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IWK Health Centre Medical, Dental and Affiliated Staff Bylaws

made under Section 21 of the

Health Authorities Act

S.N.S. 2014, c. 32

N.S. Reg. 4/2016, N.S. Reg. 5/2016 and N.S. Reg. 6/2016 (January 5, 2016,
effective January 15, 2016)



Table of Contents

Please note: this table of contents is provided for convenience of reference and does not form part of the regulations.
Click here to go to the text of the regulations.


Part A

Title

Definitions

Purpose and application

Amendment

Application to Part B


Part B

Organizational structure

Medical, dental and affiliated staff categories

Provisional

Active (facility), active (secondary facility) and active (community)

Active without admitting medical staff (community)

Locum tenens

Assistant staff

Affiliated staff

Temporary privileges

Residents

Vice-President of Medicine and Academic Affairs

Department chiefs, associate department chiefs and division chiefs (as applicable)

Duties and responsibilities of a department chief, associate department
chief and division chief

The Medical Advisory Committee

Credentials Committee

Departmental organization

Provincial programs of care

Medical, Dental and Affiliated Staff Organization (MDAS)

Leave of absence

Continuing professional review and development

Ethics and ethical relationships

Affiliation agreements

Rules & [and] regulations


Part C

MAC hearing pool and MAC hearing committee

Composition of Board appeal panel

Appointments & [and] privileges– general

Appointment of medical, dental and affiliated staff–general

Privileges–general

Applications for new appointments

Applications for reappointment

Temporary appointments to the medical, dental and affiliated staff

Miscellaneous

Automatic suspensions

Affiliation agreements with Dalhousie University

Notices

Delegation by CEO

Transition

Revocation/suspension/variation regarding medical, dental and affiliated staff privileges–complaint

Immediate action regarding privileges

Facilitated mediation process

Hearing process

Appeal panel


Part A

 

1.       Title

These are the Izaak Walton Killam Health Centre Medical, Dental and Affiliated Staff Bylaws.

 

          1.1       These bylaws become effective when recommended by the Board and approved by the Minister of Health.

 

          1.2       “Former bylaws” means the bylaws in effect at the IWK Health Centre which existed until January 30th and under the Health Authorities Act, S.N.S. 2000, C.6.

 

          1.3       Where there is an inconsistency between the former bylaws and these bylaws, these bylaws shall prevail.

 

          1.4       Medical, dental and affiliated staff who, as of the effective date of these bylaws, hold medical, dental and affiliated staff privileges under the former bylaws will be advised in writing by the Office of the VP Medicine and Academic Affairs of the category and location of their privileges under these bylaws and of the mechanism through which any errors of assignment may be brought to the attention of the VP Medicine and Academic Affairs for resolution.

 

          1.5       Medical practitioners who, as of the effective date of these bylaws, are practicing [practising] medicine in this Province and who do not hold privileges under the former bylaws but require privileges under Part B, Section 1.2 of these bylaws shall be required to apply for privileges under these bylaws.

 

          1.6       Unless specifically determined to the contrary in the IWK bylaws, rules, regulations or policies, the authority to admit and discharge patients from the IWK’s services, programs or facilities is limited to only those medical practitioners and dental staff members who are granted admitting privileges and those to whom such authority is granted under the IWK’s rules, regulations, or policies. For clarity, nothing in these bylaws shall be deemed to limit the authority to discharge patients which is granted under subsection 12(1) of the Hospitals Regulations under the Hospitals Act, made pursuant to the Hospitals Act, unless such limit is outlined in IWK policy, rules or regulations.

 

          1.7       For further clarity, a medical practitioner may authorize registered nurses to discharge patients pursuant to subsection 12(1) of the Hospitals Regulations under the Hospitals Act, through a collaborative practice agreement, care directive or policy approved by the relevant department chief, department and MAC.


Definitions

Appendix 1 of these bylaws contains the definitions which apply to the words commonly used in Parts A, B and C of these bylaws. The contents of Appendix 1 have the same force and effect as if included within the body of these bylaws.

 

2.       Purpose and application

          2.1       The bylaws are developed and enacted in order to:

 

                      2.1.1    outline the medical, dental and affiliated staff structure, including the categories of privileges, the medical, dental and affiliated staff committees and the duties and functions of senior medical leaders appointed by the IWK Health Centre;

 

                      2.1.2    define the rules governing the medical, dental and affiliated staff including the key elements of appointment, reappointment, privileging and the orderly resolution of issues while at all times ensuring the principles of due process/procedural fairness are maintained;

 

                      2.1.3    ensure clinical criteria and standards to oversee and manage quality assurance, utilization review, performance evaluation and other medical, dental and affiliated staff activities are in place; and

 

                      2.1.4    address processes through which issues respecting the medical, dental and affiliated staff relationship with the IWK may be considered and resolved.

 

          2.2       These bylaws apply to all health care facilities, services, resources and programs in the IWK.

 

          2.3       Any medical practitioner or dentist whose relationship with the health authority is established solely through granting of privileges shall be subject to these bylaws.

 

          2.4       [The] IWK may enter into contracts for services with persons who are subject to these bylaws including but not limited to, medical practitioners, dentists or members of the affiliated staff.

 

          2.5       Any person who is subject to these bylaws and has a relationship with the Board or IWK established by means of a contract or a contract and privileges, whereby the person is provided compensation for services directly by the IWK, either as an independent contractor or as an employee, shall have the renewal, extension and termination of that contract and, if applicable, the variation, suspension, non-renewal or revocation of privileges under that contract determined in accordance with the terms of that contract. Without restricting the generality of the foregoing and for greater clarity: clinical associates, clinical trainees, residents, and members of the affiliated staff are not members of the medical, dental and affiliated staff and shall have the renewal, extension, and termination of their contract and, if applicable the variation suspension, non-renewal or revocation of privileges determined in accordance with their contract and shall not be entitled to access the provisions in the Part C of these bylaws.

 

          2.6       If a medical practitioner or dentist has been granted membership in the medical, dental and affiliated staff by virtue of a contract and has not had his/her relationship with the IWK granted solely through privileges under Part C of these bylaws and Section 21 of the Health Authorities Act, nothing in these bylaws is intended to entitle such a person to access the provisions of Part C of these bylaws; and

 

          2.7       If the only contract governing the medical practitioner or dentist’s relationship with the Health Authority is an agreement under the Health Services and Insurance Act, 1989, R.S.N.S. [1989,] c. 197 as amended (or any successor legislation), for alternative funding arrangements to which the Province of Nova Scotia and the Medical Society of Nova Scotia are included as parties, or agreements with medical practitioners made to confirm their agreement with such alternative funding, then such a contract shall not be interpreted as being a contract for purposes of this Section.

 

3.       Amendment

Amendments to these bylaws, subject to Sections 21 and 22 of the Act, may be recommended by the Board to the Minister of Health and Wellness after consultation with or on a recommendation from MAC.


Amendments shall become effective when recommended by the Board and approved by the Minister of Health and Wellness.

 

4.       Application to Part B

Part A of these bylaws applies to Part B of these bylaws once Part B is made by the Board and approved by the Minister of Health and Wellness under subsection 22(1) of the Health Authorities Act, [S.N.S.] 2014[, c. 32].



Part B

 

1.       Organizational structure

          1.1       The medical, dental and affiliated staff shall be organized as provided in these bylaws.

 

          1.2       No medical practitioner, dentist or other health professional, not employed by the Health Authority, is authorized to admit, provide any service to a patient, conduct research in or access any service provided by the IWK unless such medical practitioner, dentist or health professional holds an appointment to the medical, dental and affiliated staff of which includes the privileges to do so, or has been otherwise authorized by the Board to do so. For clarity, appointment to the medical, dental and affiliated staff of either of the HAs shall constitute sufficient authority to access diagnostic services of the HAs subject to any additional requirements for accessing such services as may be stipulated by the Province of Nova Scotia or in the rules, regulations or policies of the HAs.

 

          1.3       Where a member has been appointed to a category of the medical, dental and affiliated staff which has been materially amended or deleted by the Board, the Board may assign that member to another category of the medical, dental and affiliated staff appropriate for the qualifications of the individual and the Board must inform the member of such reassignment.

 

2.       Medical, dental and affiliated staff categories

          2.1       Members shall be appointed to the appropriate medical, dental and affiliated staff category as determined by the Board.

 

          2.2       The medical, dental and affiliated staff of the IWK shall consist of the categories of members listed below:

 

provisional

active (facility)

active (secondary facility)

active (community)

active without admitting (community)

locum tenens–absence

locum tenens–temporary

assistant staff

affiliated staff

temporary–time limited

temporary–visiting

 

          2.3       Documentation granting medical, dental and affiliated staff appointments to the IWK must stipulate the department, program or service which shall serve as the primary appointment and also outline any other services or programs or health care to which the member may hold any category of privileges. No member may hold an appointment in more than one category in any department, service or program at the same time. Where the Board grants privileges to a member at more than one department, service, or program, the privileges granted to the member must not conflict. For greater clarity the obligations and responsibilities of members shall be applicable to and determined with reference to only their primary category of appointment as outlined in the letter granting privileges.

 

          2.4       Duties, responsibilities and activities and any limitations pertaining to privileges granted to any member of the medical, dental and affiliated staff must be further defined by the Board decision which grants the privileges and are subject to the provisions of these bylaws, the rules & [and] regulations and the IWK’s policies and procedures, all as may be amended from time to time.

 

          2.5       Duties, responsibilities, activities and any conditions or limitation pertaining to any category of medical, dental and affiliated staff privileges as outlined in these bylaws may, in the Board’s discretion, be clarified in the IWK’s rules and regulations and/or policies, as may be amended from time to time.

 

          2.6      Members must abide by these [IWK] Medical, Dental and Affiliated Staff Bylaws, the rules & [and] regulations and policies and procedures of the IWK, all as they are amended from time to time.

 

          2.7       Provisional

                      2.7.1       Unless, in exceptional circumstances where the Board may, in writing, grant an exemption from the requirement under Section 2.7.2, all applicants for active (facility), active (secondary facility), active (community) privileges or assistant privileges who are granted such privileges on or after the effective date of these bylaws, must complete a period of provisional privileges as outlined in these bylaws. Persons fulfilling such provisional period shall constitute the IWK’s provisional medical, dental and affiliated staff.

 

                      2.7.2       The Board may, at its discretion, exempt applicants for active (facility), active (secondary facility), active (community) privileges or assistant privileges from the requirement to complete a period of provisional [privileges], in exceptional circumstances where both the VP Medicine and Academic Affairs and the CEO request such an exemption and where the Board decides that the quality of care, patient and staff safety and fulfilment of the IWK’s mission, vision, values and strategy priorities will not be negatively impacted by the exemption.

 

                      2.7.3       The Board shall provide that the grant of provisional privileges is for a period of no less than one year and that during the term of the provisional privileges, one formal evaluation of the member’s clinical competence and compliance with IWK’s mission, vision, values, policies and procedures, bylaws and rules and regulations, must be conducted pursuant to Section 13.3 [10.3] of Part B of these bylaws by the relevant department chief within the first 6- to 8-month period following the grant of provisional privileges and submitted to the Credentials Committee and the VP Medicine and Academic Affairs. The Credentials Committee, with input from the VP Medicine and Academic Affairs, may then recommend appointment to the active (facility), active (secondary facility), active (community) or assistant categories to the MAC or may recommend a further period of provisional membership of up to one year.

