MEDICAL STAFF BYLAWSTABLE OF CONTENTS

DEFINITIONS……………………………………………………………………………………………………………………………………….2

MEDICAL STAFF ORGANIZATIONPurpose of the Medical Staff

Organization………………………………………………………………………………3Responsibilities of the Medical Staff

Organization………………………………………………………………….3Membership of the Medical

Staff……………………………………………………………………………………………4Appointment and

Reappointments……………………………………………………………………………………….10Professional

Conduct…………………………………………………………………………………………………………….14

CLINICAL DEPARTMENTS AND DIVISIONS………………………………………………………………………………………….18

Responsibilities……………………………………………………………………………...…………………………………….18

Functions of Clinical Departments/Divisions…………………………………………………………………………20

Duties of the Medical Director……………………………………………………………………………………………..20

Duties of the Associate Medical Director………………………………………………………………………………22

Duties of the Chief of the OPD………………………………………………………………………………………………22

Duties of the Director of Medical Education………………………………………………………………………….23

Duties of the Director of Research………………………………………………………………………………………..23

MEDICAL STAFF COMMITTEES…………………………………………………………………………………………………………..25

Standing Committees of the Medical Staff…………………………………………………………………………….25

Medical Executive Committee………………………………………………………………………………………………26

Bylaws Team…………………………………………………………………………………………………………………………27

Credentials Committee…………………………………………………………………………………………………………28

Department Chairs Committee……………………………………………………………………………………………..28

Ophthalmology Division Chiefs……………………………………………………………………………………………..28

Promotions Committee…………………………………………………………………………………………………………29

Education Committee……………………………………………………………………………………………………………29

Fellowship Team…………………………………………………………………………………………………………………..30

Medical Library Team……………………………………………………………………………………………………………31

Research Council…………………………………………………………………………………………………………………..31

Human Ethics Committee/Institutional Review Board…………………………………………………………..32

Morbidity and Mortality Committee……………………………………………………………………………………..32

Medical Care Committee………………………………………………………………………………………………………33

Pharmacy and Therapeutics Committee………………………………………………………………………………..33

Nursing/Pharmacy Team………………………………………………………………………………………………………34

MEDICAL STAFF MEETINGS……………………………………………………………………………………………………………….36AMMENDMENTS TO AND ADOPTION OF MEDICAL STAFF BYLAWS……………………………………………………38RULES AND REGULATIONS…………………………………………………………………………………………………………………39ADOPTED BY THE MEDICAL STAFF…………………………………………………………………………………………………….41

DEFINITIONS

The term “HOSPITAL” means Hospital.

The Supervisor General represents the Ministry of Health and is the final governing authority of the Hospital.

The Supervisor General is the individual responsible for the overall management of the Hospital.

The Supervisor General Assistant is the individual who reports to the Supervisor General Deputy and participates in the daily operation of the hospital.

The term “Medical Director” means the physician, appointed by the Supervisor General, who shall oversee the carrying out of medical programs and policies.

The term “Medical Staff” means all persons holding MD or equivalent degree who are privileged totreat patients within their licensure in HOSPITAL.

The term “Clinical Department Chair” means a member of the Medical Staff designated by theMedical Director to assume medical administrative responsibilities for one of the MedicalDepartments.

The term “Ophthalmology Division Chief” means a member of the Medical Staff designated by the Medical Director to assume medical administrative responsibilities within a recognized subspecialty or organizational section.

“Medical Staff Bylaws” means the set of Bylaws governing the medical administration of HOSPITAL.

The term “Medical Staff Year” means the Gregorian calendar year beginning January 1 and ending December 31.

The term “Quorum” of the Medical Staff Committees means at least 50% of the Committee members, including those excused or on leave, who must be present at the outset of each meeting.

“MEC” shall refer to Medical Staff Executive Committee.

Nothing contained in these Bylaws, Rules and Regulations can supersede, replace or modify any of the provisions of the Employment Contracts between members of the Medical Staff and HOSPITAL.

These Bylaws are meant to clarify the professional environment at HOSPITAL.

The Bylaws Committee is proud of the achievements and standards maintained at HOSPITAL.

Suggestions for improving the Bylaws are welcomed. Written recommendations may be submitted at regular or special meetings of the Medical Staff or directly to the Bylaws Team.

Purpose of the Medical Staff Organization:

There shall be a single organized, self-governing Medical Staff that has overall responsibility for the quality of professional services provided by individuals with clinical privileges, maintaining the medical education and research programs, and ensuring ethical conduct and professional practice of its members, as well as the responsibility of accounting to the Supervisor General.

The Medical Staff has the following characteristics:

It includes fully licensed physicians permitted to provide patient care services in the Hospital.

All Medical Staff members have delineated clinical privileges that define the scope of patient care services they may provide independently or with supervision in the Hospital.

All Medical Staff members are subject to Medical Staff bylaws, rules and regulations, and policies and procedures, and are subject to review as part of the organization’s performance improvement activities.

Responsibilities of the Medical Staff Organization:

The responsibilities of the Medical Staff are to:

Develop and adopt bylaws and policies and procedures to establish a framework of self-governance of Medical Staff activities and accountability to the Supervisor General. Medical staff bylaws are adopted by the Medical Staff and approved by the Supervisor General before becoming effective. Neither body may unilaterally amend the Medical Staff bylaws. Medical Staff bylaws. Medical Staff bylaws create a framework within which the Medical Staff members can act with a reasonable degree of freedom and confidence.

Organize committees to accomplish the functions of the Medical Staff. The responsibilities of the Committees are to:

o Make recommendations of individuals for Medical Staff membership and reappointment.

o Review credentials and delineate clinical privileges for eligible individuals in order to ensure that all patients admitted and treated in the facilities of HOSPITAL shall receive high quality medical care.

o Ensure the participation of Medical Staff members in organization performance improvement activities.

o Determine the mechanisms of fair-hearing procedures and the means of reduction or termination of Medical Staff membership or delineated clinical privileges.

o The Medical Staff committees will report the Medical Executive Committee which will receive and act on reports and recommendations from Medical Staff committees, clinical departments, and assigned activity groups and be responsible for making its recommendations directly to the Supervisor General approval.

oMembership of the Medical Staff:

Basic Qualifications for Membership:

Only those physicians holding appropriate current licensure and offering documentation of their academic achievements, experience, training, demonstrated competence, adherence to the ethics of the profession, good reputation, ability to work with others and of physical and mental health sufficient to carry out the privileges granted, will be eligible for appointment to the Medical Staff. All physicians appointed to the Medical Staff must be graduates of an acceptable medical school and must have completed post-graduate medical education and certification appropriate to their professional activities at HOSPITAL unless appointed as a fellow of resident.

All qualified candidates for Medical Staff appointment must have the Supervisor General’s approval for employment.

Principles Regulating Professional Practice:

Membership on the Medical Staff or the exercise of temporary privileges shall be extended only to professionally competent physicians who continuously meet the qualifications, standards, and requirements set forth in these bylaws. Appointment to, and membership on the Staff shall confer on member only such clinical privileges and prerogatives as have been granted by the Credentials Committee and approved by the Medical Executive Committee, Medical Director, and Supervisor General in accordance with these Bylaws. No physician shall admit or provide services to patients in the hospital unless he/she is a member of the Medical Staff or has been granted temporary privileges in accordance with the procedure set forth on providing services to a patient under the conditions outlined under Appointment and Reappointment Process.

Categories of Medical Staff:

Physicians may be appointed to the Medical Staff as Faculty or Trainees.

There are four categories of Faculty: Active Staff/Permanent Active Staff/Temporary Collaborating Staff Visiting Staff

There are two categories of Trainees: Fellow/Associate Staff Resident/Assistant Staff

Faculty Staff:

1. Active Staff/Permanent:

Active Staff/Permanent shall consist of physicians who work full-time at HOSPITAL, are not in training, meet the qualifications for membership as set forth in these bylaws, and have been appointed to the Medical Staff for a period of one year or greater. Members of the Active Staff/Permanent are responsible for the continuous care of patients treated at HOSPITAL, including emergency service care, on-call responsibilities, and consultation

assignments. Members of the Active Staff/Permanent assume clinical responsibilities, as designated by the Medical Director, Department Chairs, Chief of the Outpatient Department, and Ophthalmology Division Chiefs, based upon the recommendations and approval of the Credentials Committee, Medical Executive Committee, Medical Director, and Supervisor General. They are eligible to serve on Medical Staff committees, hold office, vote, and shall be required to attend 75% of Medical Staff meetings, excluding those missed due to leave, illness, emergency patient care, or other reasons excused by the Medical Director.

