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Medical, Dental and Scientific Staff (Credentialing/Disciplinary) Bylaws

made under Section 23 of the

Health Authorities Act

S.N.S. 2000, c. 6

and Section 6 of the

Hospitals Act

R.S.N.S. 1989, c. 208

N.S. Reg. 306/2007 (June 12, 2007)

 

Part I: Definitions

1     Definitions

       1.1       In these Bylaws,

 

                   1.1.1       “Applicant” means a person seeking appointment or reappointment to the IWK Health Centre Medical, Dental and Scientific Staff and includes a person applying for a temporary appointment.

 

                   1.1.2       “Application Form” means the appropriate application form to be completed by an Applicant to the MDSS, as determined by the CEO.

 

                   1.1.3       “Article” means a section or subsection of these Bylaws, as the context requires.

 

                   1.1.4       “Board” means the Board of Directors of the IWK Health Centre.

 

                   1.1.5       “Bylaws” means

 

                                  1.1.5.1       these IWK Health Centre Medical, Dental and Scientific Staff Bylaws (Credentialing/Disciplinary) when the phrase “these Bylaws” is used, or

 

                                  1.1.5.2       the IWK Health Centre Medical, Dental and Scientific Staff Bylaws (Credentialing/Disciplinary); the IWK Health Centre Medical, Dental and Scientific Staff Bylaws (General); and the IWK Health Centre Corporate Bylaws when the phrase “all Bylaws” is used.

 

                   1.1.6       “Chief Executive Officer” abbreviated as CEO means the person appointed by the Board to be the President and Chief Executive Officer of the IWK Health Centre who is responsible for the administration and management of the IWK Health Centre.

 

                   1.1.7       “Child Abuse Register Inquiry” means an inquiry pursuant to the Nova Scotia Child Abuse Register, or equivalent registers in other jurisdictions in which an applicant has resided or practised, which provides information respecting allegations or findings of child abuse against an applicant.

 

                   1.1.8       “Credentials Committee” means the committee of the MAC acting as the Credentials Committee for the purposes of these Bylaws, comprised of the membership set out in Article 2.

 

                   1.1.9       “Credentials Process” means the process outlined in these Bylaws where an Applicant seeks appointment to the MDSS, and the grant of privileges and, without limiting the generality of the foregoing, includes those processes outlined in Parts III and IV of these Bylaws.

 

                   1.1.10     “Criminal Record Inquiry” means an inquiry to local police authorities, or to police authorities in locations where an applicant has resided or practised, to determine whether the applicant is or has been convicted of any criminal offenses for which a pardon has not been granted.

 

                   1.1.11     “Day” means one business day; that is, Monday to Friday, excluding statutory holidays.

 

                   1.1.12     Dental Act” means the Dental Act, S.N.S. 1992, c. 3, s. 1.

 

                   1.1.13     “Dentist” means a dentist who, under the Dental Act, is registered in the Dentists’ Register and holds a licence to practice dentistry.

 

                   1.1.14     “Department Chief” means the physician, dentist, or scientist appointed by the Board to be the leader of an IWK Health Centre Department and who reports to the Board through the CEO.

 

                   1.1.15     “Discipline Process” means the processes outlined in Part V of these Bylaws. For greater certainty, an automatic suspension issued pursuant to Article 20 is not a discipline process.

 

                   1.1.16     “Health Centre” means the Izaak Walton Killam Health Centre established pursuant to the Izaak Walton Killam Health Centre Act, S.N.S. 2001, c. 49, s.2 [S.N.S. 1996, c. 26].

 

                   1.1.17     “Health Centre Representative” means the CEO or a person appointed by the CEO to act as the representative of the Health Centre for purposes of a Mediation Process or Discipline Process.

 

                   1.1.18     “Hearing Committee” means the committee of the MAC acting as the Hearing Committee for the purposes of these Bylaws, comprised of the membership set out in Article 3.

 

                   1.1.19     “MDSS Rules and Regulations” means rules and regulations made by the Medical, Dental and Scientific Staff Organization with respect to the governance and internal operations of the MDSS Organization.

 

                   1.1.20     “Mediated Resolution” means a unanimous agreement signed pursuant to Article 15.6.

 

                   1.1.21     “Mediation Process” means the process outlined in Article 15.

 

                   1.1.22     Medical Act” means the Medical Act, S.N.S. 1995-96, c. 10, s. 1.

 

                   1.1.23     “Medical Advisory Committee” means the Committee abbreviated as MAC established by the Board to act as the MAC for the purposes of these Bylaws, comprised of the membership set out in Article 4.

 

                   1.1.24     “Medical, Dental and Scientific Staff” abbreviated as MDSS means those physicians, dentists, and scientists who are licenced under the Medical Act and Dental Act, if applicable, and have privileges or who are otherwise permitted to practice within the Health Centre as more particularly set out in these Bylaws, the Bylaws (General) and the MDSS Rules and Regulations.

 

                   1.1.25     “Medical, Dental and Scientific Staff Executive” abbreviated as MDSS Executive means the Executive of the Medical, Dental and Scientific Staff Organization, elected in accordance with the MDSS Rules and Regulations.

 

                   1.1.26     “Medical, Dental and Scientific Staff Organization” means the entity established pursuant to the Bylaws (General) to represent the Medical, Dental and Scientific Staff.

 

                   1.1.27     “Member” means a member of the Medical, Dental and Scientific Staff.

 

                   1.1.28     “Party” means

 

                                  1.1.28.1     the Health Centre representative;

 

                                  1.1.28.2     the Member who is the subject of consideration in any process pursuant to these Bylaws; and

 

                                  1.1.28.3     any other person identified as a party pursuant to these Bylaws.

 

                   1.1.29     “Physician” means a person who, under the Medical Act, is registered and holds a licence to practice medicine.

 

                   1.1.30     “Privileges Review Committee” abbreviated as “PRC” means the Committee comprised of members of the Board as defined in Article 5.

 

                   1.1.31     “Provincial Appeal Board” abbreviated as “PAB” means the board constituted pursuant to s. 23(b) of the Health Authorities Act, S.N.S. 2000, c. 6, s. 1 that carries out those functions assigned to it by these Bylaws.

 

                   1.1.32     “Rules and Regulations” means any Rules and Regulations approved by the Board pursuant to the Bylaws, and includes MDSS Rules and Regulations approved by the MDSS Executive unless the context otherwise requires.

 

                   1.1.33     “Scientist” means an individual who has been appointed as a scientist to the Medical, Dental and Scientific Staff of the Health Centre.

 

                   1.1.34     “Variance” means any change from the appointment or privileges requested by an Applicant.

 

                   1.1.35     “VP Medicine” means the Vice-President, Medicine.

 

Part II: Committees

 

2     Credentials Committee

       2.1       The Credentials Committee is a committee of the MAC and consists of:

 

                   2.1.1       the VP Medicine, who will serve as Chair (or his/her delegate);

 

                   2.1.2       a member of MDSS Executive, appointed by the MDSS Executive; and

 

                   2.1.3       three members of the MDSS, who shall not be Chiefs, appointed by the MDSS Executive.

 

       2.2       A quorum of the Credentials Committee consists of three individuals, one of whom must be the VP Medicine or his/her delegate.

 

       2.3        Credentials Committee shall:

 

                   2.3.1       undertake detailed investigation and analysis of applications for appointments, privileges, and applications for reappointment;

 

                   2.3.2       review Mediated Resolutions arising out of the Mediation Process, where required pursuant to these Bylaws; and

 

                   2.3.3       perform such other functions as set out in these Bylaws.

 

       2.4       The chair of the Credentials Committee is a voting member of the Credentials Committee, and shall cast an additional vote in the event of a tie among the remaining members of the Credentials Committee.

 

       2.5       The MAC retains the authority at any time to appoint or replace new members of the Credentials Committee where no quorum is available, where a conflict of interest may exist, or for any other reason where a member of the Credentials Committee is not available to act. In the absence of appointments by the MDSS Executive for replacement members of the Credentials Committee, the MAC may appoint any member of the MDSS to replace a member of the Credentials Committee appointed pursuant to Article 2.1.

