Be part of
something bigger.

Qualifications: Appointees to the category must:

1. Admit or otherwise be involved in a minimum of fifty (50) patient contacts at the Hospital in a two-year period. A patient contact is defined as an inpatient admission or referral, consultation, or performance of a Hospital inpatient or outpatient surgical procedure; except as expressly waived for practitioners with at least twenty (20) years of service in the active category and/or for those practitioners who document their efforts to support the Hospital’s patient care mission to the satisfaction of the MEC and Board of Directors.
2. Intentionally omitted.

Prerogatives: Appointees to this Category may:

1. Admit patients to the Hospital without limitation, except as otherwise provided in the Medical Staff Rules and Regulations, or by specific privilege restriction.

2. Vote on all matters presented at the Hospital general and special meetings of the Medical Staff. Vote on all matters at the Hospital and system committees and department to which he/she is appointed.

3. Hold office and/or be the chairperson or member of any committee, unless otherwise specified elsewhere in the Bylaws.

4. Exercise such clinical privileges as are granted to them.

Responsibilities: Appointees to this category must:

1. Contribute as defined by the Organization and Functions Section to the organizational and administrative affairs of the Medical Staff.

2. Actively participate in recognized functions of Staff appointment including quality improvement and other monitoring activities, in monitoring initial appointees and in discharging other Staff functions as may be required from time to time.

3. Participate in the emergency service and other special coverage programs as determined by the MEC based on a recommendation from the department chief.

* The information provided is in summary form and more fully set forth in various Credentials Policies and Procedure Manual available to Members of the Medical Staff and verified applicants.

Qualifications: Appointees to this category must:

1. The Active Affiliate Category is reserved for practitioners who do not meet the eligibility requirements for the active category or choose not to pursue active status. Practitioners assigned to this category, may admit or otherwise be involved in the care or treatment of patients in providing consultations, ordering diagnostic or therapeutic services consistent with their Board approved privileges. Active Affiliate members may refer patients to other physicians on the Staff of the Hospital. This category is also appropriate for those practitioners who may not have admitting privileges; but document other important efforts (i.e., teaching or telemedicine) which support the Hospital’s patient care mission to the satisfaction of the MEC and Board of Directors.
2. In the event an appointee to the Active Affiliate Medical Staff does not meet the qualifications for appointment to the Active Affiliate Medical Staff, his/her appointment to the Staff shall automatically terminate; provided, however, that if the practitioner provides written notification that the Hospital is his/her Hospital of choice and that he/she utilizes the Hospital for greater than half of his/her patients requiring Hospital services, the MEC and the Board of Directors may, upon their joint approval, allow the practitioner to retain his/her appointment to the Active Affiliate Medical Staff.

Prerogatives: Appointees to this category may:

1. Admit patients to the Hospital in the same manner as an Active Medical Staff member, consistent with privileging criteria.
2. Complete their appropriate peer review requirement(s) as may be determined by the department chief, Credentials Committee, MEC, and approved by the Board of Directors. See Appendix A: Medical Staff Collegial Peer Review Policy.
3. Not vote at General Medical Staff Meetings or hold office.
4. Attend meetings of the General Medical Staff (without vote) and may attend and vote at the Hospital or System committee and department, as appropriate to which he/she is an appointee and may attend any Medical Staff or Hospital education programs.
5. Exercise such clinical privileges as are granted to them.

Responsibilities:

1. Appointees to this category may participate in emergency service and other specialty coverage programs, as determined by the MEC based on a recommendation from the department chief.
2. Contribute to the organizational and administrative affairs of the Medical Staff.
3. Actively participate in recognized functions of the Staff appointment including quality/performance improvement, risk management and monitoring activities, including monitoring of new appointees and in discharging other Staff functions as may be required.

* The information provided is in summary form and more fully set forth in various Credentials Policies and Procedure Manual available to Members of the Medical Staff and verified applicants.