2. Active Staff/Temporary:

Active Staff/Temporary shall consist of physicians who work full-time at HOSPITAL, are not in training, and meet the qualifications of membership as set forth in these bylaws, and have been appointed to the Medical Staff for a period of less than one year. These positions are available to appropriately qualified physicians to fill vacancies, on an interim (locum tenens) basis, in Clinical Departments or Ophthalmology Divisions. Members of the Active Staff/Temporary are responsible for the continuous care of patients treated at HOSPITAL, including emergency service care, on-call responsibilities, and consultation assignments during their period of appointment. Members of the Active Staff/Temporary assume clinical responsibilities, as designated by the Medical Director, Department Chairs, Chief of the Outpatient Department, Ophthalmology Division Chiefs, based upon the recommendation and approval of the Credentials Committee, Medical Executive Committee, Medical Director, and Supervisor General.Active Staff (Temporary) may attend the Medical Staff meeting (as invites) and maybe appointed by the Medical Director to serve on Medical Staff committees. Active Staff/Temporary will be subject to the same corrective action and appeal procedure as members of the Active Staff.

3. Collaborating Staff:

Selected physicians who meet all qualifications for membership on the Active Staff may be nominated by the Medical Director for appointment as Collaborating Staff. Such appointment will be based upon the opportunity to contribute toward such goals as facilitating professional linkages between HOSPITAL and collaborating institutions, as well as patient care and educational activities. The duties of the members of the Collaborating Staff will be individualized with respect to the purpose of the appointment. The process of the initial appointment of the Medical Staff, reappointment of the Medical Staff, delineation of clinical privileges (if requested), and renewal of delineation of clinical privileges (granted), will be identical to that of the Active Staff. Members of the Collaborating Staff may attend the Medical Staff meeting (as invitees) and may be appointed by the Medical Director to serve on Medical Staff committees. Collaborating Staff will be subject to the same corrective action and appeal procedures as members of the Active Staff.

4. Visiting Staff:

Visiting Physicians (e.g. Visiting Professors) are invited to HOSPITAL from time to time by the Medical Director of the Director of Medical Education to undertake research, teaching, consultation, or care of patients. Appointment to the Visiting Staff for the purpose of involvement in any clinical care including examination and surgery must be initiated by the Medical Director. Normally, Visiting Staff appointments will be for a specific period of time, as designated by the Medical Director.

Trainee staff:

1. Fellow/Associate Staff: A Physician who has completed Residency Training in an approved and recognized

residency-training program and is board certified or eligible bay be accepted by the Fellowship Selection committee for a minimum of one year of subspecialty training at HOSPITAL.

Physicians in the Fellowship Program will be assigned to an Ophthalmology Division or Clinical Department for training in the subspecialty fellowship program that has been designed and that will be executed under the direct supervision of the Ophthalmology Division Chief Departmental Chair. Members of the Faculty Staff will participate in supervision and educational activities of the Fellow s at HOSPITAL. Participation in the educational programs of the Fellows is a mandatory activity of the Faculty Staff and evaluation of such performance will be a part of the renewal and reappointment process of Medical Staff members.

Fellows will be appointed as Associate Medical Staff contingent upon their concomitant appointment as a Fellow by the Fellowship Selection Committee. Fellows may have independent core clinical privileges granted at the time of initial appointment or later in the fellowship year, as warranted by prior training and experience. In addition, Fellows may have additional independent privileges granted at the time of initial appointment or later in the fellowship year, as warranted by documented proficiency, upon a specific request submitted to the Credentials Committee and supported by the recommendation of the Ophthalmology Division Chief and subsequently approved by the Medical Executive Committee, Medical Director, and Supervisor General.

The Chief Fellow may attend the Medical Staff meeting (as an invitee). Fellows may be appointed as non-voting members to Medical Staff Committees by the Medical Director.

Fellows must discharge all the professional obligations as required by him/her. These include being on an on-call roster for nights and weekends (including holiday). They may be assigned to duty in any of the clinical and surgical activities performed by active members of the Faculty Staff.

Fellows will be evaluated by Chief of the Ophthalmology Division, Fellowship Committee, and Director of Medical Education. Continuation in the fellowship program is contingent upon satisfactory performance of duties as judged by those responsible for evaluating fellow performance. The Director of Medical Education may make a recommendation to the Medical Director for dismissal from the training program for consistently poor clinical performance or lack of satisfactory progress toward satisfying the curriculum requirements of the specialty training program. If the Medical Director concurs with the decision, the Fellow will be dismissed from the program. The fellow may appeal the decision to the Supervisor General whose ruling on the matter will be final.

Fellows who violate the standards of clinical practice or Medical Staff Bylaws may be disciplined by the Director of Medical Education, with the approval of the Medical Director. Disciplinary action includes, but it is not limited to the following: ; letter of warning/reprimand; modification, reduction, or revocation of clinical privileges; temporary suspension from clinical duties, or expulsion from the fellowship training program. The Fellow may appeal the decision to the Supervisor General whose ruling on the matter will be final.

Because Fellows may not be independently privileged for many of their clinical care activities at HOSPITAL the following mechanisms of supervision are necessary:

*Each Fellow will be assigned to a specific member of the Faculty Staff during each clinical rotation at HOSPITAL. A Fellow assigned to the emergency room will report to the Chief/ER or Associate Chief/ER.

*The Faculty Staff member and the Ophthalmology Division Chief will be responsible for evaluation of Fellow performance. All such evaluations, as well as any identified deficiencies in performance, will be reported to the Director of Medical Education.

*A Faculty Staff Member shall evaluate and countersign the history, physical examination, and preoperative notes of all patients admitted by the Fellows if the case is one for which the Fellow does not have independent clinical privileges. The Faculty Staff member will also be responsible for evaluating the findings, recommendations for therapy, and orders for treatment of all patients treated by the Fellow for which the Fellow does not have independent privileges.

*All surgical procedures (major and minor for which the Fellow does not have independent privileges must be supervised by a Medical Staff member (Faculty or Associate Staff) who has independent surgical privileges for the procedure. The name of the Medical Staff member, as well as his level of participation (assistant, observer), must be clearly stated in the medical record.

*It is the responsibility of the Fellow’s Division Chief to ensure that the Fellow completes the medical record s in a proper and timely fashion. The Faculty Staff member is ultimately responsible for final medical record completion and accuracy.

*Fellows may provide clinical care as Attending Physicians, subject to the General Rules and Regulations for Medical Staff Participation in Care at HOSPITAL (p.52), in conjunction with independent clinical privileges that have been awarded by the Credentials Committee and approved by the Medical Executive Committee, Medical Director, and Supervisor General. In such cases, they have the responsibility for the overall care of patient, including sick leave requests and medical record documentation.

2. Resident/Assistant Staff:

The Residency/Assistant Staff shall consist of members of the four-year Riyadh Integrated Residency Program. Physicians will be accepted and appointed to the Residency Staff by the Admissions Committee of the Riyadh Integrated Residency Program Supervisory Committee.

Physicians in the Residency Program will be assigned to HOSPITAL in accordance with the curriculum designed by the Riyadh Integrated Residency Program Supervisory Committee in order to meet the educational requirements of the Saudi Board of Ophthalmology. The Director of Medical Education and the Education Committee will ensure that HOSPITAL-sponsored educational activities are available to meet the mandated educational requirements of the Saudi Board of Ophthalmology. The Faculty Staff will participate in supervision and educational activities of the Resident Staff as designated by the Director of Medical Education. Participation in the educational programs of the Resident Staff is a mandatory activity of the Faculty Staff and evaluation of such performance will be a part of the renewal and reappointment process of Medical Staff members.

Resident physicians will have no independent clinical privileges while on rotation at HOSPITAL with the exception of limited privileges for performing minor treatment procedures as approved by the Director/ER.

