programs for the treatment and care of aged and infirm persons. (g) To participate in any activities designed and carried on to promote the general health of the

community. (h) To promote and develop standards of health care administration and service.

AND WHEREAS the governing body of the Corporation deems it expedient that all By-Laws of the Corporation heretofore enacted be canceled and revoked and that the following By-Laws be adopted for regulating the affairs of the Corporation. NOW THEREFORE BE IT ENACTED and it is hereby enacted that all By-Laws of the Corporation heretofore enacted be canceled and revoked and that the following By-Laws be substituted in lieu thereof.

ARTICLE 1. DEFINITIONS AND INTERPRETATION

1.01 Definitions In this By-Law, the following words and phrases shall have the following meanings, respectively: (a) “Academic Duties and Responsibilities” means those activities related to the teaching

and supervision of health sciences students/trainees and the promotion and conduct of research;

(b) “Act” means the Corporations Act (Ontario), and where the context requires, includes the Regulations made under it;

By-law 2 – June 2011 1

(c) “Admitting and Procedural Privileges” means the privileges granted to members of the Medical, Dental, non-employee Extended Class Nurse, and the Midwifery staff related to the admission of in-patients, registration of out-patients, and the diagnosis,

assessment and treatment of in-patients and out-patients of the Hospital, and with respect to the Extended Class Nurse, related to privileges granted to diagnose, prescribe for or treat out-patients;

(d) “Affiliation Agreement” means the agreement between the Hospital and the University dated December 15, 2000 regarding their joint relationship with respect to patient care, teaching and research;

(e) “Associates” in relation to an individual means the individual’s parents, children, siblings, spouse, or common law partner, and includes any organization, agency, company, or individual (such as a business partner) with a formal relationship to the individual;

(f) “Board” means the Board of Directors of the Corporation; (g) “By-Law” means any By-Law of the Corporation from time to time in effect; (h) “Certification” means the holding of a certificate in a medical or surgical specialty

issued by any professional body recognized by the Board after consultation with the Medical Advisory Committee;

(i) “Chair” means the Director elected by the Board to serve as Chair of the Board; (j) “Chair FHS” means the Physician appointed to be in charge of an academic

department of the Faculty of Health Sciences, McMaster University; (k) “Chair MAC” means the Physician appointed by the Board of Directors to serve as

Chair of the Medical Advisory Committee (l) “Chief Executive Officer” means, in addition to ‘administrator’ as defined in section 1 of

the Public Hospitals Act, the President and Chief Executive Officer of the Corporation; (m) “Chief Nursing Executive” means the senior nurse employed by the Hospital who

reports directly to the Chief Executive Officer and is responsible for nursing services provided in the Hospital;

(n) “Chief of a Department” means a member of the Medical Staff appointed by the Board to be responsible for the professional standards and quality of medical care rendered by the members of that department at the Hospital;

(o) “Clinical Assistants” means Physicians who are required to perform specific duties under the direct supervision of a member of the Medical Staff;

(p) “Clinical Duties and Responsibilities” means those activities related to the delivery of patient care, diagnosis, and treatment within the Hospital;

(q) “Clinical Nurse” means a staff nurse employed by the Hospital; (r) “Clinical Resource Plan” means the plan developed by the Vice-President, Medical in

consultation with the Chiefs of Department, Program and Service Medical Directors, and with the appropriate academic department and Regional Partners, based on the mission and strategic plan of the Corporation and on the regional needs of the community, which provides information and future projections of this information with respect to the management and appointment of Physicians, Dentists, Midwives, and Extended Class Nurses who are or may become members of the Medical, Dental, Midwifery and Extended Class Nursing Staff;

(s) “Clinical Scholars” means Physicians who wish an additional period of specialized post-residency training involving clinical care and academic pursuits. Each Clinical Scholar appointment will be granted in conjunction with an appropriate Faculty of Health Sciences appointment;


(t) “College” means, as the case may be, the College of Physicians and Surgeons of Ontario, the Royal College of Dental Surgeons of Ontario, the College of Midwives of Ontario, and/or the College of Nurses of Ontario;

(u) “Committee” means a committee of the Board or as otherwise specified in this By-Law; (v) “Corporation” means the Hamilton Health Sciences Corporation located at the head

office at 1200 Main Street West, Suite 2E28, Hamilton, Ontario, L8S 4J9; (w) “Dental Staff” means the collection of legally qualified dentists appointed by the Board

to attend or perform dental services for patients in the Hospital; (x) “Dentist” means a dental practitioner in good standing with the Royal College of Dental

Surgeons of Ontario; (y) “Department” or “department” means an organizational unit of the Medical Staff to

which members with a similar field of practice have been assigned; the Corporation’s departments are those named in section 15.01 of this By-Law, and as the Board may amend from time to time;

(z) “Director” means a member of the Board; (aa) “Ex officio” means membership “by virtue of the office” and includes all rights, and

responsibilities, and the power to vote unless otherwise specified; (bb) “Extended Class Nurses” means those registered nurses in the extended class to

whom the Board has granted Privileges namely: (i) nurses that are employed by the Hospital and are authorized to diagnose,

prescribe for or treat out-patients in the Hospital; and (ii) nurses who are not employed by the Hospital and to whom the Board has

granted privileges to diagnose, prescribe for or treat out-patients in the Hospital. (cc) “Head of a Service” means the Physician or Dentist appointed by the Board to be in

charge of one of the organized divisions of a medical department; (dd) “Hospital” means the Corporation; (ee) “Impact Analysis” means a study to determine the impact upon the resources of the

Corporation of the proposed or continued appointment of any person to the Medical Staff;

(ff) “Joint Relations Committee” means the joint relations committee established pursuant to section 10 of the Affiliation Agreement;

(gg) “Liaison Committee” means the liaison committee established pursuant to subsection 10.2 of the Affiliation Agreement;

(hh) “Locum Tenens or “locum tenens” means Physicians who provide coverage for a member of the Medical Staff during their absence;

(ii) “Medical Staff” means those Physicians who are appointed by the Board and who are granted Privileges to practice medicine in the Hospital;

(jj) “Medical Staff Rules” means provisions concerning the practice and professional conduct of the members of the Medical Staff;

(kk) “Member” means a member of the Corporation; (ll) “Midwife” means a Midwife in good standing with the College of Midwives of Ontario; (mm) “Patient” means, unless otherwise specified, any in-patient, out-patient or other patient

of the Corporation; (nn) “Person” means and includes any individual, corporation, partnership, firm, joint-

venture, syndicate, association, trust, government, government agency, board, commission or authority, or any other form of entity or organization;


(oo) “Physician” means a medical practitioner in good standing with the College of Physicians and Surgeons of Ontario;

(pp) “Policies” means the administrative, medical and professional policies of the Hospital; (qq) “Privileges” or “privileges” means the clinical services and involvement in education

and research which the Board has granted to a member of the Medical, Dental, non-employee Extended Class Nurse and Midwifery Staff;

(rr) “Professional Staff” means those Physicians, Dentists, non-employee Extended Class Nurses and Midwifery Staff that are appointed by the Board and who are granted specific Privileges to practise medicine, dentistry, midwifery or extended class nursing respectively;

(ss) “Professional Staff Appointment” means the appointment or assignment of a Professional Staff member to a department or division in the Hospital within the categorization of active, associate, courtesy, honorary or locum tenens staff;

(tt) “Program” means a cluster of patient-centred services which optimizes patient care, education and research and is consistent with the mission and vision of the Corporation;

(uu) “Public Hospitals Act” means the Public Hospitals Act (Ontario), and, where the context requires, includes the Regulations made under it;

(vv) “Regional Partners” means the health care institutions and agencies with whom the Corporation has developed collaborative relationships for the provision of patient care, and education and research;

(ww) “Rules and Regulations” means the Rules and Regulations governing the practice of the Medical, Dental, and Midwifery Staff in Hospital both generally and within a particular department, which have been established respectively by the staff in general and the staff of the department;

(xx) “Service” or “service” means an organizational unit of a department which is based on a sub-specialty area of medical practice;

(yy) “Special Professional Staff” means qualified non-Physician professionals who are appointed to the Medical Staff for their expertise or assistance in patient treatment, education, and research;

(zz) “Supervisor” means a Physician who is assigned the responsibility to oversee the work of another person;

(aaa) “Supportive Care” means the provision of support to the patient through a physician-patient relationship which has developed over time; and

(bbb) “University” means McMaster University.

1.02 Interpretation In this By-Law, unless the context otherwise requires, words importing the singular number shall include the plural number and vice versa and references to persons shall include firms and corporations and words importing one gender shall include the opposite.

ARTICLE 2. MEMBERSHIP IN THE CORPORATION

2.01 Members The Members of the Corporation shall consist of the Directors from time to time of the Corporation who shall be ex officio Members for so long as they serve as Directors.


2.02 Fees No fees shall be payable by the Members.

2.03 Voting Each Member shall be entitled to one vote.

ARTICLE 3. MEETINGS OF THE MEMBERS OF THE CORPORATION

3.01 Location of Meetings Meetings of the Members shall be held at the head office of the Corporation or at any place in Ontario as the Board determines.

3.02 Annual Meetings In accordance with the Public Hospitals Acts, the annual meeting of the Members shall be held between the 1st day of April and 31st day of July of each year.

3.03 Calling Meetings The Board or Chair shall have the power to call, at any time, an annual or general meeting of the Members of the Corporation.

3.04 Quorum A majority of the Members entitled to vote, present in person at a meeting will constitute a quorum at a meeting of the Members.

3.05 Notice Notice of meeting of Members shall be given to each member, each Director and the auditor appointed under section 11.04 by one of the following methods: (a) by sending it to each Member entitled to notice by one of the methods set out in Article

31 addressed to the Members at their most recent addresses as shown on the Corporation’s records at least ten (10) days prior to the meeting;

(b) By publication at least once a week for two (2) consecutive weeks next preceding the meeting in a newspaper or newspapers circulated in the municipality or municipalities in which the majority of the Members reside as shown by their addresses on the records of the Corporation.

3.06 Votes (a) Each Member entitled to vote and in attendance at a meeting shall have the right to

exercise one vote. (b) At all meetings of the Members of the Corporation every question shall be determined

by a major of votes unless otherwise specifically provided by statue or by this By-law. (c) Votes at all meeting of Members shall be cast in person and not by proxy.


(d) Every question submitted to any meeting of Members shall be decided in the first instance by a show of hands and in the case of equality of votes, whether on a show of hands or at a poll, the chair of the meeting shall have a second vote to break the tie.

(e) At any meeting of Members, unless a poll is demanded, a declaration by the chair of the meeting that a resolution has been carried or carried unanimously or by a particular majority or lost or not carried by a particular majority shall be conclusive evidence of the fact.

(f) A poll may be demanded either before or after any vote by show of hands by any Member entitled to vote at the meeting. If a poll is demanded on the election of a chair or on the question of adjournment it shall be taken forthwith without adjournment. If a poll is demanded on any other question or as to the election of the Directors, the vote shall be taken by ballot in such manner and either at once, later in the meeting or after adjournment as the chair of the meeting directs. The result of a poll shall be deemed to be the resolution of the meeting at which the poll was demanded. A demand for a poll may be withdrawn.

3.07 Chair of the Meeting (a) The chair of a meeting of the Corporation shall be:

(i) the Chair of the Corporation; or (ii) the Vice-chair of the Corporation, if the Chair is absent or is unable to act; or

(b) a chair elected by the Members present if the Chair and Vice-chair are absent or are unable to act. The Secretary shall preside at the election of the chair, but if the Secretary is not present, the Directors, from those present, shall choose a Director to preside at the election.

3.08 Adjourned Meeting If, within one-half (1/2) hour after the time appointed for a meeting of the Members, a quorum is not present, the meeting shall stand adjourned until a day to be determined by the Board.

3.09 Notice of Adjourned Meeting Not less than three (3) days’ notice of an adjourned meeting of Members shall be given in such manner as the Board may determine.

ARTICLE 4. BOARD OF DIRECTORS

4.01 Board Composition The Board shall consist of: (a) a minimum of twelve (12) Directors and a maximum of fifteen (15) Directors who

satisfy the criteria set out in section 4.03 and who are elected by the Members entitled to vote in accordance with section 4.07 or appointed in accordance with section 4.09; and

(b) the President and Chief Executive Officer, the Chair of the Medical Advisory Committee, the Chief Nursing Executive, the President of the Medical Staff Association and the Dean, Faculty of Health Sciences, McMaster University, as non-voting ex officio Directors.


4.02 Duties and Responsibilities The Board shall govern and oversee the management of the affairs of the Corporation and may exercise all such other powers and do all such other acts and things as the Corporation is, by its charter or otherwise, authorized to exercise and do.

4.03 Qualification of Directors No personal shall be qualified for election or appointment as a Director referred to in subsection 4.1(a) if he or she: (a) is less than eighteen (18) year of age; (b) has the status of a bankrupt; and (c) does not have their principal residence or carry on business within the area served by

the Corporation as established by the Board from time to time.

4.04 Vacancy and Office The office of an elected Director shall automatically be vacated: (a) if a Director shall resign such office by delivering a written resignation to the Secretary

of the Corporation; (b) if the Director becomes bankrupt; or (c) if, in the case of an elected Director, he or she ceases to meet the requirements of

section 4.03. Where there is a vacancy in the Board, the remaining Directors may exercise all the powers of the Board so long as a quorum remains in office.

4.05 Removal The office of a Director may be vacated by a simple majority resolution of the Board: (a) if a Director, without being granted a leave of absence by the Board, is absent for three

(3) consecutive meetings of the Board, or if a Director is absent for one quarter (1/4) or more of the meetings of the Board in any twelve (12) month period; or

(b) if a Director fails to comply with the Public Hospitals Act, the Act, the Corporation’s Letters Patent, By-Laws, Rules, policies and procedures, including without limitation the confidentiality and conflict of interest requirements.

The Members may, by resolution passed by at least 2/3rds of the votes cast at a meeting of members of which notice specifying the intention to pass such a resolution has been given, remove any Director before the expiration of his or her term of office and may, by a majority of votes cast at that meeting, elect any person in his or her stead for the remainder of the term.

4.06 Election and Term Directors shall be elected and retire in rotation as herein provided. The Directors referred to in subsection 4.1(a) shall be elected for a term of three (3) years provided that each such Director shall hold office until the earlier of the date on which their office is vacated pursuant to sections 4.04 or 4.05 or until the end of the meeting at which his or her successor is elected or appointed. Four (4) Directors shall retire from office each year subject to re-election as permitted by section 4.08.


4.07 Nomination Procedure for Election of Directors Nominations made for the election of Directors at a meeting of Members may be made only by the Board in accordance with the nominating and election procedure prescribed by the Board from time to time. For greater certainty, no nominations shall be accepted by the Members of the Corporation which are not submitted and approved by the Board in accordance with the approved process. The decision of the Board as to whether or not a candidate is qualified to stand for election shall be final.

4.08 Maximum Terms Each Director referred to in subsection 4.01(a) shall be eligible for re-election provided that such Director shall not be elected or appointed for a term that will result in the Director serving more than nine (9) consecutive years. Such Director may also be eligible for re-election for another term or terms (to a maximum of nine (9) consecutive years) if one (1) year has elapsed since the termination of his or her last term. In determining a Director’s length of service as a Director, service prior to the coming into force of this By-law shall be included.

4.09 Filling Vacancies So long as there is a quorum of Directors in office, any vacancy occurring in the Board of Directors may be filled by a qualified person appointed for the remainder of the term by the Directors then in office. In the absence of a quorum of the Board, or if the vacancy has arisen from a failure of the Members to elect the number of Directors required to be elected at any meeting of the Members, the Board shall forthwith call a meeting of the Members to fill the vacancy. A Director so appointed or elected shall hold office for the unexpired portion of the term vacated.

4.10 Directors Remuneration The Directors shall serve as such without remuneration and no Director shall directly or indirectly receive any profit from his or her position as such provided that a Director may be reimbursed reasonable expenses incurred by the Director in the performance of his or her duties.

ARTICLE 5. MEETINGS OF DIRECTORS

5.01 Meetings of Directors The Board shall meet at such times and in such places as may be determined by the Board, the Chair, the Vice Chair or the President & Chief Executive Officer. Special meetings of the Board may be called by the Chair, the Vice Chair or by the President & Chief Executive Officer and shall be called by the Secretary upon receipt of the written request of five (5) Directors.

5.02 Regular Meetings The Board may appoint one (1) or more days for regular meetings of the Board at a place and time named. A copy of any resolution of the Board fixing the place and time of regular meetings of the Board shall be given to each Director forthwith after being passed and no other notice shall be required for any such regular meetings.


5.03 Notices Notice of meetings, other than regular meetings, shall be given to all Directors at least forty-eight (48) hours prior to the meeting. The Chair, the Vice Chair or the President and Chief Executive Officer may call a meeting on less notice, by such means as are deemed appropriate, provided that notice is given to all Directors and the majority of the Directors consent to the holding of such meeting. In calculating the said forty-eight (48) hours notice periods Saturdays, Sundays and statutory holidays shall be excluded.

