10A NCAC 28F .0308 MEDICAL STAFF BYLAWS FORM

(a) Preamble

(1) Recognizing that the medical and dental staff is responsible for the quality of medical care in the hospital and must take steps to assume this responsibility, and that the best interests of the patient are protected by concerned effort, subject to the authority of the Division of Mental Health Services, the physicians and dentists practicing in (fill in name) hospital hereby organize themselves in conformity with the bylaws, rules, and regulations hereinafter stated.

(2) For the purpose of these bylaws the words "medical staff" shall be interpreted to include all physicians and dentists who are privileged to attend to patients in (fill in name) hospital.

(3) The term "governing body" means the Director of the Division of Mental Health Services.

(4) Whenever the term "director" appears, it shall be interpreted to refer to the Director of (fill in name) hospital as duly appointed by the Director of the Division of Mental Health Services, North Carolina Department of Human Resources.

(5) Whenever the term "Director of Clinical Services" appears, it shall be interpreted to mean that person responsible for all medical and clinical services where the Director is a non‑medical administrator.

(6) Whenever the term "paramedical staff" appears, it shall be interpreted to include the professional members of the Department of vocational rehabilitation, rehabilitation services, departments of physical therapy, psychology, nursing, social services, pharmacy, medical records, physicians' assistants, and nurse practitioners.

(7) These bylaws, rules, and regulations of the medical staff shall state the policies under which the medical staff regulates itself, creating and defining an atmosphere and framework within which members of the medical staff act with a reasonable degree of freedom and confidence. These medical staff bylaws, rules, and regulations shall provide for an effective formal means by which the medical staff may participate in the development of facility policy relative both to facility management and patient care not inconsistent with the North Carolina statutes and policies of the Division of Mental Health Services.

(b) Name of Organization. The name of this organization shall be "The Medical Staff of (fill in name) Hospital."

(1) to insure that the best possible care is rendered to all patients admitted to this hospital or treated by physicians and paramedical staff in the employ of this hospital;

(2) to provide a means whereby problems of medico‑administrative nature may be discussed by the medical staff with the administration of the hospital and the Division of Mental Health Services;

(3) to initiate and maintain rules and regulations for self‑governance of the medical staff;

(4) to provide an active education and training program and to maintain educational and training standards;

(5) to carry out through the hospital all appropriate duties of the Division of Mental Health Services;

(6) to carry out research in the fields of mental health;

(7) to attain and maintain the standards of the accreditation council of psychiatric facilities (Joint Commission on Accreditation of Hospitals);

(8) to insure a high level of professional performance of all practitioners authorized to practice in the hospital through the appropriate delineation of the clinical privileges that each practitioner may exercise in the hospital and through an ongoing review and evaluation of each practitioner's performance in the hospital;

(9) to promote the well‑being of the medical staff, permitting them to practice medicine in a congenial atmosphere and with the support and stimulus of working with their colleagues; and

(10) to advise and assist the Division of Mental Health Services and management of (fill in name) hospital in their responsibilities of providing an environment conducive to the practice of medical care of high quality, and to promote liaison with county, state and national professional societies, and with medical colleagues in community hospitals.

(d) Qualifications for Membership

(1) Licensing. Applicants for membership on the medical staffs shall be duly licensed or authorized to practice medicine or dentistry in the State of North Carolina according to those standards set forth by the North Carolina State Board of Medical Examiners or the North Carolina State Board of Dental Examiners. Externs, interns, and resident physicians must have appropriate recognition and authorization by the North Carolina State Board of Medical Examiners. Physicians' assistants and nurse practitioners shall have at least one physician supervisor appointed by the Director or Director of Clinical Services of the hospital.

(2) Criteria for Membership. No applicant shall be denied membership on the basis of any other criteria not related to professional competence or good standing with the North Carolina State Board of Medical Examiners or the North Carolina State Board of Dental Examiners.

(3) Ethics. Acceptance of membership on the medical staff shall constitute the staff member's agreement that he will strictly abide by the principles of medical ethics of the American Medical Association or the American Dental Association, whichever is applicable.

(4) Medical Director. The medical director shall be a member of the hospital medical staff and shall be a medical doctor duly licensed to practice medicine in the State of North Carolina with approved training and experience in the practice of psychiatry.