 

                      2.7.4       Members of the provisional staff, shall, unless otherwise provided by the Board, have all the rights, privileges and responsibilities associated with the category for which they have applied but are not eligible to be a member of or Chair MAC including but not limited to any MAC committee.

 

          2.8       Active (facility), active (secondary facility) and active (community)

                      2.8.1       The active (facility), active (secondary facility) and active (community) medical, dental and affiliated staff shall consist of medical practitioners and dentists who, unless exempted from such requirement under Section 2.7.2, have completed the required period of provisional privileges, have been appointed or assigned by contract by the Board to this category and who are actively engaged in the practice of medicine or dentistry within the departments, facilities, programs or services of the IWK, who have privileges to treat and may, at the discretion of the department chief in consultation with the VP Medicine and Academic Affairs admit patients to the IWK, have committed to the terms and conditions of the appointment including but not limited to the commitment to participate fully in achieving the IWK’s mission, vision, values and strategic priorities and to comply with the terms and conditions of these bylaws, the rules and regulations and the IWK’s policies and procedures.

 

                      2.8.2       Active (facility), active (secondary facility) and active (community) members:

                                     2.8.2.1    may admit, at the discretion of the VP Medicine and Academic Affairs in consultation with the department chief(s), and treat patients as provided for and within the limits approved by the Board and as specifically interpreted by the department chief and communicated to the member.

 

                      2.8.3       Active (facility) medical, dental and affiliated staff

                                     2.8.3.1    must participate equitably in the on-call requirements of their division/ department, program or service as set by their department chief unless in exceptional circumstances where they are exempted from doing so based on their department chief’s finding that it is appropriate to allow such an exemption and that the quality, patient safety and care needs of patients of the department are otherwise satisfied;

 

                                     2.8.3.2    must attend, participate in the general business of their division/ department, program or service and the IWK and be entitled to vote at the MDAS meetings and meetings of the division and department to which they are appointed;

 

                                     2.8.3.3    must participate in administrative matters including but not limited to membership on such committees as the department chief, the division chief or the VP Medicine and Academic Affairs, or their designate, may request;

 

                                     2.8.3.4    must participate in educational and clinical activities of the department members; the medical, dental and affiliated staff, other IWK personnel, medical learners and clinical trainees at the discretion of their department chief, reasonably exercised;

 

                                     2.8.3.5    must supervise members of the provisional staff as requested by their department chief;

 

                                     2.8.3.6    must maintain, at the discretion of their department chief, [a] satisfactory standard of professional medical, dental or oral and maxillofacial surgery knowledge and ability in the fields of their practice;

 

                                     2.8.3.7    may teach students and conduct research as may be requested by their department chief or if holding a university appointment as may be directed by the applicable university department head;

 

                                     2.8.3.8    must perform such other duties as their department chief, the VP Medicine and Academic Affairs or their division chief may, at their discretion reasonably exercised, assign to them from time to time and as may be required by these bylaws, the rules and regulations and by IWK policies and procedures; and

 

                                     2.8.3.9    the patient service responsibilities of each active (facility) member shall be under the supervision of the department chief, and any applicable university-based academic activities of active (facility) members shall be under the supervision of the applicable university department head.

 

                      2.8.4       Active (secondary facility)

                                     2.8.4.1    must participate equitably in the on-call requirements of their division/ department, program or service as set by their department chief unless in exceptional circumstances where they are exempted from doing so based on their department chief’s finding that it is appropriate to allow such an exemption and that the quality, patient safety and care needs of patients of the department are otherwise satisfied;

 

                                     2.8.4.2    may attend, participate in the general business of their division/department, program or service and the IWK and be entitled to vote at the MDAS meetings and but not at meetings of the division and department to which they are appointed;

 

                                     2.8.4.3    may participate in administrative matters including but not limited to membership on such committees as the department chief, the division chief or the VP Medicine and Academic Affairs or their designate may request at their discretion reasonably exercised;

 

                                     2.8.4.4    may participate in educational and clinical activities of the department members; the medical, dental and affiliated staff, other IWK personnel, medical learners and clinical trainees at the discretion of their department chief, reasonably exercised;

 

                                     2.8.4.5    must supervise members of the provisional staff as requested by their department chief;

 

                                     2.8.4.6    must maintain a satisfactory, at the discretion of their department chief, standard of professional medical, dental or oral and maxillofacial surgery knowledge and ability in the fields of their practice;

 

                                     2.8.4.7    may teach students and conduct research as may be requested by their department chief or if holding a university appointment as may be directed by the applicable university department head;

 

                                     2.8.4.8    must perform such other duties as their department chief, the VP Medicine and Academic Affairs or their division chief may, at their discretion reasonably exercised, assign to them from time to time and as may be required by these bylaws, the rules and regulations and by IWK policies and procedures; and

 

                                     2.8.4.9    the patient service responsibilities of each active (facility) and active (secondary facility) members shall be under the supervision of the department chief, and any applicable university-based academic activities of active (secondary facility) members shall be under the supervision of the applicable university department head.

 

                      2.8.5       Active (community) members:

                                     2.8.5.1    may participate in the on-call requirements of their division/department, program or service as set by their department chief unless in exceptional circumstances where they are exempted from doing so based on their department chief’s finding that it is appropriate to allow such an exemption and that the quality, patient safety and care needs of patients of the department are otherwise satisfied;

 

                                     2.8.5.2    may attend, participate in the general business of their division/department, program or service and the IWK and be entitled to vote at the MDAS meetings and but not at meetings of the division and department to which they are appointed;

 

                                     2.8.5.3    may participate in administrative matters including but not limited to membership on such committees as department chief, the division chief or the VP Medicine and Academic Affairs or their designate may request at their discretion reasonably exercised;

 

                                     2.8.5.4    may participate in educational and clinical activities of the department members; the medical, dental and affiliated staff, other IWK personnel, medical learners and clinical trainees at the discretion of their department chief, reasonably exercised;

 

                                     2.8.5.5    may supervise members of the provisional staff as requested by their department chief;

 

                                     2.8.5.6    must maintain a satisfactory, at the discretion of their department chief, standard of professional medical, dental or oral and maxillofacial surgery knowledge and ability in the fields of their practice;

 

                                     2.8.5.7    may teach students and conduct research as may be requested by their department chief or if holding a university appointment as may be directed by the applicable university department head;

 

                                     2.8.5.8    must perform such other duties as their department chief, the VP Medicine and Academic Affairs or their division chief may, at their discretion reasonably exercised, assign to them from time to time and as may be required by these bylaws, the rules and regulations and by IWK policies and procedures; and

 

                                     2.8.5.9    the patient service responsibilities of each active (community) members shall be under the supervision of the department chief, and any applicable university-based academic activities of active (community) members shall be under the supervision of the applicable university department head.

 

          2.9       Active without admitting medical staff (community)

                      2.9.1       The active without admitting staff (community) shall consist of medical practitioners and dentists who have been appointed or assigned by contract by the Board to this category and who are actively engaged in the practice of medicine or dentistry within the programs, services, and geographic location of the IWK, who access the services provided through the IWK but who do not have privileges to treat in or admit patients to the IWK facilities and who have committed to the terms and conditions of the appointment including but not limited to the commitment to participate fully in achieving the IWK’s mission, vision, values and strategic priorities and to comply with the terms and conditions of these bylaws, the rules and regulations and the IWK’s policies and procedures.

 

                      2.9.2       Active without admitting medical staff (community) members:

                                     2.9.2.1    may consult on, but not admit to health care facilities, patients as provided for and within the limits approved by the Board and as specifically interpreted by the department chief and communicated to the member;

 

                                     2.9.2.2    may, on request of the applicable department chief, participate in the on-call requirements of their division/department; may attend, participate in the general business of their department, division, program or service and the IWK and be entitled to vote at the MDAS meetings and meetings of the division and department to which they are appointed;

 

                                     2.9.2.3    may participate in administrative matters including but not limited to membership on such committees as, the division chief, the VP Medicine and Academic Affairs or designate, or the department chief may request;

 

                                     2.9.2.4    may participate in educational and clinical activities of the department; the medical, dental and affiliated staff, other IWK personnel, medical learners and clinical trainees as determined by their department chief;

 

                                     2.9.2.5    must maintain a satisfactory, in the department chief’s discretion reasonably exercised, standard of professional medical, [or] dental knowledge and ability in the fields of their practice;

 

                                     2.9.2.6    may teach students and conduct research as may be requested by the applicable department chief or if holding a university appointment as may be directed by any applicable university department head; and

 

                                     2.9.2.7    may perform such other duties as the their department chief; division chief or the VP Medicine and Academic Affairs may request from time to time, at their discretion reasonably exercised and as may be required by these bylaws, the rules and regulations and by IWK policies and procedures;

 

                                     2.9.2.8    the patient service responsibilities of each active without admitting privileges (community) staff members shall be under the supervision of the department chief, and any applicable university-led academic activities of active (secondary facility) privileges staff member must be under the supervision of the applicable university department head.

 

          2.10     Locum tenens

                      2.10.1     The locum tenens staff shall consist of medical practitioners and dentists appointed by the Board to this category who have been granted privileges or retained to:

 

                                     2.10.1.1  populate a qualified pool of locum tenens medical, dental and affiliated staff who are assigned by the VP Medicine and Academic Affairs, or a department chief to address short term absences of members of the active with or without admitting privileges or assistant medical staff; or

 

                                     2.10.1.2  address a temporary vacancy in an approved position in the active with or without admitting privileges or assistant staff until such time as a qualified person can be recruited and appointed to the vacant position but in any event not for a period of more than one year.

 

                      2.10.2     The appointment of a medical practitioner or dentist as a locum tenens under Section 2.10.1.1 shall be for a period of not less than 30 days and not more than 3 years unless re-appointed pursuant to Part C of these bylaws.

 

                      2.10.3     A medical practitioner or dentist appointed under Section 2.10.1.1 must have overall accountability for performance under these bylaws to the department chief.

 

                      2.10.4     The term of the locum tenens appointment under Section 2.10.1.2 may be extended for a further period not to exceed 1 year if the Board considers it necessary to do so to address the applicable medical, dental and affiliated staff resource needs and where the locum tenens continues to meet all qualifications and criteria for such appointment.

 

                      2.10.5     Locum tenens staff must follow the same process for obtaining privileges as any other potential member of the active staff with or without admitting privileges or the assistant staff and shall be subject to the same processes for professional development and ongoing oversight as the members of the active (facility) or active (secondary facility) or assistant staff.

 

                      2.10.6     Unless otherwise restricted by their privileges, locum tenens staff:

 

                                     2.10.6.1  may admit and treat patients with the approval of the department chief as approved by the Board unless such actions are specifically restricted by the department chief where patient care services are being provided;

 

                                     2.10.6.2  may teach students and conduct research as directed by the university department chief and approved by the department chief for the locum tenens’ department; and

 

                                     2.10.6.3  if appointed under Section 2.10.1.1 must act as a substitute for the absent practitioner in any of that practitioner’s regularly scheduled on-call duties or if appointed under Section 2.10.1.2 must participate equitably in the call schedule for their applicable division or department call schedule as determined by the department chief.