5.04 Quorum A majority of the voting Directors shall constitute a quorum.

5.05 First Meeting of New Board Provided a quorum of Directors is present, each newly elected Board may, without notice, hold its first meeting immediately following the meeting of Members at which such Board is elected.

5.06 Persons Entitled to be Present Guests may attend meetings of the Board with the consent of the meeting on the invitation of the Chair or Chief Executive Officer. The Board may adopt a policy from time to time with respect to the attendance of the public at meetings of the Board.

5.07 Voting and Notice Each Director entitled to vote and present at a meeting of the Board shall be entitled to one (1) vote on each matter. A Director shall not be entitled to vote by proxy. Any question arising at any meeting of the Board, shall be decided by a majority of votes. Any Director that is an employee or a member of the Professional Staff of the hospital, shall not be entitled to vote at a meeting of the Board but shall otherwise be entitled and subject to all the rights, responsibilities and obligations applicable to voting Directors, including the right to notice of, to attend and to participate in meetings of the Board and to receive the materials that are distributed to voting Directors.

5.08 Casting Vote In the case of an equality of votes, the Chair shall not have a second vote.

5.09 Polls The vote on any question shall be taken by secret ballot if so demanded by any Director present and entitled to vote. Such ballots shall be counted by the chair of the meeting. Otherwise a vote shall be taken by a show of hands. A declaration by the chair of the meeting that a resolution has been carried by a particular majority or not carried shall be conclusive.


5.10 Adjournment of the Meeting If within one-half (1/2) hour after the time appointed for a meeting of the Board a quorum is not present, the meeting shall stand adjourned until a day with two (2) weeks to be determined by the chair of the meeting.

5.11 Notice of Adjourned Meeting At least 24 (24) hours notice of the adjourned meeting by an appropriate means shall be given to each Director; provided that in calculating such twenty-four (24) hour notice period Saturday, Sundays and statutory holidays shall be excluded.

ARTICLE 6. INTEREST OF DIRECTORS IN CONTRACTS (a) Any Director who is in any way, directly or indirectly, interested in a contract or

proposed contract with the Corporation shall disclose in writing or have entered in the minutes, the nature and extent of such Director’s interest in such contract or proposed contract with the Corporation.

(b) The disclosure required in subsection 6(a) shall be made: (i) at the meeting at which a proposed contract is first considered if the Director is

present, and otherwise, at the first meeting after the Director becomes aware of the contract or the proposed contract;

(ii) if the Director was not then interested in a proposed contract, at the first meeting after such Director becomes so interested; or

(iii) if the Director becomes interested after a contract is made, at the first meeting held after the Director becomes so interested.

(c) A Director referred to in subsection 6.1(a) is not liable to account for any profit made on the contract by the Director or by a corporate entity, business firm or organization in which the Director has a material interest, provided: (i) the Director disclosed the Director’s interest in accordance with subsection

6.1(b) or (e); and (ii) the Director has not voted on the contract.

(d) A Director referred to in subsection 6.1(a) shall not vote on any resolution to approve the contract and shall not take part in the discussion or consideration of, or in any way attempt to influence the voting on any question with respect thereto and shall exit the meeting when the applicable issue is under consideration.

(e) For the purposes of this section 6.1 a general notice to the Directors by a Director declaring that the person is a director or officer of or has a material interest in a body corporate, business firm or organization and is to be regarded as interested in any contract made therewith, is a sufficient declaration of interest in relation to any contract so made.

(f) The provisions of this Article are in addition to any conflict of interest policy adopted by the Board from time to time.

ARTICLE 7. PROTECTION OF OFFICERS AND DIRECTORS

By-law 2 – June 2011 10

7.01 Protection of Directors, Officers and Committee Members (a) Any Director, officer or member of any Committee appointed or authorized by the

Board shall not be liable for any act, receipt, neglect or default of any other Director, officer, employee or Committee member for any loss, damage or expense happening to the Corporation through the deficiency of title to any property acquired by the Corporation or for the deficiency of any security or upon which any of the moneys of the Corporation shall be invested, or for any loss or damage arising from bankruptcy, insolvency or tortuous act of any person including any person with whom any of the moneys, securities or effects of the Corporation shall be deposited, or for any loss, conversion, or misappropriation of or any damage resulting from any dealings with any moneys, securities or other assets belonging to the Corporation or from any other loss, damage or misfortune which may happen in the execution of the duties of such Director’s or officer’s respective office unless such occurrence is a result of such Director’s or officer’s own willful neglect or default.

7.02 Indemnification of Directors and Others Every Director or officer of the Corporation and his or her heirs, executors, administrators and estates and effects, respectively, shall from time to time and at all times, be indemnified and saved harmless out of the funds of the Corporation from and against: (a) all costs, charges and expenses whatsoever which such Directors, officer or committee

member sustains or incurs in or about any action, suit or proceeding which is brought, commenced or prosecuted against him or her, for and in respect of any act, deed, matter or thing whatsoever made, done, permitted to be done or permitted by him or her, in or about the execution of any of their duties of his or her office; and

(b) all other costs, charges and expenses which he or she sustains or incurs in or about or in relation to the affairs of the Corporation, except such costs, charges or expenses as occasioned by his or her own willful neglect or default.

(c) The indemnity provided for in the preceding paragraph: (i) shall not apply to any liability which a Director, officer or committee member of

the Corporation may sustain or incur as the result of any act or omission as a member of the Professional staff of the Corporation; and

(ii) shall be applicable only if the Director, officer or committee member of the Corporation acted honestly and in good faith with a view to the best interests of the Corporation and in the case of criminal or administrative action or proceeding that is enforceable by a monetary penalty, had reasonable ground for believing that his or her conduct was lawful.

7.03 Insurance The Corporation shall purchase and maintain insurance for the benefit of any Director, officer or other person acting on behalf of the Corporation against any liability incurred in that person’s capacity as a Director, officer or other person acting on behalf of the Corporation, except where the liability relates to that person’s failure to act honestly and in good faith with a view to the best interests of the Corporation and subject to the terms and conditions contained in any such policy of insurance.

By-law 2 – June 2011 11

ARTICLE 8. COMMITTEES OF THE BOARD

8.01 Committees The Board may establish committees from time to time. The Board shall determine the duties of such committees. The committees of the Board shall be: (a) Standing Committees, being those committee whose duties are normally continuous;

and (b) Special Committees, being those committees appointed for specific duties whose

mandate shall expire with the completion of the tasks assigned.

8.02 Functions, Duties, Responsibilities and Powers of Committees The functions, duties, responsibilities and powers of committees shall be provided in the resolution of the Board by which such committee is established or in terms of reference adopted by the Board.

8.03 Committee Members, Chair Unless otherwise provided by by-law or by Board resolution, the Board shall appoint the members of the committee, the chair of the committee and, if desirable, the vice chair thereof. The members of any committee (other than Executive Committee) may not be Directors of the Corporation. The members and the chair of a committee will hold their office at the will of the Board. Each chair of a Standing Committee shall be a member of the Board. Unless otherwise provided, the Chair and the President & Chief Executive Officer shall be ex-officio members of all committees. Procedures at committee meetings shall be determined by the chair of each committee, unless established by the Board by resolution or in the Board committee policy.

8.04 Quorum for Committees Unless otherwise determined by the Board, a quorum for a Committee shall be a majority of the voting members of a Committee.

8.05 Executive Committee The Board may, but shall not be required to, elect an Executive Committee consisting of not fewer than three (3) elected Directors and may delegate to the Executive Committee any powers of the Board, subject to such restrictions, as may be imposed by the Board by resolution. The Executive Committee shall fix its quorum at not less than a majority of its members. Any Executive Committee members may be removed by a majority vote of the Board.

ARTICLE 9. OFFICERS

9.01 Officers The officers of the Corporation shall include: (a) Chair of the Board; (b) Vice Chair of the Board;

By-law 2 – June 2011 12

(c) President & Chief Executive Officer; and (d) Secretary/Treasurer. The officers shall be elected or appointed by resolution of the Board at the first meeting of the Board following the annual meeting of Members at which the Directors are elected or at such other times when a vacancy shall occur. A person may hold more than one office.

9.02 Terms of Office Unless otherwise provided in this by-law, the officers of the Corporation shall hold office for one (1) year from the date of appointment or election or until their successors are elected or appointed in their stead and shall be eligible for reappointment. Officers shall be subject to removal by resolution of the Board at any time.

ARTICLE 10. DUTIES OF OFFICERS

10.01 Chair of the Board The Chair shall be elected by the Board from among the elected Directors. The Chair shall, when present, preside at all meetings of the Members and the Board and shall represent the Corporation and the Board as may be required or appropriate and shall have other powers and duties as the Board may specify. The Chair shall be an ex officio member of all committees of the Board. The Chair shall be responsible for naming of Directors to Committees not otherwise provided in the By-Laws of the Corporation. The Chair shall be elected annually and shall be eligible for re-election provided that the Chair shall serve no longer than two (2) consecutive years. Notwithstanding the foregoing, where a Director has served two (2) consecutive years as Chair, the Board may, by resolution approved by two-thirds (2/3) resolution of the Board, provide that such member is eligible for re-election as Chair provided.

10.02 Vice Chair A Vice Chair shall, in the absence or disability of the Chair, perform such duties and exercise the powers of the Chair and shall perform such other duties as shall from time to time assigned to the Vice Chair by the Board.

10.03 President and Chief Executive Officer The President and Chief Executive Officer shall be a non voting Director, the President of the Corporation and the administrator of the Hospital for the purposes of the Public Hospitals Act. Subject to the authority of the Board, the President and Chief Executive Officer shall be responsible for the administration, organization and management of the affairs of the Corporation.

10.04 Secretary / Treasurer The Secretary/Treasurer shall carry out the duties of the secretary of the Corporation generally and shall attend or cause a recording secretary to attend all meetings of the Members, Board, Executive Committee and other committees to act as a clerk thereof and to record all votes and minutes of all proceedings in the books to be kept for that purpose. The Secretary / Treasurer shall ensure that the books of account and accounting records of the Corporation required to be kept by the provisions of the Act are kept secure in appropriate administrative offices of the Corporation. The Secretary/Treasurer shall perform such other duties as may be prescribed by the by-laws or the Board.

By-law 2 – June 2011 13

ARTICLE 11. ORGANIZATIONAL AND FINANCIAL

11.01 Seal The seal of the Corporation shall be kept secure in the office of the President and Chief Executive Officer.

11.02 Signing Officers - The Board may from time to time by resolution direct the manner in which and the person or persons by whom any particular instrument of class of instruments or document may or shall be signed.

11.03 Banking Arrangements The banking business of the Corporation or any part thereof shall be transacted with such banks, trust companies or other financial institutions as the Board may, by resolution, from time to time determine.

11.04 Financial Year Unless otherwise determined by the Board and subject to the Public Hospitals Act, the fiscal year end of the Corporation shall be the last day of March in each year.

11.05 Appointment of Auditor The Members entitled to vote shall, at each annual meeting, appoint an auditor to audit the accounts of the Corporation and to report to the Members at the next annual meeting. The auditor shall hold office until the next annual meeting, provided that the Directors may fill any casual vacancy in the office of auditor. The remuneration of the auditor shall be fixed by the Board of Directors.

11.06 Borrowing Power Without limiting the borrowing powers of the Corporation as set forth in the Act, the Board may from time to time, on behalf of the Corporation, without authorization of the Members: (a) borrow money on the credit of the Corporation; (b) issue, sell or pledge securities (including bonds, debentures, note or other similar

obligations, secured or unsecured) of the Corporation; or (c) charge, mortgage, hypothecate or pledge all or any of the real or personal property of

the Corporation, including book debts and unpaid calls, rights and powers, franchises and undertakings, to secure any securities or for any money borrowed, or other debt, or any other obligation or liability of the Corporation.

11.07 Investments Subject to the Corporation’s charter, the Board is authorized to make or receive any investments which the Board in its discretion considers advisable.

By-law 2 – June 2011 14

ARTICLE 12. BOOKS AND RECORDS The Directors shall see that all necessary books and records of the Corporation required by the by-laws of the Corporation or by any applicable statute or law are regularly and properly kept.

ARTICLE 13. CONFIDENTIALITY

13.01 Confidentiality Every Director, officer, member of the Professional Staff, member of a committee of the Board, employee and agent of the Corporation shall respect the confidentiality of matters: (a) Brought before the Board; (b) Brought before a committee; (c) Dealt with in the course of the employee’s employment or agent’s activities; or (d) Dealt with in the course of the Professional Staff member’s activities in connection with

the Corporation.

13.02 Board Spokesperson The Board may give authority to one or more Directors, officers or employees of the Corporation to make statements to the news media or public about matters brought before the Board.

ARTICLE 14. PURPOSES OF PROFESSIONAL STAFF BY-LAWS, RULES, PLAN

14.01 Purposes of the Professional Staff By-Laws The purposes of the Professional Staff By-Laws are to: (a) outline clearly and succinctly the purposes and functions of the Professional Staff; (b) identify specific organizational units (departments, committees, programs, etc.)

necessary to allocate the work of carrying out those functions; (c) to identify the process for the selection of the Chair of MAC and Chief of Department

and for the election of the Medical Staff Association officers; (d) provide an organizational structure which defines responsibility, authority and

accountability of every organizational component, and which is designed to ensure that each Professional Staff member exercises responsibility and authority commensurate with the member’s contribution to patient care and to the teaching and research needs of the Hospital, and fulfills like accountability obligations;

(e) provide a mechanism for accountability to the Board, through defined professional components, for patient care, professional and ethical conduct, and teaching and research activities of each individual practitioner holding membership in the Professional Staff; and

(f) create a Medical Staff Association structure which will advocate the interests of and support the rights and privileges of the Professional Staff as provided herein.

By-law 2 – June 2011 15

14.02 Purposes of the Professional Staff Structure The purposes of the Professional Staff, in addition to fulfilling the responsibilities established by the laws of the Province of Ontario and this By-Law, are: (a) to provide a structure whereby the members of the Professional Staff participate in the

Hospital’s planning, policy setting and decision making; (b) to serve as a quality assurance system for care rendered to patients by the

Professional Staff and to ensure the continuing improvement of the quality of medical care; and

(c) to facilitate the best possible environment for learning and research in respect of the Corporation’s role as a teaching hospital.

14.03 Rules and Regulations The Medical Advisory Committee may make Rules and Regulations, as well as corresponding policies and procedures, as it deems necessary for patient care, and the conduct of members of the Professional Staff that are consistent with the academic mission of the Hospital, its By-Laws and the Affiliation Agreement. Such Rules and Regulations, or any amendments thereto, will become effective when approved by the Board. Notice specifying the proposed By-law or amendments thereto shall be posted and the Professional Staff shall be afforded an opportunity to comment on the proposed Rules and Regulations or amendments.

14.04 Medical/Professional Staff Human Resource Plan (a) The Medical Advisory Committee will recommend to the Board for approval, on an

annual basis, a Medical/Professional Staff Human Resource Plan for each Department of the Medical Staff, after receiving the recommendation of the Chief of Department with the advice of the Chair of the Academic Department and appropriate Regional Partners. This plan will be consistent with the strategic directions of the Corporation as established by the Board, and the provisions of the Public Hospitals Act, regarding cessation of services.

(b) A component of the Medical/Professional Staff Human Resource Plan shall be a recruitment plan, which shall include an Impact Analysis.

ARTICLE 15. APPOINTMENT AND REAPPOINTMENT TO MEDICAL STAFF

15.01 Appointment and Revocation (a) The Board will appoint annually (subject to subsections 11.03 (1) (c) and 12.09) a

Medical Staff for the Corporation and may appoint additional members of the Medical Staff during each year as it deems necessary and shall grant such Admitting and Procedural Privileges to each member of the Medical Staff as it deems appropriate. All appointments to the Medical Staff are, subject to subsection 11.03 (1) (c), conditional upon an academic appointment to the Faculty of Health Sciences of the University being granted to the applicant.

(b) Notwithstanding the other requirements of this By-Law, a person who is not a Physician may be honoured by an annual appointment to the Honourary.

(c) The Board may, at any time, make, revoke or suspend any appointment to the Medical Staff or any other appointment of a member of the Professional Staff to any office in the Corporate, in accordance with the Public Hospitals Act.

By-law 2 – June 2011 16

(d) Each appointment shall be for a term of up to one year but shall continue in effect until the Board has made appointments for the ensuing year unless otherwise provided in the appointment.

15.02 Application for Appointment to the Medical Staff (a) An application for appointment to the Medical Staff will be processed in accordance

with the provisions of the Public Hospitals Act, this By-Law, and the Affiliation Agreement.

(b) The Chief Executive Officer will supply a copy of this By-Law, the Rules and Regulations and Policies of the Corporation, the relevant provisions of the Affiliation Agreement, the Public Hospitals Act and regulations thereunder, to each Physician who expresses in writing an intention to apply for appointment to the Medical Staff.

(c) Each applicant for membership to the Medical Staff will submit on the prescribed forms a written application to the Chief Executive Officer who shall provide a copy of the application to the Vice President, Medical.

