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Nova Scotia Health Authority Medical Staff Bylaws

made under Section 21 of the

Health Authorities Act

S.N.S. 2014, c. 32

(April 1, 2015), N.S. Reg. 187/2015 (Part A), 188/2015 (Part B) and 189/2015 (Part C)

 

Table of Contents

Text of Bylaws


Part A

      1       Title

      1A    Transition

      2       Definitions

      3       Purpose and application

      4       Amendment

      5       Application to Part B

Part B

      1       Organizational structure

      2       Medical staff categories

      3       HA Vice-president of Medicine and Integrated Health Services (HA VP Medicine)

      4       Zone Medical Executive Director(s)

      5       Medical site lead(s)

      6       Zone Department Heads and [Zone] Division Heads (as applicable)

      7       The HA-MAC

      8       ZMAC(s)

      9       Departmental organization

      10     Provincial programs of care

      11     ZMSA(s)

      12     Leave of absence

      13     Continuing professional review and development

      14     Ethics and ethical relationships

      15     Affiliation agreements

      16     Rules & [and] regulations

Part C

      1       HA-MAC hearing pool and HA-MAC hearing committee

      2       Composition of Board appeal panel

      3       Appointments & privileges–general

      4       Miscellaneous

      5       Revocation/suspension/variation regarding medical staff privileges–complaint

      6       Immediate action regarding privileges

      7       Facilitated mediation process

      8       Hearing process

      9       Appeal panel

Appendix 1–Definitions


Part A

 

1    Title

 

      1.1        These are the Nova Scotia Health Authority Medical Staff By-laws.

 

1A Transition

 

      1A.1     These by-laws become effective when recommended by the Board and approved by the Minister of Health.

 

                   1A.1.1  “Former by-laws” means the by-laws in effect at or for the nine district health authorities which existed until March 31, 2015, and under the Health Authorities Act, S.N.S. 2000, c. 6.

 

                   1A.1.2  Where there is an inconsistency between the former by-laws and these by-laws, these by-laws shall prevail.

 

                   1A.1.3  Medical staff who, as of the effective date of these by-laws, hold medical staff privileges under the former by-laws will be advised in writing by the Office of the VP Medicine of the category and location of their privileges under these by-laws and of the mechanism through which any errors of assignment may be brought to the attention of the VP Medicine for resolution.

 

                   1A.1.4  Medical practitioners who, as of the effective date of these by-laws, are practicing [practising] medicine in this Province and who do not hold privileges under the former by-laws but require privileges under Part B, Section 1.2 of these by-laws shall be granted active without admitting medical staff (community) privileges as long as they continually hold and show evidence, on an annual basis, of a license [licence] in good standing with the College of Physicians and Surgeons of Nova Scotia and show evidence in writing of membership in the Canadian Medical Protective Association or in the discretion of the VP Medicine evidence of equivalent medical malpractice liability protection.

 

                   1A.1.5  Subject to compliance with the requirements of the Sections 3.2.4.1, 3.2.4.2 and 3.2.4.4 of Part C of these by-laws, members of the active without admitting medical staff (community) and such other medical staff members who, in the discretion of the VP Medicine, practice [practise] primarily in the community will not become subject to Section 13 of Part B of these by-laws for the first year following their effective date and this one-year period may, on the initiative of the VP Medicine, be further extended for a maximum of one further year.

 

                   1A.1.6  Unless specifically determined to the contrary in the HA by-laws, rules, regulations or policies, the authority to admit and discharge patients from the HA’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 HA’s rules, regulations, or policies. For clarity, nothing in these by-laws 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 HA policy, rules or regulations.

 

                   1A.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, if done in compliance with HA policy, rules or regulations outlining the conditions under which such authorization can occur.

 

2    Definitions

 

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

 

3    Purpose and application

 

      3.1        The by-laws are developed and enacted in order to:

 

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

 

                              define the rules governing the medical 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;

 

                              establish clinical criteria and standards to oversee and manage quality assurance, utilization review, performance evaluation and other medical staff activities; and

 

                              address processes through which issues respecting the medical staff relationship with the with the NSHA may be considered and resolved.