 

                      2.10.7     Subject to Section 2.10.3, the patient service responsibilities of each locum tenens staff member shall be under the supervision of the department chief for the locum tenens’ department and any university academic activities of each locum tenens staff member shall be under the supervision of any applicable university department chief as approved by their department chief.

 

                      2.10.8     Subject to Section 2.10.6.1, locum tenens staff must have the same requirements for attendance, voting and committee obligations, as the member for whom the locum tenens staff member is relieving.

 

                                     2.10.8.1  Locum tenens staff are not eligible to hold office on the MAC or on the MDAS.

 

          2.11     Assistant staff

                      2.11.1     Assistant staff consists of those members who unless exempted from such requirement under Section 2.7.2, have completed the required period of provisional privileges and who apply for and are granted specifically defined medical, dental and affiliated staff roles within a program or department (for example as assists for surgical procedures) and who are approved for such privileges by the Board.

 

                      2.11.2     Members of the assistant staff shall not have admitting privileges.

 

                      2.11.3     Each member of the assistant staff must:

 

                                     2.11.3.1  attend patients and undertake such medical and surgical treatments only as approved by the Board;

 

                                     2.11.2.2  attend any meetings of the medical, dental and affiliated staff as may be mandated by the IWK’s rules and regulations and policies and procedures; and

 

                                     2.11.3.3  abide by applicable legislation, bylaws, rules and regulations, professional standards of practice, policies and procedures.

 

                      2.11.4     Members of the assistant medical, dental and affiliated staff may be a member of any committee of the medical, dental and affiliated staff relevant to their professional designation but shall not be entitled to hold any office or be a voting member on any such committee(s).

 

          2.12     Affiliated staff

                      2.12.1     Affiliated staff are medical practitioners, dentists and other health care professionals who:

 

                                     2.12.1.1  hold a PhD or an equivalent combination of education and expertise in a health care profession;

 

                                     2.12.1.2  are not part of the complement of medical, dental and affiliated staff for the IWK; and

 

                                     2.12.1.3  perform clinical functions and/or research functions in collaboration with IWK medical or health professional staff.

 

                      2.12.2     Persons meeting the requirements outlined in Section 2.12.1 may apply for and receive affiliated staff privileges under these bylaws.

 

                      2.12.3     Affiliated staff:

 

                                     2.12.3.1  may not admit or treat patients but may advise on the care of patients;

 

                                     2.12.3.2  must carry out such duties and functions as are described in their approved position description or as otherwise approved by the Board and must meet the terms of all IWK employment or other applicable agreements, IWK policies and procedures and the standards associated with their profession in carrying out those duties and functions;

 

                                     2.12.3.3  may, subject to IWK research policies and procedures, act as principal investigators for research studies or projects;

 

                                     2.12.3.4  may attend and vote at MDAS meetings or hold office in the in MDAS;

 

                                     2.12.3.5  may attend but not vote at department or division meetings or at the MAC unless they are appointed to the role of division or department chiefs.

 

          2.13     Temporary privileges

                      2.13.1     Under and subject to Section 2.5 of Part C of these bylaws the CEO or the VP Medicine and Academic Affairs, may grant temporary privileges to a medical practitioner or dentist.

 

                      2.13.2     Temporary medical, dental and affiliated staff:

 

                                     2.13.2.1  may admit and treat patients as recommended by the department chief;

 

                                     2.13.2.2  may teach students and conduct research as directed and approved by the university department chief and approved by the department chief as applicable; and

 

                                     2.13.2.3  Temporary Medical, Dental and Affiliated Staff may attend MDAS meetings, but are not required to do so.

 

                      2.13.3     Temporary medical, dental and affiliated staff must, unless specifically exempted from doing so by the applicable department chief, participate in the on-call services of the IWK as directed by the department chief.

 

          2.14     Residents

                      2.14.1     Medical/dental students/residents/fellows shall not be members of the IWK medical, dental and affiliated staff or of the MDAS.

 

                      2.14.2     Medical/dental students/residents/fellows must be assigned to an appropriate department as defined in the rules and regulations.

 

                      2.14.3     Medical/dental students/residents/fellows must be registered and have an undergraduate/postgraduate appointment at the university Faculty of Medicine or Faculty of Dentistry and meet the pre-placement and ongoing requirements outlined in the IWK’s rules and regulations and in the IWK policies and procedures. Elective students and residents who are not appointed to training programs at the university must be registered with the Dean’s office of the Dalhousie Faculty of Medicine or [Faculty of] Dentistry as applicable.

 

                      2.14.4     Each medical/dental student/resident/fellow must be accountable to the appropriate department chief or division chief for the clinical services provided to patients and to the post-graduate residency training program director (as applicable) for their educational requirements while in the clinical environments of the IWK. In the event, there is no applicable post-graduate residency training program director then the resident’s educational requirements shall be under the supervision of the department chief.

 

                      2.14.5     The nature, extent and number of responsibilities, including patient care responsibilities, assigned to a medical/dental student/resident/fellow at any given time must be commensurate with any applicable requirements in the IWK’s rules and regulations, division/department chief decisions as to such responsibilities and the medical/dental student’s or resident’s demonstrated level of skills.

 

3.0     Vice-President of Medicine and Academic Affairs

          3.1       The VP Medicine and Academic Affairs must be appointed by and accountable to the CEO for any medical and dental staff matters arising from the operation of the IWK and for those roles and responsibilities which are outlined in the position description for the VP Medicine and Academic Affairs.

 

          3.2       Where the VP Medicine and Academic Affairs is absent or for any reason is unable to perform his or her duties, the CEO shall appoint an Acting VP Medicine and Academic Affairs.

 

          3.3       The VP Medicine and Academic Affairs is responsible for the effective functioning of the medical, dental and affiliated staff and for the implementation of policies established by the Board for medical, dental and affiliated staff affairs, those duties which are defined in the role description and contractual agreements applicable to the VP Medicine and Academic Affairs and such duties as may be assigned by the CEO and without limiting their generality, these duties include:

 

                      3.3.1       leading the development and implementation of measures to evaluate and enhance medical and dental staff clinical performance;

 

                      3.3.2       leading the development and implementation of processes for credentialing, both general and procedural specific privileging;

 

                      3.3.3       co-leading with the VP People and Organizational Development the development and implementation of leadership development initiatives;

 

                      3.3.4       with the Nova Scotia Health Authority and the Nova Scotia Department of Health & [and] Wellness, participating in and implementing initiatives for provincial human resource planning, recruitment and retention;

 

                      3.3.5       overseeing the development of appropriate measures to ensure the quality of services offered by all members of the medical, dental and affiliated staff; and compliance with these bylaws, the rules and regulation and IWK policies and procedures; is evaluated on a regular basis and that any required corrective actions are taken; [sic]

 

                      3.3.6       monitoring of the medical, dental and affiliated staff practices to ensure compliance with these bylaws, the rules & [and] regulations and policies established by the MAC and the IWK;

 

                      3.3.7       ensuring mechanisms are in place to monitor and encourage medical, dental and affiliated staff involvement in continuing education;

 

                      3.3.8       monitoring the performance and effectiveness of the department/division chiefs;

 

                      3.3.9       participating on pertinent medical, administrative and Board committees; and

 

                      3.3.10     leading, promoting and ensuring medical, dental and affiliated staff engagement in quality improvement and in the development and implementation of strategic priorities/plans.

 

          3.4       The VP Medicine and Academic Affairs may delegate any of his/her day-to-day oversight responsibilities in consultation with the CEO.

 

4.       Department chiefs, associate department chiefs and division chiefs (as applicable)

          4.1       Department chiefs must be members of the active staff and members of the departments concerned and must be appointed by the Board following consultation with the CEO, VP Medicine and Academic Affairs and any search process which may be set out in the rules and regulations. Department chiefs are accountable for any medical, dental and affiliated staff practice-related matters arising from the operation of the IWK within the applicable department and for those roles and responsibilities which are outlined in the position description for the department chief. Department chiefs shall ordinarily be required to have an academic appointment with the university unless specifically exempted from this requirement by the Board.

 

          4.2       Associate department chiefs must be members of the active staff and members of the departments concerned and are appointed by the department chief following consultation with the VP Medicine and Academic Affairs.

 

          4.3       Division chiefs must be members of the active staff and members of the departments/divisions concerned and are appointed by the department chief following consultation with the VP Medicine and Academic Affairs. The division chief is accountable to the department chief for any medical, dental and affiliated staff practice-related matters arising from the operation of the IWK within the department and for those roles and responsibilities which are outlined in the position description for the division chief. Division chiefs shall ordinarily be required to have an academic appointment with the university unless specifically exempted from this requirement by the Board.

 

          4.4       Subject to any action as may be taken pursuant to the applicable terms of appointment and any contractual arrangement with a department or division chief, department and division chief appointments will normally be for a period of 5 years with a possible re-appointment for an additional 5 year appointment.

 

          4.5       Department chiefs and, to the extent applicable division chiefs must act as both the clinical and academic heads for their departments/divisions and, in some instances, the department chief may also be appointed by the university as the university department head.

 

          4.6       Duties and responsibilities of a department chief, associate department chief and division chief

A department chief must fulfill all obligations which are included in the department chief’s role description forming part of the contract with the IWK and must without limiting the foregoing:

 

                      4.6.1       be directly responsible to the CEO or designate and, through him/her, to the Board of the IWK Health Centre;

 

                      4.6.2       have the authority and responsibility for the general supervision of the medical and dental care of the patients treated by department members and the medical/dental students or residents under the guidance of members of the department to ensure acceptable quality of care;

 

                      4.6.3       be responsible for the medical/dental/scientific administration and function of the department;

 

                                     4.6.3.1    upon receipt of notification that a member of the department or a division of the department is unable to perform her/his duties, shall ensure that arrangements are made for proper care of the patients affected by that member’s inability to perform her/his duties;

 

                                     4.6.3.2    make necessary arrangement[s] to replace the attending physician/dentist unable to perform her/his duties and this replacement physician/dentist shall be identified on the patients’ health record [sic];

 

                                     4.6.3.3    be responsible for taking steps to suspend temporarily the privileges of any department member under the circumstances and utilizing the processes set out in the bylaws. When affecting a patient(s), these actions shall also include:

 

                                                    4.6.3.3.1   discussing the condition, diagnosis, care and treatment of the patient(s) with the member being suspended and with the patient’s (s’) attending physician/dentist (if this is a difference [different] person);

 

                                                    4.6.3.3.2   if change[s] in diagnosis, care of [or] treatment satisfactory to the chief of the department are not promptly made, assumption by the chief of the department of the responsibilities of the member being suspended or, if appropriate, assignment by the chief of the department of such responsibilities to another member of the department; and

 

                                                    4.6.3.3.3   when the chief of the department is unable to discuss the problem with the suspended member, she/he shall proceed as if she/he had spoken with the member.