(d) Each application must contain the following: (i) confirmation by the applicant that the applicant is bound by and will comply with

the Public Hospitals Act, the regulation thereunder including the Hospital Management Regulation 965, the Hospital’s By-Laws, Rules and Regulations, Policies and the relevant provisions of the Affiliation Agreement that were included in the application;

(ii) an undertaking that, if the applicant is appointed to the Medical Staff of the Hospital, the applicant will provide the services to the Hospital as stipulated in the application including “on-call” responsibilities, and will act in accordance with the Public Hospitals Act, the regulations thereunder including the Hospital Management Regulation, and with the Hospital’s By-laws, its Rules and Regulations and Policies, as established or revised by the Hospital from time to time;

(iii) an acknowledgment by the applicant that:

(A) unless the applicant is exempted by subsection 11.03 (1)(c) (e.g., grandfathered), the appointment to the Medical Staff is conditional upon an academic appointment being granted to the Faculty of Health Sciences;

(B) the failure of the applicant to provide the services as stipulated in the application in accordance with applicable legislation, the Hospital’s By-Laws and Rules and Regulations and Policies will constitute a breach of the applicant’s obligations to the Hospital, and the Hospital may, upon consideration of the individual circumstances, remove access by the Physician to any and all Hospital resources, or take such actions as are reasonable, in accordance with the Hospital’s By-Laws, Rules and Regulations;

(C) the failure of the applicant to comply with the undertaking set out in paragraph (ii) above may result in the applicant’s privileges being restricted, suspended, revoked or the applicant being denied reappointment and may, depending on the circumstances, be a matter which is reportable to the College. Any such actions by the Hospital will

By-law 2 – June 2011 17

(D) concurrent with the provision of the application, for a position consistent with the Affiliation Agreement, the University’s person responsible for faculty recruitment will be notified of the applicant’s application for privileges; and

(E) a copy of the applicant’s résumé and any other documents or information provided or disclosed to the Hospital by the applicant or any other party as a result of the application for appointment to the Medical Staff of the Hospital may be shared with the University as part of the joint appointment process;

i. the applicant will provide evidence of membership in the Canadian Medical Protective Association, or evidence of individual liability insurance coverage comparable to the above, any of which is subject to verification.

ii. a copy of the applicant’s current registration or licence to practice in Ontario; iii. a copy of the applicant’s medical school certificate; iv. a record of eligibility for certification for specialty/sub-specialty certifications and

for re-certification; v. an up-to-date résumé, including a record of the applicant’s professional

education, post-graduate training, and continuing medical education acceptable to the Credentials Committee and a chronology of academic and professional career, organizational positions and committee memberships;

vi. evidence of current Tuberculosis status and Measles, Mumps and Rubella inoculation and such other inoculations and screening as may be required by the Board or the Public Hospitals Act or other legislation from time to time;

vii. a current certificate of Professional Conduct from the College and a signed consent authorizing any medical licensing authority to provide a report on:

(A) any action taken by or any matters pending before a disciplinary or fitness to practice committee; and

(B) whether the applicant’s privileges have been curtailed or cancelled by any medical licensing authority or by another hospital because of incompetence, negligence or any act of professional misconduct;

viii. (A) subject to clause (B) below, a recital and description of pending or completed disciplinary actions, competency investigations, previous or ongoing performance reviews, and details with respect to prior privileges disputes with other hospitals regarding appointment, re-appointment, change of privileges, or mid-term suspension or revocation of privileges;

(B) the applicant will not have to provide any recital or description in a matter where there has been a final decision and there was no adverse finding relating to the above provided the applicant did not voluntarily or involuntarily resign or restrict the applicant’s privileges or provide an undertaking of any kind while under review or in anticipation of an investigation or performance review;

By-law 2 – June 2011 18

ix. a statement with respect to failure to obtain, reduction in classification or voluntary or involuntary resignation of any professional license or certification, fellowship, professional academic appointment or privileges at any other hospital or health care institution;

x. the name of the service or division to which the application is being made; xi. a list of the Admitting and Procedural Privileges which are requested; xii. information regarding the applicant’s health, including any impairments, medical

conditions, diseases or illnesses that may impact on the applicant’s ability to practice, and current treatments therefore, as well as the date of the applicant’s last examination, the name of the treating health professional and an authorization to the treating health professional to release relevant information to the Hospital. Any information provided by the applicant’s treating Physician will not become part of the applicant’s credentialing file and will not be provided to the Credentials Committee unless in the sole discretion of the Vice President, Medical, the Vice President, Medical:

(A) reasonably believes that the information provided by the applicant’s treating Physician discloses a condition or situation that adversely impacts the applicant’s ability to practise; and

(B) the applicant agrees to the release of the information to the Credentials Committee. In the event that the applicant refuses to authorize the Vice President, Medical to release the information to the Credentials Committee, the applicant will be deemed to have withdrawn the application for appointment;

xiii. information regarding any criminal convictions involving the applicant for which a pardon has not been granted;

xiv. information of any civil suit related to medical practice where there was a finding of negligence or battery, including any such suit settled by a payment;

xv. a direction to the Chief Executive Officer and Vice President, Medical and Chief of Department authorizing any one of them to contact any previous hospitals where the applicant has provided services for the purposes of conducting a reference check, such direction to include names and addresses of at least three (3) appropriate references including:

(A) the Chief Executive Officer and Chief of Staff and Chief of Department of the last hospital where the applicant held privileges or received training;

(B) the service director or head of training program if enrolled in a graduate training program within the past three (3) years;

(C) the dean of medicine or chair of department or delegate of the last educational institution in which the applicant held an appointment or was trained or was a post graduate student;

xvi. a signed authorization to any applicable hospital, healthcare institution or regulatory body to the release of information relating to any of the above;

By-law 2 – June 2011 19

xvii. such additional information relating to the provision of medical services or professional conduct as from time to time the Medical Advisory Committee may recommend and/or the Board approves;

xviii. an undertaking, in writing, that:

(A) the applicant understands the requirements for accepting clinical, academic and administrative responsibilities as requested by the Board following consultation with the Medical Advisory Committee and/or Chief of Department;

(B) if appointed, the applicant will act in accordance with the Laws of the Province of Ontario relating to hospital practice, and abide by and be guided by the requirements set out in the By-Laws and the Rules and Regulations and Policies of the Corporation, and will act in accordance with ethical standards of the profession;

(C) if appointed, the applicant will abide by the Corporation’s Policies as related to confidentiality and privacy of patient information and Corporation matters. No member will make statements on behalf of the Corporation to the news media or public without the express authority of the Chief Executive Officer or delegate; and

(D) if appointed, will use best efforts to provide the Hospital three (3) months prior written notice of the Physician’s intention to resign the Physician’s privileges and that a failure to provide the required notice will result in the Chief of Department notifying the College that the Physician has failed to comply with the Hospital’s By- Laws and a notation of the breach of the By-Laws will be noted in the Physician’s file. The Physician may be exempted from the notice requirements if the Chief of Department believes, after considering the Medical/Professional Staff Human Resource Plan, that the notice is not required or if the Chief of Department believes that there are reasonable or compassionate grounds to grant the exemption.

15.03 Criteria for Appointment to the Medical Staff Each applicant for appointment to the Medical Staff will meet the following qualifications: (a) be a registrant in good standing of the College licensed to practice medicine in

accordance with the laws of Ontario; (b) subject to subsection 11.03 (1) (c) below, all applicants must hold a current academic

appointment in the Faculty of Health Sciences of the University or be in the process of applying for such application and have received evidence satisfactory to the Medical Advisory Committee and the board that such appointment will be granted;

(c) the following applicants shall be excluded from the requirement to hold a current academic appointment in the Faculty of Health Sciences, and from the joint appointment requirements contained in the Affiliation Agreement, and for such applicants, resignation or termination from either the Hospital or the University does not result in resignation or termination from the other:

By-law 2 – June 2011 20

(i) as of the date of the Affiliation Agreement, all members of Active, Senior and Courtesy Medical Staff, whether they had joint appointments at that date or not. The exemption applicable to the existing Active, Senior and Courtesy members

of the Medical Staff shall apply to all their respective future applications, provided that only Courtesy Staff members who have Active Staff privileges at the St. Joseph’s Hospital shall be eligible to transfer their grandfathered status from Courtesy to Active;

xix. any applicant for appointment to the Department of Family Medicine. Notwithstanding the exemption, applicants to the Department of Family Medicine may apply to the Faculty of Health Sciences – Department of Family Medicine. Any such applicant can elect at any time for any reason whatsoever to resign a Faculty appointment and still maintain a Hospital appointment. This exemption shall also apply to Dentists, Midwives and Extended Class Nurses with the necessary changes in points of detail;

xx. all Clinical Assistants, and all members of the Honourary and Locum and Temporary Medical Staff; and

xxi. an applicant or member of the Medical Staff who is granted an exemption by the Board of the Hospital, following consultation with the Dean or the Dean’s delegate, due to Exceptional Circumstances. As defined in the Affiliation Agreement, Exceptional Circumstances means circumstances in which:

(A) the Physician has the training, skills and experiences which are required in the community; and

(B) the Physician does not meet the academic requirements of the University; and

(C) the Hospital is unable to attract a Physician with like skills, training and experiences, who would meet the academic requirements of the University; and

(D) the inability of the Hospital to grant Privileges would be prejudicial to the health and welfare of the members of the community; or

(E) a Physician has applied for an appointment to the Hospital and there is no shared academic and clinical mission;

(d) all Medical Staff members practicing in a specialty recognized by the Royal College of Physicians and Surgeons of Canada must hold a current certificate issued by the Royal College of Physicians and Surgeons or an educational licence for which they have met all requirements, either by way of examination or by academic eligibility;

(e) subject to the determination otherwise of the Board: (i) Medical Staff members in the Department of Family Medicine should hold

certification by the College of Family Physicians of Canada or equivalent; and xxii. Medical Staff members in the Department of Emergency Medicine should hold

either (i) certification by the Royal College of Physicians and Surgeons of Canada, (ii) certification in Emergency Medicine by the College of Family Physicians of Canada, or equivalent;

(f) an applicant who is expected to participate in patient care will have demonstrated the ability to provide patient care at an appropriate level of quality and efficiency;

(g) an applicant will be judged by: (i) his or her demonstrated ability to work and co-operate with and relate to others

in a collegial and professional manner; By-law 2 – June 2011 21

(ii) his or her demonstrated ability to communicate and relate appropriately with patients and patients’ relatives and/or substitute decision makers;

(iii) his or her willingness to participate in the discharge of staff, committee and, if applicable, teaching responsibilities, obligations appropriate to membership category;

(iv) his or her interest and aptitude towards scholarly activities; (v) his or her ethical performance and/or behaviour; and (vi) if applicable, the applicant’s continuing medical education must be acceptable

to the Credentials Committee; (h) the applicant must agree in writing to accept the mission statement and philosophy of

the Hospital and to abide by the Public Hospitals Act and its Regulations, the Hospital’s By-Laws, Rules and Policies and the Affiliation Agreement;

(i) the applicant must disclose and indicate to the satisfaction of the Board on the recommendation of the Medical Advisory Committee adequate control of any significant physical or behavioural impairment that affect skill, attitude or judgment;

(j) all appointments will be consistent with community need defined by the strategic plan and mission of the Hospital;

(k) all new appointments will be contingent upon an Impact Analysis demonstrating that the Hospital has the resources to accommodate the applicant and that the applicant meets the needs of the respective department as described in the Medical/Professional Staff Human Resource Plan; and

(l) the applicant will provide evidence of membership in the Canadian Medical Protective Association, or evidence of individual liability insurance coverage comparable to the above, any of which is subject to verification.

In addition to any other provisions of the By-Laws, the Board may refuse to appoint any applicant to the Medical Staff on any of the following grounds: (a) the applicant was not granted an academic appointment; (b) the appointment is not consistent with the need for service, as determined by the

Board from time to time; (c) the Medical/Professional Staff Human Resource Plan and/or the Impact Analysis of

the Corporation and/or department does not demonstrate sufficient resources to accommodate the applicant; and/or

(d) the appointment is not consistent with the strategic plan and mission of the Corporation.

15.04 Procedure for Processing Applications for Medical Staff Appointments (a) The Chief Executive Officer or delegate, on receipt of a completed application on the

prescribed forms, will refer the application to the relevant Chief of the Department and the Chair of the Academic Department. If both the Chief of Department and the Chair of the Academic Department agree, the application shall be referred by the Chief of the Department to the Credentials Committee pursuant to Section 11.04 (b). Failure of the Chief of the Department and Chair of the Academic Department to agree that the applicant should be considered by the Credentials Committee shall be dealt with in accordance with the Affiliation Agreement as follows: (i) The matter will be reviewed by the Chief Executive Officer, (or Vice President,

Medical as delegate of the Chief Executive Officer) Chair of MAC, Dean, Health

By-law 2 – June 2011 22

Sciences or designate, the Chief of Department and the Chair of the Academic Department.

(ii) In the event that an agreement can still not be reached, the Chief of Department and Vice President Medical Affairs and Quality will consider whether the applicant should be considered for the exception set out in paragraph 11.03 (1) (c) (iv). If a determination is made that the exception applies the application shall be referred to the Credentials Committee in accordance with paragraph (b).

(iii) In the event that the Chief of Department and the Vice President Medical Affairs and Quality determine that the applicant does not fall within the exception set out in paragraph 11.03 (1) (c) (iv), the Vice President Medical Affairs and Quality and the Chief of Department will submit a recommendation to the Medical Advisory Committee that the applicant not be granted privileges.

(iv) In the event of a recommendation that the applicant not be granted an appointment, the applicant will be processed by the Medical Advisory Committee pursuant to Section 11.04(c).

(b) Upon receipt of a recommendation from the Chief of Department, the Credentials Committee will investigate each application together with the qualifications and experience of the applicant. The Credentials Committee will make a written report to the Medical Advisory Committee, having given consideration to the recommendation of the Chief of the relevant Department with the advice of the Chair of the Academic Department. The Credentials Committee will: (i) review the application to ensure that it contains all the information required

under section 11.02 of this By-Law; (ii) take into consideration whether the criteria set out in section 11.03 of this By-

Law has been complied with; (iii) ensure that an analysis of the impact of the appointment on human and fiscal

resources and in particular, the impact or consistency of the appointment with the Medical/Professional Staff Human Resource Plan has been completed and approved; and

(iv) include a recommendation to appoint, or not appoint, the applicant. (c) (i) The Medical Advisory Committee will receive and consider either the

recommendations of the Chief of Department pursuant to Section 11.04 (a) (3) or the application and report of the Credentials Committee. The Medical Advisory Committee shall send its recommendation in writing to the Board within sixty (60) days of the date of receipt by the Chief Executive Officer or delegate of the completed application, as outlined in the Public Hospitals Act. The Medical Advisory Committee may make its recommendation to the Board later than sixty (60) days after the receipt of the completed application if, prior to the expiry of the sixty (60) day period, it indicates in writing to the Board and the applicant that a final recommendation cannot yet be made and includes written reasons for the delay.

(ii) The Medical Advisory Committee shall give its recommendation to the applicant and the Board.

(d) Wherehere the Medical Advisory Committee recommends to the Board that an application for appointment, reappointment or requested Privileges not be granted, the notice under (ii) shall inform the applicant that he or she is entitled to written reasons for the recommendation and a hearing before the Board pursuant to the provisions of

By-law 2 – June 2011 23

the Public Hospitals Act, if such a hearing is requested within the time prescribed by the Public Hospitals Act. The procedures to be followed at such a hearing are outlined in Schedule “A” of this By-Law.

(e) Where a hearing is not requested the Board may deal with the application in accordance with the Public Hospitals Act.

15.05 Reappointment to the Medical Staff (a) Subsections 11.02(a) and 11.02(c) shall apply to applications for reappointment with

necessary changes to points of detail. In light of the duration of the academic appointments and the Hospital’s annual re-appointment process, the Hospital’s re-appointment process will deem that the applicant has satisfied the requirements of the academic appointment process unless the Chair of the Academic Department advises the Chief of Department otherwise.

(b) The applicant’s application for reappointment shall contain the following: (i) a restatement or confirmation of the items requested in paragraphs 11.02(d)(i),

(ii), (iii)A, B and C, (iv), (v), (ix), (x), (xiii), (xiv) and (xxi); xxiii. either:

(A) a declaration that all information relating to paragraphs 11.02(d)(xi), (xii), (xv), (xvi), and (xvii) on file at the Hospital from the applicant’s most recent application is up-to-date, accurate and unamended as of the date of the current application; or

(B) a description of all material changes to the information requested in paragraphs 11.02(d)(xi), (xii), (xv), (xvi), and (xvii) on file at the Hospital since the applicant’s most recent application; and

xxiv. information and evidence relating to the applicant’s prior year with the Hospital, including:

(A) participation in continuing education programs;

(B) ability to communicate with patients and staff, together with information regarding patient or staff complaints regarding the applicant, if any;

(C) the applicant’s ability to work and cooperate with and relate to in a collegial and professional manner the Board, the Chair of MAC, Chief of the department and other members of the Medical Advisory Committee, Clinical and Program Service Directors, other members of the Professional Staff, the nursing staff, other healthcare practitioners and learners within the Hospital and other employees of the Corporation;

(D) “on-call” responsibilities;

(E) staff and committee responsibilities;

(F) quality of care issues;

(G) discharge of clinical and academic responsibilities;

(H) ability to supervise staff; By-law 2 – June 2011 24

(I) monitoring of patients, together with evidence of appropriate and completed clinical record documentation;

(J) appropriate and efficient use of Hospital resources;

(K) general compliance with the Public Hospitals Act, the Hospital’s By-Laws, Rules and its Policies; and

xxv. such other information that the Board may require, from time to time, having given consideration to the recommendation of the Medical Advisory Committee.