 

      3.2        These by-laws apply to all health care facilities, services, resources and programs in the NSHA.

 

      3.3        Any medical practitioner or dentist whose relationship with the health authority is established solely through granting of privileges shall be subject to these by-laws,

 

                   3.3.1     NSHA may enter into contracts for services with persons who are subject to these by-laws including but not limited to, medical practitioners, dentists or members of the affiliated staff.

 

                   3.3.2     Any person who is subject to these by-laws and has a relationship with the Board established by means of a contract or a contract and privileges, whereby the person is provided compensation for services, either as an independent contractor or as an employee, must 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:

 

                                 3.3.2.1     clinical associates, clinical trainees, residents, and members of the affiliated staff are not members of the medical staff and must 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 must not be entitled to access the provisions in the Part C of these by-laws;

 

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

 

                                 3.3.2.3     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 must not be interpreted as being a contract for purposes of this Section.

 

4    Amendment

 

      4.1        Amendments to these by-laws, 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 HA-MAC.

 

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

 

5    Application to Part B

 

      5.1        Part A of these by-laws applies to Part B of these by-laws once Part B is made by the Board and approved the Minister of Health and Wellness under subsection 22(1) of the Health Authorities Act, 2014.


Part B

 

1    Organizational structure

 

      1.1        The medical staff shall be organized as provided in these by-laws.

 

      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 NSHA or the IWK unless such medical practitioner, dentist or health professional holds an appointment to the medical staff of that Health Authority which includes the privileges to do so, or has been otherwise authorized by the Board to do so. For clarity, appointment to the medical staff of any of the health care facilities, departments or services of any one HA 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 staff which has been materially amended or deleted by the Board, the Board may assign that member to another category of the medical staff appropriate for the qualifications of the individual and the Board must inform the member of such reassignment.

 

2    Medical staff categories

 

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

 

      2.2        The medical staff of the NSHA shall consist of the categories of members listed below:

 

probationary

active with admitting

active without admitting (facility)

active without admitting (community)

locum tenens–absence

locum tenens–temporary

assistant staff

                   affiliated staff 

temporary–time limited

temporary–visiting

 

      2.3        Documentation granting medical staff appointments to the NSHA must stipulate the zone, health care facility, program or service which shall serve as the primary site for the member’s privileges and also outline any other services, 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 at any one health care facility, service or program at the same time. Where the Board grants privileges to a member at more than one health care facility, service, or program in one or more zones, 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 staff must be further defined by the Board decision which grants the privileges and are subject to the provisions of these by-laws, the rules & [and] regulations and the NSHA’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 staff privileges as outlined in these by-laws may, in the Board’s discretion, be clarified in the NSHA’s rules, regulations and policies, all as they may be amended from time to time

 

      2.6        Members must abide by these medical staff by-laws, the rules & [and] regulations and policies and procedures of the NSHA, all as they are amended from time to time.

 

      2.7        Probationary

 

                   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 with or without admitting (facility) privileges or assistant privileges who are granted such privileges on or after the effective date of these by-laws, must complete a period of probationary privileges as outlined in these by-laws. Persons fulfilling such probationary period shall constitute the NSHA’s probationary medical staff.

 

                   2.7.2     The Board may, in its discretion, exempt applicants for active with or without admitting (facility) medical staff privileges or assistant medical staff privileges from the requirement to complete a period of probationary membership, in exceptional circumstances where both the VP Medicine and the President & CEO request such an exemption and where the Board decides that the quality of care, patient and staff safety and fulfilment of the NSHA’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 probationary privileges is for a period of no less than one year and that during the term of the probationary privileges, one formal evaluation of the member’s clinical competence and compliance with NSHA’s mission, vision, values, policies and procedures, by-laws and rules and regulations, must be conducted pursuant to Section 13.3 of Part B of these by-laws by the relevant Zone Department Head within the first 6- to 8-month period following the grant of probationary medical staff membership and submitted to the HA-Credentials Committee and the VP Medicine. The HA Credentials Committee, with input from the VP Medicine, may then recommend appointment to the active with admitting or active without admitting or assistant medical staff categories to the HA-MAC or may recommend a further period of probationary membership of up to one year.