(5) Appointments

(A) Appointments to the medical staff shall be made by the Director of the hospital with concurrence of the Director of Clinical Services.

(B) The Director shall consult with the credentials committee of the medical staff before taking action on any application or cancelling any appointment previously made.

(C) Appointment to the medical staff of (fill in name) hospital shall confer upon the appointee only such privileges as may hereinafter be provided.

(D) Initial appointments shall be for a period extending to the end of the current medical staff year of the hospital. Reappointments shall be for a period of not more than two medical staff years. For the purpose of these bylaws the medical staff year commences on the first day of July and ends the 30th day of June of each year.

(6) Appointment Procedure

(A) Application for membership on the medical staff shall be presented in writing conforming to the requirements laid down by the North Carolina State Personnel Department and such other requirements as may be determined by the Director of the Division of Mental Health Services. The application shall state the qualifications and references of the applicant and shall signify his agreement to abide by the bylaws, rules and regulations of the medical staff. The application for employment on the medical staff shall be presented to the Director and Director of Clinical Services who shall transmit it to the Secretary of the medical staff.

(B) The Secretary of the medical staff shall present the application immediately to the credentials committee. This committee shall review the application and the applicant in order to determine suitability and eligibility for employment in the hospital.

(C) The credentials committee shall submit a report of findings to the Director and to the Director of Clinical Services as soon as possible and in all cases within one month recommending that the application be accepted, deferred, or rejected. Wherever a recommendation to defer is made, it must be accompanied by reasons for the deferment and must be followed by a subsequent report to accept or reject the applicant within a period of 30 days. Any recommendation for appointment shall include a delineation of privileges.

(D) The Director of the hospital in concurrence with the Director of Clinical Services shall either accept the recommendation of the credentials committee or shall refer it back for further consideration stating the reasons for such action. After further consideration the credentials committee will report to the Director and Director of Clinical Services who will take final action on the application.

(E) When a final decision has been made by the Director and Director of Clinical Services, they shall be authorized to transmit this decision to the candidate for employment, and if the candidate accepts employment, to secure his signed agreement to be governed by the bylaws, rules, and regulations.

(F) It is recommended that the Director and Director of Clinical Services may utilize the consultative services of the credentials committee in reviewing the credentials of paramedical personnel who are being considered for appointment to responsible positions of leadership at (fill in name) hospital.

(7) Reappointment Process

(A) At least 60 days prior to the final scheduled governing body meeting in the medical staff year, the executive committee of the medical staff shall review all pertinent information available on each practitioner scheduled for periodic appraisal, for the purpose of determining its recommendations for reappointments to the medical staff and for the granting of clinical privileges for the ensuing period, and shall transmit its recommendations, in writing, to the Director of Clinical Services. Where non-reappointment or a change in clinical privileges is recommended, the reason for such recommendation shall be stated and documented.

(B) Recommendations for reappointment shall normally be made by the credentials committee and shall normally be considered at the annual meeting.

(C) Each recommendation concerning the reappointment of a medical staff member and the clinical privileges to be granted upon reappointment shall be based upon such member's professional competence and clinical judgement in the treatment of patients, his ethics and conduct, his attendance at medical staff meetings and participation in staff affairs, his compliance with the hospital bylaws and the medical staff bylaws, rules and regulations, his cooperation with hospital personnel, his use of the hospital's facilities for patients, his relations with other practitioners, and his general attitude toward other practitioners, and his general attitude toward patients, the hospital and the public.

(D) Thereafter, the procedure provided in Part (d)(6)(C) to Part (d)(6)(F) of this Rule relating to recommendations on applications for initial appointment shall be followed.

(8) Appeals

(A) Should the superior of any physician or dentist recommend restriction or termination of the employment of any physician or dentist of the medical staffs, such recommendation will be forwarded in writing to the Director and Director of Clinical Services who in turn may, within a period of five days, refer said recommendation to the executive committee of the medical staff for review. The result of this review will be forwarded to the director within five days. If the Director and Director of Clinical Services accept the recommendation of the executive committee of the medical staff, said recommendation will be made known to the physician or dentist in question. The physician or dentist may, if he wishes, appeal his case to the regional director of mental health. Further appeal can be made by the physician or dentist in question to the Director of the Division of Mental Health Services, the Secretary of the North Carolina Department of Health and Human Services, and finally, to the State Personnel Board within a period not to exceed two weeks. Should the Director and Director of Clinical Services disagree with the recommendation of the executive committee of the medical staff committee, they can proceed with their decision after consulting with the regional director of mental health.