(c) to be eligible for re-appointment the applicant shall: (i) continue to meet the criteria of Section 11.03 (1); and (ii) demonstrate adequate and effective performance of the matters listed in

Section 11.05 (b) (iii). (d) The applicant shall forward to the Chief Executive Officer (or designate) a copy of the

application. The Chief Executive Officer shall refer the application to the Chief of Department and Chair of the Academic Department. Thereafter the procedure followed shall be the same procedure as set out in section 11.04 of the By-laws except that the University will be deemed to have appointed an applicant unless the Chair of the Academic Department advises the Chief of Department otherwise and no Impact Analysis (sections 11.04 (b) (iii)) shall be required unless the application includes a request for a change in privileges or resources required.

(e) The Chief of the Department and in the case of academic appointment, Chair of the Academic Department, will review the clinical and academic responsibilities and performance of the applicant, and the Chief of Department, with the advice of the Chair of the Academic Department, in the case of academic appointment, will make a recommendation on mutually agreed upon division of the applicant’s clinical and academic responsibilities to the Medical Advisory Committee, through the Credentials Committee. The Credentials Committee shall receive the report of the Chief of Department and in the case of academic appointment the Chair of the Academic Department and shall ensure that the applicant satisfies the criteria for re-appointment and shall make a recommendation to the Medical Advisory Committee.

(f) If in the view of the Chief of Department the individual does not meet the previously agreed upon clinical and academic responsibilities, the Chief of Department may review the Physician’s continuing Medical Staff appointment, and at the Chief of Department’s discretion, may make an appropriate recommendation to the Medical Advisory Committee.

(g) The Medical Advisory Committee shall deal with the recommendation for re-appointment in accordance with the Public Hospitals Act and the provisions of subsection 11.04 (c), (ii), (d) and (e) apply with necessary changes to points of detail.

15.06 Dispute Resolution (a) In the event that a dispute arises between the Chief of Department and chair in

delineating and reviewing the performance of clinical and academic responsibilities of the applicant, the Hospital or University is entitled to submit the issue to the Liaison Committee for resolution. If the Liaison Committee cannot resolve the dispute, it shall refer the dispute to the Joint Relations Committee. If the Joint Relations Committee is unable to resolve the dispute, it shall determine which institution has the primary jurisdiction in the matter and shall refer the matter to the respective Board of that institution for resolution.

By-law 2 – June 2011 25

(b) In the event that there is not mutual agreement between the applicant and the Chief of Department, and the applicant is unwilling to accept the clinical and academic responsibilities, a dispute resolution mechanism may be initiated by the applicant in accordance with the provisions of the Public Hospitals Act as outlined in Schedule “A” of this By-Law.

(c) In the event that the Physician is not provided an opportunity to appeal any such decision, the termination of such Physician’s appointment at one institution will not result in the termination of the Physician’s appointment at the other institution.

15.07 Application for Change of Privileges (a) Each member of the Medical Staff who wishes to change his or her Privileges, shall

submit on a prescribed form to the Chief Executive Officer (or delegate) and Chief of Department, an application listing the procedures that he or she feels capable of performing proficiently, listing the change of Privileges and providing evidence of appropriate training and competence.

(b) The Chief Executive Officer shall refer any such application forthwith to the Vice President Medical Affairs and Quality, who shall keep a record of each application received and shall then refer the original application forthwith to the Chair of the Credentials Committee.

(c) The Credentials Committee, through the Chief of Department shall investigate the professional reputation and verify the qualifications of the applicant, and shall submit a report of its findings to the Medical Advisory Committee at its next regular meeting. The report shall contain a list of procedures that the applicant may perform.

(d) The Medical Advisory Committee shall receive and consider the report and recommendations of the Credentials Committee and shall send notice of its recommendations to the Board and the applicant, pursuant to the Public Hospitals Act. In the case of a recommendation for acceptance, the Medical Advisory Committee shall specify the privileges it recommends the applicant be granted. The provisions of subsections 11.04 (c), (d) and (e) shall apply with necessary changes in points of detail.

(e) The Board shall, either accept and act upon the recommendation of the Medical Advisory Committee and advise the applicant forthwith, or otherwise deal further with the application in accordance with the Public Hospitals Act.

(f) The Medical Advisory Committee and the Board shall consider and deal with each application for Privileges or changes in Privileges within the time frame specified by the Public Hospitals Act.

(g) Each application for changes in Privileges shall be considered in the light of the Corporation’s Medical/Professional Staff Human Resource Plan.

ARTICLE 16. CATEGORIES OF THE MEDICAL STAFF

16.01 Categories (a) The Medical Staff shall be divided into the following categories:

(i) Associate; (ii) Active; (iii) Honourary; (iv) Courtesy;

By-law 2 – June 2011 26

(v) Locum; (vi) Clinical Assistant; (vii) Temporary; and (viii) such categories as may be determined by the Board from time to time having

given consideration to the recommendation of the Medical Advisory Committee. (b) Appointments to these categories will be consistent with the established

Medical/Professional Staff Human Resource Plan and will be subject to completion of an Impact Analysis.

16.02 Associate Staff (a) Physicians who are applying for appointment to the Active Staff, subject otherwise to

the determination of the Board, will be assigned to the Associate Staff for a period of at least one year but in no event shall an appointment to the Associate Staff extend beyond two years.

(b) An Associate Staff member will: (i) be granted Admitting and Procedural Privileges as approved by the Board

having given consideration to the recommendation of the Chief of Department and Medical Advisory Committee;

(ii) undertake such clinical, academic and administrative duties and responsibilities as outlined in paragraphs 11.02(d)(ii), 11.02(d)(iii), 11.02(d)(xxi), 11.05(b)(i) and subsection 11.05 (e);

(iii) work with the counsel and under the supervision of an Active Staff member named by the Chief of Department;

(iv) be eligible to attend and vote at meetings of the Medical Staff; (v) be bound by the expectations for attendance, as established by the Medical

Advisory Committee, at Medical Staff, Departmental and Service meetings; and (vi) perform such other duties as may be prescribed by the Medical Advisory

Committee or requested by the Vice President Medical Affairs and Quality or Chair of MAC and Chief of the relevant Department from time to time.

(c) After one year, the appointment of a Physician to the Associate Staff will be reviewed by the Credentials Committee, which will report to the Medical Advisory Committee. The review will include an assessment of the Physician’s performance. The Medical Advisory Committee, after considering the report of the Credentials Committee, will recommend to the Board either a change in category, continuation in the Associate Staff category for a further period of time not to exceed an additional year of practice or denial of reappointment.

16.03 Active Staff (a) Members of the Active Staff will:

(i) consist of those Physicians as are appointed to the Active Staff from time to time by the Board, who are responsible for ensuring that an acceptable standard of medical care is provided to patients under their care;

(ii) have completed a prerequisite of at least one year on the Associate Staff unless, in respect of any particular member, a waiver of such requirement is consented to by the Board;

By-law 2 – June 2011 27

(iii) undertake such clinical, academic and administrative duties and responsibilities as outlined in paragraphs 11.02(d)(ii), 11.02(d)(iii), 11.02(d)(xxi), 11.05(b)(i) and subsection 11.05 (e);

xxvi. be granted Admitting and Procedural Privileges as approved by the Board having given consideration to the recommendation of the Chief of Department and Medical Advisory Committee;

xxvii. be entitled to apply for annual reappointment as provided in this By-Law; xxviii. be eligible to attend and vote at meetings of the Medical Staff and be an officer

of the Medical Staff or a committee chair; xxix. be bound by the expectations for attendance, as established by the Medical

Advisory Committee, at Medical Staff, Departmental and Service meetings; and xxx. perform such other duties as may be prescribed by the Medical Advisory

Committee or requested by the Vice President Medical Affairs and Quality or Chair of MAC and Chief of the relevant Department from time to time.

16.04 Honourary Staff (a) An individual may be honoured by the Board by an appointment to the Honourary Staff

because of the individual’s: (i) former membership on the Active Staff; or, (ii) identification by the Board as an individual qualified for such appointment.

(b) An Honourary Staff member will be eligible to attend Medical Staff meetings; (c) An Honourary Staff member will not:

(i) be granted Admitting and Procedural Privileges, or provide patient care; (ii) have any clinical, academic and administrative duties and responsibilities; (iii) vote at meetings of the Medical Staff or be an officer of the Medical Staff or be

a committee chair; and; (iv) be bound by the expectations for attendance at Medical Staff, Departmental

and Service meetings. (d) Individuals who have been honoured by an appointment to the Honourary Staff shall

hold that appointment for one year and are not subject to section 11.05 but shall annually indicate in writing to the Chair of MAC if they wish the Board to consider a renewal of their appointment.

16.05 Courtesy Staff (a) Courtesy Staff:

(i) will consist of Physicians who have been granted Admitting and Procedural Privileges, without the responsibilities of Active Staff membership, as approved by the Board having given consideration to the recommendation of the Chief of Department and Medical Advisory Committee;

(ii) will be a member of the Active or Associate Staff of another hospital at which the Physician’s primary activities are based, subject otherwise to the determination of the Board;

(iii) will undertake such clinical, academic and administrative duties and responsibilities as outlined in paragraphs 11.02(d)(ii), 11.02(d)(iii), 11.02(d)(xxi), 11.05(b)(i) and subsection 11.05 (e);

By-law 2 – June 2011 28

(iv) will admit and treat patients admitted as an emergency, or elective admissions when facilities permit;

(v) will be entitled to apply for annual reappointment as provided in this By-law; and (vi) will be eligible to attend Medical Staff meetings.

(b) Courtesy Staff will not: (i) have regularly assigned administrative duties and responsibilities; (ii) vote at meetings of the Medical Staff or be an officer of the Medical Staff or be

a committee chair; or (iii) be bound by the expectations for attendance at Medical Staff, Departmental

and Service meetings.

16.06 Locum Staff (a) Locum Staff will consist of Physicians who have been granted Admitting and/or

Procedural Privileges as approved by the Board having given consideration to the recommendation of the Chief of Department and the Medical Advisory Committee in order to meet specific clinical or academic needs for a defined period of time of up to one year (subject to renewal for a further period of up to one additional year). The Board, having considered the recommendation of the Medical Advisory Committee may permit renewal beyond two (2) years in exceptional circumstances. Such needs may include but are not limited to visiting professorships, episodic or limited surgical or consultative services;

(b) Locum Staff: (i) may be required to work with the advice, counsel and under the supervision of

an Active Staff member named by the Chief of Department; (ii) may be required to undergo a probationary period as appropriate and

determined by the Chief of Department; (iii) appointments will be consistent with the established Medical/Professional Staff

Human Resource Plan and will be subject to completion of an Impact Analysis; and

(iv) may be entitled to apply for reappointment as provided in this By- Law. (c) Locum Staff will not, subject to determination by the Board in each individual case:

(i) attend or vote at meetings of the Medical Staff or be an officer of the Medical Staff or a committee chair; and

(ii) be bound by the expectations for attendance at Medical Staff, Departmental and Service meetings.

16.07 Clinical Assistants (a) Clinical Assistants are those Physicians who:

(i) are registered with the Faculty of Medicine at the University or licensed for independent practice;

(ii) may be engaged in post-graduate training; (iii) are working under the supervision of a member of the Active Staff; (iv) are appointed by the Board on the recommendation of the Chair of MAC and

the Medical Advisory Committee subject to the terms of the Affiliation Agreement;

By-law 2 – June 2011 29

(v) hold a Certificate of Registration from the College of Physicians of Surgeons of Ontario; and

(vi) have membership in the Canadian Medical Protective Association or other evidence of medical practice protection coverage satisfactory to the Board.

(b) Clinical Assistants shall not have the right to independently admit or attend patients, but may attend patients under the supervision of a member of the Active Staff;

(c) Clinical Assistants shall not have membership or voting rights in the Medical Staff Association but may attend meetings of the Medical Staff Association;

(d) Privileges and responsibilities for Clinical Assistants must be determined and authorized by the Chair of MAC. Such privileges and responsibilities shall be appropriate to the individual’s qualifications and experience.

16.08 Temporary Staff (a) A temporary appointment of a Physician to the Medical Staff may be made only for one

of the following reasons: (i) to meet a specific singular requirement by providing a consultation and/or

operative procedure; or (ii) to meet an urgent unexpected need for a medical service; (iii) for the purpose of short-term teaching or assessment

(b) Notwithstanding any other provision of the By-law, the Chief Executive Officer, after consultation with the Chair of the MAC or his delegate may: (i) grant a temporary appointment to a Physician who is not a member of the

Medical Staff provided that such appointment shall not extend beyond the date of the next meeting of the Medical Advisory Committee at which time the action taken shall be reported; and

(ii) continue the appointment on the recommendation of the Medical Advisory Committee until the next meeting of the Board

16.09 Performance Reviews Upon recommendation of the Medical Advisory Committee, the Board shall establish a process for the annual performance review of each member of the Medical Staff. Each member of the Medical Staff shall cooperate in such performance reviews annually in accordance with the process approved by the Board.

ARTICLE 17. SUSPENSION REVOCATION

17.01 Monitoring Practices (a) Any aspect of patient care being carried out in the Corporation may be reviewed

without the approval, but where possible with the knowledge of the responsible Physician, by the Chair of MAC (or delegate) or Vice President Medical Affairs and Quality (or delegate).

(b) Where any member of the Professional Staff or Corporation staff believes that a member of the Professional Staff is attempting to exceed his or her Privileges or is incapable of providing a service that he or she is about to undertake, such individual shall communicate that belief forthwith to the chair of the MAC, the Chief of the

By-law 2 – June 2011 30

relevant Department and the Vice President Medical Affairs and Quality and to the Chief Executive Officer or delegate, so that appropriate action can be taken.

(c) The Chief of a Department on notice to the Vice President Medical Affairs and Quality, where he or she believes it to be necessary or desirable in the best interest of the patient, shall have the authority to examine the condition and scrutinize the treatment of any patient in his or her Department and to make recommendations to the attending Professional Staff member or any consulting Professional Staff member involved in the patient’s care and, if necessary, to the MAC.

(d) Pursuant to the Public Hospitals Act, where a Chief of a Department has cause to take over the care of a patient, the Chief Executive Officer, the Vice President Medical Affairs and Quality, the Chair of MAC, the attending physician or dentist, and the patient or the patient’s substitute decision maker shall be notified immediately.

17.02 Suspension/Revocation of Privileges (a) In circumstances where there are concerns about the conduct, performance or

competence of a member of the Professional Staff, the Board may, at any time, in a manner consistent with the Public Hospitals Act and in accordance with the regulations thereunder and this By-Law, revoke or suspend any appointment of a member of the Professional Staff or revoke, suspend or restrict or otherwise deal with the Privileges of the member. Unless immediate action is required for patient safety, adequate notice of suspension of Privileges shall be given by the Chief Executive Officer to the Dean of the Faculty of Health Sciences.

(b) Immediate Mid-Term Action In Emergency Situations. In circumstances where, in the opinion of the Chair of MAC, Vice President Medical Affairs and Quality, the Chief Executive Officer, or Chief of the relevant Department, the conduct, performance or competence of a member of the Professional Staff exposes or is reasonably likely to expose patient(s) to harm or injury and immediate action must be taken to protect the patient(s), and no less restrictive measure can be taken, the Chair of MAC, Vice President Medical Affairs and Quality, the Chief Executive Officer or Chief of Department, as the case may be, will take action in accordance with this By-law. This may require immediate and temporary suspension of the Privileges of the member of the Professional Staff by the Chief Executive Officer, the Vice President Medical Affairs and Quality, Chair of MAC or Chief of Department, with immediate notice to the others, pending the consideration of the suspension by the Medical Advisory Committee and the Board in keeping with the procedures outlined in Part III of Schedule “A” of this By-Law, respecting Immediate Mid-Term Action in an Emergency Situation.

(c) Non-Immediate Mid-Term Action. In circumstances where, in the opinion of the Chair of MAC, the Chief of the relevant Department, or the Vice President Medical Affairs and Quality, performance or competence of a member of the Professional Staff: (i) fails to comply with the criteria for annual reappointment; or (ii) exposes or is reasonably likely to expose patient(s) to harm or injury; or (iii) is, or is reasonably likely to be, detrimental to patient safety or to the delivery of

quality patient care within the Hospital; or (iv) has had disciplinary action taken by the College respecting that member of the

Professional Staff; or (v) has violated the By-Laws, Rules and Regulations, Policies of the Corporation,

the Public Hospitals Act, the regulations made thereunder, or any other relevant law or legislated requirement;

By-law 2 – June 2011 31

and immediate action is not required to be taken, action may be initiated in keeping with the procedures in Part IV of Schedule “A” of this By-Law, respecting Non- Immediate Mid-Term Action.