 

                   2.7.4     Members of the probationary medical staff, shall, unless otherwise provided by the Board, have all the rights, privileges and responsibilities associated with the medical staff category for which they have applied but are not eligible to be a member of or chair any ZMAC or the HA-MAC including but not limited to any ZMAC or HA-MAC committee;

 

      2.8        Active with admitting medical staff and active without admitting medical staff (facility)

 

                   2.8.1     The active with admitting medical 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 probationary 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 zones, facilities, programs or services of the NSHA, have committed to the terms and conditions of the appointment including but not limited to the commitment to participate fully in achieving the NSHA’s mission, vision, values and strategic priorities and to comply with the terms and conditions of these by-laws, the rules and regulations and the NSHA’s policies and procedures.

 

                                 2.8.1.2     The active without admitting (facility) medical 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 probationary 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 zones, facilities, programs or services of the NSHA, who have privileges to treat but not admit patients to the NSHA’s facilities and have committed to the terms and conditions of the appointment including but not limited to the commitment to participate fully in achieving the NSHA’s mission, vision, values and strategic priorities and to comply with the terms and conditions of these by-laws, the rules and regulations and the NSHA’s policies and procedures.


                   2.8.2     Active with admitting members:

 

                                 2.8.2.1     May admit and treat patients as provided for and within the limits approved by the Board and as specifically interpreted by the Zone Department Head and communicated to the member.

 

                   2.8.3     Active with admitting and active without admitting (facility) medical staff:

 

                                 2.8.3.1     must participate equitably in the on-call requirements of their division/department, program or service as set by their Zone Department Head unless in exceptional circumstances where they are exempted from doing so based on their Zone Department Head’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 NSHA and be entitled to vote at the ZMSA 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] Zone Department Head, the Zone Division Head or the VP Medicine or their designate may request in their discretion reasonably exercised;

 

                                 2.8.3.4     must participate in educational and clinical activities of the department members; the medical staff, other NSHA personnel, medical learners and clinical trainees in the discretion of their Zone Department Head, reasonably exercised;

 

                                 2.8.3.5     must supervise members of the probationary staff as requested by their Zone Department Head;

 

                                 2.8.3.6     must maintain a satisfactory, in the discretion of their Zone Department Head, 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 Zone Department Head or if holding an university appointment as may be directed by the applicable university department head;

 

                                 2.8.3.8     must perform such other duties as the their Zone Department Head, the VP Medicine or their Zone Division Head may, in their discretion reasonably exercised, assign to them from time to time and as may be required by these by-laws, the rules and regulations and by NSHA policies and procedures; and

 

                                 2.8.3.9     The patient service responsibilities of each active with admitting privileges and active without admitting privileges (facility) medical staff members shall be under the supervision of the Zone Department Head, and any applicable university-based academic activities of active with admitting privileges and active without admitting privileges (facility) medical staff 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 privileges medical 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, zones and geographic location of the NSHA , who access the services provided through the NSHA but who do not have privileges to treat in or admit patients to the NSHA’s 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 NSHA’s mission, vision, values and strategic priorities and to comply with the terms and conditions of these by-laws, the rules and regulations and the NSHA’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 Zone Department Head and communicated to the member;

 

                                 2.9.2.2     may, on request of the applicable Zone Department Head, 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 NSHA and be entitled to vote at the ZMSA 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 head, the VP Medicine or designate, or the Zone Department Head may request;

 

                                 2.9.2.4     may participate in educational and clinical activities of the department; the medical staff, other NSHA personnel, medical learners and clinical trainees as determined by their Zone Department Head;

 

                                 2.9.2.5     must maintain a satisfactory, in the Zone Department Head’s discretion reasonably exercised, standard of professional medical, dental or oral and maxillofacial surgery 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 Zone Department Head 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 Zone Department Head; Zone Division Head or the HA-VP Medicine may request from time to time, in their discretion reasonably exercised and as may be required by these by-laws, the rules and regulations and by HA policies and procedures.