 

                      4.6.4       when informed that the privileges of a member of her/his department has [have] been suspended or altered in accordance with bylaws be responsible for implementing such changes;

 

                      4.6.5       ensure the development of mechanisms for and exercise such authority as is necessary to ensure the quality of health care and safety of patients cared for through the department;

 

                      4.6.6       organize and implement processes for clinical review within the department;

 

                      4.6.7       ensure the development of mechanisms to maintain and enforce professional standards in the department;

 

                      4.6.8       be responsible for the ethical conduct and professional practice of the department members.

 

                      4.6.9       facilitate and support teaching and research within the department;

 

                      4.6.10     be responsible to the IWK Health Centre and the head of the university department for the supervision, control and education of students assigned to the department;

 

                      4.6.11     establish a process of and encourage continuing education within the department;

 

                      4.6.12     ensure department members are informed about and are compliant with the bylaws, rules and regulations, and policies;

 

                      4.6.13     implement any medical care policies and procedures applicable to the department;

 

                      4.6.14     review annually the professional conduct, competence, performance and qualifications of members of the department for the purpose of making recommendations to the Credentials Committee for reappointments;

 

                      4.6.15     report to the Credentials Committee any requests for a change of privileges by any member of the department;

 

                      4.6.16     report to the VP Medicine and Academic Affairs progress affecting any member of the department and, when requested, report on the conduct or professional performance of a department member;

 

                      4.6.17     in accordance with IWK Health Centre’s requirements and processes, if any, submit a departmental budget;

 

                      4.6.18     ensure an appropriate orientation of new members of the medical, dental and affiliated staff appointed to the department;

 

                      4.6.19     hold and chair regular department meetings and cause attendance to be recorded and minutes to be taken;

 

                      4.6.20     receive recommendations concerning medical care policies and procedures;

 

                      4.6.21     submit annually a report of the department functioning;

 

                      4.6.22     be a member of MAC and as such:

 

                                     4.6.22.1  advise on the quality of care and treatment provided to patients, including reporting of violations of the IWK policies which jeopardize safety or the efficient conduct of IWK business and advise what actions are being taken to prevent recurrence;

 

                                     4.6.22.2  participate in the development of the IWK overall objectives, planning and resource allocation and utilization;

 

                                     4.6.22.3  make recommendations regarding the medical, dental and affiliated staff human resource requirements of the department, following consultation with the medical, dental and affiliated staff of the department, the VP Medicine and Academic Affairs and, where appropriate, chiefs of divisions;

 

                                     4.6.22.4  report on activities of the department, including utilization of resources;

 

                      4.6.23     notify the CEO or designate and assign an alternate from within the department to act as her/his delegate when absent from the IWK;

 

                      4.6.24     participate in the development of the department’s mission, objectives and strategic plans;

 

                      4.6.25     participate in the IWK strategic planning and the department’s resource allocation decisions;

 

                      4.6.26     implement and maintain appropriate measurers for reviewing and managing the use of resources by members;

 

                      4.6.27     delegate appropriate responsibilities to the division chiefs (where they exist) within the department;

 

                      4.6.28     have the authority to appoint a chair and members of any committees within the department necessary to carry out the functions of the department.

 

          4.7       The associate chief must fulfill all obligations delegated by the department chief and fulfill the role of department chief in his/her absence.

 

          4.8       The division chief must fulfill all obligations which are included in the division chief’s position description forming part of the contract with the IWK and must:

 

                      4.8.1       be a member of the active staff of the department;

 

                      4.8.2       be appointed by the department chief of which the division forms a party; [sic]

 

                      4.8.3       establish a process of continuing professional development or implement any applicable IWK process related to the division;

 

                      4.8.4       ensure the development of programs to maintain and enforce professional standards in the division;

 

                      4.8.5       review the performance of members of the division for the purpose of making recommendation[s] for reappointment or contract renewal;

 

                      4.8.6       hold regular meetings of the division and advise members regarding current IWK department/division policies, rules and regulations;

 

                      4.8.7       submit minutes of regular division meetings to the department chief; and

 

                      4.8.8       liaise with the university department head respecting academic activities within the division.

 

5.       The Medical Advisory Committee

          5.1       The MAC is a committee of the IWK which advises the Board and the CEO on matters concerning the provision of quality patient care and service, teaching and research as prescribed by the mandate of IWK.

 

          5.2       The MAC must consist of the following:

 

                      5.2.1       VP Medicine and Academic Affairs;

 

                      5.2.2       department chiefs;

 

                      5.2.3       any other members, as may be outlined in the terms of reference approved by the Board; and

 

                      5.2.4       the CEO ex officio and other non-voting representatives from IWK executive leadership team.

 

          5.3       The chair of the MAC shall be accountable to the Board through the CEO.

 

          5.4       The MAC must meet at regular intervals and not less than 10 times per year. Special meetings may be called by the Chair, and written or oral notice must be given to all members of the committee at least 48 hours prior to any meeting.

 

          5.5       The quorum for a meeting of the MAC or any of its committees must be 50% of the voting members.

 

          5.6       The Chair shall be entitled to vote and in the situation of an equality of votes, the motion must be considered defeated.

 

                      5.6.1       MAC must:

 

                      5.6.2       be responsible, for oversight of the ethical conduct and professional practice of the members of the medical, dental and affiliated staff;

 

                      5.6.3       be responsible, for the supervision, quality, organization and delivery of all services provided by the medical, dental and affiliated staff including patient care, teaching and research;

 

                      5.6.4       consider, coordinate, and recommend to the Board the rules & [and] regulations and policies as they apply to the medical, dental and affiliated staff as a whole or to individual departments or divisions;

 

                      5.6.5       make recommendations to the Board of the IWK concerning appointments, reappointments, discipline, and privileges of the medical, dental and affiliated staff;

 

                      5.6.6       consider and take appropriate action on all matters and recommendations forwarded from standing and ad hoc committees or subcommittees;

 

                      5.6.7       consider and make recommendations on such matters as may be referred to it by the Board;

 

                      5.6.8       advise the Board of such committees as it considers necessary for the proper governance of the MAC and must set their terms of reference and appoint the members and chairs of such committees including but not limited to the Credentials Committee as defined in Section 5.7 below; and

 

                      5.6.9       perform those functions set out in its terms of reference as approved by the Board.

 

          5.7       Credentials Committee

                      5.7.1       There shall be a Credentials Committee.

 

                      5.7.2       The Credentials Committee is a committee of the MAC and consists of the following persons appointed by the MAC:

 

                                     5.7.2.1    VP Medicine and Academic Affairs who will serve as chair (or his/her delegate);

 

                                     5.7.2.2    a member of the MDAS Executive, appointed by the MDAS Executive; and

 

                                     5.7.2.3    other members appointed by the MAC from the medical, dental and affiliated staff, as nominated by medical, dental and affiliated staff who shall not be department chiefs MDAS [sic].

 

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

 

                      5.7.4       Each Credentials Committee shall:

 

                                     5.7.4.1    undertake detailed investigation and analysis of applications for appointments, privileges, and applications for reappointment and make recommendations as to such appointments and re-appointments to the MAC;

 

                                     5.7.4.2    review mediated resolutions arising out of the mediation processes outlined in Part C of these bylaws and where required pursuant to these bylaws; and

 

                                     5.7.4.3    perform such other functions as set out in these bylaws or in the rules and regulations.

 

                      5.7.5       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.

 

                      5.7.6       The MAC retains the authority at any time to appoint new or replace 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.

 

6.       Departmental organization

          6.1       The medical, dental and affiliated staff must be divided into departments and, if appropriate, divisions and programs as recommended by the MAC upon consultation with the VP Medicine and Academic Affairs and CEO and approved by the Board.

 

          6.2       Members must be assigned individually to an appropriate department by the Board and, if appropriate, also to a division.

 

          6.3       Members must undertake their activities in accordance with the rules and regulations and IWK policies and procedures.

 

          6.4       The Board, after seeking advice from the CEO, the VP Medicine and Academic Affairs, the Chair of [the] MAC and the Dean[s] of Medicine/[ and ]Dentistry may change the status of a department or division. Any such change must be reflected in the rules and regulations.

 

          6.5       Each department must have a department chief appointed by the Board following consultation with the CEO, VP Medicine and Academic Affairs and any search process which may be established in the rules and regulations. The terms of the appointment must be confirmed in writing.

 

7.       Provincial programs of care

          7.1       The Board may establish provincial programs of care on the recommendation of the IWK’s executive leadership team and the Board shall in its decision outline how such provincial programs of care interact with the MDAS and MAC under these bylaws.

 

          7.2       A provincial program of care medical program director must:

 

                      7.2.1       be responsible for the administration and operation of the program in accordance with the terms and conditions approved by the Board; and

 

                      7.2.2       be eligible to be a member of the MAC.

 

8.       Medical, Dental and Affiliated Staff Organization (MDAS)

          8.1       There must be a[n] MDAS which must have terms of reference and policies and processes.

 

          8.2       Members of the MDAS must consist of members of the medical, dental and affiliated staff eligible for membership under these bylaws and who have such designated as the primary base for application of their privileges.

 

          8.3       Membership in the MDAS does not convey, confer or imply any benefits, rights or privileges of membership in the medical, dental or affiliated staff.

 

          8.4       The purpose of the MDASs is to represent the interests of the medical, dental and affiliated staff to the IWK’s executive management team and on the MAC and other committees.

 

          8.5       The Medical, Dental and Affiliated Staff Organization shall develop MDAS rules and regulations that are not inconsistent with the bylaws or the rules and regulations made pursuant to the bylaws, which MDAS rules and regulations shall form the governance documents of the MDAS Organization.

 

          8.6       The MDAS executive shall:

 

                      8.6.1       be elected or appointed in the manner prescribed in the MDAS rules and regulations and shall include a president and a vice-president;

 

                      8.6.2       assist in dealing with conflicts within the medical, dental and affiliated staff;

 

                      8.6.3       carry out such functions as assigned in the bylaws and the rules and regulations;

 

                      8.6.4       conduct the business of the Medical, Dental and Affiliate[d] Staff Organization between regular meetings.

 

          8.7       At the time of the coming into force of these bylaws, the MDAS executive in place at such time shall continue as the MDAS executive until a new executive is elected pursuant to the MDAS rules and regulations.

 

          8.8       The MDAS executive in place at the time of the coming into force of these bylaws shall develop the MDAS rules and regulations for approval by the medical, dental and affiliated staff at a meeting to be called within three months of the passage of these bylaws.

 

9.       Leave of absence

          9.1       A member who proposes to take a leave of absence exceeding 12 consecutive weeks shall, if they wish to return to their pre-leave membership status in the medical, dental and affiliated staff, apply for a leave in writing to the department chief stating the duration and purpose of the proposed absence.

 

                      9.1.1       Subject to 9.2, a leave of absence must not exceed 12 months;

 

                      9.1.2       the department chief must notify the MAC of his/her decision regarding the proposed absence; and

 

                      9.1.3       the MAC must notify the Board of the absence.

 

          9.2       The member may, with reasonable notice, apply in writing to the department chief for an extension of a leave of absence granted under Section 9.1 for a period not to exceed 1 year and the total continuous amount of time to be granted through such leaves cannot exceed 2 years without the member being required to submit a new application for appointment to the medical, dental and affiliated staff.