Qualifications:

The Ambulatory Care Staff consists of those practitioners who:

1. desire to be associated with, but who do not intend to establish a clinical practice at, this Hospital and meet the eligibility criteria set forth in the Medical Staff Credentials Policy with the exception of Sections 2.2.11 to 2.2.18; and
2. have indicated or demonstrated a willingness to assume all the responsibilities of membership on the Ambulatory Care Staff as outlined in Section 3.4.2.

The primary purpose of the Ambulatory Care Staff is to promote professional and educational opportunities, including continuing medical education, and to permit these individuals to access Hospital services for their patients by referral of patients to Active Staff members for admission and care.

Prerogatives and Responsibilities:

Ambulatory Care Staff members:

1. may attend meetings of the Medical Staff and applicable departments (without vote);
2. may not hold office or serve as department chiefs or committee chairs;
3. shall generally have no Staff committee responsibilities, but may be invited to serve on committees (with vote);
4. may attend educational activities sponsored by the Medical Staff and the Hospital;
5. may refer patients to members of the Active Staff for admission and/or care;
6. are encouraged to submit their relevant outpatient records for inclusion in the Hospital’s medical records for any patients who are referred;
7. are encouraged to communicate directly with Active Staff members about the care of any patients referred, as well as to visit any such patients;
8. may review the medical records and test results (via paper or electronic access) for any patients who are referred;
9. may perform history and physical examinations in the office and have those reports entered into the Hospital’s medical records; and
10. may not: admit patients, attend patients, exercise inpatient or outpatient Clinical Privileges, write inpatient orders, perform consultations, assist in surgery, or otherwise participate in the provision or management of clinical care to patients at the Hospital.

* The information provided is in summary form and more fully set forth in various Credentials Policies and Procedure Manual available to Members of the Medical Staff and verified applicants.

Qualifications:

The Coverage Staff shall consist of practitioners who:

1. desire Appointment to the Medical Staff either for the purpose of providing telemedicine services, in which event they shall comply with Section 6.10.6 of the Credentials and Policy Procedures Manual, or for the purpose of being able to provide coverage assistance to Active Staff members who are members of their group practice or coverage group;
2. at each Reappointment time, provide such quality data and other information as may be requested to assist in an appropriate assessment of current clinical competence and overall qualifications for Appointment and Clinical Privileges (including, but not limited to, information from another hospital, information from the individual’s office practice, information from managed care organizations in which the individual participates, and/or receipt of confidential evaluation forms completed by referring/referred to physicians);
3. are not required to satisfy any defined response time requirements in place at the Hospital, except for those times when they are providing coverage; and
4. agree that their Medical Staff Appointment and Clinical Privileges will be automatically relinquished, with no right to a hearing or appeal, if their coverage arrangement with the Active Staff member(s), or if their telemedicine arrangement, terminates for any reason.

Prerogatives and Responsibilities

Coverage Staff members:

1. when providing telemedicine services shall exercise telemedicine services in accordance with Section 6.10.6 of the Credentials and Policy Procedures Manual;
2. when providing coverage assistance for an Active Staff member, shall be entitled to admit and/or treat patients who are the responsibility of the Active Staff member who is being covered (i.e., the Active Staff member’s own patients or unassigned patients who present through the Emergency Department when the Active Staff member is on call);
3. shall assume all Medical Staff functions and responsibilities as may be assigned, including, where appropriate, care for unassigned patients, emergency service care, consultation, and teaching assignments when covering for members of their group practice or coverage group;
4. shall be entitled to attend Medical Staff and department meetings (without vote);
5. may not hold office or serve as department chiefs or committee chairs;
6. shall generally have no Staff committee responsibilities, but may be invited to serve on committees (with vote); and
7. shall pay applicable fees and assessments.

* The information provided is in summary form and more fully set forth in various Credentials Policies and Procedure Manual available to Members of the Medical Staff and verified applicants.