 

                   2.9.3     The patient service responsibilities of each active without admitting privileges (community) staff members shall be under the supervision of the Zone Department Head, and any applicable university led academic activities of active without admitting 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 staff who are assigned by the VP Medicine, a Zone [Medical] Executive Medical Director or a Zone Department Head 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 medical 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   A medical practitioner’s or dentist’s appointment 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 by-laws.

 

                   2.10.3   A medical practitioner or dentist appointed under Section 2.10.1.1 must be zone-based and may be NSHA-based but in such instances a primary zone base for privileges will be defined in the locum tenens’ letter of appointment and the locum tenens must have overall accountability for performance under these by-laws to the department head for that zone. Clinical accountability for services provided in any zone, other than the primary zone base for privileges must be to the applicable department head for the zone where services are provided.

 

                   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 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 medical staff with or without admitting privileges or the assistant medical staff and shall be subject to the same processes for professional development and ongoing oversight as the members of the active with or without admitting privileges or assistant medical 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 Zone Department Head for the locum tenens’ primary zone and as approved by the Board unless such actions are specifically restricted by the department head where patient care services are being provided;

 

                                 2.10.6.2   may teach students and conduct research as directed by the university department head and approved by the Zone Department Head for the locum tenens’ primary zone; 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 Zone Department Head.

 

                   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 Zone Department Head for the locum tenens’ primary zone and any university academic activities of each locum tenens staff member shall be under the supervision of any applicable university department head as approved by their Zone Department Head.

 

                   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 ZMAC or HA-MAC or on the ZMSA.

 

      2.11      Assistant staff

 

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

 

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

 

                   2.11.3   Each member of the assistant medical 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 [2.11.3.2]attend any meetings of the medical staff as may be mandated by the NSHA’s rules and regulations and policies and procedures; and

 

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

 

                   2.11.4   Members of the assistant medical staff may be a member of any committee of the medical 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 staff for the HA; and

 

                                 2.12.1.3   perform clinical functions and/or research functions in collaboration with NSHA 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 by-laws.

 

                   2.12.3   Affiliated medical 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 NSHA employment or other applicable agreements, NSHA policies and procedures and the standards associated with their profession in carrying out those duties and functions;

 

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

 

                                 2.12.3.4   may attend but not vote at ZMSA meetings or hold office in the in ZMSA;

 

                                 2.12.3.5   may attend but not vote at zone department or zone division meetings or at the ZMAC or HA-MAC unless they are appointed to the role of division or department heads.

 

                   2.12.4   If the education and experience of affiliated staff as defined in Section 2.12.1 meet the requirements of the position profile or description for the role, affiliated staff may apply for and may be appointed to and serve in zone division or zone department head roles.

 

      2.13      Temporary privileges

 

                   2.13.1   Under and subject to Section 2.5 [3.5] of Part C of these by-laws a CEO or the Zone Medical Executive Director or the HA VP Medicine, grant temporary privileges to a medical practitioner or dentist. [sic]

 

                   2.13.2   Temporary medical staff:

 

                                 2.13.2.1   may admit and treat patients as recommended by the Zone Department Head;

 

                                 2.13.2.2   may teach students and conduct research as directed and approved by the university department head and approved by the Zone Department Head as applicable; and

 

                                 2.13.2.3   temporary medical staff may attend ZMSA meetings, but are not required to do so.

 

                   2.13.3   Temporary medical staff must, unless specifically exempted from doing so by the applicable Zone Department Head, participate in the on-call services of the NSHA as directed by the Zone Department Head.

 

      2.14      Residents

 

                   2.14.1   Medical/dental students/residents shall not be members of the HA medical staff or of the ZMSA.

 

                   2.14.2   Medical/dental students and residents must be assigned to an appropriate zone department as defined in the rules and regulations and this zone will be their primary site however residents may under Section 2.14.4 and subject to the approval of the Zone Medical Executive Director and the program director undertake some of their clinical education in another zone.

 

                   2.14.3   Medical/dental students and residents 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 NSHA’s rules and regulations and in the NSHA 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 and resident must be accountable to the appropriate Zone Department Head or Zone Division Head 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 NSHA. 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 Zone Department Head.