ARTICLE 18. MEDICAL STAFF DUTIES AND RESPONSIBILITIES

18.01 Collective Duties and Responsibilities Collectively, the Medical Staff practising within the jurisdiction of the Corporation have responsibility and accountability to the Board for: (a) ensuring that care at the Hospital is appropriately directed to meeting patients’ needs

and is consistent with sound health care resource utilization practices; (b) participating in quality and error management initiatives by conducting all necessary

and appropriate activities for assessing and improving the effectiveness and efficiency of care provided in the Hospital;

(c) ensuring that ethical practice standards compatible with those of contemporary medical practice are observed;

(d) providing and maintaining undergraduate and postgraduate medical education and health professional education in accordance with the mission of the Corporation;

(e) providing and maintaining the development of continuing medical education and continuing interdisciplinary health professional education;

(f) providing, maintaining and participating in medical, clinical health services and outcomes research;

(g) promoting evidence-based decision making; (h) ensuring that any concerns relating to the operations of the Hospital are raised and

considered through the proper channels of communication within the Hospital such as the Medical Staff Association or the Chair of MAC, Vice- President Medical, Chiefs of Department, Medical Advisory Committee and/or the Board;

(i) assisting to fulfill the mission of the Corporation through contributing to the strategic planning, community needs assessment, resource utilization management and quality management activities; and

(j) contributing to the development and ensuring compliance with the By-Laws, and Rules and Regulations, and Policies of the Corporation.

18.02 Individual Duties and Responsibilities Each member of the Medical Staff has individual responsibility to the Corporation and the Board to: (a) ensure a high professional standard of care is provided to patients under their care that

is consistent with sound healthcare resource utilization practices; (b) practise medicine of the highest professional and ethical practice standards within the

limits of the Privileges provided; (c) maintain involvement, as a recipient, in continuing medical and interdisciplinary

professional education; (d) contribute in academic activities within the parameters of a mutual agreement as

determined within the department in which the Physician is appointed;

By-law 2 – June 2011 32

(e) recognize the authority of the Vice President, Medical, Heads of Service, Deputy Chiefs of Department, Chief of the Department, the Chair of MAC, Site Leads,

Program and Service Medical Directors, the Medical Advisory Committee and the Board;

(f) comply with this By-Law and Rules and Regulations and Policies; (g) participate in quality, complaint and error management initiatives, as appropriate; (h) prepare and complete patient records in accordance with the Hospital’s Policies as

may be established from time to time, applicable legislation and accepted industry standards;

(i) use best efforts to provide the member’s Chief of Department with three (3) months notice of the members’ intention to resign or restrict the member’s Privileges;

(j) work and cooperate with others in a manner consistent with the Hospital’s mission, vision and values;

(k) notify the Board in writing through the Chief Executive Officer or delegate of any additional professional degrees or qualifications obtained by the member or of any change in the licence to practice medicine made by the College or change in professional liability insurance;

(l) serve as required on various Hospital and Professional Staff committees; (m) not undertake any conduct that would be prejudicial to the Hospital’s reputation or

standing in the community, including making prejudicial or adverse public statements with respect to the Hospital’s operations which have not first been addressed through the proper communication channels identified above and such official channels have not satisfactorily resolved the Physician’s concerns; and

(n) to participate in “on call” requirements of the Department or Division as scheduled by the Chief of Department or Head of Division, as applicable.

ARTICLE 19. DEPARTMENTS AND THEIR CHIEFS

19.01 Medical Staff Departments (a) The Medical Staff will be organized into such Departments as may be approved by the

Board from time to time. (b) Each Medical Staff member will be appointed to a minimum of one of the Departments.

Appointment may extend to one or more additional Departments. These secondary appointments are dependent on educational preparation, interest and working affiliation with members of other Departments and the Medical/Professional Staff Human Resource Plans of the Department.

(c) The Board, having given consideration to the recommendation of the Chair of MAC, following consultation with the Medical Advisory Committee, may at anytime create such additional Departments or Services as may be required. It may also change a Service of an existing Department into a Department, change a Department into a Service within a Department or disband a Department or Service: all these actions to reflect changing situations of the Hospital.

(d) The Board, having given consideration to the recommendation of the Chair of MAC, following consultation with the Medical Advisory Committee Executive, will appoint a Chief of each Department.

19.02 Services in a Department (a) At least annually and whenever requested by the Medical Advisory Committee the

Chief of Department will present to the Medical Advisory Committee for its approval a

By-law 2 – June 2011 33

proposed Departmental service structure to which members of the Medical Staff will be assigned.

(b) Within the Departmental leadership structure, the Chief of Department may recommend to the Medical Advisory Committee individuals for appointment to the following categories of leadership role: (i) Deputy Chief of Department; (ii) Site leader; or (iii) Head of Service.

19.03 Appointment of Chiefs of Department (a) Subject to the determination otherwise by the Board, a Physician who is a member of

the Active Staff will be appointed by the Board as Chief of each Department. Notwithstanding any other provisions contained in the By-Laws, the office of the Chief of Department may be revoked at any time by the Board.

(b) Subject to the results of the annual performance evaluations outlined in section 15.05, Chiefs of Department will be eligible to serve two (2) consecutive five (5) year terms.

(c) Under exceptional circumstances, such as when a suitable replacement can not be found at that time, a search committee, appointed at the end of the second five-year term may, after review of all external and internal candidates, recommend that the incumbent’s term be extended and, in addition, recommend the length of time of the extension.

(d) Notwithstanding the above described lengths of tenure of position, a Chief of a Department may hold office until a successor is appointed.

(e) In the event of a vacancy of a Chief of Department, the Board will direct the Medical Advisory Committee to cause the Vice President Medical Affairs and Quality to establish a committee to undertake a search for the express purpose of recommending a candidate for the vacant position. The committee will conduct the search and make a recommendation through the Chair of MAC to the Board. The work of the committee will include, but not be limited to, establishing criteria to be used in the selection, making a decision between a local or a national search, overseeing the process to obtain candidates, interviewing candidates and agreeing on a process by which to make a final recommendation.

(f) The search committee will be chaired by the Vice President Medical Affairs and Quality or delegate and include : (i) at least one member of the Active Staff of the Department for which the Chief of

Department is being sought; (ii) a representative of the corresponding academic discipline appointed by the

Dean/Vice-President, Faculty of Health Sciences; (iii) the Chief Executive Officer or delegate; (iv) a representative of the Board, appointed by the Board; (v) a member of the Professional Advisory Committee; and (vi) such other members of the Active Medical Staff from departments which work

closely with the Department Chief as determined by the Vice President Medical Affairs and Quality.

(g) On an individual, non-precedent setting basis, with prior approval of the Faculty of Health Sciences, an incumbent chair of an academic department may be recommended, using the above search process, to be the Chief of Department.

By-law 2 – June 2011 34

(h) Where there are simultaneous vacancies of a Chief of Department and academic department chair, the search processes of the two may be merged. This can only occur with prior approval of the Board having given consideration to the recommendation of the Medical Advisory Committee, the Faculty of Health Sciences and appropriate Regional Partners.

19.04 Duties of Chiefs of Department (a) Through the Chair of MAC, the Chief of the Department is responsible to the Board for

the quality of clinical care provided by the Professional Staff to all patients by members of the Department.

(b) With the advice of the chair of the corresponding academic department, relevant committees and leadership through the Chair of MAC, the Chief of the Department is responsible to the Board for the promoting and conduct of research and academics undertaken by members of the Department.

(c) The Chief will collaborate with the Hospital in the management of any complaint relating to a Physician.

(d) So as to carry out the clinical, academic, and administrative responsibilities of a Chief of Department in concert with other related Departments, the Chief of Department shall receive reports of Medical Staff standing and ad hoc committees, work with other Chiefs of Department in collaboration with the Clinical Program and Service Medical Directors, the Vice-President, Medical and the Corporation’s management in forming and recommending policy to the Board.

(e) As a member of the Medical Advisory Committee, the Chief of Department is responsible to ensure that the responsibilities under this By-law, Rules and Regulations, Policies of the Hospital, the Medical Staff, the Medical Advisory Committee and the Department are complied with by all members of the Department.

(f) The Chief of Department is responsible for forming, revising and interpreting departmental policy to all departmental members with a special emphasis on the need for orientation and policy interpretation to new members of the Department.

(g) The Chief of Department is responsible for ensuring that the resources of the Hospital allocated for the Department are equitably distributed among the members of the department.

(h) The Chief of Department is responsible for conducting a written performance evaluation of all members of the Department on an annual basis. This includes, with the advice of the chair of the corresponding academic department, the annual evaluation of all members of the Department and the periodic reviews of heads of service within the Department.

(i) In addition to duties included elsewhere in this By-Law, with Department members assistance, duties of the Chief of Department include: (i) developing with the medical leadership and Vice- President, Medical with the

advice of the chair of the corresponding academic department, the Department’s goals, objectives and strategic plan including a Medical Professional Staff Human Resource Plan for presentation to the Board through the Medical Advisory Committee;

(ii) participating in the organization and implementation, with the medical leadership and Vice President Medical Affairs and Quality, of clinical utilization management review within the Department;

By-law 2 – June 2011 35

(iii) participating in the development with the medical leadership and Vice-President, Medical with the advice of the chair of the corresponding academic department, and Regional Partners, of a recruitment plan, including appropriate Impact Analysis, in keeping with the approved Medical Professional Staff Human Resource Plan of the Department;

(iv) with the advice of the corresponding academic department chair, development with newly appointed members of the Department of a mutually agreed upon accountability statement related to items of patient care and academic responsibility which serve as the basis for individual members’ annual evaluation; and

(v) development and maintenance of a process to both promote and document quality management improvements in the Department including a continuous learning process of members of the Department.

(j) The duties of the Chief of Department will also include the responsibility for discipline of Department members in regard to matters of patient care, academic responsibilities with the advice of the chair of the corresponding academic department, co-operation with Hospital employees, and documentation of care.

(k) Other duties assigned by the Board, Medical Advisory Committee or Vice President Medical Affairs and Quality from time to time.

19.05 Performance Evaluation of Chiefs of Department (a) Chiefs of Department will be subject to annual reappointment by the Board to coincide

with the Chief of Department’s date of appointment. The annual performance evaluation will be conducted by the Vice President Medical Affairs and Quality, in consultation with the Chair of MAC, pursuant to a process to be established from time to time by the Vice President Medical Affairs and Quality.

(b) In the second year of a Chief of Department’s five year term, a review of the performance of the Chief of Department will be undertaken. This may be undertaken by the Vice President Medical Affairs and Quality, or delegated to Chair of MAC or be undertaken by another member of the Medical Advisory Committee Executive and should include formal assessment of the Chief of Department by peers/colleagues, persons who are accountable to the Chief of Department and persons to whom the Chief of Department is accountable in addition to the Chair of MAC.

(c) At the beginning of the fifth year of the Chief of Department’s first term, a formal evaluation similar to that set out at subsection 15.05(b) will be undertaken in preparation for the decision regarding reappointment of the Chief of Department for a second (2nd) five (5) year term. Under exceptional circumstances where it is known that the Chief of Department will continue beyond the second (2nd) term, a formal evaluation should occur at the beginning of the final year of the Chief of Department’s term.

(d) The duties of Chiefs of Department as set out in section 15.04 of this By-Law, and the specific duties, if any, as determined at the time of appointment, will be used as the criteria against which the performance of the Chief of Department will be evaluated.

(e) A review of the Chief of Department’s performance may be initiated at other times by the Vice President Medical Affairs and Quality, or delegated to the Chair of MAC on the basis of a request from: (i) the Board; or, (ii) any of the standing sub-committees of the Medical Advisory Committee; or,

By-law 2 – June 2011 36

(iii) the President of the Medical Staff Association; or, (iv) the Chief Executive Officer or designate.

(f) In preparation for the annual performance evaluation, the Chief of Department will prepare a brief summary of: (i) the Department’s objectives over the past year; (ii) the attainment or status of these objectives; and (iii) the objectives for the year ahead.

19.06 Appointment of Deputy Chiefs of Departments/Site Leaders (a) The Medical Advisory Committee, on the recommendation of the Chief of Department,

will appoint a deputy Chief of Department and/or Site Leader. Notwithstanding any other provisions contained in the By-Laws, the office of the Deputy Chief of Department or Site Leader may be revoked at any time by the Board.

(b) In bringing forward the recommendation, the Chief of Department will demonstrate a process of consultation within the Department (and if appropriate, between departments), with programs, with the Faculty of Health Sciences and the Chief Executive Officer or delegate. There will also be consultation with the Chair of MAC prior to presentation of the recommendation to the Medical Advisory Committee.

(c) Reappointment will be on an annual basis, in accordance with the academic year, on recommendation of the Chief of the Department to the Medical Advisory Committee.

19.07 Duties of Deputy Chiefs of Department/Site Leaders (a) The Deputy Chief of Department and Site Leader are the delegates of the Chief of

Department. As such, they have responsibilities and duties similar to those of the Chief of Department. These responsibilities and duties are determined by the Chief of Department.

19.08 Performance Evaluation Duties of Deputy Chiefs of Department/Site Leaders (a) The appointments will be subject to annual review by the Chief of Department.

19.09 Appointment of Heads of Service (a) Heads of Service may be Service specific, Site specific, or function specific, as

deemed necessary by the Chief of Department. (b) The Chief of Department is responsible for recommending to the Medical Advisory

Committee for its approval both the Service leadership structure and the specific individuals within that proposed structure.

(c) The Chief of Department, in arriving at these recommendations, will demonstrate a process of consultation within the Department (and if appropriate, between Departments), with programs and with the Faculty of Health Sciences.

(d) The Medical Advisory Committee, on the recommendation of the Chief of Department, will appoint a Head of Service. Notwithstanding any other provisions contained in the By-Laws, the office of the Head of Service may be revoked at any time by the Board.

(e) Reappointment will be on an annual basis, in accordance with the academic year, on recommendation of the Chief of the Department to the Medical Advisory Committee.

By-law 2 – June 2011 37

19.10 Duties of Heads of Service The Head of Service is the delegate of the Chief of the Department. As such, the Head of the Service has responsibilities and duties similar to those of the Chief of the Department. These responsibilities and duties, however, focus on the quality of care and operation of the Service and the specific subspecialty.

19.11 Performance Evaluation of Heads of Service (a) Heads of service appointments will be subject to annual review by the Chief of

Department. (b) The annual review of Heads of Service will coincide with the annual review of

appointments within the respective departments.

ARTICLE 20. MEDICAL ADVISORY COMMITTEE

20.01 Composition of Medical Advisory Committee (a) The Medical Advisory Committee shall consist of the following voting members:

(i) The Chair of MAC; (ii) the Vice-Chair of the Medical Advisory Committee as appointed by the Chair of

MAC; (iii) the Chiefs of Department; (iv) the President, Vice-President and Secretary/Treasurer of the Medical Staff;

(b) In addition, the following shall be entitled to attend the meetings of the Medical Advisory Committee as observers and without a vote but with notice and entitled to receive copies of the minutes: (i) the Vice President Medical Affairs and Quality and any other vice-president of

the Hospital; (ii) the Director of Medical Affairs; (iii) the Director of the Midwifery Service; (iv) the Head of the Dental Service; (v) the Chief Executive Officer; (vi) the Chief Nursing Executive/Vice President Professional Affairs; (vii) the Dean of the Faculty of Health Sciences or delegate; (viii) Vice President Medical of St. Joseph’s Hospital; and (ix) Chair of the Board of Directors or delegate. The ex officio members (other than the Vice President Medical Affairs and Quality) shall not be entitled to attend or participate in meetings of the Medical Advisory Committee as ex officio members where the purpose of the meeting relates to the Appointment, Re-Appointment or Suspension of a Professional Staff Member or the restriction of a Professional Staff members privileges.

20.02 Accountability of Medical Advisory Committee The Medical Advisory Committee is accountable to the Board, in accordance with the Public Hospitals Act, as amended and the Regulations pertaining thereto.

By-law 2 – June 2011 38

20.03 Medical Advisory Committee Duties and Responsibilities (a) The Medical Advisory Committee shall, in addition to those matters set out in the Public

Hospitals Act: (i) make recommendations to the Board concerning the following Professional

Staff matters: (ii) every application for appointment or re-appointment to the Professional Staff; (iii) the Privileges to be granted to each member of the Professional Staff; (iv) By-Laws respecting any Professional Staff; (v) the dismissal, suspension or restrictions of Privileges of any member of the

Professional Staff; (vi) the quality of care provided in the Hospital by the Professional Staff; and (vii) the Rules and Regulations regarding the Professional Staff; (viii) provided that subsection 16.03(a)(i), 16.03(a)(ii) and 16.03(a)(iv) only be

performed with respect to those members of the Extended Class Nurses who are not employees of the Hospital and to whom the Board has granted privileges to diagnose, prescribe for or treat out-patients of the Hospital;

(b) supervise the practice of the Professional Staff; (c) appoint the Professional Staff members of all Professional Staff committees; (d) receive reports of the committees of the MAC; (e) advise the Board on any matters referred to the Medical Advisory Committee by the

Board; (f) recognizing the impact of regionalization, make recommendations to Hospital

Administration and to the Board on matters of patient care, professional education and research;

(g) develop, maintain and recommend to the Board a Medical/Professional Staff Human Resource Plan; and

(h) facilitate the development and maintenance of Rules and Regulations, and policies and procedures of the Professional Staff.