 

3     Hearing Committee

       3.1       The Hearing Committee is a committee of the MAC and consists of:

 

                   3.1.1       one member of the MAC appointed by the MAC, who is not the Chair of the MAC or the VP Medicine, and who shall act as Chair of the Hearing Committee;

 

                   3.1.2       two other members of the MAC, appointed by the MAC, none of whom is the chair of the MAC or the VP Medicine; and

 

                   3.1.3       three members of the MDSS nominated by the MDSS Executive.

 

       3.2       A quorum of the Hearing Committee consists of five individuals.

 

       3.3       The Hearing Committee shall act as an independent adjudicative body during the Hearing Process, in accordance with Articles 16 and 17.

 

       3.4       Members of the Hearing Committee shall excuse themselves from any discussions at the MAC regarding the credentialing or discipline of individuals who may become a party before the Hearing Committee.

 

       3.5       A member of the Hearing Committee shall not serve concurrently on the Credentials Committee.

 

       3.6       In a proceeding before the Hearing Committee, the Hearing Committee may retain independent legal counsel.

 

       3.7       The chair of the Hearing Committee is a voting member of the Hearing Committee, and shall cast an additional vote in the event of a tie among the remaining members of the Hearing Committee.

 

       3.8       The MAC retains the authority to appoint or replace new members of the Hearing Committee where no quorum is available, where a conflict of interest may exist, or for any other reason where a member of the Hearing Committee is not available to act. Replacement members of the Hearing Committee need not be members of MAC, but may be appointed by the MAC from any members of the MDSS.

 

4     Medical Advisory Committee

       4.1       The Medical Advisory Committee is the senior medical committee appointed by and accountable to the Board and consists of:

 

                   4.1.1       the VP Medicine;

 

                   4.1.2       the VP Research;

 

                   4.1.3       the President, MDSS;

 

                   4.1.4       the Vice-President, MDSS;

 

                   4.1.5       the Department Chiefs;

 

                   4.1.6       the CEO, who shall be a non-voting member of the MAC; and

 

                   4.1.7       such other persons as determined by resolution of the Board.

 

       4.2       A quorum of the MAC shall consist of 50 per cent of the MAC members.

 

       4.3       The members of the MAC shall elect the Chair, who shall hold a position of Chair for a two year term. The incumbent Chair can offer for re-election for two additional two year terms, with six years being the maximum time for any one person to occupy the position of Chair.

 

       4.4       The nomination process for the Chair of the MAC and the process for election of the Chair shall be set out in the Rules and Regulations pursuant to these Bylaws.

 

       4.5       The MAC shall:

 

                   4.5.1       perform those functions assigned to it by the Medical Advisory Committee Terms of Reference, as approved by the Board; and

 

                   4.5.2       perform such other functions as set out in these Bylaws.

 

5     Privileges Review Committee

       5.1       The Privileges Review Committee is a committee of three members of the Board, appointed by the Board. The PRC shall act in the place of the Board and shall be the Board’s final decision-making authority with respect to the Credentials Process and the Discipline Process, as authorized by s. 9 of the Izaak Walton Killam Health Centre Act, S.N.S. 2001, c. 49 [S.N.S. 1996, c. 26].

 

       5.2       Without limiting the generality of the foregoing, the PRC shall:

 

                   5.2.1       make decisions regarding applications for credentialing;

 

                   5.2.2       review all Mediated Resolutions and Hearing Committee decisions referred to it pursuant to these Bylaws;

 

                   5.2.3       make decisions on appeals from Hearing Committee decisions;

 

                   5.2.4       forward its decisions to the chair of the Board and the CEO for information; and

 

                   5.2.5       perform such other functions as set out in these Bylaws.

 

       5.3       The chair of the Privileges Review Committee shall be appointed by the Board, and shall be a voting member of the Privileges Review Committee.

 

       5.4       A quorum of the Privileges Review Committee is three members of the Board.

 

       5.5       The Board retains the authority at any time to appoint or replace members of the PRC where no quorum is available, where a conflict of interest may exist, or for any other reason where a member of the PRC is not available to act.

 

Part III: Appointments & Privileges – General

 

6     Appointment of Medical, Dental and Scientific Staff – General

       6.1       The Board may appoint physicians, dentists, and scientists in its sole and absolute discretion to the Medical, Dental and Scientific Staff in the manner provided for in these Bylaws.

 

       6.2       All appointments to the MDSS shall be conditional on the physician, dentist, or scientist agreeing in writing to abide by:

 

                   6.2.1       all IWK Health Centre Bylaws, policies, and procedures;

 

                   6.2.2       the Rules and Regulations;

 

                   6.2.3       the limits of the appointment and privileges as specified in these Bylaws and granted to the Member; and

 

                   6.2.4       the Code of Ethics of the Canadian Medical Association (for physicians), the Canadian Dental Association (for dentists), or such codes of ethics as exist and pertain to their field (for scientists).

 

7     Privileges – General

       7.1       A physician, dentist, or scientist who is appointed to the MDSS shall be granted privileges appropriate to his/her role and practice, as determined by the processes established pursuant to these Bylaws. When privileges are granted pursuant to these Bylaws, the decision granting such privileges shall specify the extent and limitation of the privileges, including the category of appointment pursuant to Article 8 and the departments in which the applicant may exercise privileges.

 

       7.2       All privileges granted to members of the MDSS in accordance with these Bylaws shall be for a period of 36 months. In the case of members of the MDSS who have privileges in effect at the time these Bylaws are approved, the privileges granted to such members remain in effect until the expiration date of such privileges.

 

       7.3       Notwithstanding Article 7.2, privileges granted to a member shall be for a term less than thirty-six (36) months, where:

 

                   7.3.1       specified in a decision made pursuant to these Bylaws;

 

                   7.3.2       granted as part of a temporary appointment pursuant to Article 12; or

 

                   7.3.3       an employment contract or another contractual relationship with a Member states otherwise.

       7.4       Members shall annually, on a date specified by the CEO, provide evidence as required by the CEO of:

 

                   7.4.1       appropriate insurance or coverage through a protective association;

 

                   7.4.2       registration and current licensing with the relevant regulatory body; and

 

                   7.4.3       such other items as may be required by the CEO.

 

       7.5       A Member of the Medical, Dental and Scientific Staff may request a change in privileges or category if the member submits a request in writing to the CEO.

 

       7.6       Upon receipt of a request for a change in privileges or category pursuant to Article 7.5, the CEO shall forward the request to the VP Medicine and relevant Department Chief, and the matter shall be processed as if it were an application from the member to the CEO for reappointment pursuant to Article 11.

 

       7.7       If a Member’s privileges expire prior to completion of the Credentials Process outlined in these Bylaws, such privileges shall be continued until the Credentials Process is completed, unless such privileges are suspended or varied pursuant to Articles 13, 14, or 20.

 

8     Categories of Appointments

       8.1       The categories of appointment within the IWK Health Centre Medical, Dental and Scientific Staff shall be:

 

                   8.1.1       Active Staff;

 

                   8.1.2       Consulting Staff;

 

                   8.1.3       Courtesy Staff;

 

                   8.1.4       Clinical and Research Trainees;

 

                   8.1.5       Clinical Associate Staff;

 

                   8.1.6       Scientific Staff;

 

                   8.1.7       Honorary Staff;

 

                   8.1.8       Locum Tenens; and

 

                   8.1.9       Visiting Consultant.

 

       8.2       Active Staff:

 

                   8.2.1       The Active Staff consists of those physicians and dentists who are appointed in accordance with these Bylaws and the University-Health Centre Affiliation Agreement and have appointments in either the Faculty of Medicine or the Faculty of Dentistry at the University.

 

                   8.2.2       Unless otherwise recommended by the Chief of the appropriate Department of the IWK Health Centre and approved by the Credentials Committee, Members of the Active Medical and Dental Staff shall be primarily based at the IWK Health Centre.

 

                   8.2.3       Physicians who are Members of the Active Staff are eligible to be granted IWK Health Centre privileges, including regular attendance to patients, and have attending privileges as delineated in the terms of their appointment.