 

          9.3       During a leave of absence, the member must remain a member of the medical, dental affiliated staff but is excused from clinical, teaching, research and committee duties and responsibilities.

 

                      9.3.1       Upon return, the Member may resume the status held prior to the leave provided all requirements for reappointment are met.

 

                      9.3.2       Prior to the resumption the member must provide the department head with an accounting of activities conducted during the leave of absence, including proof of good standing in all jurisdictions in which he/she practice medicine since the commencement of the leave of absence, if applicable.

 

          9.4       The member on leave must be required to keep the member’s file current during the leave by completing the reappointment application at the usual time.

 

          9.5       Where a department chief or division chief applies for and receives a leave of absence, the VP Medicine and Academic Affairs must appoint an acting chief for that department or division on the recommendation of the department head and with the approval of the VP Medicine and Academic Affairs.

 

10.     Continuing professional review and development

          10.1     Each member must have and agree to a review for purposes of evaluating his/her performance and their ongoing appointment to the IWK medical, dental and affiliated staff on an annual basis and otherwise as may be determined by the IWK VP Medicine and Academic Affairs in consultation with the applicable department chief. Members who hold appointments with the university may also be subject to the university’s professional review and development processes.

 

          10.2     The applicable department chief shall conduct an annual review of a member. The annual review will include documentation from the department chief to the VP Medicine and Academic Affairs confirming:

 

                      10.2.1     evidence of compliance with any continuing medical education requirements as may be required by the applicable department chief;

 

                      10.2.2     evidence of current active licensure or registration status with the member’s professional licensing/regulatory body;

 

                      10.2.3     a determination as to compliance with code of ethics and workplace behaviour requirements as outlined in these bylaws, the rules and regulations and in the IWK’s policies and procedures;

 

                      10.2.4     information on any physical or health condition that affects or may affect the proper exercise by the member of the necessary skill, ability and judgment to deliver appropriate patient care and service;

 

                      10.2.5     information on any disciplinary actions taken by the member’s professional regulatory college or by the IWK;

 

                      10.2.6     evidence of current membership in the CMPA or other professional liability protection approved by the Board and in the category appropriate to the member’s practice;

 

                      10.2.7     a list of the current privileges/areas of practice held or performed by the member and any additional areas of practice or privileges requested;

 

                      10.2.8     information on any legal action arising out of the member’s professional activity; and

 

                      10.2.9     a finding by the applicable department chief that the member continues to meet the requirements for continuing appointment to the category and level of privileges granted to the member by the Board. Such finding must be based on the evaluation of the information required under this Section of the bylaws and any other information known by or received by the department chief in connection with the member’s privileges.

 

          10.3     In at least one year of the period for which any member is granted privileges and within the first 6- to 8-month period following a grant of provisional medical staff, the member’s annual performance review must be a comprehensive performance and development review which must be developed by the VP Medicine and Academic Affairs with input from the MAC and which must include, as a minimum, those items to be included in the annual review required under Section 10.2 and the additional requirements and considerations as are outlined in the medical, dental and affiliated staff rules and regulations.

 

          10.4     The comprehensive performance review required under Section 10.3 must occur in the year in which the member staff member is seeking re-appointment and in the year in which a provisional member is being considered for appointment to active medical staff with or without admitting privileges or assistant staff privilege categories.

 

          10.5     The applicable department must provide a copy of the reviews contemplated by this Section to the member and must receive in writing any input which the member wishes to provide and both the review and the input provided must be stored in the member’s credentials files and such information must be made available to any committee of the HA which is vested with assessing the credentials of the member or to the Board for purposes of making a decision as to the member’s medical, dental and affiliated staff privileges.

 

          10.6     In the event that the review requires consideration of a change to the member’s privileges in advance of any scheduled or anticipated review of the member’s privileges, the provisions of Part C of these bylaws must be invoked.

 

11.     Ethics and ethical relationships

          11.1     The IWK code of ethics, code of conduct and these bylaws must govern the professional conduct of members. In the absence of a[n] IWK code of ethics, the codes of ethics adopted by the College of Physicians and Surgeons of Nova Scotia and the Provincial Dental Board of Nova Scotia must govern the professional conduct of the members.

 

          11.2     All members of the medical, dental and affiliated staff shall practice [practise] in a manner consistent with the laws of Canada and of the Province of Nova Scotia and with the values and guiding principles in keeping with an academic, family-centered health centre of similar size and type to the IWK Health Centre.

 

12.     Affiliation agreements

Upon the effective date of these bylaws, any existing affiliation agreements must remain in place until such time as there is a Board resolution to change those agreements. In the event of conflict between these bylaws, the rules and regulations and any affiliation agreement, precedence must be given to these bylaws and the rules and regulations.

 

13.     Rules & [and] regulations

          13.1     Subject to the approval of the Board, the MAC may make such rules and regulations as it deems necessary with respect to:

 

          13.2     the management of medical activities, programs of care, medical services provided through the IWK, education and research; and

 

          13.3     the conduct of the medical, dental and affiliated staff.

 

          13.4     Should there be any perception of or actual conflict between these bylaws and the rules & [and] regulations then the rules and regulations must to [the] extent reasonably possible be interpreted to reconcile any conflict and failing that, these bylaws must take precedence.



Part C

 

1.       MAC hearing pool and MAC hearing committee

          1.1       The MAC hearing pool is composed of 4 MDAS members appointed by the MAC in consultation with the MDAS executive.

 

          1.2       Where the MAC receives notice regarding a hearing with respect to a member’s privileges, the Chair of MAC shall constitute a hearing committee to hold a hearing.

 

          1.3       A hearing committee is a committee of the MAC and consists of:

 

                      1.3.1       two members of the MAC appointed by the MAC, who are not the Chair of the MAC or the VP Medicine and Academic Affairs, the member’s department chief, and one of whom shall act as chair of the hearing committee; and

 

                      1.3.2       two members of the MAC hearing pool who do not represent the member’s department.

 

          1.4       A quorum of a hearing committee consists of 3 individuals, one of whom must be the Chair.

 

          1.5       A hearing committee shall act as an independent adjudicative body during the hearing process in accordance with Section 8.

 

          1.6       Members of a hearing committee or the MAC hearing pool shall excuse themselves from any discussions at the MAC regarding the credentialing or discipline of individuals who may become a party before a hearing committee.

 

          1.7       A member of a MAC hearing pool shall not serve concurrently on the Credentials Committee.

 

          1.8       In a proceeding before a hearing committee, the Chair of the hearing committee may retain independent counsel to advise the hearing committee regarding matters of law and procedure.

 

          1.9       The HA representative may retain legal counsel to present or to assist in presenting the case on behalf of the IWK before the hearing committee.

 

          1.10     The member who is the subject of the hearing may retain counsel to represent the member at the member’s expense.

 

          1.11     The Chair of a 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.

 

          1.12     Subject to Section 1.13, the MAC retains the authority to replace members of a hearing committee where no quorum is available, where a conflict of interest may exist or for any other reason where a member of a hearing committee is not available to act.

 

          1.13     Where the MAC replaces a member of the hearing committee under Section 1.12, it must appoint the new member from the original category under Section 1.1 [1.3] from which the original member was appointed from.

 

          1.14     Notwithstanding Section 1.12, if a member of a hearing committee becomes unable, for any reason, to continue participation on the hearing committee, the remaining members may complete the work of the hearing committee and render a decision.

 

2.       Composition of Board appeal panel

          2.1       An appeal panel is a panel who is delegated by the Board to hear appeals from a hearing committee’s decision.

 

          2.2       Where the Board receives a notice of appeal regarding a member’s privileges, an appeal panel shall be created and shall conduct an appeal with the following composition:

 

                      2.2.1       the Chair of the Board who shall sit as Chair of the appeal panel; and

 

                      2.2.2       2 members of the Board selected by the Chair.

 

          2.3       An appeal panel may retain independent legal counsel to advise the appeal panel regarding matters of law and procedure.

 

          2.4       If a member of the appeal panel becomes unable, for any reason, to continue participation on the appeal panel, the remaining members may complete the work of the appeal panel and render a decision.

 

3.       Appointments & [and] privileges– general

          3.1       Appointment of medical, dental and affiliated staff–general

                      3.1.1       The Board may appoint medical practitioners, dentists and other health professionals in its sole and absolute discretion to the medical, dental and affiliated staff in the manner provided for in these bylaws.

 

                      3.1.2       Any medical, dental and affiliated staff whose relationship with the IWK is established solely through granting of privileges shall be subject to these bylaws with respect to variation, suspension, revocation or other non-renewal of privileges.

 

                      3.1.3       All appointments to the medical, dental and affiliated staff shall be conditional on the member agreeing in writing to abide by:

 

                                     3.1.3.1    all bylaws, policies and procedures;

 

                                     3.1.3.2    the rules and regulations;

 

                                     3.1.3.3    the limits of the appointment and privileges as specified in these bylaws and granted to the member; and

 

                                     3.1.3.4    the IWK code of ethics, code of conduct and these bylaws must govern the professional conduct of members. In the absence of a[n] IWK code of ethics, the codes of ethics adopted by the College of Physicians and Surgeons of Nova Scotia and the Provincial Dental Board of Nova Scotia must govern the professional conduct of the members.

 

          3.2       Privileges–general

                      3.2.1       A medical practitioner, dentist or other health professional who is appointed to the medical, dental and affiliated staff shall be granted privileges appropriate to his/her role and practice, as determined by the processes established under these bylaws. When privileges are granted under these bylaws, the decision granting such privileges shall specify the extent and limitation of the privileges, including the category of appointment under Section 2 of Part B, the departments and facilities in which the applicant may exercise privileges and the scope of privileges and procedures.

 

                      3.2.2       Privileges granted to members of the medical, dental and affiliated staff in accordance with these bylaws shall normally be for a period of 36 months. In the case of members of the medical, dental and affiliated staff 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.

 

                      3.2.3       Notwithstanding Section 3.2.2, privileges granted to a member shall be for a term less than thirty-six (36) months, where:

 

                                     3.2.3.1    it is a provisional appointment;

 

                                     3.2.3.2    specified in a decision made under these bylaws;

 

                                     3.2.3.3    granted as part of a temporary appointment under Section 2.5 [3.5];

 

                                     3.2.3.4    specified in an initial grant or renewal of privileges;

 

                                     3.2.3.5    an employment contract or another contractual relationship with a member states otherwise;

 

                                     3.2.3.6    agreed to by the member and the VP Medicine and Academic Affairs or the VP Medicine and Academic Affairs’ delegate; and

 

                                     3.2.3.7    the member has not participated in the annual performance review, the performance review has not been provided or the result has recommended a shorter term appointment in order to address performance concerns.

 

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

 

                                     3.2.4.1    appropriate insurance or coverage through a protective association or insurer;

 

                                     3.2.4.2    registration and current licensing with the relevant regulatory body;

 

                                     3.2.4.3    completed performance review; and

 

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

 

                      3.2.5       A member may request a change in privileges or category if the member submits a request in writing to the CEO or designate.