(B) (A) of this Subpart does not preclude the right of the Director and Director of Clinical Services to suspend any physician or dentist from his duties for flagrant misconduct pending the appeal mechanism as in (A) of this Subpart. Any superior recommending termination or restriction of the rights and privileges of a physician or dentist of the staff of this hospital must show cause for such recommendations. If the cause is basically performance, evidence shall be presented of two successive verbal warnings having been given as well as a written warning having been previously forwarded to the physician or dentist in question.

(9) Emergency and Temporary Privileges

(A) Regardless of his departmental staff status, in the case of an emergency, the physician attending any patient shall be expected to do all in his power to save the life of any patient at (fill in name) hospital including the calling of such consultation as may be available or desirable. For the purpose of this Subpart, an emergency is defined as a condition in which the life of the patient is in immediate danger and in which any delay in administering treatment would increase the danger.

(B) The Director and Director of Clinical Services of the hospital shall have the authority to grant temporary privileges to a qualified physician who is not a member of the medical staff. Such a physician shall work under the direct supervision of the Director and of the Director of Clinical Services of the hospital. Such temporary privileges shall last until the credentials committee meets, but not to exceed 30 days.

(e) Categories in the Medical Staff

(1) Divisions of Medical Staff. The medical staff shall be divided into honorary, visiting, active, and resident staffs.

(2) Honorary Staff. The honorary medical staff shall consist of physicians who are not active in the hospital and who are honored by emeritus positions. These may be physicians who have retired from active hospital service or physicians of outstanding reputation not necessarily resident in the community. The honorary staff is not eligible to vote or hold office, ordinarily does not admit patients, and shall have no assigned duties.

(3) Visiting Medical Staff

(A) The visiting medical staff shall consist of physicians of recognized professional ability who are active in programs carried out by the hospital or who have signified willingness to accept such appointment.

(B) The duties of the members of the visiting medical staff shall be to give their services in the care of patients on request of any member of the active medical staff or duties as designated by the Director or Director of Clinical Services of (fill in name) hospital.

(4) Active Medical Staff

(A) The active medical staff shall consist of those physicians who are employed either full‑time or part‑time by (fill in name) hospital.

(B) The active medical staff shall consist of physicians who have been selected to transact all business of the medical staff and attend patients who are in the hospital and to whom all such patients shall be assigned. Only members of the active medical staff shall be eligible to hold office on committees of the medical staff.

(C) Members of the full‑time active medical staff shall be required to attend three‑fourths of the medical staff meetings.

(D) Members of the active medical staff shall be required to attend meetings of all committees upon which they agree to serve by virtue of appointment or election.

(E) Each active staff physician may have one and not more than two physicians' assistants and nurse practitioners under his supervision and responsibility in (fill in name) hospital, after first having the individual's credentials approved by the credentials committee and medical staff. These individuals will be registered and function in conformity with North Carolina General Statute 90‑18(13), 1971.

(5) The House Staff

(A) The house staff consists of interns, assistant residents, and residents, who shall be assigned to the clinical departments in such numbers as may from time to time be decided by the Director and Director of Clinical Services.

(B) Members of the house staff must be graduates of or students in good standing of approved and recognized schools of medicine. Members of the house staff will perform such duties as may seem appropriate to the Director of the service to which they are assigned. Graduates of medical schools approved and recognized other than those in the United States, Canada, or Puerto Rico must present a valid certificate from the Educational Council for Foreign Medical Graduates, or a similar organization approved by the North Carolina State Board of Medical Examiners as an added condition of appointment.

(f) Determination of Qualifications

(1) Classification of Privileges

(A) Determination of privileges granted to members of the medical staff will be made by the Director and Director of Clinical Services of the hospital after recommendations of the executive committee of the medical staff. In determining these recommendations the executive committee of the medical staff shall consult with the medical staff and the members of the credentials committee.

(B) Restricting the privileges of any physician or dentist by reason of age or disability will be the duty of the Director and Director of Clinical Services at the request of the credentials committee. Any restrictions will be made known in writing to the involved physician or dentist. Should the physician or dentist refuse the recommended restriction or restrictions, he may appeal.