 

                   2.14.5   The nature, extent and number of responsibilities, including patient care responsibilities, assigned to a medical/dental student or resident at any given time must be commensurate with any applicable requirements in the NSHA’s rules and regulations, Zone Division [Head]/[Zone] Department Head decisions as to such responsibilities and the medical/dental student’s or resident’s demonstrated level of skill.

 

3    HA Vice-president of Medicine and Integrated Health Services (HA VP Medicine)

 

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

 

      3.2        Where the HA VP Medicine is absent or for any reason is unable to perform his or her duties, the CEO shall appoint an acting HA VP Medicine.

 

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

 

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

 

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

 

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

 

                   3.3.4     with other HA(s) 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 that the quality of services offered by all members of the medical staff; and compliance with these by-laws, the rules and regulation[s] and the HA policies and procedures; is evaluated on a regular basis and that any required corrective actions are taken;

 

                   3.3.6     monitoring of the medical staff practices to ensure compliance with these by-laws, the rules & [and] regulations and policies established by the ZMAC and the HA;

 

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

 

                   3.3.8     monitoring the performance and effectiveness of the Zone Medical Executive Director(s) and through Zone Medical Executive Directors ensuring that the performance and effectiveness of Zone Medical Department [Heads]/[Zone] Division Heads and medical site leads is monitored and acted upon as required;

 

                   3.3.9     participating on pertinent medical, administrative and Board committees including but not limited to chairing the HA-MAC; and

 

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

 

      3.4        The HA VP Medicine may delegate any of his/her day-to-day medical staff oversight responsibilities to the applicable Zone Medical Executive Director.

 

4    Zone Medical Executive Director(s)

 

      4.1        A Zone Medical Executive Director(s) shall be appointed to each of the four HA zones by the CEO on the recommendation of the HA VP Medicine and shall be accountable to the HA VP Medicine for any medical staff practice-related matters arising from the operation of the NSHA within the applicable management zone and for those roles and responsibilities which are outlined in the position description for the zone medical executive director(s).

 

      4.2        Where a Zone Medical Executive Director is absent or for any reason is unable to perform his or her duties, the CEO shall, in consultation with the HA-VP Medicine appoint an acting zone medical executive director.

 

      4.3        Zone Medical Executive Directors are responsible for the effective functioning of the medical staff within their applicable zone and for the implementation of policies established by the Board for medical staff affairs in that zone and without limiting that generality, these duties include:

 

                   4.3.1     with other Zone Medical Executive Directors, advising the HA VP Medicine on and participating in the development and implementation of strategic plans for the Nova Scotia health system including but not necessarily limited to strategic plans for the NSHA within their management zone;

 

                   4.3.2     co-leading with their zone’s executive operations director;

 

                   4.3.3     participating on pertinent medical, administrative and Board committees including but not limited to chairing the ZMAC;

 

                   4.3.4     addressing zone operational issues that require medical staff input;

 

                   4.3.5     leading the collaboration and cooperation between zones which is required for effective, quality and safe patient care;

 

                   4.3.6     coordinating medical and dental learner placement within the zone and educational experience residents pursuant to the needs identified and agreements reached with the university;

 

                   4.3.7     coordinating and overseeing, with the zone executive operations director and Zone Department Heads, the implementation of initiatives related to programs of care at the NSHA level and the provision of medical services within the applicable zone;

 

                   4.3.8     working in conjunction with Zone Department Heads, the HA VP Medicine and medical site leads for the recruitment and retention of medical staff required to provide medical services within the applicable zone;

 

                   4.3.9     overseeing the development of appropriate measures to ensure that: the quality of services offered by all members of the medical staff in the applicable zone; and compliance with these by-laws, the rules and regulation[s] and the NSHA policies and procedures; is evaluated on a regular basis and that any required corrective actions are taken;

 

                   4.3.10   ensuring mechanisms are in place to monitor and encourage zone-based medical staff involvement in continuing education;

 

                   4.3.11   monitoring the performance and effectiveness of the site medical leads and Zone Department Heads and acting on issues identified as may be required;

 

                   4.3.12   leading, promoting and ensuring medical staff engagement in quality improvement and in the development and implementation of strategic priorities/plans; and

 

                   4.3.13   carrying out such administrative functions as assigned by the HA VP Medicine.