The Chief Resident may attend the Medical Staff members (as an invitee). Residents may be appointed as non-voting members to Medical Staff Committees by the Medical Director.

Resident Staff must discharge all of the professional obligations as required by him/her. These include on an on-call roster for nights and weekends (including Holiday). They may be assigned to duty in any of the clinical and surgical activities performed by active members of the Faculty Staff.

Because the Resident Staff is not independently privileged the following mechanisms of supervision are necessary:

*Each Resident will be assigned to a specific member of the Faculty Staff during each clinical rotation at HOSPITAL. A Resident assigned to the emergency room will report to the Chief/ER. The Faculty Staff member and the Ophthalmology Division Chief will be responsible for evaluation of Resident performance. All such evaluations, as well as any identified deficiencies in performance, will be reported to the Director of Medical Education.

*A Faculty Staff member shall evaluate and countersign the history, physical examination, and preoperative notes of all patients admitted by the Resident Staff. The Faculty Staff member will also be responsible for evaluating the findings, recommendations for therapy, and orders for treatment of all patients treated by the Resident Staff.

*All surgical procedures (major and minor) must have the supervision of a Medical Staff member (Faculty Staff or Associate Staff) who has independent surgical privileges for the procedure with the exception of procedures approved for the residents to perform independently in the minor treatment room. The name of the Medical Staff member, as well as his level of participation (assistant, observer), must be clearly stated in the medical record.

*It is the responsibility of the member of the Faculty Staff responsible for each Resident rotation to ensure that the Resident completes the medical record in a proper and timely fashion. The Division Chief is ultimately responsible for final medical record completion and accuracy.

Appointments and Reappointments:

Application for Initial Appointment:

Application for membership on the Medical Staff must be submitted in writing. At the time of application, the potential candidate will be provided with a complete copy of the HOSPITAL Medical staff bylaws for review.

The Application must contain the following information:

Medical education and training documents. Valid current license to practice medicine. Summary of professional experience. Three or more references from persons knowledgeable about the applicant’s competence

and character. Specific request for staff assignment and delineation of clinical privileges. Information relevant to voluntary or involuntary loss of previous licensure or reduction of

clinical privileges. Involvement in any prior medical malpractice judgment, current malpractice suits, or any

previously successful or currently pending challenges to licensure or registration.

The completed application must be signed by the applicant. The applicant must sign a statement on the application package that affirms the following:

The applicant has read and pledges to abide by the Medical Staff Bylaws and to honor the policies and procedures established by HOSPITAL.

The applicant pledges to provide continuous care for all HOSPITAL patients.

Application Process:

The completed application package and privilege request forms, along with verification of training, licensure, and certifications, will be reviewed by the Medical Director and the appropriate Department Chair or Ophthalmology Division Chief to determine the suitability and need for the candidate’s appointment to the Medical Staff. A decision will be made on the completed application package within one month.

If the Medical Director determines that the application is acceptable for consideration for appointment to the Medical Staff and that an appropriate need and opening for the position exists, the application for appointment and delineation of clinical privileges will be sent to the Credentials Committee for appropriate action and the Promotions Committee for determination of academic rank. The credentials Committee and Promotions Committee will act upon the application within one month.

Initial Appointment:

The Credentials Committee must approve or disapprove all applications for appointment to the Medical Staff (with the exception of the Resident Staff category), as well as the delineation of specific clinical privileges.

The decision to approve or disapprove an appointment to the Medical Staff, as well as the delineation of specific clinical privileges, must be based upon an assessment of the quality of medical care of the proposed candidate. For ophthalmologists, the request for clinical privileges must be for specific procedures performed in each of the subspecialty Divisions as well as specified medical and diagnostic interventions. For non-ophthalmologists, the privileges will be stated with greater precision than broad terms like “General Medicine, General Radiology, General Anesthesia or General Pathology”.

For new appointments to the Medical Staff will be based upon, not limited to the following:

Prior education, training, and clinical experience. Board certification. Subspecialty fellowship training and certification. Clinical privileges previously and currently held at other hospitals. Letters of recommendation from previous residency program directors, fellowship

program directors, department chairs / division chiefs at previous hospital and university positions, and previous chiefs of staff.

The Medical Executive Committee must approve or disapprove the recommendations of the Credentials Committee. If approved, the recommendations must be forwarded to the Medical Director and Supervisor General for final approval. Following approval by the Credentials Committee, these final approvals should be requested and obtained within one month.

At the time of initial appointment, physicians will be awarded “provisional privileges”. During this provisional period, the Division Chief or Medical Director (if the physician is appointed as a Division Chief) will be responsible for organizing a proctoring program to confirm the medical and surgical skills of the newly appointed physician. After three months the individual responsible for proctoring program will submit a report to the Chair of the Credentials Committee with a recommendation to approve the recommended privileges, valid for two years, if performance is consistent with the recommended privileges. Concerns about any of the recommended medical or surgical privileges must be communicated to the Credentials Committee for further discussion.

Six months after initial appointment, the Director of Quality Management will provide the Credentials Committee with a summary report of the clinical activities of the newly

appointed physician. This will be reviewed by the Credentials Committee and any identified concerns regarding clinical performance will be discussed by the committee.

Appointments to the Medical Staff and delineation of clinical privileges must be renewed every two years.

A comprehensive list of the specific clinical privileges awarded to each new member of the Medical Staff must be provided to the patient care units (Outpatient Department, Operating room, Nursing Administration) to allow personnel to determine whether or not the diagnostic intervention and whether or not each physician provides services within the scope of privileges granted.

In the event of an undue delay on the part of the Credentials Committee to appoint or delineate clinical privileges of a new Medical Staff member, the Medical Director may act upon the basis of documented evidence of the applicants’ professional and ethical qualifications from reliable sources and grant a temporary appointment and delineation of clinical privileges until the next meeting of the Credentials Committee.

Reappointments:

The Credentials Committee must review the reappointment of each individual to the Medical Staff and the continuation of delineated privileges prior to the expiration of the two-year term of appointment. Applications of reappointment will be processed in a similar fashion to the initial appointment. The same process will be followed for reappointment of current Medical Staff and for physicians who return to the Medical Staff after a period of absence. In case of physicians who return after a period of absence, the review will include their performance at the institutions in which they have held clinical privileges since their last appointment, as a review of their previous HOSPITAL privileges and clinical performance.

The reappointment to the Medical Staff and continuation of delineated clinical privileges will be based upon an evaluation of quality of care provided by the individual physician with respect to each specific clinical privilege as evidence by but not limited to the following:

Evaluation of the Medical Director. Written evaluation of the Department Chair and/or Ophthalmology Division Chief

on the physician’s professional performance, judgment, technical skills, and health status.

Peer-review by the other members of the Medical Staff as requested in writing by the Chair of the Credentials Committee.

The physician’s pattern of care, as demonstrated by reviews conducted by the Quality Management Department, Pharmacy and Therapeutics Committee, Morbidity and Mortality Committee, Infection Control Committee, Health Information Management Committee, and Incident Reports submitted to the Risk Management Coordinator.

Performance in Resident and Fellow supervision and educational activities. Participation in the Performance Improvement Program of HOSPITAL.

Participation and attendance at Medical Staff and Performance Improvement Committee meetings.

Participation in continuing medical education activities. Valid cardiopulmonary resuscitation certification. Any other relevant documentation such as completion of annual safety and infection

control, fire safety, laser (if applicable). Participation in research.

Any decision of an adverse nature with respect to reappointment or voluntary or involuntary revocation or suspension of previously delineated clinical privileges must be documented in the Credentials Committee files. In addition, the physician must be granted fair hearing before the Credentials Committee regarding any adverse decision regarding reappointment to the Medical Staff or the continuation of a previously granted clinical privilege. Any action that results in revocation, modification, or reduction of clinical of privileges must be approved by eight (8) of the twelve members of the Credentials Committee. Any recommendation for a corrective action, below the level of revoking, modifying, or reducing clinical privileges must be approved by six (6) of the twelve members of the Credentials Committee.

The Credentials Committee must review, at its next regularly scheduled meeting, any interim requests for delineation of additional clinical privileges for any Medical Staff member. Such a request for additional clinical privileges must be initiated by a request from the individual physician, supported by evidence of training and experience with the proposed privilege, and approved by the appropriate Department Chair or Ophthalmology Division Chief, or the Medical Director (in case of a Department Chair or Ophthalmology Division Chief).