(2) Determination of Privileges

(A) Determination of initial privileges shall be based on an applicant's training, experience, and demonstrated competence. Determination of such recommended privileges shall be made by the credentials committee.

(B) Determination of extension of further privileges shall be based upon the applicant's training, experience and demonstrated competence, and his continued satisfactory performance of duties in the hospital.

(C) It shall be the duty of the credentials committee to recommend specific rights and privileges of each physician and dentist as practicing at (fill in name) hospital. Such recommendation will be made part of the minutes of that committee. This will include those physicians given the right to perform specialized procedures such as an electrocardiogram and liver biopsies. It shall in like manner be the duty of the credentials committee to recommend rights and privileges of paramedical staff.

(g) Officers and Committees

(1) Officers. The officers of the medical staff shall be the president, vice president, and secretary. Ultimate authority and accountability remain with the governing body and with the Director and Director of Clinical Services.

(2) Requirements to be Officers. Officers must be members of the active medical staff at the time of appointment or nomination and election and must remain members in good standing during their term of office. Failure to maintain such status shall immediately create a vacancy in the office involved.

(3) Election of Officers

(A) The president, the vice president, and the secretary shall be elected at the annual meeting of the medical staff. All officers shall be members of the active medical staff. Only members of the active medical staff shall be eligible to vote.

(B) The nominating committee shall consist of members of the active medical staff appointed by the president of the medical staff. This committee shall offer one or more nominees for each office.

(C) Nominations may also be made from the floor at the time of the annual meeting or be made by petition signed by at least five members of the active staff and filed with the Secretary of the medical staff at least 30 days prior to the annual meeting.

(4) Term. Elected officers shall serve a one year term from their election date or until a successor is elected. They shall take office on the first day of the medical staff year.

(5) Vacancies. Vacancies of the officers during the medical staff year shall be filled by the president of the medical staff.

(6) President. The president shall serve as the chief administrative officer of the medical staff to do the following:

(A) act in coordination and cooperation with the Director and Director of Clinical Services in all matters of mutual concern within the hospital;

(B) call, preside at, and be responsible for the agenda of all general meetings of the medical staff;

(D) serve as ex officio member of all other medical staff committees without vote;

(E) be responsible for the enforcement of medical staff bylaws, rules, and regulations, for implementation of sanctions where these are indicated, and for the medical staff's compliance with procedural safeguards in all instances where corrective action has been requested against a practitioner;

(F) appoint committee members to all standing, special, and multidisciplinary medical staff committees except elected members of the executive committee and joint conference committee;

(G) represent the views, policies, needs, and grievances of the medical staff to the governing body and to the Director and Director of Clinical Services;

(H) receive and interpret the policies of the governing body to the medical staff and report to the governing body on the performance and maintenance of quality with respect to the medical staff's delegated responsibility to provide medical care;

(I) be responsible for the educational activities of the medical staff; and

(J) be the spokesman for the medical staff in its external professional and public relations.

(7) Absence of President. In the absence of the president, the vice president shall assume all the duties and have the authority of the president. He shall be a member of the executive committee of the medical staff and of the joint conference committee. He shall automatically succeed the president when the latter fails to serve for any reason.

(8) Secretary‑Treasurer. The Secretary‑treasurer shall be a member of the executive committee of the medical staff. The Secretary shall keep accurate and complete minutes of all medical staff meetings, call medical staff meetings on order of the president, attend to all correspondence, and perform such other duties as ordinarily pertain to his office. He shall be the Secretary of the ad hoc bylaws committee whenever it convenes, unless this becomes a standing committee.

(h) Committees

(1) Committees shall be designated as standing and special. All committee members other than elected members of the executive and the joint conference committee shall be appointed by the president of the medical staff. Committees shall be known as committees of the medical staff of the hospital and can include, other than members of the active medical staff, persons representing disciplines from within and without the hospital. Committee reports shall be filed in the Director's and director of clinical service's offices. The report of all committee meetings will be brought to the attention of the executive committee. It shall be the duty of the president or his designee to compile and present these committee reports for the consideration of the executive committee at its next regular meeting.

(2) The executive committee shall be composed of the president, vice president, secretary, and two other elected members of the medical staff. The Director and Director of Clinical Services shall be ex officio members.