20.04 Establishment of Committees of the Medical Advisory Committee (a) The Medical Advisory Committee shall establish an Executive Medical Advisory

Committee. (b) The Medical Advisory Committee may establish such other standing and special

committees as may be necessary from time to time to comply with their duties under the Public Hospitals Act or the By-Laws of the Hospital or as they may deem appropriate from time to time.

(c) The terms of reference for the standing committees and special committees not set out below shall be set out in the Rules and Regulations.

20.05 Composition of Executive Committee of the Medical Advisory Committee (a) The Executive Committee of the Medical Advisory Committee shall be comprised of the

following voting members: (i) the Chair of MAC; (ii) the Vice-President, Medical (non-voting); (iii) President of the Medical Staff; and

By-law 2 – June 2011 39

(iv) such other members of the Medical Advisory Committee as may be appointed from time to time by the Medical Advisory Committee.

(b) In addition, the following ex officio members shall be entitled to attend meetings of the Executive Committee of the Medical Advisory Committee: (i) the Chief Executive Officer or delegate; (ii) Chief Nursing Executive/Vice-President Professional Affairs; (iii) Director of Medical Affairs; and (iv) Dean of the Faculty of Health Sciences or delegate.

20.06 The Executive Committee of the Medical Advisory Committee Duties and Responsibilities

The Executive Committee of the Medical Advisory Committee shall: (a) perform the role of the Medical Advisory Committee in matters of administrative

urgency, reporting their actions at the next meeting of the Medical Advisory Committee and the Board; and

(b) perform such other duties as may be assigned by the Medical Advisory Committee.

ARTICLE 21. CHAIR OF MAC

21.01 Appointment of Chair of MAC (a) The Board, unless it determines otherwise, will appoint as Chair of MAC a Physician

who is a member of the Active Staff. The position of Chair of MAC will be open to any Active Staff member.

(b) The appointment will be made following consultation with the Medical Advisory Committee.

(c) The Board will establish a search committee for the position of Chair of MAC and will establish the composition and terms of reference for any such search committee. (i) The search committee will be chaired by a member of the Board appointed by

the Board for this purpose and will include at least two representatives of appointed Medical Staff leaders and the President of the Medical Staff Association.

21.02 Term of Office (a) Subject to annual reappointment by the Board, and unless the Board otherwise

determines, the Chair of MAC will be eligible to serve one two (2) year term which may be renewed for a second term of two (2) years.

(b) Notwithstanding any other provisions contained in the By-Laws, the office of the Chair of MAC can be revoked at any time by the Board.

21.03 Role of Chair of MAC The Chair of MAC will: (a) provide leadership in the establishment of an interdisciplinary approach to patient and

family centred care and service; (b) collaborate with representatives of other disciplines to create an environment that

promotes commitment to continuous improvement of patient care outcomes; (c) enhance education and research throughout the organization; and

By-law 2 – June 2011 40

(d) champion and participate in organization and development at a strategic and project level.

21.04 Responsibilities and Duties of Chair of MAC (a) The chair of MAC is accountable to the Board for chairing the Medical Advisory

Committee Executive, and the Medical Advisory Committee. In chairing, it is also the responsibility of the Chair of MAC to report regularly to the Board on the work and recommendations of the Medical Advisory Committee and its component parts and subcommittees, and similarly to the Medical Advisory Committee, and its component parts and subcommittees, on the decisions and policies of the Board.

(b) In addition, the Chair of MAC has the following other specific duties: (i) the Chair of MAC will be a member of the Board and such committees of the

Board as provided in the By-Laws, and such other committees as determined by the Board from time to time;

(ii) the Chair of MAC will advise the Board with respect to the Quality of care provided by Medical, Dental, Midwifery and Extended Class Nursing Staff to patients;

(iii) through the Chiefs of Department, the Chair of MAC ensures adequate supervision of any member of the Professional Staff for any period of time when a Physician, dentist, Midwife or extended class nurses begins practice at the Corporation or is learning a new procedure;

(iv) through the Chief of a Department, the Chair of MAC, when necessary, assumes or assigns to any other member of the Professional Staff, responsibility for the direct care and treatment of any patient of the Corporation under the authority of the Public Hospitals Act, and notifies the responsible Professional Staff Member, Chief Executive Officer or delegate, and, if possible, the patient of this reassignment of care;

(v) the Chair of MAC will liaise with the Dean of the Faculty of Health Sciences and the Chief of Staff, St. Joseph’s Hospital;

(vi) the Chair of MAC will cooperate with the Vice-President, Medical in coordinating the work of the Chiefs of Department in the development, periodic review and revision of departmental Clinical Resource Plans and clinical utilization management review activities;

(vii) the Chair of MAC will also work with the Vice President Medical Affairs and Quality in investigating matters of patient care, academic responsibilities or conflicts with Hospital employees and Physicians, dentists, Midwives or extended class nurses. Similarly, the duties include implementing procedures to monitor and ensure Professional Staff compliance with By-Laws, Rules and Regulations, Policies and practice of the Professional Staff; and

(viii) the Chair of MAC will support the Chiefs of Departments in encouraging participation of Professional Staff in continuing education and professional development.

21.05 Vice Chair, Medical Advisory Committee The Vice-Chair of the Medical Advisory Committee shall perform such duties as assigned from time to time by the Chair of the Medical Advisory Committee.

By-law 2 – June 2011 41

21.06 Appointment of Vice-President, Medical The Vice President Medical Affairs and Quality shall be selected and hired by the Chief Executive Officer.

21.07 Responsibilities and Duties of the Vice President, Medical The Vice President Medical Affairs and Quality responsibilities and duties shall be set out in an employment agreement and shall include: (a) assisting the Chair of MAC and Chiefs of Department in the development and periodic

review and revision of the Hospital’s By-Laws, Rules and Regulations and departmental policy and practices;

(b) providing secretariat support to the Chair of MAC; (c) assisting the Chair of MAC in carrying out duties assigned to the Chair of MAC under

these By-Laws; (d) facilitating the work of the Chiefs of Department in the development, periodic review

and revision of Departmental Medical/Professional Staff Human Resource Plans; (e) coordinating and supporting the organization-wide utilization management strategy and

monitoring such utilization on an ongoing basis; (f) responsibility for the creation and review of all medical impact analysis; (g) be primarily responsible for all medical/professional compensation and

medical/professional human resource activities in the Hospital; (h) through the Chiefs of Department ensuring adequate supervision of any member of the

Professional Staff for any period of time when concerns arise about the quality of care of a specific Physician, Dentist, Midwife or Extended Class Nurse.

(i) work with the Chair of MAC in investigating matters of patient care, academic responsibilities or conflicts with the Hospital employees and Physicians, Dentists, Midwives or Extended Class Nurses. Similarly, the duties include implementing procedures to monitor and ensure Professional Staff compliance with By-laws, Rules and Regulations, Policies and practice of Professional Staff.

(j) carrying out the performance evaluation of all Chiefs of Departments. (k) implementing procedures to monitor and ensure Medical, Dental, Midwifery and

Extended Class Nursing Staff compliance with By-Laws, the Affiliation Agreement, Rules and Regulations, Policies and practice of the staff; and

(l) working through departmental Chiefs encourage participation of Professional Staff in continuing education and professional development.

ARTICLE 22. MEETINGS OF THE MEDICAL STAFF ASSOCIATION

22.01 Meetings of the Medical Staff Association (a) At least four (4) meetings of the Medical Staff will be held in conformity with the

Hospital Management Regulation under the Public Hospitals Act, one of which will be the annual meeting.

(b) A written notification of each regular meeting will be distributed by the Secretary of the Medical Staff at least forty-eight (48) hours prior to each regular meeting and written notice of the annual meeting will be distributed at least ten (10) days in advance of the meeting.

By-law 2 – June 2011 42

22.02 Special Meetings of the Medical Staff Association (a) In cases of emergency where determined by the President of the Medical Staff, may

call a special meeting of the Medical Staff. (b) Special meetings will be called by the President of the Medical Staff on the written

request of any twenty (20) members of the Active or Associate Staff. (c) Notice of any special meeting will be as required for a regular meeting, except in cases

of emergency, and will state the nature of the business for which the special meeting is called.

(d) The usual period of time required for giving notice of any special meeting will be waived in cases of emergency, subject to ratification of this action by the majority of those members present voting at the special meeting as the first item of business of the meeting.

22.03 Quorum Fifty (50) Medical Staff members entitled to vote (e.g., Active, Associate) will constitute a quorum at any annual or regular meeting of the Medical Staff, and seventy-five (75) Medical Staff members entitled to vote will constitute a quorum at any special meeting of the Medical Staff.

22.04 Attendance for Meetings of the Medical Staff Association and Medical Staff Association Dues

(a) The Secretary of the Medical Staff will make a record of the attendance of each meeting of the Medical Staff and provide to the Chief of the department.

(b) Each member of the Active and Associate Staff will be expected to attend at least fifty (50) percent of the meetings of the Medical Staff and seventy (70) percent of the meetings of the respective department to which they are associated.

(c) Each member of the Medical Staff shall be required to pay such dues as are established by the offices of the Medical Staff Association rom time to time.

ARTICLE 23. OFFICERS OF THE MEDICAL STAFF ASSOCIATION

23.01 Officers of the Medical Staff (a) The officers of the Medical Staff will be:

(i) the President; (ii) the Vice-President; (iii) the Secretary/Treasurer; (iv) up to five (5) members-at-large, it being the intention but not the requirement

that up to two (2) of whom shall be Family Physicians; and (v) immediate past President of the Medical Staff.

(b) With the exception of the immediate past President of the Medical Staff who shall be an ex officio officer of the Medical Staff, these officers will be elected prior to the annual meeting of the Medical Staff by a majority vote of the Active and Associate Members of the Medical Staff in accordance with the procedures as set out in section 19.06 of this By-Law.

By-law 2 – June 2011 43

(c) The officers will be elected for a one (1) year term and may be re-elected to the same office for an additional one (1) year term. An officer may be re-elected to the same position for up to two (2) terms following a break in continuous service of at least one year.

23.02 Eligibility for Office Only members of the Active Staff may be elected to any position or office of the Medical Staff, as established by this By-Law.

23.03 President of the Medical Staff The President of the Medical Staff will: (a) preside at all meetings of the Medical Staff; (b) call special meetings of the Medical Staff; (c) be a member of the Medical Advisory Committee; (d) be a non-voting member of the Board and as a Director, fulfill fiduciary duties to the

Hospital by making decisions in the best interest of the Hospital as required pursuant to the By-Laws;

(e) be a member of Committees of the Board as designated by the By-Laws of the Corporation, and all committees of the Medical Advisory Committee and the Medical Staff Association; and

(f) act as a liaison between the Medical Staff, the Chief Executive Officer, and the Board with respect to matters concerning the Medical Staff.

23.04 The Vice-President of the Medical Staff The Vice-President of the Medical Staff will: (a) act in the place of the President of the Medical Staff and perform the duties and

possess the powers of the President, in the absence or disability of the President; (b) be a member of the Medical Advisory Committee; and (c) perform such duties as the President of the Medical Staff may delegate.

23.05 The Secretary/Treasurer of the Medical Staff The Secretary/Treasurer of the Medical Staff will: (a) attend to the correspondence of the Medical Staff; (b) be a member of the Medical Advisory Committee; (c) maintain the financial records of the Medical Staff and provide a financial report at the

annual meeting of the Medical Staff; (d) ensure notification of all members of the Medical Staff at least 48 hours prior to each

regular meeting; (e) ensure that minutes are kept of Medical Staff meetings; and (f) act in the absence of the Vice-President of the Medical Staff, performing the duties and

possessing the powers of the Vice-President in the absence or disability of the Vice-President of the Medical Staff.

23.06 Election Procedures of Officers of the Medical Staff Association (a) Election of the officers of the Medical Staff, will be by mail ballot.

By-law 2 – June 2011 44

(b) At least sixty (60) days before the annual meeting of the Medical Staff, the nominating committee, composed of the President and the two most immediate Past Presidents available on the Medical Staff, will, by mail, call for nominations of the Active Staff members to stand for the offices of the Medical Staff, which are to be filled by election in accordance with the regulations under the Public Hospitals Act.

(c) In order for a nomination to be valid, each nomination must be signed by at least two (2) members of the Active or Associate Staff, and the nominee must signify in writing on the nomination form their acceptance of it.

(d) At least twenty-one (21) days prior to the annual meeting, a ballot will be mailed to the Active and Associate Staff members at the last address according to the records.

(e) Ballots must be received by the nominating committee seven (7) days prior to the annual meeting.

(f) Election results will be announced at the annual meeting.

23.07 Vacancies (a) When vacancies occur during the term of office, they will be filled for the balance of the

term through an election process. (b) This election process will be by mail ballot. (c) Within thirty (30) days of a vacancy, the nominating committee, consisting of the

remaining Officers of the Medical Staff, will, by mail, call for nominations of the Active Staff members to stand for the vacant position.

(d) In order for a nomination to be valid, each nomination must be signed by at least two (2) members of any of the Active or Associate Staff, and the nominee must signify in writing on the nomination form their acceptance of it.

(e) Within five (5) working days of the completion of the nomination period, ballots will be mailed to the Active and Associate Staff members at the last address according to the records.

(f) Ballots must be received by the nominating committee by 1700 hours on the tenth (10th) business day following the ballot mailing.

(g) Election results will be posted within two (2) business days of the close of the balloting period and will be announced at the next meeting of the Medical Staff.

ARTICLE 24. DENTAL STAFF/SERVICE

24.01 Preamble (a) For the purpose of brevity only, certain sections of Articles 10, 11, 12, 13, 14 and 15 -

Medical Staff, of this By-Law will apply, with substitution of the words “Dental” for “Medical” and “dentist” for “Physician”, to form part of this Article 20- Dental Staff where the content requires.

(b) The applicable sections include: Purposes of the By-Law (section 10.01), Application for Appointment (sections 11.01 and 11.02), Criteria for Appointment to the Medical Staff (section 11.03), Procedure for Processing Applications (section 11.04), Reappointment to the Medical Staff (section 11.05), Dispute Resolution (section 11.06), application for Change of Privileges (section 11.07); Categories of the Medical Staff (section 12.01), Honourary Staff (section 12.05), Performance Reviews (section 12.09), Monitoring Practices (section 13.01), Suspension/Revocation of Privileges (section 13.02), Duties and Responsibilities (sections 14.01 and 14.02), Chiefs/Deputy

By-law 2 – June 2011 45

Chiefs/Site Leader/Heads of Service and their Duties (sections 15.03, 15.04, 15.06, 15.07, 15.09 and 15.10), and Schedule “A”.

24.02 Dental Service The Dental Staff will function in the Dental Service as part of the Department of Surgery.

24.03 Appointment The Board, having given consideration to the advice of the Medical Advisory Committee, may on an annual basis appoint one or more dentists to the Dental Staff of the Hospital. As part of the appointment, the Board will specify the Privileges for each dentist.

24.04 Admitting Privileges (a) Active and Associate Staff members who are oral and maxillofacial surgeons may be

granted Admitting and Procedural Privileges, as approved by the Board, after haven given consideration through recommendation of the Chief of Department and Medical Advisory Committee; and

(b) Active Staff members, other than an oral and maxillofacial surgeon, may on the joint order of a Physician who is a member of the Medical Staff, admit a patient for treatment

24.05 Head of the Dental Service (a) The Medical Advisory Committee, on the recommendation of the Chief of Surgery, will

assign a member of the Active Dental Staff as Head of the Dental Service. (b) Appointment, duties and performance evaluation of the Head of Dental Service are as

outlined in Section 15.04.

24.06 Dental Clinical Resource Plan The Medical Advisory Committee will recommend to the Board for approval, on an annual basis, a Dental Clinical Resource Plan for the Dental Service as recommended by the Vice President Medical Affairs and Quality in consultation with the Chief of Surgery, Head of the Dental Service and Program and Service Medical Directors in collaboration with appropriate Regional Partners. This plan will be consistent with the strategic directions of the Corporation as established by the Board and will form part of the Medical/Professional Staff Human Resource Plan.

24.07 Meetings (a) Medical Staff Meetings

(i) A member of the Dental Staff is eligible, but not required to attend Medical Staff meetings.

(ii) A member of the Dental Staff is not eligible to vote at a Medical Staff meeting or to hold office other than the Head of the Dental Service.

(b) Dental Staff Meetings Dental Staff members are expected to attend seventy (70) percent of the meetings of the Dental Service.