All actions of the Credentials Committee on reappointment of Medical Staff, continuation of delineated clinical privileges, or granting of additional clinical privileges must be approved by the Medical Director and Supervisor General for final approval.

A comprehensive list of renewed or additional clinical privileges awarded to each member of the Medical Staff must be approved to the patient care units (Outpatient Department, Operating Room, and Nursing Administration) to allow personnel to determine whether or not diagnostic intervention and whether or not the physician is privileged to perform each specific procedure, medical intervention, or diagnostic intervention and whether or not each physician provides services within the scope of privileges granted.

In the event of an undue delay on the part of the Credentials Committee to reappoint or renew clinical privileges of a Medical Staff member, the Medical Director may act upon the basis of documented evidence of the applicant’s professional and ethical qualifications from reliable sources and grant a temporary reappointment and continuation of delineated clinical privileges until the next meeting of the Credentials Committee.

Administrative Appointments:

Administrative appointments within the Medical Staff are made by the Medical Director. Administrative appointments must be reviewed and renewed annually by the Medical Director.

The procedure for initial appointment to the Medical Staff, reappointment to the Medical Staff, and delineation of clinical privileges is identical for individuals holding administrative appointments and those not holding administrative appointments.

Emergency Clinical Privileges:

In case of an emergency, any member of the Medical staff shall be permitted and assisted to do everything possible to save the life of a patient, using every necessary facility at HOSPITAL, including the calling of any available consultation necessary or desirable. When an emergency situation no longer exists, the care will be transferred to an appropriate credentialed member of the Medical Staff. An emergency is defines as a “condition in which serious permanent harm would result to a patient, or in which the life of a patient is in imminent danger, and delay in administering treatment would add to that danger”.

Professional Conduct:

Whenever the activities or professional conduct of any Medical Staff member are such as to indicate violation of the Bylaws, Rules and Regulations, departure from the principles of professional ethics, or conduct that is unacceptable to the hospital and Medical Staff, corrective action against the member may be requested by any member of the Medical Staff, Medical Director, or Supervisor General. All requests for corrective action shall be made in writing to the MEC and supported by specific evidence.

Upon receipt of such a request, it shall be the responsibility of the MEC to investigate the charges in accordance with the following procedures.

The hearing must be within a period of seven days. Ten members of the MEC must be present. If necessary, the Medical Director may appoint each replacement members for physician on leave for the purpose of participating in the hearing.

The accused staff member shall be permitted a fair hearing by the MEC. This includes the right to appear before the MEC to hear and address the specific charges.

If the individual requesting the corrective action is a member of the MEC, he/she may not participate as a voting member and may serve only as a witness to the proceedings. The Medical Director must nominate a replacement to the MEC to replace the excused member.

If the requesting member is the Medical Director, the Supervisor General must nominate a replacement member to the MEC for these hearings and designate a permanent member of the MEC to chair the proceedings.

Upon conclusion of the investigation, the MEC shall, in writing, record its recommendation as follows:

Requires the approval of ten (10) of the 12 members of the MEC. The terminated or suspended staff member will be notified in writing of this

decision by the Medical Director. The terminated or suspended staff member shall have the right of appeal

(see: Appeal Procedures). He/she will be informed of this right in the letter from the Medical Director informing the accused staff member of the MEC recommendation.

The recommendation for termination of contract by the MEC will be forwarded to the Supervisor General.

*Corrective action involving revocation, modification, or reduction of clinical privileges:

Requires the approval of eight (8) of the 12 members of the MEC. Whenever clinical privileges are revoked, modified, or reduced, the accused

staff member shall be notified in writing by the Medical Director prior to application of the suspension.

The staff member will have the right to appeal the decision of the MEC see Appeal Procedures). He/she will be informed of this right in the letter from the Medical Director informing the accused staff member of the MEC recommendation.

The recommendation for corrective action will be forwarded to the Supervisor General.

All requests and recommendations for corrective action shall be implemented through the Clinical Department Chair, Chief of the Outpatient Department, or Ophthalmology Division Chief, after notification by the Medical Director.

*Corrective action not involving revocation, modification, or reduction of clinical privileges (including , but not limited to, letter of warning, letter of reprimand, recommendation of remedial courses or training):

Requires the approval of seven (7) of the 12 member s of the MEC. The recommendation for corrective action will be forwarded to the staff

member by the Medical Director. The staff member will have the right to appeal the decision of the MEC (see

Appeal Procedures). He/she will be informed of this right in the letter from the Medical Director informing the staff member of the MEC recommendation.

The recommendation for corrective action will be forwarded to the Supervisor General.

All requests and recommendations for corrective action shall be implemented through the Clinical Department Chair. Chief of the Outpatient Department, or Ophthalmology Division Chief after notification by the Medical Director.

Summary Suspension:

For conduct disruptive to hospital and Medical Staff function, or for other unacceptable behavior, the Medical Director, or Supervisor General in consultation with two members of the MEC, shall have authority to immediately suspend clinical and hospital privileges pending investigation. Concurrent with the imposition of an immediate suspension, the Medical Director or designee shall organize alternative medical coverage for the patient(s) of the suspended physician in the hospital at the time of such suspension.

Whenever action must be taken immediately in the interests of patient care, the Medical Director in consultation with any two members of the MEC shall have the authority to immediately suspend all or any portion of the clinical privileges of a Physician. Such summary suspension shall become effective upon imposition. Concurrent with the imposition of an immediate suspension, the Medical Director or designee shall provide for alternative coverage for the patient(s) of the suspended physician in the hospital at the time of such suspension.

Such summary of suspension of some or all clinical and/or hospital privileges imposed by the Medical Director or Supervisor General, will be followed by a meeting of available MEC members to be held within 72 hours of the summary suspension. The MEC will recommend approval, modification, or rejection of the recommendations of the summary suspension in accordance with procedures discussed above.Automatic Suspension:

Automatic suspension or termination of clinical privileges shall ensue for any action that suspends or terminates a Medical Staff member’s medical license.

It shall be the duty of the Department Chair/Divisional Chief to cooperate with the Medical Director in enforcing all automatic suspensions.

Appeal Procedures:

If the MEC recommends (1) termination or suspension from the Medical Staff, (2) revocation, reduction, or modification of clinical privileges, or (3) corrective action below the level of revocation, reduction, or modification of clinical privileges, the staff member has the right to appeal before the decision is finalized.

If the MEC recommends termination or suspension from the Medical Staff, the staff member has the right to appeal the decision to the Supervisor General. Within three days of being informed of such recommendation, the accused member must inform the Supervisor General in writing that he/she wishes to make an appeal. If he/she fails to do so within the specified time, he/she shall be deemed to have waived the right of appeal and the MEC decision will be final. If an appeal is filed, the decision of the Supervisor General will be final.

If the MEC recommends corrective action resulting in revocation, reduction, or modification of clinical privileges, the staff member has the right to appeal the decision to the Supervisor General within seven days of being informed of such recommendation, the accused member must inform the Supervisor General in writing that he/she wishes to make an appeal. If he/she fails to do so within the specified time, he/she shall be deemed to have waived the right of appeal and the decision of the MEC will be final. If an appeal is filed, the decision of the Supervisor General will be final.

If the MEC recommends corrective action below the level of revocation, reduction, or modification of clinical privileges, the staff member has the right to appeal the decision to the Supervisor General. Within seven days of being informed of such recommendation, the accused member must inform the Supervisor General in writing that he/she wishes to make an appeal.

If he/she fails to do so within the specified time, he/she shall be deemed to have waived the right of appeal and the decision of the MEC will be final. If an appeal is filed, the decision of the Supervisor General will be final.

Notwithstanding any of the above provisions, all physicians shall have protection as provided by the HOSPITAL employment contract.

CLINICAL DEPARTMENTS AND DIVISIONS

The Medical Staff at HOSPITAL shall be organized into Clinical Departments and Ophthalmology Divisions to facilitate professional activity for the delivery of quality patient care.