(3) The executive committee shall be empowered to act on behalf of the medical staff. The committee shall meet at least monthly, and shall maintain a permanent record of its proceedings and actions. The Director and Director of Clinical Services shall attend all meetings of this committee. Functions and responsibilities of the executive committee include the following:

(A) to receive and act upon the reports of medical staff committees;

(B) to consider and recommend action to the Director and Director of Clinical Services all matters of a medico‑administrative nature;

(D) to make recommendations to the governing body;

(E) to take all reasonable steps to ensure professionally ethical conduct on the part of all members of the medical staff and to initiate such prescribed corrective measures as are indicated;

(F) to fulfill the medical staff's accountability to the governing body for the diagnosis, treatment and care rendered to the patients in the facility; and

(G) to ensure that the medical staff is kept abreast of the accreditation program and informed of the accreditation status of the facility.

(4) The following committees are essential and report to the executive committee of the medical staff:

(A) administrative committees which include the joint conference committee, the credentials review committee, and the accreditation committee; and

(B) clinical committees which include patient care evaluation, utilization review, medical records, tissue review, pharmacy and therapeutics, infections, and research.

(5) Committees may be combined consistent with proper management.

(i) Meetings

(1) Annual Meeting. The annual meeting of the medical staff shall be held near the end of the hospital fiscal year. At this time, the officers and committees shall make such reports as may be desirable; committee recommendations and committee appointments for the ensuing year shall be made.

(2) Monthly Meeting. The medical staff shall meet monthly to review the clinical work of the hospital since its last meeting and make recommendations for improvement. It will hear reports from the executive committee and the other standing committees. Business and other executive sessions of the medical staff will be conducted by the active staff except that other categories of the medical staff may be present and participate but without the right to vote.

(3) Special Meetings

(A) Special meetings of the medical staff may be called at any time by the Director, Director of Clinical Services, president of the medical staff or by written request of at least five members stating the purpose of the meeting. At any special meeting no business shall be transacted except that stated in the notice calling the meeting. Sufficient written notice of any meeting shall be provided at least 48 hours before the time set for the meeting.

(B) The joint conference committee will meet quarterly with the governing body.

(4) Attendance at Meetings

(A) Members of the active medical staff shall attend at least three‑fourths of the regular staff meetings unless excused by the executive committee for just cause. Absence from more than one‑fourth of the regular staff meetings of the year, unless excused by the executive committee for just cause such as sickness or absence from the community shall be considered a basis for disciplinary action.

(B) Reinstatement of members of the active staff to positions rendered vacant because of absence from meetings may be made on application, the procedure being the same as in the case of original appointment.

(C) Members of the honorary and visiting categories of medical staff shall not be required to attend meetings but it is expected that they will attend and participate in these meetings unless unavoidably prevented from doing so.

(D) A member of any category of the staff who has attended a case that is to be presented for discussion at any meeting shall be notified and shall be required to be present.

(5) Quorum. Fifty percent of the total membership of the active medical staff shall constitute a quorum.

(6) Agenda

(A) The agenda at any regular meeting shall be as follows:

(i) business, which includes call to order, acceptance of the minutes of the last regular and of all special meetings, unfinished business, communications, reports of standing and of special business committees, and new business; and

(ii) medical, which includes review and analysis of the clinical work of the hospital, reports of standing and of special medical committees, discussion and recommendations for improvement of the professional work of the hospital, and adjournment.

(B) The agenda at special meetings shall be as follows:

(i) reading of the notice calling the meeting,

(ii) transaction of the business for which the meeting was called, and

(iii) adjournment.

(7) Robert's Rules. Unless specified otherwise, Robert's Rules of Order will be followed at all medical staff meetings where business is conducted and at all committee meetings, except each committee may adopt its own rules or suspend the rules if a majority of members agree.

(8) Amendments. Amendments to these bylaws shall be made upon consideration and recommendation of the medical staff, the Director and Director of Clinical Services, and with approval of the governing body.

(9) Signatures. Adoption by the medical staff shall be indicated by signatures of the Director and Director of Clinical Services and the Director of the Division of Mental Health Services as the governing body.

History Note: Authority G.S. 143B‑147;

Eff. February 1, 1976;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. August 24, 2019.