 

                   8.2.4       Dentists who are Members of Active Staff are eligible to be granted IWK Health Centre privileges, including regular attendance to patients, as delineated in the terms of their appointment.

 

       8.3       Consulting Staff:

 

                   8.3.1       The Consulting Staff consists of those physicians and dentists who are appointed in accordance with these Bylaws and the University-Health Centre Affiliation Agreement, and have appointments in either the Faculty of Medicine or Faculty of Dentistry at the University.

 

                   8.3.2       Unless otherwise recommended by the Chief of the appropriate Department of the IWK Health Centre and approved by the Credentials Committee, the Consulting Staff shall consist of those physicians and dentists who are primarily based at another health care facility whose consultation and advice may be required from time to time at the IWK Health Centre.

 

                   8.3.3       Physicians who are Members of the Consulting Staff are eligible to be granted IWK Health Centre privileges and have attending privileges as delineated in the terms of their appointments. Consulting Staff shall respond to requests for consultations in a timely manner.

 

                   8.3.4       Dentists who are Members of the Consulting Staff are eligible to be granted IWK Health Centre privileges as delineated in the terms of their appointments. They shall not admit patients to inpatient units of the IWK Health Centre. Consulting Staff shall respond to requests for consultations in a timely manner.

 

       8.4       Courtesy Staff:

 

                   8.4.1       The Courtesy Staff consists of those physicians and dentists who are appointed in accordance with these Bylaws. Unless otherwise recommended by the Chief of the appropriate Department of the IWK Health Centre and approved by the Credentials Committee, Members of the Courtesy Staff may hold a University appointment.

 

                   8.4.2       Physicians who are Members of the Courtesy Staff are eligible to be granted IWK Health Centre privileges and have attending privileges as delineated in the terms of their appointments.

 

                   8.4.3       Dentists who are Members of the Courtesy Staff are eligible to be granted IWK Health Centre privileges as delineated in the terms of their appointments. They shall not admit patients to inpatient units of the IWK Health Centre.

 

       8.5       Clinical and Research Trainee Staff:

 

                   8.5.1       The Clinical and Research Trainees consist of those physicians, dentists and scientists who do not qualify for appointment in another staff category and who are appointed in accordance with these Bylaws for a specified period up to one (1) year which may be renewed annually.

 

                   8.5.2       Clinical and Research Trainees shall only be appointed after appropriate consultation with the University.

 

                   8.5.3       Clinical and Research Trainees shall be physicians, dentists or scientists who do not have Post-graduate or Faculty appointments at the University Faculty of Medicine or Faculty of Dentistry and who are employed by the IWK Health Centre or who have sought access to the IWK Health Centre to pursue specific limited term learning objectives at the IWK Health Centre, such as mandatory re-training or additional training not provided through the University Post-Graduate Education programs.

 

                   8.5.4       Clinical and Research Trainees are eligible to be granted IWK Health Centre privileges which shall be delineated in the terms of their appointment. They shall serve only under the supervision of Members of the Active Staff.

 

       8.6       Clinical Associate Staff:

 

                   8.6.1       The Clinical Associate Staff consists of those physicians and dentists who are appointed in accordance with these Bylaws. Members of the Clinical Associate Staff shall not hold a University appointment in the Faculty of Medicine or Dentistry.

 

                   8.6.2       Members of the Clinical Associate Staff shall be appointed to work under the supervision of Members of the Active Staff to carry out specified tasks or specialist services in the IWK Health Centre.

 

       8.7       Scientific Staff:

 

                   8.7.1       The Scientific Staff consists of those persons appointed in accordance with these Bylaws who perform clinical and/or research functions at the IWK Health Centre, who are not practicing physicians or dentists, and who possess at least a MD, DDS, PhD or equivalent degree in a discipline or disciplines which may provide special expertise to the IWK Health Centre and who hold an appointment in at least one of such disciplines with the University and who, on appointment, shall be assigned to an appropriate Department defined in the Rules and Regulations.

 

                   8.7.2       Members of the Scientific Staff are eligible to be granted such IWK Health Centre privileges as delineated in the terms of their appointment, or, if Scientific Staff Members’ privileges are not so delineated, then such privileges as are delineated pursuant to the appointment procedure stipulated in the Bylaws and in the Rules and Regulations.

 

                   8.7.3       Members of the Scientific Staff are not eligible to admit patients to the inpatient units of the IWK Health Centre.

 

                   8.7.4       Members of the Scientific Staff shall not ordinarily be employees of the IWK Health Centre.

 

       8.8       Honorary Staff:

 

                   8.8.1       Honorary Staff may be appointed by the Board on the recommendation of the Executive Committee.

 

                   8.8.2       Honorary Staff Members are those persons who have retired from active service with the IWK Health Centre and have made a significant contribution to the IWK Health Centre during the period in which they were active or are Members of outstanding reputation or extraordinary accomplishment, who have demonstrated a strong interest in children’s or women’s health care.

 

                   8.8.3       Honorary Staff Members shall not have regularly assigned duties or responsibilities and shall not attend patients.

 

       8.9       Locum Tenens:

 

                   8.9.1       The Locum Tenens Staff consists of those physicians or dentists appointed in accordance with these Bylaws and the University-Health Centre Affiliation Agreement to be granted privileges for periods not less than 30 days and not to exceed twelve (12) months in order that they may relieve Members of the Medical, Dental and Scientific Staff who may be on vacation or other such extended leave of absence.

 

                   8.9.2       Locum Tenens Staff shall be required to follow the same processes for obtaining privileges as any other potential Member of the Medical, Dental and Scientific Staff, and their credentials shall be reviewed following the processes outlined in these Bylaws.

 

                   8.9.3       Locum Tenens Staff shall be entitled to admit and treat patients according to the privileges granted and will be required to substitute for the absent practitioner in any of the practitioner’s regularly scheduled on-call duties.

 

       8.10     Visiting Consulting Staff:

 

                   8.10.1     Visiting Consulting Staff shall consist of physicians, dentists and scientists who are on the Active Staff of a health centre outside the Capital Health District Authority and who are appointed, after consultation with the applicable Department Chief, by the Board because of special knowledge, skills and experience and who may be consulted by Members of the Active or Courtesy Staff.

 

                   8.10.2     Visiting Consulting Staff may be granted privileges solely to examine and recommend/treat patients in clinics or on the inpatient units after receiving a referral from a Member of the Active or Courtesy Staff.

 

9     Emergency Privileges

       9.1       Emergency privileges are deemed to exist when a Member of the Medical, Dental and Scientific Staff believes the life of a patient is in immediate danger, and a Member anticipates that delay in administering treatment will increase the danger. The Member shall assess and assist the patient and the privileges of that Member shall be deemed to encompass the giving of such assistance. Any Member of the Medical, Dental and Scientific Staff responsible for the care of such patient may obtain consultation from any physician reasonably deemed appropriate and such consulting physicians shall have emergency privileges restricted to the treatment of such patient during an emergency situation. The Member shall notify the Chief of the appropriate Department that such emergency action has been taken.

 

Part IV: Credentialing Processes

 

10   Applications for New Appointments

       10.1     The CEO or the CEO’s designate, on receipt of an inquiry from a physician, dentist, or scientist seeking appointment to the MDSS, shall, following consultation with the relevant Department Chief and the VP Medicine assess the inquiry from the perspective of need and availability of resources, not from the perspective of the individual merit of the Applicant.

 

       10.2     Upon completion of the assessment pursuant to Article 10.1, the CEO or the CEO’s designate shall advise the Applicant of the result of the assessment, and if the result of the assessment is negative, the application process shall end. This is a final decision by the CEO or the CEO’s designate, from which there is no right of review or appeal by the Applicant.

 

       10.3     If the result of the assessment pursuant to Article 10.1 is positive, the CEO or the CEO’s designate shall provide the Applicant with a copy of an application form, a copy of all Bylaws, and copy of the Rules and Regulations.