Responsibilities:

Each Clinical Departments will have a Clinical Department and each Ophthalmology Division will have a Division Chief appointed by the Medical Director. Appointments will be for a one-year period, beginning on 1 January of each calendar year. Reappointments will be considered and made annually by the Medical Director based upon performance of the incumbent, performance of other applicants for the position, and the institutional needs. All administrative appointments will be submitted to the Supervisor General for approval.

The removal and replacement of a Clinical department Chair or Division Chief between annual appointment / reappointment may be done upon the recommendation of the Medical Director, with approval of the MEC and Supervisor General of the Hospital.

Individuals appointed to these positions will possess the clinical, academic, and administrative competence necessary to fulfill the responsibilities of their position, based upon review of previous training and professional practice prior to and during their tenure at HOSPITAL.

The responsibilities of the Clinical Department Chair or Division Chief shall include, but not be limited to:

Monitoring of all clinical related activities of the department/division. All administrative related activities of the department/division unless otherwise provided

for by the Hospital. Continued surveillance of the professional performance of all individuals in the

department/division who have delineated clinical privileges. This includes, but is not limited to, assessment of each member after 90 days of initial employment, and at the time of each 2-year reappointment to the Medical Staff.

Recommendation to the Credentials Committee the criteria for clinical privileges that are relevant to the department/division.

Assess and recommend to the MEC off-site sources for needed patient care services not provided by the department /division of HOSPITAL.

Coordination and integration of intradepartmental services to facilitate the patient care, teaching, and research mission of HOSPITAL.

Coordination and integration of intradepartmental/interdivisional services through appropriate meetings and communication with members of the department/division.

Coordination and integration of intradepartmental/interdivisional services through participation in the Department Chair/Division Chiefs Committees.

Development of department/division policy and procedures that guide and support the provision of services.

Make recommendations to the Medical Director regarding the sufficient number of qualified and competent persons to provide the care and services of the department/division.

Determine the qualification and competence of department/division personnel who are not licensed independent practitioners and who provide patient care services.

Continually assess and improve the quality of care and services provided.

Maintain appropriate quality-improvement programs within the department/division. Provide orientation and continuous education of all members of the department/division. Participation in department/division planning (budgets, staffing, etc.) and assisting in the

preparation of all required reports. The Clinical Department Chairs of Medicine and Ophthalmology will assure that emergency

service patient care is appropriately performed and documented, and further, assure that orientation, scheduling and such other physician activities are integrated into emergency service care as may be required.

The Chair of the Medicine Department (or designee) will serve as the Medical Coordinator for the Internal and External Emergency Plan.

Each member of the Medical Staff will be assigned to a Clinical Department at the time of initial appointment. If assigned to the Department of Ophthalmology, the Medical Staff will also be assigned to an Ophthalmology Division. Depending upon qualifications and the needs of the institution, a member of the Medical Staff may be assigned to multiple departments/divisions.

The Clinical Departments are:

Anesthesia Diagnostic Imaging Medicine (Internal Medicine/Pediatrics) Ophthalmology Research

The Ophthalmology Divisions are:

Anterior Segment/External Disease Emergency Room Glaucoma Neuro-Ophthalmology Ocuplastics and Orbit Pediatric Ophthalmology and Strabismus Uveitis Vitreoretinal

The formation, elimination, subdivision, or combination of Clinical Department and Ophthalmology Divisions may be made upon the recommendation of the Medical Director, with approval of the MEC.

Functions of Clinical Departments/Divisions:

The primary responsibility delegated to each Clinical Department /Division is to implement and conduct specific review and evaluation activities that contribute to the presentation and improvement of the quality and efficiency of patient care provided. Such activities shall be subject to MEC review and approval.

The general functions of each Clinical Department/Division shall include:

Review, analysis, and evaluation of clinical work performed.

Recommendation of clinical aspects of patient care, risk management and safety issues for monitoring to the Performance Improvement Committee.

Preparation of written reports to the MEC on a regularly scheduled basis concerning:*Findings of the Clinical Department’s review, evaluation and monitoring activities.*Recommendations for maintaining and improving the quality of care provided in the Clinical Department.

Preparation of written reports to the Credentials Committee on a regularly scheduled basis concerning:

*Requests for continuation, or modification of delineated clinical privileges of Department/Division.

Meetings at least six times per year or more as required for the purpose of receiving, reviewing, and considering the evaluation and monitoring activities, and of performing receiving reports on other staff and department functions.

Duties of the Medical Director:

The Medical Director must be an Ophthalmologist who shall serve as the Chief Administrative Officer of the Medical Staff to:

Act in coordination and cooperation with the Supervisor General on all matters of mutual concern within HOSPITAL.

Receive, interpret, and communicate the policies of HOSPITAL to the Medical Staff through the MEC and Medical Staff meetings.

Receive, interpret, and communicate issues related to performance and maintenance of quality care to the Supervisor General. This includes, but is not limited to recommendations regarding Medical Staff requirements, equipment, needs, educational issues, etc.

Represent the view, policies, needs, and grievances of the Medical Staff to the Supervisor General.

Call, preside at, an e responsible for the agenda of all general meetings of the Medical staff. Serve as Clinical Department Chair of the Ophthalmology Department. Serve as Chair of the following committees:

o Medical Executive Committeeo Department Chairs Committeeo Promotions Committeeo Bylaws Team

Serve as Member of the following committees:o Credentials Committeeo Research Councilo Performance Improvement Committee

Be responsible for initiating disciplinary action for active Medical staff members in accordance with the Medical Staff bylaws and for insuring Medical Staff compliance with procedural safeguards in all instances when corrective action has been requested against a physician.

Be responsible for the enforcement of Medical Staff Bylaws and Department/Division policies and procedures.

Be responsible for recruitment of physicians to the Medical Staff and submission of proposed appointments to the Credentials Committee, Promotions Committee and MEC and the Supervisor General.

Appoint Department Chairs and Ophthalmology Division Chiefs on an annual basis. Appoint Chair and Committee Members of al standing Medical Staff committees, in

accordance with the Medical Staff bylaws. Recommend Medical Staff appointments to physician positions on Performance

Improvement committees. Be responsible, through the Medical Education Department, for the coordination of

continuing medical education programs, fellowship training programs, and the residency education program conducted at HOSPITAL as part of the Riyadh Residency Program.

Be responsible, through the Director of Research, for the Research Program and HOSPITAL. Ensure maintenance of all established and approved medical and surgical services by active

Medical Staff members as monitored by the MEC; ensure that all members of the Medical Staff participate in continuous performance-improvement activities as monitored by the Performance Improvement Committee; and ensure effective communication be maintained between the MEC, the Hospital Management and Operation Committee (HMOC), and Supervisor General (Governing Authority).

Be spokesman for the Medical Staff in its external professional and public relations. Recommend a member of the full-time HOSPITAL Department of Ophthalmology to serve as

Acting Medical Director and Associate Medical Director are on leave subject to approval by the supervisor General.

Practice medicine in accordance with qualifications as time permits.

Duties of the Associate Medical Director

The Associate Medical Director must be an ophthalmologist and a member of the HOSPITAL Medical Staff and will:

Work directly with the Medical Director on issues related to the administrative management of the Medical Staff.

During the absence of the Medical Director, act in coordination with the Supervisor General on all matters of mutual concern within HOSPITAL.

During the absence of the Medical Director carry out all the designated duties and responsibilities of the Medical Director.

Serve as Chair of the following committee:o Credentials Committee

Serve as member of the following committees:o Medical Executive Committeeo Research Councilo Education Committeeo Bylaws Team

Practice medicine in accordance with qualifications according to a schedule approved by the Medical Director.

Duties of the Chief of the OPD

The Chief of the OPD must be an ophthalmologist and a member of the HOSPITAL Medical Staff will:

Work directly with the Medical Director on issues related to patient care provided y the Medical Staff as follows:

o Act in coordination and cooperation with the Medical Director on all physician related activities within the Outpatient Department and Operating Room.

o Be responsible for all ophthalmologists’ schedules in the ambulatory services and in the operating room, subject to approval by the Medical Director.

o Be responsible for ensuring that an appropriate on-call schedule for general and subspecialty ophthalmology services is prepared and implemented at all times.

o Participate in Outpatient Department planning (budgets, staffing, etc.) and assist in preparation of all relevant and requested reports.

o Ensure that regular review and evaluation of the quality and appropriateness of patient care rendered within the clinical services is carried out through designated mechanisms.