 

                      3.2.6       Upon receipt of a request for a change in privileges or category under Section 3.2.5, the CEO, or designate shall forward the request to the VP Medicine and Academic Affairs and the relevant department chief, and the matter shall be processed as if it were an application from the member to the CEO for reappointment under Section 3.4.

 

                      3.2.7       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 under Sections 3.1, 3.4, or 3.5.

 

          3.3       Applications for new appointments

                      3.3.1       The CEO or the CEO’s designate, on receipt of an inquiry from a physician, dentist, or scientist seeking appointment to the medical, dental and affiliated staff, shall, following consultation with the relevant department chief, and the VP Medicine and Academic Affairs assess the inquiry from the perspective of need and availability of resources, not from the perspective of the individual merit of the applicant. Such assessment is to determine whether there is a position approved by the Board and, to the extent required, by the Department of Health and Wellness, and resources to support the position. Such assessment is to be completed within sixty (60) working days of the inquiry.

 

                      3.3.2       Upon completion of the assessment under Section 3.3.1, 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 under these bylaws.

 

                      3.3.3       If the result of the assessment under Section 3.3.1 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.

 

                      3.3.4       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:

 

                                     3.3.4.1    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;

 

                                     3.3.4.2    in the case of a physician, membership in the Canadian Medical Protective Association or other equivalent liability protection, in the case of a dentist, such malpractice insurance as required under the regulations of the Dental Act and in the case of a scientist or other independent contractor, proof of liability protection;

 

                                     3.3.4.3    the results of a vulnerable sector search and the results of a criminal record inquiry; and

 

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

 

                      3.3.5       The CEO or designate shall, within five (5) working days of the receipt of a completed application form with the required accompanying documentation, forward the application to the VP Medicine and Academic Affairs to administer and coordinate the credentials process.

 

                      3.3.6       The VP Medicine and Academic Affairs, upon receipt of the material under Section 3.3.5 shall forward the material to the Credentials Committee within five (5) working days. The Credentials Committee, upon receipt of the material under this Section, shall consider the application by:

 

                                     3.3.6.1    consulting with the appropriate department chief to assess the application on its merit;

 

                                     3.3.6.2    verifying the accuracy of information provided by the applicant;

 

                                     3.3.6.3    conducting such other inquiries as it deems appropriate;

 

                                     3.3.6.4    interviewing such persons as it deems appropriate; and

 

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

 

                      3.3.7       Upon completion of its review, the Credentials Committee, within sixty (60) working days of receiving the application from the VP Medicine and Academic Affairs, shall:

 

                                     3.3.7.1    recommend to the MAC an appointment and specific privileges for the applicant;

 

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

 

                                     3.3.7.3    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.

 

                      3.3.8       Upon receipt of the recommendation from the Credentials Committee, the MAC shall review the Credentials Committee’s recommendations and any response, and shall, within thirty (30) working days of receipt of the application from the Credentials Committee:

 

                                     3.3.8.1    accept the Credentials Committee’s recommendations;

 

                                     3.3.8.2    reject the Credentials Committee’s recommendations; or

 

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

 

and shall inform the appropriate department chief, CEO and applicant of its disposition.

 

                      3.3.9       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.

 

                      3.3.10     The Chair of the MAC shall forward its recommendations to the Board, including the applicant’s position on any suggested variance, within five (5) working days of making its recommendation under Section 3.3.8.

 

                      3.3.11     The Board shall review all recommendations from the Credentials Committee and [the] MAC.

 

                      3.3.12     If the Board determines it does not have sufficient information to make a final decision on the application, the Board may make inquiries of the MAC Chair, it deems necessary to make a decision.

 

                      3.3.13     The Board shall make the final decision on the application within forty-five (45) working days of receipt of the MAC’s recommendations.

 

                      3.3.14     The Board Chair shall immediately forward the Board’s written decision to the CEO or designate and the appropriate department chief for information.

 

                      3.3.15     After the Board Chair has informed the CEO and the appropriate department chief of its decision, the CEO or designate shall inform the applicant of the decision.

 

                      3.3.16     The decision of the Board under Section 3.3.13 shall be a final decision, and there shall be no right of review or appeal by the applicant under these bylaws.

 

          3.4       Applications for reappointment

                      3.4.1       The CEO or designate shall forward an application form for reappointment to a member at least one hundred (100) working days before the completion of the member’s current term of appointment.

 

                      3.4.2       If the member desires reappointment, the member shall forward the completed reappointment application at least eighty-five (85) working days before the completion of his/her current term of appointment to the CEO or his/her designate.

 

                      3.4.3       The CEO or designate shall immediately forward the application to the VP Medicine and Academic Affairs, whose office shall administer the reappointment process.

 

                      3.4.4       The VP Medicine and Academic Affairs shall, within five (5) working days of receipt of the application, forward the application and all accompanying documentation to the applicant’s department chief.

 

                      3.4.5       The VP Medicine and Academic Affairs shall assess the application and shall:

 

                                     3.4.5.1    recommend the appointment, and forward such recommendation to the Credentials Committee within ten (10) working days of receiving the application from the department chief;

 

                                     3.4.5.2    recommend a variance which is acceptable to the applicant, in which event the accepted recommendation is forwarded to the Credentials Committee within ten (10) working days of receiving the application from the department chief; or

 

                                     3.4.5.3    not recommend the reappointment, or suggest a variance that is not acceptable to the applicant, in which case the matter shall be referred within [ten] (10) working days of receiving the application from the department chief to the CEO in order to commence the facilitated mediation process.

 

                      3.4.6       Where a facilitated mediated resolution is reached, the application for reappointment shall be revised to reflect the facilitated mediation resolution and presented as a recommendation to the Credentials Committee.

 

                      3.4.7       Where no facilitated mediated resolution is reached, the application for reappointment, the department chief’s recommendation and the applicant’s response shall be provided to the Credentials Committee.

 

                      3.4.8       Where a recommendation is made in accordance with Sections 3.4.5.1, 3.4.5.2, 3.4.6 or 3.4.7 the recommendation shall be reviewed by the Credentials Committee.

 

                      3.4.9       In its review under Section 3.4.8, the Credentials Committee shall consider the matter by:

 

                                     3.4.9.1    consulting with the CEO and the VP Medicine and Academic Affairs (and/or the Integrated Vice-president of Research and Innovation for affiliated staff);

 

                                     3.4.9.2    verifying the accuracy of information provided by the applicant;

 

                                     3.4.9.3    conducting such other inquiries as it deems appropriate;

 

                                     3.4.9.4    interviewing such persons as it deems appropriate; and

 

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

 

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

 

                                     3.4.10.1  approve the recommendation forwarded under Section 3.4.5.1., 3.4.5.2, 3.4.6, 3.4.7 or 3.4.14.3 [3.4.15.3];

 

                                     3.4.10.2  recommend a variance to the recommendation under Section 3.4.5.1, 3.4.5.2 or 3.4.7 which is acceptable to the applicant, or recommend a variance to the recommendation under Section 3.4.6 which is acceptable to the signatories to the facilitated mediated resolution;

 

                                     3.4.10.3  reject the recommendation under Section 3.4.6 or suggest a variance that is not acceptable to the signatories of the facilitated mediated resolution; or

 

                                     3.4.10.4  reject the recommendation made under Section 3.4.5.1, 3.4.5.2, 3.4.7 or 3.4.15.3, or suggest a variance that is not acceptable to the applicant; and

 

                      3.4.11     [and] inform the department chief and the applicant of its decision.

[Note: text numbering as in original.]

 

                      3.4.12     If the Credentials Committee makes a decision under Section 3.4.10.1 or 3.4.10.2, the decision shall be forwarded to the MAC within thirty (30) working days of the Credentials Committee’s receipt of the matter.

 

                      3.4.13     If the Credentials Committee makes a decision under Section 3.4.10.3 or 3.4.10.4, the matter shall be referred to the hearing committee, in accordance with Section 8, at the request of the applicant who has fifteen (15) working days from the date of receiving the Credentials Committee’s decision to tell the Credentials Committee they want the matter referred to the hearing committee.

 

                      3.4.14     Where the matter is referred to the MAC in accordance with Section 3.4.12, the MAC shall conduct any inquiries it deems necessary and shall consider:

 

                                     3.4.14.1  the application;

 

                                     3.4.14.2  the recommendation of the Credentials Committee;

 

                                     3.4.14.3  the recommendations forwarded to the Credentials Committee by the CEO, the VP Medicine and Academic Affairs, and the department chief; and

 

                                     3.4.14.4  any information that it gains from its inquiries.

 

                      3.4.15     Upon completion of its review under Section 3.4.14, the MAC shall:

 

                                     3.4.15.1  approve the application as recommended by the Credentials Committee and forward such approval within twenty (20) working days of the referral of the matter to the MAC from the Credentials Committee, to the Board for a final decision;

 

                                     3.4.15.2  recommend a variance acceptable to the applicant and forward such recommendation within twenty (20) working days of receipt of the application from the Credentials Committee, to the Board for a final decision;

 

                                     3.4.15.3  reject the Credentials Committee’s recommendation or recommend a variance that is not acceptable to the applicant within twenty (20) working days of the recommendation being forward to the MAC, in which event the matter shall be referred to the Credentials Committee for review and consideration of the MAC recommendation. Should the Credentials Committee reject the MAC recommendation or the recommendation is not acceptable to the applicant, the matter shall be referred to the hearing committee under 3.4.13 within twenty (20) working days of referral to the Credentials Committee;

 

and shall inform the department chief and the applicant of its decision.

 

                      3.4.16     Where a recommendation is made under Section 3.4.15.1 or 3.4.15.2, the Board shall conduct such inquiries it deems necessary and shall consider:

 

                                     3.4.16.1  the application;

 

                                     3.4.16.2  the recommendation of the Credentials Committee;

 

                                     3.4.16.3  the recommendation of the MAC; and

 

                                     3.4.16.4  any information that it gains from its inquiries.

 

                      3.4.17     Where the Board has considered the matter, the Board shall, within twenty (20) working days of receipt of the recommendation from the MAC make a final determination with respect to the matter and shall immediately notify the CEO of such decision.

 

                      3.4.18     After the CEO has been notified of the Board’s decision, the CEO shall notify the applicant, the MAC, the Credentials Committee, the HA VP Medicine and Academic Affairs and the department chief of such decision.

 

          3.5       Temporary appointments to the medical, dental and affiliated staff

                      3.5.1       Notwithstanding any other provisions in these bylaws, the CEO or designate, or the VP Medicine and Academic Affairs or designate, after gathering such information as they deem appropriate in the circumstances, may grant temporary privileges to an applicant where:

 

                                     3.5.1.1    a member requests a replacement for a short period of time and an application for active medical staff (facility) or (secondary facility) or assistant staff privileges cannot be processed within the time frames associated with the appointment or re-appointment process outlined in Part C of these bylaws, or it is necessary to approve a temporary appointment to the medical, dental and affiliated staff until such time as a permanent appointment to the active medical staff can be recruited and appointed; or

 

                                     3.5.1.2    a medical practitioner or dentist who does not have privileges within the applicable department is required to consult on or treat a particular patient for a specific purpose.