 

       10.4     Upon completion of the application form, the Applicant shall submit the form and supply to the CEO or the CEO’s designate such documentary proof as required by the CEO including:

 

                   10.4.1     registration with the College of Physicians and Surgeons of Nova Scotia in accordance with the Medical Act or registration in the Provincial Dental Board’s Dentists’ Register in accordance with the Dental Act, as applicable,

 

                   10.4.2     in the case of a physician, membership in the Canadian Medical Protective Association or other equivalent malpractice insurance and in the case of a dentist, such malpractice insurance as required pursuant to the regulations under the Dental Act; and

 

                   10.4.3     the results of a Child Abuse Register Inquiry and the results of a Criminal Record Inquiry; and

 

                   10.4.4     such other information or evidence as required by the CEO or the CEO’s designate.

 

       10.5     The CEO or designate shall, within five days of the receipt of a completed application form with the required accompanying documentation, forward the application to the Office of the VP Medicine to administer and coordinate the Credentials Process.

 

       10.6     The VP Medicine, upon receipt of the material pursuant to Article 10.5 shall forward the material to the Credentials Committee within 5 days. The Credentials Committee, upon receipt of the material pursuant to Article 10.5, shall consider the application by:

 

                   10.6.1     consulting with the appropriate Department Chief (and/or the Vice-President of Research for Scientists) to assess the application on its merit;

 

                   10.6.2     verifying the accuracy of information provided by the Applicant;

 

                   10.6.3     conducting such other inquiries as it deems appropriate;

 

                   10.6.4     interviewing such persons as it deems appropriate; and

 

                   10.6.5     engaging in any other form of investigation it deems necessary.

 

       10.7     Upon completion of its review, the Credentials Committee, within 45 days of receiving the application from the VP Medicine, shall:

 

                   10.7.1     recommend to the MAC an appointment and specific privileges for the Applicant;

 

                   10.7.2     recommend to the MAC a rejection of the application; or

 

                   10.7.3     recommend a variance, which shall be reviewed with the Applicant, and the recommendation and the Applicant’s response to the recommendation shall be provided to the MAC;

 

and shall inform the appropriate Department Chief of its recommendation.

 

       10.8     Upon receipt of the recommendation from the Credentials Committee, the MAC shall review the Credentials Committee’s recommendations and shall, within 25 days of receipt of the application from the Credentials Committee:

 

                   10.8.1     accept the Credentials Committee’s recommendations;

 

                   10.8.2     reject the Credentials Committee’s recommendations; or

 

                   10.8.3     suggest a variance to the Credentials Committee’s recommendations;

 

and shall inform the appropriate Department Chief of its disposition.

 

       10.9     Where a variance is recommended by the MAC, the MAC shall review the suggested variance with the Applicant, and determine the Applicant’s position on the variance.

 

       10.10   The Chair of the MAC shall forward its recommendations to the PRC, including the Applicant’s position on any suggested variance, within 5 days of making its recommendation pursuant to Article 10.8.

 

       10.11   The PRC shall review all recommendations from the Credentials Committee and MAC.

 

       10.12   If the PRC determines it does not have sufficient information to make a final decision on the application, the PRC may conduct any further investigation it deems necessary.

 

       10.13   The PRC shall make the final decision on the application within 20 days of receipt of the MAC’s recommendations, unless further time is needed, as determined by the PRC, to complete its review.

 

       10.14   The PRC Chair shall immediately forward the PRC’s written decision to the Board, the CEO and the appropriate Department Chief for information.

 

       10.15   After the PRC Chair has informed the Board, the CEO and the appropriate Department Chief of its decision, the CEO or designate shall inform the Applicant of the decision.

 

       10.16   The decision of the PRC pursuant to Article 10.13 shall be a final decision, and there shall be no right of review or appeal by the Applicant arising from any decision pursuant to this article to the Board, the Provincial Appeal Board, or to any other person, committee or any other entity.

 

11   Applications for Reappointment

       11.1     The CEO shall forward an application form for reappointment to a Member at least 100 days before the completion of the Member’s current term of appointment.

 

       11.2     If the Member desires reappointment, the Member shall forward the completed reappointment application at least 80 days before the completion of his/her current term of appointment to the CEO or his/her designate.

 

       11.3     The CEO shall immediately forward the application to the VP Medicine, whose office shall administer the reappointment process.

 

       11.4     The VP Medicine shall, within five days of receipt of the application, forward the application and all accompanying documentation to the Applicant’s Department Chief (and the Vice-President of Research if it is a reappointment to the Scientific Staff).

 

       11.5     The Department Chief (and the Vice-President of Research if it is a reappointment to the Scientific Staff) shall assess the application and shall:

 

                   11.5.1     recommend the appointment, and forward such recommendation to the Credentials Committee within 25 days of receiving the application from the VP Medicine;

 

                   11.5.2     recommend a variance which is acceptable to the Applicant, in which event the accepted recommendation is forwarded to the Credentials Committee within 25 days of receiving the application from the VP Medicine; or

 

                   11.5.3     not recommend the reappointment, or suggest a variance that is not acceptable to the Applicant, in which case the matter shall be referred within 25 days of receiving the application from the VP Medicine to the CEO in order to commence the Mediation Process in accordance with Article 15.

 

       11.6     Where a recommendation is made in accordance with Articles 11.5.1 or 11.5.2, or where a Mediated Resolution is reached pursuant to Article 15, the recommendation or Mediated Resolution shall be reviewed by the Credentials Committee.

 

       11.7     In its review pursuant to Article 11.6, the Credentials Committee shall consider the matter by:

 

                   11.7.1     consulting with the CEO and the appropriate Department Chief (and/or the Vice-President of Research for Scientists);

 

                   11.7.2     verifying the accuracy of information provided by the Applicant;

 

                   11.7.3     conducting such other inquiries as it deems appropriate;

 

                   11.7.4     interviewing such persons as it deems appropriate; and

 

                   11.7.5     engaging in any other form of investigation it deems necessary.

 

       11.8     The Credentials Committee, upon completion of its review shall:

 

                   11.8.1     approve the Mediated Resolution or recommendation forwarded pursuant to Article 11.5.1 or 11.5.2 ;

 

                   11.8.2     recommend a variance to the recommendation pursuant to Article 11.5.1 or 11.5.2 which is acceptable to the Applicant, or recommend a variance to the Mediated Resolution which is acceptable to the signatories to the Mediated Resolution;

 

                   11.8.3     reject the Mediated Resolution or suggest a variance to the Mediated Resolution that is not acceptable to the signatories of the Mediated Resolution; or

 

                   11.8.4     reject the recommendation made pursuant to Article 11.5.1 or 11.5.2, or suggest a variance that is not acceptable to the Applicant; and

 

and inform the Department Chief of its decision.

 

       11.9     If the Credentials Committee makes a decision pursuant to Article 11.8.1 or 11.8.2, the decision shall be forwarded to the MAC within 45 days of the Credentials Committee’s receipt of the matter.

 

       11.10   If the Credentials Committee makes a decision pursuant to Article 11.8.3, the matter shall be referred to the Hearing Committee, in accordance with Articles 16 and 17.

 

       11.11   If the Credentials Committee makes a decision pursuant to Article 11.8.4, the matter shall be referred to the CEO in order to commence the Mediation Process in accordance with Article 15, and:

 

                   11.11.1   if a Mediated Resolution is achieved, the Mediated Resolution shall be forwarded to the MAC; and

 

                   11.11.2   if a Mediated Resolution is not achieved, the matter shall be referred to the Hearing Committee in accordance with Articles 16 and 17.

 

       11.12   Where the matter is referred to the MAC in accordance with Article 11.9 or 11.11.1, the MAC shall conduct any investigation its deems necessary and shall consider:

 

                   11.12.1   the application;

 

                   11.12.2   the recommendation of the Credentials Committee;

 

                   11.12.3   the recommendations forwarded to the Credentials Committee by the CEO and the Department Chief;

 

                   11.12.4   any recommended Mediated Resolutions; and

 

                   11.12.5   any information that it gains from its investigations.