Serve as Chair of the following committees:o Division Chiefs

Serve as member of the following committees:o Medical Executive Committeeo Bylaws Teamo Credentials Committeeo Education Committee

Practice medicine in accordance with qualifications according to a schedule approved by the Medical Director.

Duties of Director of Medical Education:

The Director of Medical Education must be an ophthalmologist and a member of the HOSPITAL Medical Staff and will:

Act in coordination and cooperation with the Medical Director on all matters of educational activity within HOSPITAL.

Be responsible to develop, plan and implement subspecialty fellowship programs at HOSPITAL. This will be done in consultation with the Ophthalmology Division Chiefs but the final plan will be the responsibility of the Director of Education, subject to approval by the Medical Director.

Be responsible to develop, plan and implement residency training programs and activities at HOSPITAL. This is done in cooperation with the Ophthalmology Division Chiefs and Integrated Residency Steering Committee and is ultimately subject to approval by the Medical Director and the Saudi Council foe Health Specialties.

Be responsible for coordinating medical instruction as needed by Clinical Departments and Ophthalmology Divisions at HOSPITAL.

Plan the continuing medical education activities for the Medical Staff including Grand Rounds, the Annual Symposium and other symposia.

Serve as the Chair of the following committees/teams:o Education Committeeo Fellowship Selection Teamo Medical Library Team

Serve as Member of the following committees:o Medical Executive Committeeo Credentials Committeeo Bylaws Team

Practice medicine in accordance with qualifications according to a schedule approved by the Medical Director.

Duties of the Director of Research:

The Director of Research at HOSPITAL must be an ophthalmologist and a member of the HOSPITAL Medical staff and will:

Be responsible for the overall direction of the Research Department. Prepare the yearly research program and budget; subject to approval by the, ensure quality of research activities by periodic assessment of ongoing studies; supervise all work-related matters for the Department and evaluate the performance of all full time and part time members of the Research Department in accordance with Hospital and Departmental Personnel Policies.

Be responsible for the recruitment program of the Research Department under the guidance of the Medical Director.

Appoint administrative officers (Associate/Assistant Director of Research) of the Research Department, Chief Research Associate, Chief of Coordination Section, Chief of Laboratory Section and Administrative Assistant, subject to the approval of the Medical Director.

Receive and review research applications prepared by staff members. Assist the applicant in improving the quality of the application and recommend finally whether or not the research proposal should be sent to the Research Council for final consideration and funding.

Act as Chair of the Research Council.

Engage actively on research (basic, clinical or both) in the course of regular professional activities and participate in patient care as a member of Medical Staff and practice clinical medicine in accordance with qualifications as permits or as necessary.

Establish and maintain a system for the operation and supervision of the research laboratories and work with the Medical Director in long-range planning for additional research facilities and equipment. Pursue the progressive growth of investigative work at HOSPITAL by submitting proposals for extramural funding, stimulating investigative studies by the Medical Staff members, and by appropriate promotional efforts.

Serve as a Member of the following committees:o Medical Executive Committeeo Credentials Committeeo Bylaws Teamo Human Ethics Committee/ Institutional Review Board

Practice medicine in accordance with qualifications and as time permits.

MEDICAL STAFF COMMITEES

There shall be a Medical Executive Committee (MEC) and such other standing and special committees of the staff responsible to the MEC, as may be necessary and desirable to perform Medical Staff functions. The MEC may, by resolution and upon approval by the Medical Director, establish additional Medical Staff committees to execute such functions. Each standing committee of the Medical Staff may commission ad hoc teams as necessary to accomplish specific tasks.

All meetings shall be conducted in accordance with Robert’s Rules of Order. Minutes must be recorded and submitted to the MEC via the Medical Director.

STANDING COMMITTEES OF THE MEDICAL STAFF

The following will be the standing committees/teams of the Medical Staff that will report to the Medical Executive Committee:

Bylaws Team Credentials Committee Department Chairs Committee Ophthalmology Division Chiefs Committee Promotions Committee Education Committee

o Fellowship Teamo Medical Library Team

Research Council

Human Ethics Committee/ Institutional Review Board Morbidity and Mortality Committee Medical Care Committee Pharmacy and Therapeutics Committee

o Nursing /Pharmacy Team

The Medical Executive Committee will provide the Performance Improvement Committee with a monthly report submitted on the first Saturday of the month summarizing the activities of all Medical Staff committees.

Medical Staff Committee members and chairs shall be appointed by the Medical Director annually in accordance with the membership charters established in the Bylaws. Appointments begin in January each year.

Vacancies shall be filled by appointment by the Medical Director for the remainder of any unfilled team. The Supervisor General is an ex officio member of all Medical Staff Committees.

Members of the Medical Staff, who are members of standing Medical Staff or Performance Improvement Committees by virtue of their administrative appointment, must instruct the person acting for them during their leave to attend their committee meetings. For other committee memberships, it will be at the discretion of the Chair of the committee as to whether or not a replacement should be designated to replace a Medical Staff member who is on leave.

A committee chair may request that the Medical Director replace a member who does not satisfactorily discharge his/her responsibilities to the committee if the member is an obligatory appointee by virtue of an administrative position, he/she may not be removed from the committee. If the member is an “at large” appointee, the Medical Director has the option of selecting a suitable replacement. If the member has been elected to the committee by the Medical Staff, the Medical Director may appoint a substitute member pending a new election by the Medical Staff. The removed committee member is eligible to run for reelection, but in such a case, the committee chair may express his grievance regarding deficiencies in committee performance. If re-elected by the Medical Staff he/she must be reinstated to the committee.

The following are committees which report to the Performance Improvement Committee and on which the Medical Staff shall have representation. The Medical Director will nominate candidates for appointment to these committees to Hospital Administration.

Performance Improvement Committeeo HOSPITAL JCIA Teamo Staff Development Team

Health Information Management Committeeo Closed/open Chart Review Team

Operative and Other Invasive Procedures Committee Infection Control Committee Environment of Care Committee

o Data Analysis and Reporting Team (DART) Health Education Committee

o Inpatient Education Teamo Outpatient Education Team

MEDICAL EXECUTIVE COMMITTEE (MEC)

Members are:

Medical Director (Chair) Associate Medical Director Chief of OPD Director of Research Director of Medical Education Two non-ophthalmologists appointed by the Medical Director representing

and selected from the Clinical Departments of Pathology, Anesthesia, Diagnostic Imaging and Medicine.

Two ophthalmologists appointed by the Medical Director to be selected at large from entire Medical Staff.

Two members at large, one ophthalmologist and one non-ophthalmologists elected annually by the Medical Staff.

Director of Quality Management (invitee) Supervisor General ( ex officio)

Duties are to:

Directly communicate via the Medical Director on all matters of professional practice activities at HOSPITAL with the Hospital Executive Committee and Supervisor General.

Act on behalf of the Medical Staff in intervals between Medical Staff meetings.

Receive, review and act on reports and recommendations from Medical Staff committees, Clinical Departments/ Divisions and assigned activity groups; document its conclusions, recommendations directly to the Hospital Executive Committee and Supervisor General for approval.

Review the minutes of the meetings of all Medical Staff Committees. Discuss and take action on relevant issues raised in the meetings of Medical Staff Committees that have not been referred to the MEC, as per item 3 (above).

Ensure the participation of the entire Medical Staff in Resident and Fellow supervision and educational activities.

Delineate the structure and function of Medical staff committees, in compliance with the bylaws.

Reports findings and recommendations to the Medical Director, Hospital Executive Committee and Supervisor General.

The Medical Executive Committee shall meet at least nine times per year.

BYLAWS TEAM

The Bylaws Team shall be chaired by the Medical Director and shall consist of all of the membership of the Medical Executive Committee. By definition, actions approved by the Bylaws team will be considered approved by the Medical Executive Committee.

The Bylaws Team will conduct annual reviews of the Bylaws, Rules and Regulations, policies, forms, etc.

The Bylaws Team will review all requested changes in the existing Bylaws as submitted by any member of the Medical Staff, or Supervisor General of HOSPITAL.