 

                      3.5.2       Temporary privileges granted to a person under Section 3.5.1 must be for a period not to exceed 45 days and may be renewed provided that the person may not be granted temporary privileges for more than a total of 135 days in a calendar year. The VP Medicine and Academic Affairs or CEO may in exceptional circumstances extend the period of temporary privileges to a maximum total of 180 days with written approval of the Board.

 

                      3.5.3       The CEO must report any appointment(s) made under this Section to the Board at the Board meeting following the appointment.

 

                      3.5.4       The granting of a temporary appointment shall be conditional on the applicant providing proof of:

 

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

 

                                     3.4.4.2    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.

 

                      3.5.5       The Credentials Committee shall review and approve any requests for extension of temporary privileges beyond the initial period of forty-five (45) days.

 

                      3.5.6       Temporary privileges may be revoked by the CEO or designate 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 [of] privileges.

 

                      3.5.7       Decisions to grant, refuse or revoke temporary privileges are final decisions and there shall be no right of review or appeal from such decisions.

 

4.       Miscellaneous

          4.1       Automatic suspensions

                      4.1.1       The privileges of a member shall be immediately and automatically suspended by the CEO or designate when:

 

                                     4.1.1.1    a member fails to complete a patient’s record within the rules and regulations and has failed to comply within a ten (10) working day notice period for completion which is provided by the CEO or designate;

 

                                     4.1.1.2    a member has ceased to be a member of the Canadian Medical Protective Association or to carry and have in force equivalent liability protection, and in the case of a dentist, has ceased to carry and have in force such malpractice insurance as required under the regulations under the Dental Act or other malpractice insurance as is deemed appropriate by the Board; or

 

                                     4.1.1.3    a member’s licence has been suspended or revoked by the College of Physicians and Surgeons or in the case of a dentist, their licence has been suspended or revoked by the Provincial Dental Board.

 

          4.2       An automatic suspension under 4.1.1.1 or 4.1.1.2 shall continue until the violation has been corrected, at which time the CEO or designate shall automatically reinstate the member.

 

          4.3       An automatic suspension under 4.1.1.3 shall continue until such time as the license [licence] has been reinstated and the CEO or designate has determined the circumstances of suspension/ revocation pose no concern to continued practice at the HA under the grant of privileges. The CEO or designate may determine a review of the member’s privileges is required under Section 4 or 5.

 

          4.4       Affiliation agreements with Dalhousie University

                      4.4.1       Where a member is subject to an affiliation agreement with Dalhousie University, an appointment to the medical, dental and affiliated staff shall take into account the provisions of such an affiliation agreement.

 

                      4.4.2       Where there is a conflict between these bylaws and an affiliation agreement with Dalhousie University, these bylaws shall prevail.

 

          4.5       Notices

                      4.5.1       All notices in these bylaws shall be deemed duly given to a party:

 

                                     4.5.1.1    upon delivery if delivered by hand;

 

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

 

                                     4.5.1.3    upon two (2) working days after the date of the transmission, if by email or facsimile transmission.

 

          4.6       Delegation by CEO

                      4.6.1       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.

 

          4.7       Transition

                      4.7.1       Applications for appointments or reappointments initiated prior to or after the effective date of these bylaws shall be governed by these bylaws.

 

                      4.7.2       Subject to Section 1.3 of Part A, any matter where a reappointment process, or a special review process or an immediate suspension/variance process has been initiated prior to the implementation of these bylaws shall be completed in accordance with the provisions of these bylaws and any deviation from the process set out in the former bylaws on account of this transition shall not be considered material.

 

5.       Revocation/suspension/variation regarding medical, dental and affiliated staff privileges–complaint

          5.1       The grounds for a complaint under Section 5 may consist of, but are not limited to, issues of unprofessional or unethical conduct, issues of clinical care or competencies, behaviour otherwise contrary to the values, policies and procedures of the IWK or failure to meet the requirements of any of the bylaws or the rules and regulations.

 

          5.2       The CEO or the VP Medicine and Academic Affairs, referred to in this Section as “the person initiating the complaint” may file a complaint in writing to the department chief, with respect to the privileges of any member at any time and shall advise the member concerned within 24 hours of such action and provide the member with a copy of the complaint.

 

          5.3       A department chief may initiate a complaint in writing to the VP Medicine and Academic Affairs with respect to the privileges of any member at any time and shall advise the member concerned within 24 hours of such action and provide the member with a copy of the complaint.

 

          5.4       In filing a complaint, the person initiating the complaint shall indicate, in writing the grounds giving rise to such a complaint and the remedy being sought.

 

          5.5       The department chief or the VP Medicine and Academic Affairs, upon receipt of the complaint, shall make an initial determination as to whether the complaint moves forward to a formal process.

 

          5.6       In the case where the department chief (or the VP Medicine and Academic Affairs, as relevant) finds that the grounds for the complaint are unfounded, the department chief (or the VP of Medical and Academic Affairs as relevant) shall notify the person initiating the complaint, the member, and the MDAS that the complaint is being dismissed.

 

          5.7       In the case where the department chief (or the VP Medicine and Academic Affairs, as relevant) finds:

 

                      5.7.1       that the grounds for the complaint are founded;

 

                      5.7.2       that the matter is appropriate to be dealt with by informal mediation; and

 

                      5.7.3       there is reasonable likelihood of success of coming to an agreement between the parties.

 

the department chief (or the VP Medicine and Academic Affairs, as relevant) shall attempt to resolve the issues through informal mediation as detailed in the IWK’s code of conduct policy.

 

          5.8       Where the parties agree to a recommended course of action as the result of the informal mediation, the department chief shall document the result in the member’s file.

 

          5.9       In the case where the department chief is unable fulfill the requirements of Section 5.7 or where the parties cannot agree to a recommended course of action from the informal mediation, the department chief shall initiate the facilitated mediation process.

 

          5.10     Where the person initiating the complaint is not the CEO, the CEO shall be notified of the complaint by the department chief within 24 hours of initiating the facilitated mediation process.

 

          5.11     If a facilitated mediated resolution is not achieved through the facilitated mediation process, the parties shall proceed immediately to the hearing committee for a hearing to address the grounds of the complaint, in accordance with Section 8.

 

          5.12     If a facilitated mediated resolution is achieved under Section 7, the facilitated mediated resolution shall be forwarded to the MAC.

 

          5.13     Where the MAC agrees with the facilitated mediated resolution, the Chair of the MAC shall forward the facilitated mediated resolution and its recommendation to the Board within five (5) working days of the receipt of the facilitated mediated resolution by the MAC and the Board shall proceed under Section 5.15.

 

          5.14     Where the MAC does not agree with the facilitated mediated resolution, the MAC shall refer the matter to a hearing committee under Section 8.

 

          5.15     The Board shall review the facilitated mediated resolution received under Section 5.13 and shall, within fifteen (15) working days of receipt from the Chair of the MAC:

 

                      5.15.1     approve the facilitated mediated resolution;

 

                      5.15.2     recommend a change to the facilitated mediated resolution that is acceptable to the signatories to the facilitated mediated resolution, and approve such change; or

 

                      5.15.3     reject the facilitated mediated resolution with reasons and refer the matter to a hearing committee under Section 8.

 

          5.16     Upon receipt of the decision from the Board, the CEO shall inform the member, the person initiating the complaint, the appropriate department chief and the MAC of the decision.

 

6.       Immediate action regarding privileges

          6.1       The CEO or designate, or a department chief or designate (referred to in this Section as “the person initiating the immediate action”) may suspend or vary the privileges of any member at any time where the person initiating the immediate action reasonably believes that the member has engaged in conduct which:

 

                      6.1.1       is reasonably likely to expose patients or any other persons to harm or injury at IWK or by services provided through the IWK;

 

                      6.1.2       is reasonably likely to be detrimental to safety or to the delivery of care in the IWK or by services provided through the IWK; or

 

                      6.1.3       is reasonably likely to be detrimental to the member, the patient, or the public.

 

          6.2       If someone other than the CEO immediately suspends or varies a member’s privileges, the CEO must be informed within twenty-four (24) hours of the suspension or variance.

 

          6.3       The person initiating the immediate action shall inform the Chair of the MAC within twenty-four (24) hours of the suspension or variation under Section 6.1.

 

          6.4       When the CEO initiates the immediate action, the CEO shall advise the VP Medicine and Academic Affairs and the department chief of the suspension or variance, and at such time, or when the CEO becomes aware of the initiation of immediate action by the department chief, whichever is the later, the CEO shall, within 48 hours appoint a[n] IWK representative to commence the facilitated mediation process.

 

          6.5       If no facilitated mediated resolution is achieved under the facilitated 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 Section 8.

 

          6.6       If a facilitated mediated resolution is achieved, the facilitated mediated resolution shall be forwarded to the MAC.

 

          6.7       Where the MAC agrees with the facilitated mediation resolution, the Chair of the MAC shall forward the facilitated mediated resolution and its recommendation to the Board within five (5) working days of the review of the facilitated mediated resolution by the MAC.

 

          6.8       Where the MAC does not agree with the facilitated mediation resolution, the MAC shall refer the matter to a hearing committee under Section 8.

 

          6.9       The Board shall review the facilitated mediated resolution received under Section 6.7 and shall within fifteen (15) working days of receipt from the Chair of the MAC:

 

                      6.9.1       approve the facilitated mediated resolution;

 

                      6.9.2       recommended a change to the facilitated mediated resolution that is acceptable to the signatories to the facilitated mediated resolution, and approve such change; or

 

                      6.9.3       reject the facilitated mediated resolution and refer the matter to a hearing committee under Section 8.

 

          6.10     Upon receipt of the decision of the Board, the CEO shall advise the member, the relevant department chief, the relevant division chief, if applicable, and the MAC of the decision.

 

7.       Facilitated mediation process

          7.1       When the facilitated mediation process is engaged, the CEO or designate shall within 48 hours appoint an IWK representative to act for purposes of the facilitated mediation process.

 

          7.2       The parties involved in the facilitated mediation process shall be:

 

                      7.2.1       the member who is the subject of the facilitated mediation process;

 

                      7.2.2       the IWK representative selected by the CEO or designate (who must not be the department chief of the member who is the subject of the facilitated mediation process, and who is not the person named in Section 7.2.4);

 

                      7.2.3       a[n] MDAS member appointed by the MDAS executive; and

 

                      7.2.4       the member’s department chief in the case of a reappointment application; the person initiating a complaint in case of the Section 5; or the person initiating the immediate action in the case of Section 6.

 

          7.3       The IWK representative shall facilitate the facilitated mediation process unless the IWK representative determines that a third party mediator shall be used to facilitate the facilitated mediation process.

 

          7.4       The parties to the facilitated 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 facilitated mediated resolution.

 

          7.5       The signatories to a facilitated mediated resolution are the parties to the facilitated mediation process under Section 7.2, and the CEO.