 

       11.13   Upon completion of its review pursuant to Article 11.12, the MAC shall:

 

                   11.13.1   approve the application as recommended by the Credentials Committee, or approve the Mediated Resolution, and forward such approval within 25 days of the referral of the matter to the MAC from the Credentials Committee, to the PRC for a final decision;

 

                   11.13.2   recommend a variance acceptable to the Applicant or recommend a variance to the Mediated Resolution which is acceptable to the signatories of the Mediated Resolution, and forward such recommendation within 25 days of receipt of the application from the Credentials Committee, to the PRC for a final decision;

 

                   11.13.3   reject the Credentials Committee’s recommendation or recommend a variance that is not acceptable to the Applicant within 25 days of the recommendation being forward[ed] to the MAC, in which event the matter shall be referred to the CEO in order to commence a mediation process in accordance with Article 15;

 

                   11.13.4   reject the Mediated Resolution or recommend a variance to the Mediated Resolution is now acceptable to the signatories to the enumerated resolution, within 25 days of a net being referred to the MAC, in which event the matter shall be referred to the Hearing Committee in accordance with Articles 16 and 17 [sic];

 

and shall inform the Department Chief of its decision.

 

       11.14   Where a matter has been referred to the mediation process pursuant to Article 11.13.3:

 

                   11.14.1   if a Mediated Resolution is achieved, the Mediated Resolution shall be forwarded to the MAC for consideration and the MAC shall:

 

                                  11.14.1.1   approve the Mediated Resolution or recommend a variance to the Mediated Resolution that is acceptable to the signatories of the Mediated Resolution, and forward such decision within 25 days of receipt of a Mediated Resolution to the PRC for decision; or

 

                                  11.14.1.2   reject the Mediated Resolution or recommend a variance to the Mediated Resolution that is not acceptable to the signatories of the Mediated Resolution, in which events the matter shall be referred to the Hearing Committee in accordance with Articles 16 and 17; or

 

                   11.14.2   If a Mediated Resolution is not achieved, the matter shall be referred to the Hearing Committee in accordance with Articles 16 and 17.

 

       11.15   Where a recommendation is made pursuant to Article 11.13.1, 11.13.2 or 11.14.1.1, the PRC shall conduct such investigation it deems necessary and shall consider:

 

                   11.15.1   the application,

 

                   11.15.2   the recommendation of the Credentials Committee,

 

                   11.15.3   the recommendation of the MAC,

 

                   11.15.4   any proposed Mediated Resolution, and

 

                   11.15.5   any information that it gains from its investigations.

 

       11.16   Where the PRC has considered the matter, the PRC shall, within 25 days of receipt of the recommendation from the MAC:

 

                   11.16.1   accept the recommendation of the MAC;

 

                   11.16.2   recommend a variance that is acceptable to the Applicant and, in the case of a Mediated Resolution, to all signatories to the Mediated Resolution; or

 

                   11.16.3   reject the recommendation or the Mediated Resolution, in which event the matter shall be referred to the Hearing Committee in accordance with Articles 16 and 17.

 

       11.17   Where a matter is referred to the Hearing Committee pursuant to Article 11.18.3 [11.16.3], then upon completion of the Hearing in accordance with Articles 16 and 17, the members of the PRC who participated in the decision pursuant to Article 11.18.3 [11.16.3] shall not participate in any Appeal Hearing before the PRC pursuant to Article 18. In this event, the Board shall appoint three different Board Members to act as the PRC.

 

       11.18   Where the PRC makes a decision pursuant to Article 11.16, it shall immediately notify the Board and CEO of such decision.

 

       11.19   After the Board and the CEO have been notified of the decision of the PRC pursuant to Article 11.18, the CEO shall notify the Applicant, the MAC, the Credentials Committee, the VP Medicine and the Department Chief of such decision.

 

12   Temporary Appointments to the MDSS

       12.1     Notwithstanding any other provisions in these Bylaws, the CEO or designate, and the Chair of the Credentials Committee or designate, after gathering such information as they deem appropriate in the circumstances, may grant temporary privileges to an Applicant where:

 

                   12.1.1     the Health Centre requires an extra physician, dentist, or scientist on a temporary basis;

 

                   12.1.2     the physician or dentist requests a replacement for a short period of time;

 

                   12.1.3     a specialist who does not have privileges within the Health Centre is required to consult on a particular patient or to deal with a particular situation including, but not restricted to, harvest of organs;

 

                   12.1.4     a physician, dentist, or scientist has been accepted for a clinical traineeship; or

 

                   12.1.5     a Department Chief requests other temporary appointments as appropriate from time to time.

 

       12.2     The granting of a temporary appointment shall be conditional on the Applicant providing proof of:

 

                   12.2.1     Canadian Medical Protective Association coverage or its equivalent (or malpractice insurance in accordance with the Dental Act, if the Applicant is a dentist); and

 

                   12.2.2     a licence in good standing granted to the Applicant by the College of Physicians and Surgeons of Nova Scotia (or a licence granted by the Provincial Dental Board, if the Applicant is a dentist).

 

       12.3     Temporary appointments granted to a particular Applicant under this Article shall be for a period of up to 30 days.

 

       12.4     Subject to Article 12.5, temporary appointments may be extended by the CEO or designate and/or the Chair of the Credentials Committee, provided that a particular Applicant may not be granted temporary privileges for more than a total of 180 days in a calendar year.

 

       12.5     The Credentials Committee shall review and approve any requests for extension of temporary privileges beyond the initial period of 30 days.

 

       12.6     Temporary privileges may be revoked by the CEO at any time, in which event the CEO shall immediately notify the holder of the temporary privileges and any relevant Department Chief at the earliest opportunity of such revocation privileges.

 

       12.7     Decisions to grant, refuse or revoke temporary privileges are final decisions and there shall be no right of review or appeal from such decisions to the PRC, the Board, the Provincial Appeal Board, or to any other person, committee or entity, from any decision pursuant to this Article.

 

       12.8     The CEO shall report an appointment or extension made under this Article to the Credentials Committee at the Credentials Committee meetings following the appointment or extension.

 

       12.9     The appropriate Department Chief shall be notified of any decision to grant or extend a temporary appointment.

 

Part V: Disciplinary Processes

 

13   Special Review of Privileges

       13.1     The CEO or Department Chief, referred to in this Article as the “person initiating the special review” may request, in writing, a special review of privileges of any Member of the MDSS at any time and shall advise the Member concerned within 24 hours of such action.

 

       13.2     Where the person initiating the special review is not the CEO, the CEO shall be notified by the person initiating the special review within 24 hours of such action.

 

       13.3     The grounds for a special review may consist of, but are not limited to, issues of unprofessional or unethical conduct, behaviour otherwise contrary to the values, policies, and procedures of the IWK Health Centre or failure to meet the requirements of any of the Bylaws or the Rules and Regulations.

 

       13.4     In making a request for a special review, the person initiating the special review shall indicate, in writing, the grounds giving rise to such a review and the remedy that is being sought.

 

       13.5     When the CEO is the person initiating the special review, or when the CEO is informed by the Department Chief of the request for the special review, the CEO shall initiate the Mediation Process in accordance with Article 15.

 

       13.6     If a Mediated Resolution is not achieved through the Mediation Process, the parties shall proceed immediately to the Hearing Committee for a hearing to address the grounds for a special review, in accordance with Articles 16 and 17.

 

       13.7     If a Mediated Resolution is achieved pursuant to Article 14, the Mediated Resolution shall be forwarded to the MAC for information.

 

       13.8     The Chair of the MAC shall forward the Mediated Resolution to the PRC within five days of the receipt of the Mediated Resolution by the MAC.

 

       13.9     The PRC shall review the Mediated Resolution and shall, within 15 days of receipt from the Chair of the MAC:

 

                   13.9.1     approve the Mediated Resolution;

 

                   13.9.2     recommend a change to the Mediated Resolution that is acceptable to the signatories to the Mediated Resolution, and approve such change; or

 

                   13.9.3     reject the Mediated Resolution and refer the matter to the Hearing Committee pursuant to Articles 16 and 17.

 

       13.10   The PRC Chair shall, within five days of rendering its decision, forward its decision to the Board and the CEO for information.