All changes approved by the Bylaws Team will be submitted to the Supervisor General of HOSPITAL.

The Bylaws Team shall meet at least once a year or as needed.

CREDENTIALS COMMITTEE

The Credentials Committee shall be chaired by the Associate Medical Director for Administrative Affairs and consist of all the membership of the Medical Executive Committee. By definition, actions approved by the Credentials Committee will be considered approved by the Medical Executive Committee.

Duties are to:

Review the credentials of applicants for Medical Staff membership and make recommendations for appointment and delineation of clinical privileges to the Medical Executive Committee.

Review information available regarding the competency and suitability of staff members and make recommendations for reappointment and continuation or modification of clinical privileges to the Medical Executive Committee.

The Credentials Committee shall meet at least ten times per year.

DEPARTMENT CHAIRS COMMITTEE

Members are:

Medical director (chair) Associate Medical Director Chair, Medicine Department Chair, Anesthesia Department Chair, Diagnostic Imaging Department Chair, Pathology Department Director, Outreach Program Supervisor General (ex officio).

Duties are to:

Review and act upon matters of mutual interest and concern that affect interdepartmental functions.

Make recommendations to the Medical Executive Committee.

The Departmental Chairs shall meet at least four times per year.

OPHTHALMOLOGY DIVISION CHIEFS COMMITTEE

Members are:

Medical Director (Chair) Chief, OPD Chief, Anterior Segment Division Chief, Emergency Room Chief, Glaucoma Division Chief, Neuro-ophthalmology Division Chief, MCED Chief, Oculoplastics and Orbit Division Chief, Pediatric Ophthalmology and Strabismus Chief, Uveitis Division Chief, Vitreoretinal Division Director of Medical Education Director, Outreach Program Chief, Optometry Division (invitee) Director of Surgical Services (invitee) Supervisor General ( ex officio) Medical Director (ex officio)

Duties are to:

Review and act upon matters of mutual interest and concern that affect interdivisional functions.

Make recommendations to the Medical Executive Committee.

The Division Chiefs shall meet at least six times per year.

PROMOTIONS COMMITTEE

Members are:

Medical Director (Chair) Up to five members of the Medical Staff who hold the rank of Senior

Academic Consultant will be appointed by the Medical Director on a rotational basis.

Supervisor General (ex officio)

Duties are to:

To review the academic accomplishments of all members of the Medical Staff on a semi-annual basis to consider potential candidates for promotion to Senior Consultant and Senior Academic Consultant.

The Promotions Committee shall meet at least two times per year.

EDUCATION COMMITTEE

Members are:

Director of Medical Education Associate Medical Director Director of Research Director of Residency Training Program or designee Director of Education Supervisor General (ex officio) Medical Director (ex officio)

Duties are to:

Develop and plan programs of continuing education relevant to medical care delivered at HOSPITAL.

Develop and plan programs of Fellow and Resident education at HOSPITAL. Evaluate the effectiveness of educational programs implemented. Act upon continuing education recommendations from the MEC, the Clinical

Department Chair (s), Division Chief(s) or the Staff. Approve applications and priorities, either by committee action o delegated

responsibility, for use of medical television. Review the medical library services in terms of the informational,

educational, and research-related needs of the medical and hospital staff.

Oversee the functions of the Fellowship Selection Team and the Medical Library Team.

Make recommendations to the Medical Executive Committee.

The Medical Education Committee shall meet at last four times a year.

FELLOWSHIP TEAM

Members are:

Director of Medical Education (Chair) Associate Medical Director Ophthalmology Division Chiefs from the following services:

o Anterior Segment/External diseaseo Glaucomao Neuro-Ophthalmologyo Oculoplasticso Pediatricso Uveitiso Vitreoretinal

Duties are to:

Report to the Medical Education Committee To review all applications for formally approved HOSPITAL Fellowship

Programs To recommend successful candidates to the Medical Director for

appointment to established Fellowship Programs at HOSPITAL.

The Fellowship Team shall meet at least once annually.

MEDICAL LIBRARY TEAM

Members are:

Director of Medical Education Director of Residency Training Program or designee HOSPITAL Librarian. A representative from each Ophthalmology Division, Medicine, Anesthesia,

and Diagnostic Imaging. Nursing Services Representative. Representative from the Research Department.

Duties are to:

Report to the Medical Education Committee.

Review and approve requests for purchase of books, journals, videocassettes and other sources of information for the HOSPITAL Medical Library.

Plan growth and development of the Library to enhance patient care, teaching and research resources.

The Medical Library Team shall meet at least once annually.

RESEARCH COUNCIL

Members are:

Director of Research (Chair) Associate Director of Research Medical Director Associate Medical Director Six members appointed by the Director of Research for 2-year terms Two members (one ophthalmologist and one non-ophthalmologist) elected

by secret ballot by the Medical Staff

Duties are to:

Develop, revise ad implement policies and procedures pertaining to research activities at HOSPITAL.

Receive, review and act on research applications from staff members, as well as from collaborators from other institutions.

Assist investigators in improving the quality of research. Settle disputes between investigators on participation and authorship

related to all research projects. Ensure medical staff participation in performing research. Evaluate medical staff performance in research. Make recommendations on future planning of clinical and basic research

and allocation of resources.

The Research Council shall meet at least nine times a year.

HUMAN ETHICS COMMITTEE/ INSTITUTIONAL REVIEW BOARD

Members are:

At least five HOSPITAL physician members, representative of both genders, four of whom must be Medical Staff Ophthalmologists and one of whom must be a Medical Staff member from another department. The Director of Research and the Associate Director of Research may be among the membership. One of the ophthalmologists must be the Chair.

At least two members, representing both genders, from HOSPITAL who are not physicians and are selected from the Nursing Services, Health Educational Services, or Social Services

At least one member who is not employed by HOSPITAL. At least one of three members who are not members of the HOSPITAL

Medical Staff must have a non-scientific background. Supervisor General (ex officio) Medical Director (ex officio)

Duties are to:

Review cases as per criteria recommended to the committee by department chairs and division chiefs and reviewed annually and coordinated through the Quality Management Department.

Investigate adverse outcomes of medical and surgical therapy, possibly inappropriate or unnecessary surgery, unexpected surgical cancellations, unusual patterns of practice, excessive complications and instances in which patients are required unexpectedly to return to surgery during the same hospital stay.

Identify and investigate questions of appropriateness of clinical and surgical privileges.

Report findings and recommendations to the Credential Committee, MEC, and Medical Director.

The Morbidity and Mortality Committee shall meet at least nine times a year.

MEDICAL CARE COMMITTEE

Members are:

Chair, Internal Medicine Department (Chair) Chair, Department of Anesthesia Consultant Pediatrician Chief or Associate Chief of Emergency Room Chief, Employee Health Ophthalmologist Associate Administrator, Nursing Services or designee Director of Quality Management (invitee) Supervisor General (ex officio) Medical Director (ex officio)

Duties are to:

Ensure high quality of non-ophthalmic medical care for patients in all hospital areas and hospital staff and their dependents.

Oversees all CLS related activities throughout the hospital Reviews every Code Blue to ensure satisfactory standard.

Receives and acts on reports from Cardiac Life Support. Make recommendations to the Medical Executive Committee.

The Medical Care Committee shall meet at least six times a year.

PHARMACY & THERAPEUTICS COMMITTEE

Members are:

Medical Staff Member (Chair) Food and Nutrition Service Member Medical Staff Member, Medicine Department Medical Staff Member, Anesthesiologist Medical Staff Member, Anterior Segment Medical Staff Member, Glaucoma Medical Staff Member, Vitreoretinal Medical Staff Member, Pathologist Nursing Services Member (Unit Manager) Pharmacy Member Supervisor General (ex officio) Medical (ex officio)

Duties are to:

Receive, assess and appropriately act on reports and findings related to the prescribing or ordering, preparing and dispensing, administration and monitoring the effects on patients of medications and blood/blood products used for patient care at HOSPITAL.

Review and approve a HOSPITAL Hospital Formulary, which will be maintained on a current basis.

Review Pharmacy Monitoring System. Review the medication errors monthly summary report. Assist in development and evaluation of all HOSPITAL Policies and

Procedures related to the use of medication and blood/blood components at HOSPITAL.