 

      4.4        The Zone Medical Executive Director may delegate any of his/her day-to-day medical staff oversight responsibilities to the Zone Department Head or the medical site lead.

 

      4.5        Subject to any action as may be taken pursuant to the applicable terms of appointment and any contractual arrangement with a Zone Medical Executive Director, a Zone Medical Executive Director’s appointment will normally be for a period of 5 years with a possible re-appointment for an additional 5-year appointment.

 

5    Medical site lead(s)

 

      5.1        A medical site lead shall be appointed by the HA VP Medicine, following consultation with the Zone Medical Executive Director, and shall be accountable to the Zone Medical Executive Director for any medical staff practice-related matters arising from the operation of the NSHA within the applicable management zone and for those roles and responsibilities which are outlined in the position description for a medical site lead.

 

      5.2        Where a Medical Site Lead is absent or for any reason is unable to perform his or her duties, the HA VP Medicine in consultation with the Zone Medical Executive Director shall appoint an acting medical site lead.

 

      5.3        A medical site lead:

 

                   5.3.1     acts as the Zone Medical Executive Director’s delegate at the applicable site with regard to the obligations outlined in Section 4.3 of these by-laws;

 

                   5.3.2     is responsible, with his/her administrative co-lead, for ensuring the Zone Medical Executive Director is aware of the perspectives of medical staff at the applicable site and for bringing information relevant to the site level forward for consideration during the development and implementation of strategic priorities/plans; and

 

                   5.3.3     participates in the development of and oversee[s], with his/her administrative co-lead, the implementation of the NSHA’s strategic priorities/plan at the applicable site level.

 

      5.4        Subject to any action as may be taken pursuant to the applicable terms of appointment and any contractual arrangement with a medical site lead, a medical site lead’s appointment will normally be for a period of 5 years with a possible re-appointment for an additional 5-year appointment.

 

6    Zone Department Heads and [Zone] Division Heads (as applicable)

 

      6.1        Zone Department Heads must be members of the active medical staff and members of the departments concerned and must be appointed by the HA VP Medicine following consultation with the Zone Medical Executive Director and accountable to the applicable Zone Medical Executive Director for any medical staff practice-related matters arising from the operation of the NSHA within the applicable zone department and for those roles and responsibilities which are outlined in the position description for the Zone Department Head. Zone Department Heads shall ordinarily be required to have an academic appointment with the university unless specifically exempted from this requirement by the Board.

 

      6.2        Zone Division Heads must be members of the active staff and members of the departments/divisions concerned and are appointed by the HA VP Medicine following consultation with the Zone Medical Executive Director and the applicable Zone Department Head and accountable to the applicable Zone Department Head for any medical staff practice-related matters arising from the operation of the HA within the applicable zone department and for those roles and responsibilities which are outlined in the position description for the Zone Division Head. Zone Division Heads shall ordinarily be required to have an academic appointment with the university unless specifically exempted from this requirement by the Board.

 

      6.3        Subject to any action as may be taken pursuant to the applicable terms of appointment and any contractual arrangement with a Zone Department [Head] or [Zone] Division Head, zone department and division head appointments will normally be for a period of 5 years with a possible re-appointment for an additional 5-year appointment.

 

      6.4        Zone Department Heads and to the extent applicable Zone Division Heads must act as both the clinical and academic heads for their zone departments/divisions and in some instances the Zone Department Head may also be appointed by the university as the university department head.

 

      6.5        The Zone Medical Executive Director in consultation with the HA VP Medicine and the Zone Department Head may appoint an Assistant Zone Department Head:

 

                   6.5.1     Subject to any action as may be taken pursuant to the applicable terms of appointment and any contractual arrangement with an Assistant Zone Department Head or Division Head, an assistant zone department and division head appointment will normally be for a period of 5 years with a possible re-appointment for an additional 5-year appointment.