 

       13.11   Upon receipt of the decision from the PRC, the CEO shall inform the member, the person initiating the special review, the appropriate Department Chief and the MAC of the decision.

 

       13.12   Where a matter is referred to the Hearing Committee pursuant to Article 13.9.3, then upon completion of the Hearing in accordance with Articles 16 and 17, the members of the PRC who participated in the decision pursuant to Article 13.9.3 shall not participate in any Appeal Hearing by the PRC pursuant to Article 18. In this event, the Board shall appoint three different Board Members to act as the PRC.

 

14   Immediate Suspension or Variance of Privileges

       14.1     The CEO or designate, or a Department Chief or designate (referred to in this article as “the person initiating the suspension/variance”) may suspend or vary the privileges of any Member of the MDSS at any time where the person initiating the suspension/variance reasonably believes that the Member has engaged in conduct which:

 

                   14.1.1     is reasonably likely to expose patients or staff to harm or injury at the Health Centre or by services provided through the Health Centre;

 

                   14.1.2     is reasonably likely to be detrimental to patients’ safety or to the delivery of patient care at the Health Centre or by services provided to the Health Centre; or

 

                   14.1.3     is reasonably likely to be detrimental to the Member, the Health Centre, or the public.

 

       14.2     If someone other than the CEO immediately suspends or varies a Member’s privileges, the CEO must be informed within twenty four hours of the suspension or variance.

 

       14.3     The person initiating the suspension/variance shall inform the Chair of the MAC within 24 hours of the suspension or variation pursuant to Article 14.1.

 

       14.4     When the CEO initiates the suspension/variance, the CEO shall advise the Department Chief and the Division Head of the suspension or variance, and at such time, or when the CEO becomes aware of the initiation of a suspension or variance by the Department Chief, whichever is the later, the CEO shall, within 48 hours appoint a Health Centre representative to commence the Mediation Process in accordance with Article 15.

 

       14.5     If no Mediated Resolution is achieved pursuant to the Mediation Process, the parties shall proceed immediately to the Hearing Committee for a hearing to address the issues giving rise to the immediate suspension/variance, in accordance with Articles 16 and 17.

 

       14.6     If a Mediated Resolution is achieved, the Mediated Resolution shall be forwarded to the MAC for information.

 

       14.7     The Chair of the MAC shall forward the Mediated Resolution to the PRC within five days of the review of the Mediated Resolution by the MAC.

 

       14.8     The PRC shall review the Mediated Resolution and shall within fifteen days of receipt from the Chair of the MAC:

 

                   14.8.1     approve the Mediated Resolution;

 

                   14.8.2     recommended a change to the Mediated Resolution that is acceptable to the signatories to the Mediated Resolution, and approve such change; or

 

                   14.8.3     reject the Mediated Resolution and refer the matter to the Hearing Committee.

 

       14.9     Where a decision is made pursuant to Article 14.8 the PRC Chair shall, within five days, forward its decision to the Board and CEO for information.

 

       14.10   Upon receipt of the decision of the PRC, the CEO shall advise the member, the relevant Department Chief, the relevant head of the division and the MAC of the decision.

 

       14.11   Where a matter is referred to the Hearing Committee pursuant to Article 14.8.3, then upon completion of the Hearing in accordance with Articles 16 and 17, the members of the PRC who participated in the decision pursuant to Article 14.8.3 shall not participate in any Appeal Hearing by the PRC pursuant to Article 18. In this event the Board shall appoint three different Board Members to act as the PRC.

 

Part VI: Mediation Process

 

15   Mediation Process

       15.1     The Mediation Process shall be engaged in the circumstances outlined in Articles 11, 13 and 14.

 

       15.2     When the Mediation Process is engaged, the CEO or designate shall within 48 hours appoint a Health Centre representative to act for purposes of the Mediation Process.

 

       15.3     The parties involved in the Mediation Process shall be:

 

                   15.3.1     the Member who is the subject of the Mediation Process;

 

                   15.3.2     the Health Centre Representative selected by the CEO or designate (who must not be the Department Chief of the Member who is the subject of the Mediation Process, and who is not the person named in Article 15.3.4);

 

                   15.3.3     a MDSS member appointed by the Medical, Dental and Scientific Staff Executive; and

 

                   15.3.4     the Member’s Department Chief in the case of a reappointment application; the person initiating the special review in the case of the special review; or the person initiating the suspension/variation in the case of Article 14.

 

       15.4     The Health Centre Representative shall facilitate the Mediation Process unless the Health Centre Representative determines that a third party mediator shall be used to facilitate the Mediation Process.

 

       15.5     The parties to the Mediation Process shall seek to develop a Mediated Resolution of the matter that addresses the outstanding issues to the satisfaction of the signatories to the Mediated Resolution pursuant to Article 15.6.

 

       15.6     The signatories to a Mediated Resolution are the parties to the Mediation Process pursuant to Article 15.3, and the CEO.

 

       15.7     The parties to the Mediation Process shall either reach a Mediated Resolution or determine that it is not possible to reach a Mediated Resolution:

 

                   15.7.1     in the case of a Mediation Process to consider a reappointment pursuant to Article 11, within thirty days (30) from the initiation of the Mediation Process;

 

                   15.7.2     in the case of a Mediation Process arising from a special review of privileges pursuant to Article 13, within thirty days (30) from the commencement of the Mediation Process; and

 

                   15.7.3     in the case of a Mediation Process arising from an automatic suspension or variance of privileges pursuant to Article 14, within fourteen (14) days of the commencement of the Mediation Process

 

unless parties to the Mediation Process agree in writing to extend these timelines.

 

       15.8     Where a Mediated Resolution has been reached, the Mediated Resolution shall be forwarded by the Health Centre representative to the relevant committee pursuant to Articles 11, 13 or 14, and processed in accordance with the relevant Article.

 

       15.9     Where a Mediated Resolution has not been reached, the matter shall be processed in accordance with the relevant provisions of Articles 11, 13 and 14.

 

       15.10   Where the Mediation Process is not successful and a matter is referred to a Hearing Committee pursuant to these Bylaws, no reference to discussions held during the Mediation Process, or to proposed Mediated Resolutions shall be allowed in evidence before a Hearing Committee.

 

Part VII: Hearings

 

16   Hearing Process

       16.1     The hearing process is engaged when a matter is referred to a Hearing Committee pursuant to Articles 11, 13 or 14.

 

       16.2     The parties to the hearing shall be the Member and the Health Centre Representative appointed for the particular hearing.

 

       16.3     In a proceeding before the Hearing Committee, the Health Centre Representative shall present the matter to the Hearing Committee, and the Member who is the subject of the Hearing process shall respond to the case presented by the Health Centre Representative.

 

       16.4     The Chair of the Hearing Committee may retain independent legal counsel to advise the Hearing Committee regarding matters of law and procedure.

 

       16.5     The Health Centre Representative may retain legal counsel to present or to assist in presenting the case on behalf of the Health Centre before the Hearing Committee.

 

       16.6     The Member who is the subject of the Hearing may retain counsel to represent the Member at the Member’s expense.

 

       16.7     Where a matter is referred to the Hearing Committee, the Health Centre Representative shall issue a Notice of Hearing setting out the details of the matters to be determined by the Hearing Committee, and specifying the time and the place of the Hearing. The Health Centre Representative shall consult with the Chair of the Hearing Committee and the Member before setting the date of the Hearing. In the event agreement cannot be reached regarding the date of the Hearing, the Chair of the Hearing Committee shall set the date for the commencement of the Hearing, which in any event shall not be later than forty-five (45) days from the date of the referral of the matter to the Hearing Committee, or such later date as the Member and the Health Centre Representative may agree in writing or the Hearing Committee may order following an opportunity for submissions from both parties as to such date.

 

       16.8     In any stage of the Hearing Process, any document required to be served on either party shall be deemed to be served or provided where:

 

                   16.8.1     the intended recipient or their legal counsel acknowledges receipt of the document;

 

                   16.8.2     where a registered mail receipt is provided from Canada Post at the intended recipient’s last known address;

 

                   16.8.3     where an Affidavit of Service is provided; or

 

                   16.8.4     where evidence satisfactory to the Hearing Committee is provided that all reasonable efforts to effect service have been exhausted.