The Chair report a summary of activities to the Medical Executive Committee every other month.

The Pharmacy and Therapeutics Committee shall meet at least six times a year.

NURSING/PHARMACY TEAM

Members are:

Team Leader: Nursing Services Member (unit Manager) Recorder: Selected Team Member Employee Health representative

Infection Control/Risk Management Coordinator Nurse Services representative from patient care units Nursing Services representative from ACS Nursing Services representative from OR/PARR Pharmacist, Inpatient Area Pharmacist, Outpatient Area Pre-hospitalization representative Short Stay Unit representative

Duties are to:

To receive P & T Committee actions as they relate to the purpose of the Nursing/Pharmacy Team

To review, assess and liaise with other caregivers to implement actions to improve medication distribution and pharmaceutical care to our patients.

To review the medications errors monthly summary report and submit report of action (s) to the P&T Committee.

The Nursing/Pharmacy Team will meet every other month before the P&T meeting.

MEDICAL STAFF MEETINGS

Meetings of the full Medical Staff shall be held at least quarterly. The December meeting shall be the annual meeting.

All meetings shall be conducted in accordance with Robert’s Rules of Order.

Members of the Active Medical Staff/Permanent attend the Medical Staff meeting. Majority of the members of the Active Medical Staff/ Permanent present at the outset constitute a quorum.

Members of the Active Staff/Temporary and Collaborative Staff may attend the Medical Staff Meeting as invitees.

The Chief Fellow/ Associate Staff and Chief Resident/ Assistant Staff may attend the Medical Staff Meeting as invitees.

The Chief of Optometry and the Chief of Orthoptics may attend the Medical Staff Meeting as invitees.

Hospital Administrators who present the mandatory reports at the meeting (see below) may attend the Medical Staff Meeting as invitees.

Each member of the Active Medical/Permanent Staff shall be required to attend at least 75% of all regular Medical Staff and Committee meetings in each year. A member who is compelled to b absent from any regular staff meeting shall promptly submit to the Medical Director, in writing, the reason(s) for such absence. Unless excused by the MEC, failure to meet the foregoing annual attendance requirements shall be grounds for corrective action, which might include revocation of clinical privileges.

The Medical Director, the Associate Medical Director, or any two of the Clinical Department Chairs or Division Chiefs may call a Special Meeting at any time, designating the time and place of such special meeting. No business shall be transacted at any Special Meeting except that stated in the notice calling the meeting.

Minutes of each regular and special staff meeting of a Committee or of a Department shall be prepared and include a record of the attendance of members and the vote taken on each matter. The minutes shall be signed by the presiding officer ad forwarded to the MEC for approval. The minutes shall be read at the next Committee meeting “unless waived” and approved. Each Committee and Service shall maintain a permanent file of the minutes of each meeting in the Medical Director’s office.

The agenda of any special Medical Staff meeting shall be:

Reading of the notice calling the meetingTransaction of business for which the meeting was calledAdjournment

The agenda of a regular Medical Staff meeting shall include:

Call to order Approval of the minutes if the last regular and/or special meeting Reports from Hospital Administration

o Supervisor General (or representative)

o Administrator/Patient Care Services (or representative)o Administrator/Administrative Services (or representative)o Associate Administrator for Nursing Services (or

representative)o Associate Administrator for Administrative Services (or

representative)o Director of Management Information Services (or

representative)o Director of Quality Management (or representative)o Pharmacy Director (or representative)o Medical Records Director (or representative)

Reports from Department Chairs:o Anesthesiao Diagnostic Imagingo Medicineo Ophthalmologyo Pathology

Report from the Outreach Department Report from the Research Department Report from Medical Education Old Business New Business Adjournment

AMENDMENTS TO AND ADOPTION

OF MEDICAL STAFF BYLAWS

Neither the Medical Staff nor the Supervisor General of HOSPITAL may unilaterally amend, appeal,

or revise the Medical Staff bylaws.

Any member of the Medical Staff or the Supervisor General may propose changes to the bylaws, by

submitting the proposed change(s) in writing for consideration at the next meeting of the Bylaws

Team. Approval or disapproval will by majority vote of the Bylaws Team. All approved changes will

be forwarded to the Supervisor General for final approval.

In addition, a proposal for a Medical Staff bylaws change(s) may be made at any regularly scheduled

or special meeting of the Medical Staff. If such a motion is made, seconded, and approved by a

majority vote of members, it shall be forwarded to the Supervisor General for final approval.

RULES AND REGULATIONS

General rules and regulations for medical staff participation in care at HOSPITAL:

The Medical Staff operation is governed by the Joint commission International Standards for

Hospitals (JCIA), the Hospital Plan for Patient Care, the HOSPITAL Performance Improvement and

Quality Management Plan, the HOSPITAL Strategic Plan and Hospital Policies and Procedures, in

their latest revisions. The Medical Staff must conduct all aspects of professional practice in

accordance with these standards in a manner consistent with the hospital mission of patient care,

teaching and research. A declaration of this intention must be signed at the time of initial

appointment and reappointment to the Medical Staff.

Upon appointment to the Medical Staff the physician must sign a declaration that they are familiar

with the contents of the Medical Staff By-Laws and agree to abide by them in all aspects of their

professional activities at HOSPITAL.

Upon reappointment to the Medical Staff, the physician must sign a declaration that they are

familiar with the most current version of the Medical Staff By-Laws and agree to abide by them in

all aspects of their professional activities at HOSPITAL.

Every patient at HOSPITAL will be treated by a member of the Medical Staff. The responsibilities of

the Medical Staff member include but are not limited to the following:

Provide care within the scope of delineated clinical privileges and area of expertise.

Assure timely, adequate professional care for his patients in the hospital by being

available or by having available an eligible alternative physician with whom prior

arrangements have been made.

Obtain appropriate medical, anesthetic, diagnostic imaging, ophthalmic subspecialty

consultation when indicated.

Maintain complete and accurate medical records, including documentation of the

plan of care and follow-up plan at each physician encounter, whether in the

outpatient or inpatient setting.

Communicate with other HOSPITAL Medical Staff, as needed, to provide optimal

patient care.

Communicate with referring physicians/agencies regarding the condition and

clinical course of the patient and to obtain any information needed to provide

optimal care.

Communicate with relatives regarding the condition and clinical course of the

patient, and to obtain any information needed to provide optimal care.

Be available by telephone or beeper during regular clinic hours and when assigned

to “on call” duties after regular working hours.

Do everything possible within the scope of professional experience and skill to save

a patient’s life or save a patient from serious harm in the event of an emergency.

Maintain patient confidentiality during participation in clinical care, teaching,

research and participation in Quality Management activities.

Every patient admitted to the hospital must have one member of the Medical Staff designated as the

Attending Physician, whether the patient is admitted for surgical or non-surgical care.

The Attending physician has ultimate responsibility for the care of the patient.

He/she can and must obtain consultation from other members of the Medical Staff

and obtain assistance from personnel from non-Medical Staff departments

whenever the clinical situation warrants.

For surgical cases, the Attending Physician must personally perform, supervise the

performance of the procedure by another physician, or observe the performance of

the procedure by another physician.

For non-surgical cases, the Attending Physician must personally manage or directly

supervise the medical care of the patient.

The responsibilities of the Attending are in effect until the patient has been formally

transferred to another member of the Medical Staff who has agreed to assume the

responsibility as the patient’s Attending Physician.

Any member of the Medical Staff may become involved in the care of a patient at the request of the

Attending Physician as either a Consulting Physician or Prescribing Physician.

A Consultant Physician is individual from whom the Attending Physician requests an opinion

regarding a specific issue/s related to the care of the patient. The Attending Physician has the

option to accept or reject the recommendation of the Consulting Physician. By mutual agreement,

the Attending Physician may request the Consulting Physician to assume responsibility for the care

of the patient as the Attending Physician. In such a case the transfer of responsibility must be

clearly documented in the medical record.

A Prescribing Physician is an individual whom the Attending Physician requests to assume the

responsibility for providing moderate or deep sedation, local anesthesia or general anesthesia for

the purpose of conducting an examination or procedure on a patient. The Prescribing Physician is

responsible for the sedation or anesthesia-related aspects of the case. The Attending Physician

remains for the overall care of the patient.