By-law 2 – June 2011 46

ARTICLE 25. MIDWIFERY STAFF

25.01 Preamble (a) For the purpose of brevity only, certain sections of Articles 10, 11, 12, 13, 14 and 15

Medical Staff, of this By-Law will apply, with substitution of the words “Midwifery” for “Medical” and “Midwife” for “Physician”, to form sections of Article 21- Midwifery Staff.

(b) The applicable sections include: Purposes of the By-Law (section 10.01), Application for Appointment (sections 11.01 and 11.02), Criteria for Appointment to the Medical Staff (section 11.03), Procedure for Processing Applications (section 11.04), Reappointment (section 11.05), Application for change of Privileges (section 11.07), Honourary Staff (section 12.05), Performance Reviews (section 12.09), Monitoring Practices (section 13.01), Suspension/Revocation of Privileges (section 13.02), Duties and Responsibilities (sections 14.01 and 14.02), Chiefs/Deputy Chiefs/Site Leader/Heads of Service and their Duties (sections 15.03, 15.04, 15.06, 15.07, 15.09 and 15.10), and Schedule “A”.

25.02 Midwifery Service The Midwifery Staff will function within the Department of Obstetrics and Gynaecology.

25.03 Appointment The Board, having given consideration to the advice of the Medical Advisory Committee, may on an annual basis, appoint one or more Midwives to the Midwifery Staff of the Hospital and will delineate the Privileges for each Midwife.

25.04 Criteria For Appointment to the Midwifery Staff (a) Each applicant for appointment to the Midwifery Staff will meet the following

qualifications: (i) each applicant must hold a current valid certificate of registration with the

College of Midwives of Ontario; and (ii) each applicant must be able and willing to comply with the relevant provisions

of the Affiliation Agreement and the affiliation agreement between the Corporation and Mohawk College.

(b) Notwithstanding the qualifications noted above: (i) the individual should meet the needs of the respective department as described

in the Medical/Professional Staff Human Resource Plan and will be assessed on the basis of credentials, experience and such other factors as the Board may, from time to time, consider relevant or as set out in the Rules and Regulations of the Midwifery Staff;

(ii) at the time of application, the individual will accept in writing the mission statement and philosophy of the Corporation, and agree in writing to abide by the requirements of the Public Hospitals Act, By-Laws, Rules and Regulations of the Midwifery Staff, and Policies of the Corporation;

(iii) the recommendation of a Midwife’s appointment will include mutually agreed upon clinical and academic responsibilities. These responsibilities may change from time to time throughout the term of the Midwife’s appointment with the approval of the Chief of Department with the advice of the Director of the Midwifery Service and the Midwifery Program Director.

By-law 2 – June 2011 47

(c) If in the view of the Chief of Obstetrics and Gynaecology and the Director of the Midwifery Service the individual does not meet the previously agreed upon clinical and academic responsibilities, the Chief of Obstetrics and Gynaecology and the Director of the Midwifery Service will review the Midwife’s continuing Midwifery Staff appointment and at their discretion, will make an appropriate recommendation to the Board.

25.05 Categories of the Midwifery Staff The Midwifery Staff will be divided into the following categories:

(i) Associate; (ii) Active; (iii) Courtesy; (iv) Honourary; and (v) Locum

25.06 Associate Staff (a) Midwives who are applying for appointment to the Active Midwifery Staff, subject

otherwise to the determination of the Board, will be assigned to the Associate Staff for a period of at least one year and will not extend beyond two years.

(b) An Associate Staff member will: (i) work with the advice, counsel and under the supervision of an Active Staff

Midwife or Medical Staff member named by the Chief of Obstetrics and Gynaecology with the advice of the Director of the Midwifery Service;

(ii) be granted Admitting And Procedural Privileges as approved by the Board after having given consideration to the recommendation of the Chief of Staff or Chief of Obstetrics and Gynaecology with the advice of the Director of the Midwifery Service, and the Medical Advisory Committee;

xxxi. undertake such clinical, academic and administrative duties and responsibilities as determined by the Chief of Obstetrics and Gynaecology with the advice of the Director of the Midwifery Service and the Midwifery Program Director;

xxxii. be eligible to attend meetings of the Medical Staff, but is not eligible to vote at meetings of the Medical Staff, or hold office as described in Article 18 of this By-Law;

xxxiii. be bound by the expectations for attendance at Medical Staff, departmental and service meetings; and

xxxiv. perform such other duties as may be prescribed by the Medical Advisory Committee from time to time.

(c) In preparation for renewal of appointment, the Chief of Obstetrics and Gynaecology with the advice of the Director of the Midwifery Service, will make a written report to the Medical Advisory Committee through the Credentials Committee, including comments on: (i) participation in continuing education programs; (ii) ability to communicate with patients and staff, together with information

regarding patient or staff complaints regarding the applicant, if any; (iii) the applicant’s ability to work and cooperate with and relate to others in a

collegial and professional manner with the Board, the Chair of MAC, Chief of the department and other members of the Medical Advisory Committee, Clinical

By-law 2 – June 2011 48

and Program Service Directors, other members of the Professional Staff, the nursing staff, other healthcare practitioners and learners within the Hospital and other employees of the Corporation;

(iv) “on-call” responsibilities; (v) staff and committee responsibilities; (vi) quality of care issues; (vii) discharge of clinical and academic responsibilities; (viii) ability to supervise staff; (ix) monitoring of patients, together with evidence of appropriate and completed

clinical record documentation; (x) appropriate and efficient use of Hospital resources; (xi) general compliance with the Public Hospitals Act, the Hospital’s By-Laws, Rules

and its Policies; and (xii) such other information that the Board may require, from time to time, having

given consideration to the recommendation of the Medical Advisory Committee. (d) After one (1) year, the appointment of a Midwife to the Associate Staff will be reviewed

by the Credentials Committee, which will report to the Medical Advisory Committee. The review will include an assessment of the Midwife’s performance. The Medical Advisory Committee, after considering the report of the Credentials Committee, will recommend to the Board for its consideration and determination either a change in category, continuation in the Associate Staff category for a further period of time not to exceed an additional year of practice, or denial of reappointment.

25.07 Active Staff (a) Members of the Active Midwifery Staff will:

(i) consist of those Midwives who are responsible for ensuring that an acceptable standard of care is provided to patients under their supervision, and who have not reached the age of retirement as determined by this By-Law;

(ii) usually have completed at least one year on the Associate Staff; (iii) undertake such clinical, academic and administrative duties and responsibilities

as determined by the Chief of Obstetrics and Gynaecology with the advice of the Director of the Midwifery Service and the Midwifery Program Director;

(iv) be granted Admitting And Procedural Privileges as approved by the Board having given consideration to the recommendation of the Chief of Obstetrics and Gynaecology with the advice of the Director of the Midwifery Service, and the Medical Advisory Committee;

(v) be eligible for annual reappointment, as provided in this By-Law; (vi) be eligible to attend meetings of the Medical Staff, but, with the exception of the

Director of the Midwifery Service, is not eligible to vote at meetings of the Medical Staff, or hold office as described in Article 19 of this By-Law;

(vii) be bound by the expectations for attendance at Medical Staff, departmental and service meetings;

(viii) act as a supervisor of Midwifery Staff when requested by the Chief of Obstetrics and Gynaecology with the advice of the Director of the Midwifery Service; and

(ix) perform such other duties as may be prescribed by the Medical Advisory Committee from time to time.

By-law 2 – June 2011 49

25.08 Courtesy Staff (a) Courtesy Midwifery Staff will:

(i) consist of Midwives who have been granted Admitting and Procedural Privileges as approved by the Board having given consideration to the recommendation of the Chief of Obstetrics and Gynaecology with the advice of the Director of the Midwifery Service and Medical Advisory Committee without the responsibilities of Active Midwifery Staff membership;

(ii) be a member of the Active or Associate Midwifery Staff of another hospital at which the Midwife’s primary activities are based subject to determination by the Board in each individual case;

(iii) undertake such clinical and academic duties and responsibilities as determined by the Chief of Obstetrics and Gynaecology with the advice of the Director of the Midwifery Service;

(iv) admit and treat patients admitted as an emergency, or elective admissions when facilities permit;

(v) be eligible for annual reappointment as provided in this By-Law; and (vi) be eligible to attend Medical Staff meetings.

(b) Courtesy Staff will not: (i) have regularly assigned administrative duties and responsibilities; (ii) vote at meetings of the Medical Staff or hold office as described in Article 19 of

this By-Law; or (iii) be bound by the expectations for attendance at Medical Staff, departmental and

service meetings.

25.09 Locum Midwifery Staff: (a) Locum Midwifery Staff:

(i) will consist of Midwives who have been granted Admitting and/or Procedural Privileges as approved by the Board having given consideration to the recommendation of the Chief of Obstetrics and Gynaecology with the advice of the Director of the Midwifery Service and the Medical Advisory Committee in order to meet specific clinical or academic needs for a defined period of time not to exceed three months. Such needs may include but are not limited to visiting professorships, episodic or limited consultative services, short term locum tenens, interim Privileges while applications for appointment to other categories are being processed or such other circumstances as may be required;

(ii) may be required to work with the counsel and under the supervision of an Active Medical and/or Active Midwifery Staff member named by the Chief of Obstetrics and Gynaecology with the advice of the Director of the Midwifery Service;

(iii) may be required to undergo a probationary period as appropriate and determined by the Chief of Obstetrics and Gynaecology with the advice of the Director of the Midwifery Service; and

(iv) appointments will be consistent with the established Clinical Resource Plan and will be subject to completion of an Impact Analysis.

(b) Locum Midwifery Staff will not:

By-law 2 – June 2011 50

(i) usually be eligible for reappointment on more than one occasion; (ii) attend or vote at meetings of the Medical Staff or hold office as described in

Article 19 of this By-Law; or (iii) be bound by the expectations for attendance at Medical Staff, departmental and

service meetings.

25.10 Director of the Midwifery Service (a) The Board, unless it determines otherwise, will appoint a Director of the Midwifery

Service, who is on the Active Staff or is eligible for appointment to the Active Staff. (b) The Director of the Midwifery Service will be appointed by the Board having given

consideration to the recommendation of the Medical Advisory Committee, following a search process. It is expected that the Director of the Midwifery Service will be a shared appointment between the Corporation and its Regional Partners.

(c) The Director of the Midwifery Service will be eligible to serve two consecutive five year terms, subject to annual reappointment by the Board, having given consideration to a positive formal performance evaluation at the end of the second year of both five year terms and at the end of the first five year term. However, the Director of the Midwifery Service may hold office until a successor is appointed.

(d) Such appointment may be revoked at any time or renewed by the Board. (e) The Director of the Midwifery Service will report to the Chief of Obstetrics and

Gynaecology. (f) The Director of the Midwifery Service will be responsible to the Chief of Obstetrics and

Gynaecology, Chair of MAC and Board. (g) A mutually acceptable search procedure will be established by the search committee

and approved by the Medical Advisory Committee.

25.11 Duties Of Director of the Midwifery Service (a) The Director of the Midwifery Service will: (b) supervise the professional care provided by all members of the Midwifery Staff in the

department; (c) participate in the orientation of new members appointed to the Midwifery Staff; (d) undertake the organization and implementation of a quality improvement program for

Midwifery; (e) advise the Chief of Obstetrics and Gynaecology with respect to the quality of Midwifery

care, and treatment provided to patients of the department; (f) advise the Chief of Obstetrics and Gynaecology of any patient who is not receiving

appropriate Hospital treatment and care; (g) advise the Chief of Obstetrics and Gynaecology regarding the appropriate utilization of

resources; (h) make recommendations to the Chief of Obstetrics and Gynaecology regarding

Midwifery needs of the department and of the Corporation; (i) participate in the development of the department’s mission, objectives and strategic

plan; (j) notify the Chief of Obstetrics and Gynaecology of their absence, and designate an

alternate from within the Midwifery Staff; (k) ensure that a process is in place for continuing education related to the Midwifery Staff; By-law 2 – June 2011 51

(l) review and make recommendations annually regarding the performance of members of the Midwifery Staff and concerning reappointments and Privileges; and

(m) ensure consistent standards of Midwifery service, teaching and research are applied across the Corporation and its Regional Partners.

ARTICLE 26. EXTENDED CLASS NURSES

26.01 Appointment On an annual basis, the Board, having given consideration to the advice of the Medical Advisory Committee, may appoint one or more non employed Nurses to the Extended Class Nursing Staff of the Hospital and will delineate the Privileges for each Extended Class Nurse providing services to outpatients of the Hospital in accordance with a policy to be developed by the Medical Advisory Committee. Applications from Extended Class Nurses will also be reviewed by the Chief Nursing Executive or delegate.

ARTICLE 27. SPECIAL PROFESSIONAL STAFF

27.01 Special Professional Staff (a) Special Professional Staff will, subject to determination by the Board in each individual

case: (i) consist of individuals employed by the Hospital with specific professional

expertise who are not members of a regulated health profession and who have clinical/education/research and/or clinical/education/research/administrative responsibilities;

(ii) hold a postgraduate degree; (iii) be designated by the Board having given consideration to the recommendation

of the Chief of Department and Medical Advisory Committee (iv) be employees of the Hospital and subject to annual confirmation of their

designation by the Board, on recommendation of the Chief of Department and the Medical Advisory Committee

(v) be eligible to attend Medical Staff meetings; and (vi) have regularly assigned administrative duties and responsibilities

27.02 Duties a) Special Professional Staff will not:

(i) be granted Admitting or Procedural Privileges, or engage in the practice of medicine; and

(ii) vote at meetings of the Medical Staff or be an officer of the Medical Staff or a committee chair.

27.03 Application of Clinical Plan The individual will meet the needs of the respective department as described in the Medical/Professional Staff Human Resource Plan, and will be assessed on the basis of credentials, experience, and such other factors as the Board, may from time to time, consider relevant or as set out in the Rules and Regulations.

By-law 2 – June 2011 52

By-law 2 – June 2011 53

27.04 Criteria At the time of application, the individual will accept in writing the mission statement and philosophy of the corporation, and agree in writing to abide by the requirements of the Public Hospitals Act, By-laws, Rules and Regulations, and Policies of the Corporation.

27.05 Dispute Resolution Special Professional Staff who are employees of the Corporation will be bound by its employment policies and procedures. In the event that a dispute arises regarding their employment, the employee dispute resolution mechanism of the Corporation will be followed. Should employment be terminated by the Corporation, the Special Professional Staff designation will also be terminated. For greater certainty, the provisions of Schedule “A” do not apply to Special Professional Staff.

ARTICLE 28. AMENDMENTS

28.01 Amendments to Medical Staff By-Laws Articles 14 to 28 inclusive of the By-law may be repealed, added to, amended or substituted by the Board in accordance with the following procedure: (a) notice specifying the proposed By-law or amendments thereto shall be posted; (b) the Medical Staff shall be afforded an opportunity to comment on the proposed By-law

or amendments thereto; and (c) the Medical Advisory Committee shall make recommendations to the Board concerning

the proposed By-law or amendment thereto.

ARTICLE 29. MATTERS REQUIRED BY THE PUBLIC HOSPITALS ACT

29.01 Committees and Programs Required by the Public Hospitals Act The Board shall ensure that the Corporation establishes such committees and undertakes such programs as are required pursuant to the Public Hospitals Act and the Excellent Care for All Act, 2010, including a medical advisory committee, a fiscal advisory committee and a quality committee.

29.02 Fiscal Advisory Committee The Chief Executive Officer shall appoint the members of the fiscal advisory committee required to be established pursuant to the regulations under the Public Hospitals Act.

29.03 Chief Nursing Executive The Chief Executive Officer shall ensure there are appropriate procedures in place for the appointment of the Chief Nursing Executive.

29.04 Nurses and other Staff and Professionals on Committee The Chief Executive Officer shall from time to time approve a process for participation of the Chief Nursing Executive, nurse managers, and staff nurses, staff and other professionals of the Corporation in decision making related to administrative, financial, operational and planning matters and for the election or appointment of the Chief Nursing Executive, staff nurses or nurse managers and other staff and professionals of the Corporation to those administrative committees approved by the Chief Executive officer to have a nurse, staff or professional representation.

29.05 Retention of Written Statements The Chief Executive Officer shall cause to be retained for at least twenty-five (25) years, all written statements made in respect of the destruction of medical records, notes, charts and other material relating to patient care and photographs thereof.

29.06 Occupational Health and Safety Program (a) Pursuant to the regulations under the Public Hospitals Act, there shall be an

Occupational Health and Safety Programs for the Corporation. (b) The program referred to in subsection 29.06(a) shall include procedures with respect

to: (i) a safe and healthy work environment in the Corporation; (ii) the safe use of substances, equipment and medical devices in the Corporation; (iii) safe and healthy work practices in the Corporation; (iv) the prevention of accidents to persons on the premises of the Corporation; and (v) the elimination of undue risks and the minimizing of hazards inherent in the

Corporation environment.

54

(c) The person designated by the Chief Executive Officer to be in charge of occupational health and safety in the Corporation shall be responsible to the Chief Executive Officer or his or her delegate for the implementation of the Occupational Health and Safety Program.