 

       16.9     If a party does not attend a Hearing, the Hearing Committee, upon proof of service of the Notice of Hearing or proof of substituted service in accordance with Article 16.8, may proceed with the Hearing in the party’s absence and, without further notice to the party, take such action as it is authorized to take pursuant to these Bylaws.

 

       16.10   The Hearing Committee, at any time before or during a Hearing, on its own motion or on receipt of a motion from a party to the Hearing, may amend or alter any Notice of Hearing to correct an alleged defect in substance or form, or to make the Notice conform to the evidence where there appears to be a variance between the evidence and the Notice, or where the evidence discloses issues not alleged in the Notice.

 

       16.11   If an amendment or alteration is made by the Hearing Committee pursuant to Article 16.10, the parties shall be provided sufficient opportunity to prepare an answer to the amendment or alteration.

 

17   Hearing Procedures

       17.1     The Hearing Committee may determine rules or procedures for Hearings not covered by these Bylaws or the Rules and Regulations.

 

       17.2     In a proceeding before the Hearing Committee the parties have the right to:

 

                   17.2.1     the opportunity to present evidence and make submissions, including the right to cross examine witnesses; and

 

                   17.2.2     receive written reasons for a decision within thirty (30) days of the completion of evidence and submissions before the Hearing Committee.

 

       17.3     Evidence is not admissible before the Hearing Committee unless the opposing party has been given, at least seven (7) days before a Hearing:

 

                   17.3.1     in the case of written or documentary evidence, an opportunity to examine the evidence;

 

                   17.3.2     in the case of evidence of an expert, a copy of the expert’s written report or if there is no written report, a written summary of the evidence; or

 

                   17.3.3     in the case of evidence of a witness, the identity of the witness.

 

       17.4     Notwithstanding Article 17.3 the Hearing Committee may, in its discretion, allow the introduction of evidence that would be otherwise inadmissible under Article 17.3 and may make directions it considers necessary to ensure that the opposing party has and [an] appropriate opportunity to respond.

 

       17.5     The testimony of witnesses at a Hearing shall be taken under oath or affirmation, and all evidence submitted to the Hearing Committee shall be reduced to writing, or mechanically or electronically recorded by a person authorized by the Hearing Committee.

 

       17.6     Any oath or affirmation required pursuant to these Bylaws may be administered by any member of the Hearing Committee or other person in attendance authorized by law to administer oaths or affirmations.

 

       17.7     Evidence may be given before the Hearing Committee in any manner that the Hearing Committee considers appropriate, and the Committee is not bound by the rules of law respecting evidence applicable in judicial proceedings.

 

       17.8     Notwithstanding Article 17.7, the Hearing Committee shall ensure that Hearings are conducted in accordance with the principles of natural justice and procedural fairness.

 

       17.9     At any time before or during a Hearing, after providing the opportunity for each party to make submissions, the Hearing Committee acting in good faith and on reasonable grounds may require the Member to:

 

                   17.9.1     submit to physical and mental examinations by a qualified person or persons designated by the Hearing Committee and to provide a copy of the report from such examination to the Hearing Committee and to the Health Centre Representative;

 

                   17.9.2     submit to a review of the practice of the Member by a qualified person or persons designated by the Hearing Committee and to provide a copy of such review to the Hearing Committee and to the Health Centre Representative;

 

                   17.9.3     submit to a competence assessment or other assessment or examination to determine whether the Member is competent to engage in practice and to provide a copy the assessment or the report of the examination to the Hearing Committee and to the Health Centre Representative; and

 

                   17.9.4     produce records kept with respect to the Member’s practice.

 

       17.10   If a Member fails to comply with Article 17.9, the Hearing Committee may order that the Member be suspended until the Member complies.

 

       17.11   The costs of complying with the requirements outlined in Article 17.9 shall be borne by the Health Centre.

 

       17.12   Upon completion of the evidence, and upon giving both parties the opportunity to present submissions, the Hearing Committee shall, within thirty days, or such later date as the parties may agree, issue a decision in writing with reasons, where it decides the matters raised in the Notice of Hearing and determines the final disposition of such matters. Such final disposition may include, but is not limited to:

 

                   17.12.1   for purposes of the credentialing process:

 

                                  17.12.1.1   approval, rejection or variation of the privileges requested by the applicant;

 

                                  17.12.1.2   the imposition of certain conditions or restrictions on the Member’s privileges; or

 

                                  17.12.1.3   such other disposition as the Hearing Committee deems appropriate;

 

                   17.12.2   for disciplinary purposes:

 

                                  17.12.2.1   termination of the Member’s appointment and/or privileges;

 

                                  17.12.2.2   suspension of the Member’s appointment and/or privileges;

 

                                  17.12.2.3   a variation of the Member’s appointment and/or privileges;

 

                                  17.12.2.4   conditions or restrictions on the Member;

 

                                  17.12.2.5   a reprimand;

 

                                  17.12.2.6   placement of the Member on probation with respect to his/her MDSS Membership and/or privileges, with such conditions or restrictions as deemed appropriate;

 

                                  17.12.2.7   such other disposition as deemed appropriate; or

 

                                  17.12.2.8   any combination of the above.

 

       17.13   The written decision issued pursuant to Article 17.12 shall be provided by the Chair of the Hearing Committee to the MAC for information, and to the Member, the Health Centre Representative, the Chair of the PRC and the CEO.

 

       17.14   At the time the Chair of the Hearing Committee provides a copy of the written decision to the PRC, the Chair of the Hearing Committee shall order a transcript of the proceedings before the Hearing Committee and upon receipt of such transcript shall provide it together with copies of all exhibits introduced at the hearing to the PRC.

 

Part VIII: Privileges Review Committee Processes

 

18   Referrals to the PRC from Hearing Committee

Appeal from Decision of Hearing Committee

       18.1     When a Hearing Committee has rendered a written decision pursuant to Article 17, either party may appeal the decision to the PRC by filing a Notice of Appeal within ten (10) days of receipt of the Hearing Committee’s written decision.

 

       18.2     The Notice of Appeal shall state the grounds of appeal in accordance with Article 18.3.

 

       18.3     The grounds for an appeal are:

 

                   18.3.1     errors of law;

 

                   18.3.2     that the decision in dispute is not supported by the evidence; or

 

                   18.3.3     that the decision-makers materially erred in interpreting the evidence before it.

 

       18.4     Where a Notice of Appeal has been filed pursuant to Article 18.1, the party filing the Notice of Appeal shall confirm that the PRC has received a copy of the transcript of the proceedings before the Hearing Committee and a copy of all exhibits introduced at the Hearing, pursuant to Article 17.14.

 

       18.5     Upon receipt of a Notice of Appeal, the Chair of the PRC shall meet with the parties within 10 days and set a time and place for the Appeal Hearing.

 

       18.6     At an Appeal Hearing, the parties shall have the opportunity to provide both written and oral submissions regarding the grounds of Appeal and the remedy sought.

 

       18.7     The PRC may determine rules or procedures for Appeal Hearings not covered by these Bylaws.

 

       18.8     No new evidence is admissible before the PRC unless the PRC directs otherwise.

 

       18.9     If the PRC allows the introduction of oral evidence pursuant to Article 18.8, such evidence shall be given under oath or affirmation, and any oaths or affirmation may be administered by any member of the PRC or other person in attendance authorized by law to administer oaths or affirmations.

 

       18.10   Appeal Hearings before the PRC shall be reduced to writing, or mechanically or electronically recorded by a person authorized by the PRC.

 

       18.11   Upon completion of the proceeding before the PRC, the PRC shall within thirty (30) days of the completion of the evidence and the submissions before it issue a decision in writing, with reasons, and shall provide a copy of the decision to the parties, to the Board and to the CEO.

 

       18.12   The PRC may impose any disposition available to the Hearing Committee pursuant to Article 17.12.2.

 

       18.13   Where the Member disagrees with the decision of the PRC, the Member may appeal the matter to the provincial Appeal Board, and the provincial Appeal Board shall determine the matter in accordance with processes established pursuant to the Health Authorities Act.