 

          7.6       The parties to the facilitated mediation process shall either reach a facilitated mediated resolution or determine that it is not possible to reach a facilitated mediated resolution:

 

                      7.6.1       in the case of a facilitated mediation process to consider a reappointment under Section 3.4, within thirty (30) working days from the initiation of the facilitated mediation process;

 

                      7.6.2       in the case of a facilitated mediation process arising from a complaint under Section 5, within thirty (30) working days from the commencement of the facilitated mediation process; and

 

                      7.6.3       in the case of a facilitated mediation process arising from an immediate action regarding privileges under Section 6, within fifteen (15) working days from the commencement of the facilitated mediation process,

 

unless parties to the facilitated mediation process agree in writing to extend these timelines which are not to exceed a further fifteen (15) working days.

 

          7.7       Where a facilitated mediated resolution has been reached, the mediated resolution shall be forwarded by the IWK representative to the relevant committee under these bylaws, and processed in accordance with the relevant Section.

 

          7.8       Where a facilitated mediated resolution has not been reached, the matter shall be processed in accordance with the relevant provisions of these bylaws.

 

          7.9       Where the facilitated mediation process is not successful and a matter is referred to a hearing committee under these bylaws, no reference to discussions held during the facilitated mediation process, or to a proposed facilitated mediated resolutions shall be allowed in evidence before a hearing committee.

 

8.       Hearing process

          8.1       The hearing process is engaged when a matter is referred to a hearing committee.

 

          8.2       The parties to a hearing shall be the member and the IWK representative appointed for the particular hearing.

 

          8.3       In a proceeding before a hearing committee, the IWK 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 IWK representative.

 

          8.4       In holding a hearing, the Chair of the hearing committee shall give written notice of the hearing to the member and the IWK representative, and the notice shall include:

 

                      8.4.1       the place and time of the hearing;

 

                      8.4.2       the purpose and particulars of the hearing; copies of any relevant documents; and

 

                      8.4.3       a copy of these bylaws.

 

          8.5       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:

 

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

 

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

 

                      8.5.3       where an affidavit of service is provided; or

 

                      8.5.4       where evidence satisfactory to the hearing committee is provided that all reasonable efforts to effect service have been exhausted.

 

          8.6       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 Section 8.5, 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 under these bylaws.

 

          8.7       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.

 

          8.8       If an amendment or alteration is made by the hearing committee under Section 8.7, the parties shall be provided sufficient opportunity to prepare an answer to the amendment or alteration.

 

          8.9       A hearing committee may determine rules or procedures for hearings not covered by these bylaws or the rules and regulations.

 

          8.10     In a proceeding before a hearing committee the parties have the right to:

 

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

 

                      8.10.2     receive written reasons for a decision within thirty (30) working days of the completion of evidence and submissions before a hearing committee.

 

          8.11     Evidence is not admissible before a hearing committee unless the opposing party has been given at least ten (10) working days before a hearing:

 

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

 

                      8.11.2     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

 

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

 

          8.12     Notwithstanding Section 8.11, the hearing committee may, at its discretion, allow the introduction of evidence that would be otherwise inadmissible under Section 8.11 and may make directions it considers necessary to ensure that the opposing party has an appropriate opportunity to respond.

 

          8.13     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.

 

          8.14     Any oath or affirmation required under 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.

 

          8.15     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.

 

          8.16     Notwithstanding Section 8.15, the hearing committee shall ensure that hearings are conducted in accordance with the principles of natural justice and procedural fairness.

 

          8.17     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:

 

                      8.17.1     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 HA representative;

 

                      8.17.2     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 HA representative;

 

                      8.17.3     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 HA representative; and

 

                      8.17.4     produce records kept with respect to the member’s practice.

 

          8.18     If a member fails to comply with Section 8.17, the hearing committee may order that the member be suspended until the member complies.

 

          8.19     The costs of complying with the requirements outlined in Section 8.17 shall be borne by the HA.

 

          8.20     Upon completion of the evidence, and upon giving both parties the opportunity to present submissions, the hearing committee shall, within thirty (30) working days, or such later date as the parties may agree (such later date cannot extend beyond an additional thirty (30) working days), issue recommendations to the Board, the member, the CEO and the HA representative in writing with reasons, with respect to the matters raised in the notice of hearing. Such recommended dispositions may include, but are not limited to:

 

                      8.20.1     for purposes of the credentialing process:

 

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

 

                                     8.20.1.2  the imposition of certain conditions or restrictions on the member’s privileges; or

 

                                     8.20.1.3  such other disposition as the hearing committee deems appropriate;

 

                      8.20.2     for disciplinary purposes:

 

                                     8.20.2.1  termination of the member’s appointment and/or privileges;

 

                                     8.20.2.2  suspension of the member’s appointment and/or privileges;

 

                                     8.20.2.3  a variation of the member’s appointment and/or privileges;

 

                                     8.20.2.4  conditions or restrictions on the member;

 

                                     8.20.2.5  a reprimand;

 

                                     8.20.2.6  placement of the member on probation with respect to his/her medical, dental and affiliated staff membership and/or privileges, with such conditions or restrictions as deemed appropriate;

 

                                     8.20.2.7  such other disposition as deemed appropriate; or

 

                                     8.20.2.8  any combination of the above.

 

          8.21     At the time the Chair of the hearing committee provides a copy of the written recommendations to the Chair of the Board, 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 Board.

 

          8.22     The recommendations issued under Section 8.20 shall be provided by the Chair of the hearing committee to the MAC for information, and to the member and the HA representative.

 

          8.23     In the event that the member does not file a notice of appeal under Section 9.1, the Chair of the hearing committee shall forward the committee’s recommendations to the Board and the Board shall review the hearing committee’s recommendations and issue a final determination either:

 

                      8.23.1     accepting the hearing committee’s recommendations;

 

                      8.23.2     rejecting the hearing committee’s recommendations; or

 

                      8.23.3     issuing a variance to the hearing committee’s recommendations.

 

9.       Appeal panel

          9.1       When a hearing committee has rendered recommendations under Section 8.20, the member may appeal the hearing committee’s decision regarding the recommendations to the Board by filing a notice of appeal with the hearing committee and the Board within ten (10) working days of receipt of the hearing committee’s written decision of recommendations.

 

          9.2       The member’s notice of appeal shall state the specific grounds of appeal in accordance with Section 9.3.

 

          9.3       The grounds for an appeal are errors of law.

 

          9.4       Where a notice of appeal to the Board has been filed under Section 9.1, the member must include a copy of the transcript of the proceedings before the hearing committee and a copy of all exhibits introduced at the hearing.

 

          9.5       Upon receipt of the notice of appeal, the Chair of the Board shall create an appeal panel in accordance with Section 2.

 

          9.6       An appeal panel will only consider written submissions and not oral submissions by the parties.

 

          9.7       Upon receipt of a notice of appeal, the Chair of the appeal panel shall meet with the parties within ten (10) working days and set a deadline for written submissions by the parties regarding the grounds of appeal and the remedy sought.

 

          9.8       An appeal panel may determine rules or procedures for the conduct of the appeal panel not covered by these bylaws.

 

          9.9       No new evidence is admissible before the appeal panel unless the appeal panel directs otherwise.

 

          9.10     An appeal panel shall within thirty (30) working days of the receipt of the written submissions before it issue a decision in writing, with reasons, and shall provide a copy of the decision to the parties, the Board, the CEO, and the College of Physicians and Surgeons or the Provincial Dental Board, as relevant.

 

          9.11     An appeal panel may impose any disposition available to the hearing committee under Section 8.20.

 

          9.12     The decision of an appeal panel shall be the final decision concerning the member’s appointment and privileges.



Appendix 1– Definitions

 

1.       Act means the Health Authorities Act, SNS [S.N.S.] 2014, c. 32;

 

2.       affiliation agreements mean Board-authorized written agreements describing the relationship between the Izaak Walton Killam Health Centre with academic institutions;

 

3.       appeal panel means an appeal panel of the Board established in Section 2 of Part C of these bylaws;

 

4.       Board means the board of directors of the IWK Health Centre;

 

5.       CEO means the person appointed by the Board to be the President and Chief Executive Officer of the IWK Health Centre;

 

6.       Credentials Committee means a committee of the MAC for the IWK as further defined in Part B, Section 5.7.

 

7.       dentist means a person who, under the Dental Act, is registered in the Dentist’s register and holds a licence to practise dentistry;

 

8.       department means a clinical organizational unit established under Part B Section 9 [6] consisting of members with related fields of practice;

 

9.       department chief means a person appointed to that role by the Vice-president of Medicine and Academic Affairs to lead the medical department and who is accountable to the Vice-president of Medicine and Academic Affairs;

 

10.     division means a subsection or portion of a department;

 

11.     division chief means a person recommended for that role by the department chief and approved by the Vice-president of Medicine and Academic Affairs to be the senior medical administrator of a division, and who is accountable to the department chief;

 

12.     ex officio means membership by virtue of the office and does not include all rights, responsibilities, or the power to vote unless otherwise indicated;

 

13.     facilitated mediation process means the mediation process as outlined in Section 6 [7] of Part C;

 

14.     facilitated mediated resolution means an agreement entered into by the parties to a facilitated mediation process;

 

15.     former bylaws means the bylaws in effect at or for the IWK Health Centre which existed until December 31, 2015 and under the Health Authorities Act, S.N.S. 2000, c. 6;

 

16.     HA means a health authority established under the Act and includes the IWK Health Centre;

 

17.     health authority representative means the CEO or a person appointed by the CEO to act as the representative of the health authority for purposes of a facilitated mediation process or a hearing process;

 

18.     hearing committee means the committee of the MAC acting as the hearing committee;

 

19.     hearing process means the hearing process as outlined in Section 8, Part C;

 

20.     investigation means an examination of materials and documentation provided by the parties and does not include the holding of a hearing;

 

21.     MAC means the Medical Advisory Committee for the IWK as defined in Section 5 of Part B of these bylaws;

 

22.     MDAS means the Medical, Dental and Affiliated Staff Association for a [Organization] as defined in Part B Section 8;

 

23.     medical practitioner means a person who holds a licence issued under the Medical Act or the regulations entitling such person to engage in the practice of medicine in Nova Scotia;

 

24.     medical, dental and affiliated staff means those medical practitioners, dentists, and any other class of health professionals not employed by a health authority that are prescribed by the regulations to the Act to constitute the medical, dental and affiliated staff, who have privileges granted by the Board;

 

25.     member means a member of the medical, dental and affiliated staff;

 

26.     party means: the HA and its representatives, or the member;

 

27.     patient means any person who receives care or services under the authority of the IWK and includes but is not limited to patients, clients and residents receiving care in the place designated as their home;

 

28.     policy means such guidance and directives approved by the IWK respecting the operation of health care facilities, services or programs within the health authority;

 

29.     rules and regulations mean the rules and regulations established pursuant to Part B Section 13 of these bylaws;

 

30.     university means Dalhousie University or any other educational institution that has an affiliation agreement with a health authority;

 

31.     university department chief means a person who is appointed by Dalhousie University to be the senior medical or dental education and research administrator in the university faculties of medicine or dentistry, and with the approval of the Board has designated clinical education responsibilities under an affiliation agreement at one or more of a[n] HA’s care facilities, services or programs;

 

32.     VP Medicine and Academic Affairs means the IWK’s Vice-president Medicine and Academic Affairs as defined in Part B Section 3.0 of these bylaws;

 

33.     working day means those working days of the week excluding weekends and statutory holidays.