(d) The Chief Executive Officer shall report to the Board as necessary on matters in respect of the Occupational Health and Safety Program.

29.07 Health Surveillance Program (a) Pursuant to the regulations under the Public Hospitals Act, there shall be a Health

Surveillance Program for the Corporation. (b) The program referred to in section 29.07(a) shall:

(i) be in respect of all persons carrying on activities in the Corporation, and (ii) include a communicable disease surveillance program.

(c) The person designated by the Chief Executive Officer to be in charge of health surveillance in the Corporation shall be responsible to the Chief Executive Officer or his or her delegate for the implementation of the Health Surveillance Program.

The Chief Executive Officer shall report to the Board as necessary on matters in respect of the Health Surveillance Program.

29.08 Organ Donation Pursuant to the regulations under the Public Hospitals Act, the Board shall approve procedures to encourage the donation of organs and tissues included: (a) Procedures to identify potential donors; and (b) Procedures to make potentiation donors and their families aware of the options of

organ and tissue donations, and shall ensure that such procedures are implemented in the Corporation.

ARTICLE 30. RULES AND POLICIES

30.01 Rules of Order Any questions of procedure at or for any meetings of the Members of the Corporation, or the Board, or the Professional Staff, or of any committee, which have not been provided for in this By-law or by the Act or by the Public Hospitals Act or regulations thereunder, or the Policies adopted from time to time by the Board or the Professional Staff Rules and Regulations, shall be determined by the chair of such meeting in accordance with the rules of procedure adopted by resolution of the Board, or failing such resolution, adopted by the chair of the meeting.

30.02 Policies The Board, may from time to time, make such Policies as it may deem necessary or desirable in connection with the management of the business and affairs of the Board and the conduct of the Directors and officers, provided however that any such Policy shall be consistent with the provision of this By-law.

ARTICLE 31. NOTICES Whenever under the provisions of the by-laws of the Corporation notice is required to be given, unless otherwise provided such notice may be given in writing and delivered or sent by

55

prepaid mail, by facsimile transmission or be electronic mail addressed to the Member, Director, officer, member of a committee or auditor at the postal address, the facsimile number or electronic mail address, as the case may be, as the same appears on the books of the Corporation. If any notice is sent by prepaid mail, it shall, subject to the following paragraph, be conclusively deemed to have been received on the third (3rd) business day following the mailing thereof. If delivered, a notice shall be conclusively deemed to have been received at the time of delivery, or if sent by facsimile transmission or electronic mail, it shall be conclusively deemed to be received on the next business day after transmission. Notwithstanding the foregoing provisions with respect to mailing, in the event it may be reasonably anticipated that, due to any strike, lock out or similar event involving an interruption in postal service, any notice will not be received by the addressee by not later than the third (3rd) business day following the mailing thereof, then the mailing of such notice as aforesaid shall not be an effective means of sending the same but rather any notice must be sent by an alternative method which it may be reasonably be anticipated will cause the notice to be received reasonably expeditiously by the addressee. Any person entitled to receive any such notice may waive such notice either before or after the meeting to which such notice refers.

31.01 Computation of Time If computing the date when notice must be given under the provision requiring a specified number of days’ notice of any meeting or other event, the date of giving the notice shall be excluded and the date of the meeting or other event shall be included.

31.02 Omissions and Errors The accidental omission to give any notice to any Member, Director, officer, member of a committee or the auditor of the Corporation or the non-receipt of any notice by any Member, Director, officer, member of a committee or the auditor of the Corporation or any error in any notice not affecting the substance thereof shall not invalidate any action taken at any meeting held pursuant to such notice or otherwise founded thereon.

31.03 Waiver of Notice Any Member, Director, officer, member of a committee or the auditor of the Corporation may waive any notice required to be given to him or her under any provision of the Public Hospitals Act, the Act or the Letters Patent or the by-laws of the Corporation, and such waiver, whether given before or after the meeting or other event of which notice is required to be given, shall cure any default in giving such notice. Attendance and participation at a meeting constitutes waiver of notice.

ARTICLE 32. AMENDMENT TO THE BY-LAWS

56

32.01 Amendment Subject to applicable legislation, the provisions of the by-laws of the Corporation may be repealed or amended by by-law enacted by a majority resolution of the Directors at a meeting of the Board of Directors and sanctioned by at least a majority of the Members entitled to vote and voting at a meeting duly called for the purpose of considering the said by-law.

32.02 Effect of Amendment Subject to the Act and to section 32.03 below, a by-law or an amendment to a by-law passed by the Board has full force and effect: (a) from the time the motion was passed, or (b) from such future time as may be specified in the motion.

32.03 Member Approval A by-law or an amendment to a by-law passed by the Board shall be presented for confirmation at the next annual meeting or to a general meeting of the Members of the Corporation called for that purpose. The notice of such annual meeting or general meeting shall refer to the by-law or amendment to be presented. The Members entitled to vote at the annual meeting or at a general meeting may confirm the by-law as presented or reject or amend it, and if rejected, it thereupon ceases to have effect and if amended, it takes effect as amended. In any case of rejection, amendment, or refusal to approve the by-law or part of the by-law in force and effect in accordance with any part of this section, no act done or right acquired under any such by-law is prejudicially affected by any such rejection, amendment or refusal to approve.

32.04 Amendments to the Professional Staff By-law Prior to submitting all or any part of the Professional Staff By-law to the process in sections 32.01 and 32.03, the procedures set out in Article 28 shall be followed.

57

SCHEDULE “A”

PROCEDURE FOR HEARINGS REGARDING APPOINTMENT, REAPPOINTMENT, CHANGES IN PRIVILEGES

AND MID-TERM ACTION

PART I INTRODUCTION

This schedule outlines the procedures for hearings in three different circumstances. Part II deals with recommendations from the Medical Advisory Committee for appointment, reappointment and changes in Privileges that differ from the applicant’s or member’s request. Part III outlines the procedure when there is immediate need to suspend Privileges mid-term in an emergency situation. Part IV is the procedure when mid-term action is required but not in an emergency situation. It should be noted that a Physician’s appointment and/or Privileges will continue throughout the investigation of circumstances relating to Part II (appointment, reappointment and changes in Privileges) and Part IV (non-immediate mid-term action) and until all appeals consistent with the Public Hospitals Act are completed.

PART II APPOINTMENT, REAPPOINTMENT AND CHANGES IN PRIVILEGES

1. Recommendations for Appointment, Reappointment and Changes in Privileges

In Response to the written notice pursuant to Section 11.04 (d) the applicant or member requires a hearing by the Board, the provision of this Part II will apply. The Provisions of Part II also apply where a hearing is requested pursuant to the circumstance referred to in subsections 11.05 (g), 11.06 (b) and 11.07 (d).

2. Board Hearing

(a) The Board will name a place and time for the hearing.

(b) The Board hearing will be held within fourteen (14) days of the Board receiving the written notice from the member or applicant requesting the hearing.

(c) The Board will give written notice of the hearing to the applicant or member and to the Medical Advisory Committee at least seven (7) days before the hearing date.

(d) The notice of the Board hearing will include:

(i) the place and time of the hearing;

(ii) The Board Chair shall appoint a panel comprised of a subset of the Board, normally three in number, to conduct the hearing. If the Board Chair is a member of the panel, the Board Chair shall also chair the panel. Otherwise, the Board Chair shall select one of the panel members to serve as the panel chair. The panel shall be authorized to hear and determine all matters relating to the procedure and merits of the issues that are the subject of the hearing, including issues as to its jurisdiction. A decision of the majority of the panel shall be determinative.

58

(ii) the purpose of the hearing;

(iii) a statement that the applicant or member and Medical Advisory Committee will be afforded an opportunity to examine prior to the hearing, any written or documentary evidence that will be produced, or any reports the contents of which will be given in evidence at the hearing;

(iv) a statement that the applicant or member may proceed in person or be represented by counsel, call witnesses and tender documents in evidence in support of his or her case;

(v) a statement that the time for the hearing may be extended by the Board on the application of any party; and

(vi) a statement that if the applicant or member does not attend the meeting, the Board may proceed in the absence of the applicant or member, and the applicant or member will not be entitled to any further notice in the hearing.

(e) The parties to the Board hearing are the applicant or member, the Medical Advisory Committee and such other persons as the Board may specify.

(f) The applicant or member requiring a hearing shall be afforded an opportunity to examine, prior to the hearing, any written or documentary evidence that will be produced, or any reports the contents of which will be used in evidence.

(g) (i) Members of the Board holding the hearing will not have taken part in any investigation or consideration of the subject matter of the hearing and will not communicate directly or indirectly in relation to the subject matter of the hearing with any person or with any party or their representative, except upon notice to and an opportunity for all parties to participate.

(ii) Despite the foregoing, the Board may seek legal advice.

(h) The findings of fact of the Board pursuant to a hearing will be based exclusively on evidence admissible or matters that may be noticed under the Statutory Powers Procedure Act.

(i) The Board will consider the reasons for the Medical Advisory Committee that have been given to the applicant or member in support of its recommendations. Where through error or inadvertence, certain reasons have been omitted in the statement delivered to the member, the Board may consider those reasons only if those reasons are given by the Medical Advisory Committee in writing to both the applicant or member and the Board, and the applicant or member is given a reasonable time to review the reasons and to prepare a case to meet those additional reasons.

(j) No member of the Board will participate in a decision of the Board pursuant to a hearing unless they are present throughout the hearing and heard the evidence and argument of the parties and, except with the consent of the parties, no decision of the Board will be given unless all members so present participate in the decision.

59

(k) The Board will make a decision to either follow, amend or not follow the recommendation of the Medical Advisory Committee.

(l) A written copy of the decision of the Board and the written reasons for the decision will be provided to the applicant or member and to the Medical Advisory.

60

(m) Service of a notice to the applicant may be made personally or by registered mail addressed to the person to be served at their last know address and, where notice is served by registered mail, it will be deemed that the notice was served on the third day after the day of mailing unless the person to be served establishes that they did not, acting in good faith, through absence, accident, illness or other causes beyond their control, receive it until a later date.

PART III IMMEDIATE MID-TERM ACTION IN AN EMERGENCY SITUATION

1. Immediate Steps

(a) The individual who suspends a member under section 13.02 (b) will immediately notify the member, the Medical Advisory Committee, the Chief Executive Officer or delegate, the Vice President Medical Affairs and Quality, Chair of MAC, the Chief of Department and the Board of a decision to suspend the member’s Privileges.

(b) Arrangements will be made by the Chair of MAC or the Chief of the relevant Department for the assignment of a substitute to care for the patients of the suspended member.

(c) Within forty-eight (48) hours of suspension, the individual who suspended the member will provide the member, the Medical Advisory Committee or delegate with written reasons for the suspension and copies of any relevant documents or records.

2. The Medical Advisory Committee

(d) The Medical Advisory Committee will set a date for a meeting of the Medical Advisory Committee to be held as soon as practicable but within seven (7) days from the date of suspension to review the suspension and to make recommendations to the Board.

(e) As soon as possible, and in any event, at least forty-eight (48) hours prior to the Medical Advisory Committee meeting, the Medical Advisory Committee will provide the member with written notice of:

(i) the time and place of the meeting;

(ii) the purpose of the meeting;

(iii) a statement of the matter to be considered by the Medical Advisory Committee together with any relevant documents;

(iv) a statement that the member is entitled to attend the Medical Advisory Committee meeting to make submission in respect of all matters considered by the Medical Advisory Committee;

(v) a statement that the parties are entitled to bring to the meeting and consult with legal counsel, but the legal counsel will not be entitled to participate in the meeting; and

(vi) a statement that in the absence of the member, the meeting may proceed.

61

(f) The member may request and the Medical Advisory Committee may grant postponement of the Medical Advisory Committee meeting.

(g) At the meeting of the Medical Advisory Committee, a record of the proceedings shall be kept in the minutes of the Medical Advisory Committee meeting.

(h) Before deliberating on the recommendation to be made to the Corporation’s Board, the Chair will require the member involved, and any other persons present who are not voting members of the Medical Advisory Committee, to retire. The Medical Advisory Committee will not consider any matter or case to which it did not give the member a fair opportunity to answer.

(i) The Medical Advisory Committee will provide to the member within twenty-four (24) hours of the Medical Advisory Committee meeting written notice of the Medical Advisory Committee’s recommendation and the written reasons for the recommendation and the member shall be advised of the member’s entitlement to a hearing before the Board.

(j) The Medical Advisory Committee shall provide the Board within twenty-four (24) hours of the Medical Advisory Committee meeting written notice of the Medical Advisory Committee’s recommendation.

3. Board Hearing

(a) If the member requests a hearing by the board, the procedure outlined in Part II above (Board Hearing) will be followed.

PART IV NON-IMMEDIATE MID-TERM ACTION

1. Initiation

(b) Where information is provided to the Chair of MAC, Chief of Department, Vice President Medical Affairs and Quality or Chief Executive Officer which raises concerns about any of the matters in this By-Law relating to Non-Immediate Mid-Term Action, the information will be in writing.

(c) If any of the Chief Executive Officer, Chair of MAC, Chief of Department or Vice President Medical Affairs and Quality receives information about the conduct, performance or competence of a member, that person will provide a copy of the documentation to the others.

2. Initial Interview

(a) An interview will be arranged by the Chair of MAC, Vice President Medical Affairs and Quality and/or the Chief of Department with the member at which time the member will be advised of the information about their conduct, performance or competence and will be given a reasonable opportunity to present relevant information on their behalf.

(b) A written record will be maintained reflecting the substance of the interview and copies will be sent to the member, the Chair of MAC, the Vice President Medical Affairs and Quality and the Chief of Department.

62

(c) If the member fails or declines to participate in the interview after being given a reasonable opportunity, the appropriate action may be initiated as outlined below.

3. Investigation

(a) The Chair of MAC, Vice President Medical Affairs and Quality or Chief of Department will determine whether further investigation is necessary.

(b) The investigation may be assigned to an individual(s) within the Corporation, the Medical Advisory Committee, a body within the Corporation other than the Medical Advisory Committee or an external consultant.

(c) Upon completion of the investigation the individual or body who conducted the investigation will forward a written report to the Chair of MAC, Vice President Medical Affairs and Quality and Chief of Department. The member will be provided with a copy of the written report.

(d) The Chair of MAC, Vice President Medical Affairs and Quality and Chief of Department will review the report and determine whether any further action may be required.

4. Request to the Medical Advisory Committee for Mid-Term Action

(a) Where it is determined by the Chief of Department or Chair of MAC or Vice President Medical Affairs and Quality that further action may be required and the matter relates to the revocation, suspension or restriction of a member’s Privileges and/or the quality of care, the matter will be referred to the Medical Advisory Committee who will make a recommendation to the Board.

(b) All requests for a recommendation for mid-term action must be submitted to the Medical Advisory Committee in writing and supported by references to the specific activities or conduct which constitute grounds for the request.

(c) Where the matter is referred to the Medical Advisory Committee, a copy of any reports made by an individual or body with respect to the matter will be forwarded to the Medical Advisory Committee.

(d) The Medical Advisory Committee may initiate further investigation itself, establish an ad hoc committee to conduct the investigation, refer the matter to an external consultant, dismiss the matter for lack of merit or determine to have a special meeting of the Medical Advisory Committee.

(e) Where the Medical Advisory Committee establishes an ad hoc committee to conduct the investigation or refers the matter to an external consultant, that individual or body will forward a written report of the investigation to the Medical Advisory Committee as soon as practicable after the completion of the investigation.

(f) Upon completion of its own investigation or upon receipt of the report of the body that conducted the investigation, as the case may be, the Medical Advisory Committee may either dismiss the matter for lack of merit or determine to have a meeting of the Medical Advisory Committee.

63

64

(g) Within twenty-one (21) days after receipt by the Medical Advisory Committee of the request for a recommendation for mid-term action, unless deferred, the Medical Advisory Committee will determine whether a meeting of the Medical Advisory Committee is required to be held.

(h) If additional time is needed for the investigative process, the Medical Advisory Committee may defer action on the request. The Medical Advisory Committee must act within thirty (30) days of the deferral.

(i) If the Medical Advisory Committee determines that there is merit to proceed to a Medical Advisory Committee meeting, then the member is entitled to attend the meeting.

(j) Where the Medical Advisory Committee considers a matter at its meeting, the procedures as set out in Part III, section 2 (Medical Advisory Committee Meeting) above will be followed.

(k) Where the member continues in their duties and the Chief of Department believes the member’s work should be scrutinized, the member’s work will be scrutinized in a manner to be determined by the Chief of Department in consultation with the Vice President Medical Affairs and Quality.

(l) If at any time it becomes apparent that the member’s conduct, performance or competence is such that it exposes, or is reasonably likely to expose patient(s) to harm or injury and immediate action must be taken to protect the patient(s), then the procedures as set out in Part III will be invoked.

Custodian: Board of Directors Office

Administrative and Medical By- · PDF file22.04 Attendance for Meetings of the Medical Staff...

Documents

Transcript of Administrative and Medical By- · PDF file22.04 Attendance for Meetings of the Medical Staff...