 

Review by the PRC in Absence of Notice of Appeal

       18.14   Where a party does not file a Notice of Appeal pursuant to Article 18.1, the decision of the Hearing Committee shall be reviewed by the PRC and for purposes of its review, the PRC shall have access to the decision of the Hearing Committee, the transcript of the proceeding before the Hearing Committee, and any and all exhibits provided to the Hearing Committee as part of the Hearing Committee process.

 

       18.15   The PRC shall complete its review of the Hearing Committee decision pursuant to Article Article 18.13 [18.14] within 15 days of its receipt of the materials pursuant to Article 18.13 [18.14], and shall:

 

                   18.15.1   approve the decision of the Hearing Committee, in which event the PRC shall inform the parties of the decision and inform the Board and CEO of the decision;

 

                   18.15.2   recommend a variance to the decision of the Hearing Committee that is acceptable to the member and the Health Centre representative, in which event the PRC shall inform the parties of the decision and inform the Board and CEO of the decision; or

 

                   18.15.3   reject the decision of the Hearing Committee, or recommend a variance that is not acceptable to either party, in which event the PRC shall appeal the decision of the Hearing Committee to the Provincial Appeal Board in accordance with processes established pursuant to the Health Authorities Act. In the event of such an appeal to the Provincial Appeal Board, the parties to the appeal shall be the PRC as appellant and the member as the respondent.

 

       18.16   The PRC may retain independent legal counsel to advise the PRC regarding matters of law and procedure.

 

Part IX: Provincial Appeal Board

 

19   Provincial Appeal Board

       19.1     The Provincial Appeal Board, abbreviated as “PAB,” is constituted in accordance with section 23(b) of the Nova Scotia Health Authorities Act.

 

       19.2     When a matter is appealed to the Provincial Appeal Board pursuant to these Bylaws, the Provincial Appeal Board shall take such action and conduct such processes as set out in the Health Authorities Act.

 

Part X: Miscellaneous

 

20   Automatic Suspensions

       20.1     The privileges of a Member of the Medical, Dental and Scientific Staff shall be immediately and automatically suspended by the CEO or designate, or the appropriate Department Chief or designate when:

 

                   20.1.1     a Member fails to complete a patient’s record within the Rules and Regulations of the Health Centre Medical, Dental and Scientific Staff and has failed to comply within a fourteen day notice period for completion which is provided by the CEO or designate; or

 

                   20.1.2     a Member has ceased to be a Member of the Canadian Medical Protective Association or to carry and have in force equivalent malpractice insurance, and in the case of a Dentist, has ceased to carry and have in force such malpractice insurance as required pursuant to the regulations under the Dental Act or other malpractice insurance as is deemed appropriate by the Board.

 

       20.2     An automatic suspension issued pursuant to Article 20.1 shall continue until the violation has been corrected, at which time the CEO shall automatically reinstate the Member.

 

21   Affiliation Agreements with Dalhousie University

       21.1     Where Members are subject to Affiliation Agreements with Dalhousie University, appointments to the Medical, Dental and Scientific Staff shall take into account the provisions of such Affiliation Agreements.

 

       21.2     In the case of termination of appointment by Dalhousie University for Members or applicants who have or seek an appointment with the IWK Health Centre, the effect of such termination of appointment on the Health Centre appointment is as provided in the Affiliation Agreement and, if no provision is made in the Affiliation Agreement, then the applicant or Member shall automatically have her/his appointment reviewed in accordance with the processes set out in Article 12.

 

       21.3     Where there is a conflict between these Bylaws and an Affiliation Agreement with Dalhousie University, these Bylaws shall prevail.

 

22   Employees/Independent Contractors

       22.1     Unless granted privileges through the processes set out in these Bylaws, any physician, dentist, or scientist in an employment relationship with the Health Centre shall have the terms of their employment relationship with the Health Centre determined in accordance with the provisions of the employment relationship. For greater certainty, subject to Article 22.3, the Credentials Process and the Discipline Process outlined in these Bylaws are not applicable to such employees.

 

       22.2     Any physician, dentist, or scientist in an independent contractor relationship with the Health Centre, who does not hold privileges pursuant to these Bylaws, shall have the terms of their relationship with the Health Centre determined in accordance with the provisions of the contract establishing the relationship. For greater certainty, subject to Article 22.3, the Credentials Process and the Discipline Process outlined in these Bylaws are not applicable to such persons.

 

       22.3     In the event that a physician, dentist, or scientist has privileges granted pursuant to these Bylaws and is also an employee of or independent contractor with the Health Centre, matters affecting the privileges granted pursuant to these Bylaws shall be dealt with in accordance with these Bylaws, and matters involving the employment or contractual relationship of the physician, dentist, or scientist with the Health Centre shall be governed in accordance with the relevant employment or independent contractor relationship.

 

23   Joint Appointments with Other Hospitals, Health Centres or District Health Authorities

       23.1     Any physician, dentist or scientist who has a joint appointment with the IWK Health Centre and another health facility shall be bound by these Bylaws to the extent a Member is exercising their privileges in accordance with these Bylaws.

 

       23.2     To the extent a physician, dentist or scientist is exercising privileges pursuant to privileges granted by another health facility, the actions of the physician, dentist or scientist shall be governed by the Bylaws of the other health facility.

 

       23.3     Where there is a conflict between the application of these Bylaws and the application of the bylaws of another health facility, matters involving the credentialing or discipline of the individual shall be governed by the Bylaws of the facility where the matter giving rise to the credentials or discipline matter took place. In the event of any further conflict as to the application of these Bylaws or the bylaws of another health facility, the CEOs of the health facilities involved shall determine which bylaws shall prevail, and if they cannot reach agreement, they shall appoint an independent third party whose decision with respect to the application of the applicable bylaws shall prevail.

 

24   Notices

       24.1     All notices in these Bylaws shall be deemed duly given to a party:

 

                   24.1.1     upon delivery if delivered by hand;

 

                   24.1.2     three (3) days after posting if sent by registered mail with receipt requested; or

 

                   24.1.3     upon two (2) days after the date of the transmission, if a facsimile transmission is used.

 

25   Timelines

       25.1     Time limits in these Bylaws may be extended by mutual written consent of the Health Centre Representative and the Member concerned.

 

26   Reporting to Regulatory Authorities

       26.1     Where required pursuant to the Medical Act or any other statute, the CEO shall report any variations, suspensions, terminations of privileges or any conditions or restrictions imposed on a Member, to the relevant regulatory authority.

 

       26.2     Where the statute does not require the reporting of any variation, suspension, termination of privileges or conditions or restrictions imposed on a member, the CEO may report the matter to the relevant regulatory authority, where the CEO deems it in the public interest to do so.

 

27   Delegation by CEO

       27.1     In the carrying out of any functions assigned to the CEO in these Bylaws, the CEO may designate a person to act in the place of the CEO.

 

28   Transition

       28.1     Applications for appointments or reappointments initiated prior to the effective date of these Bylaws shall be governed by these Bylaws as nearly as possible.

 

       28.2     All applications for new appointments or reappointments initiated after the effective date of these Bylaws shall be governed in accordance with the terms of these Bylaws.

 

       28.3     Any matter where a special review process or an immediate suspension/variance process has been initiated prior to the implementation of these Bylaws shall be completed as nearly as possible in accordance with the provisions of these Bylaws.

 

       28.4     Any disciplinary process initiated after the effective date of these Bylaws shall be governed in accordance with the provisions of these Bylaws.

 

29   Rules and Regulations

       29.1     The Board may approve Rules and Regulations pursuant to these Bylaws.

 

30   Effect of Other Bylaws

       30.1     These bylaws shall be read in conjunction with the IWK Health Centre Medical, Dental and Scientific Staff Bylaws (General) and the IWK Health Centre Corporate Bylaws. Any term used but not defined in these bylaws that is defined in the IWK Health Centre Medical, Dental and Scientific Staff Bylaws (General) or the IWK Health Centre Corporate Bylaws shall have the meaning given to such term in those bylaws.