 

                   6.5.2     In addition to any duties prescribed by the Zone Department Head, the Assistant Zone Department Head must perform the functions of the Zone Department Head in the head’s absence.

 

      6.6        Duties and responsibilities of a Zone Department Head and [Zone] Division Head

 

                   6.6.1     A Zone Department Head must fulfill all obligations which are included in the Zone Department Head’s role description forming part of the contract with the Zone Department Head and must without limiting the foregoing:

 

                                 6.6.1.1     be accountable to the Zone Medical Executive Director and the HA VP Medicine and to the extent applicable to the Integrated Vice President of Research & Innovation as appropriate;

 

                                 6.6.1.2     have the authority and responsibility for the clinical care of patients within the zone department;

 

                                                 6.6.1.2.1    in the unlikely event of any conflict which cannot otherwise be effectively resolved, medical care issues must have priority over teaching and research;

 

                                 6.6.1.3     be responsible for the medical administration and functioning of the zone department;

 

                                                 6.4.1.3.1    be accountable to work with appropriate representation of the geographic location of the health care facilities;

 

                                 6.6.1.4     be a member of the applicable ZMAC and as such:

 

                                                 6.6.1.4.1    advise the ZMAC on the quality of care and treatment provided to the zone department’s patients;

 

                                                 6.6.1.4.2    advise the ZMAC on the fulfillment of teaching and research responsibilities within the zone department;

 

                                                 6.6.1.4.3    participate in the development of and report on and oversee the zone department’s objectives, planning, budgeting, resource allocation and utilization;

 

                                                 6.6.1.4.4    make recommendations regarding medical manpower needs of the zone department, following consultation with the Zone Medical Executive Director, the HA VP Medicine, the medical site lead(s) and where applicable, Zone Division Heads;

 

                                 6.6.1.5     be responsible for the organization and implementation of clinical and academic activities and work with the university department head when the Zone Department Head and university department head are not the same person for the academic review within the department;

 

                                 6.6.1.6     implement the NSHA’s process for continuing professional development and evaluation related to the zone department;

 

                                 6.6.1.7     ensure the development and where applicable implement the HA’s programs to maintain and enforce professional standards in the zone department;

 

                                 6.6.1.8     at least annually review the performance of members of the zone department for the purpose of making recommendation for reappointments or contract renewal (in alignment with Section 13.3);

 

                                 6.6.1.9     hold regular meetings with members of the zone department, any Zone Division Heads within the department, and medical site leaders and ensure consultation on and compliance with current HA and departmental objectives, policies and rules and regulations;

 

                                 6.6.1.10   delegate appropriate responsibility to the Zone Division Heads, where they exist within the zone department;

 

      6.7.       The Zone Division Head must fulfill all obligations which are included in the Zone Department Head’s position description forming part of the contract with the Zone Department Head and must:

 

                   6.7.1     be responsible to the Zone Department Head for:

 

                                 6.7.1.1     the clinical care of patients in the zone division;

 

                                 6.7.1.2     the medical administration and functioning of the zone division;

 

                   6.7.2     establish a process of continuing professional development or implement any applicable HA process related to the zone division;

 

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

 

                   6.7.4     review the performance of members of the zone division for the purpose of making recommendation for reappointment or contract renewal;

 

                   6.7.5     hold regular meetings of the zone division and advise members regarding current HA and zone department/division policies, rules and regulations;

 

                   6.7.6     submit minutes of regular zone division meetings to the Zone Department Head; and

 

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

 

7    The HA-MAC

 

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

 

      7.2        The HA-MAC must consist of the following:

 

                   7.2.1     HA VP Medicine who must act as chair;

 

                   7.2.2     any other members, as may be outlined in the rules and regulations, reflecting representation of the leadership of the ZMACs as determined by the CEO after consultation with the HA VP Medicine;

 

                   7.2.3     the Zone Medical Executive Directors; and

 

                   7.2.4     the CEO ex officio and other non-voting representatives from [the] NSHA executive leadership team.

 

      7.3        The Chair of the HA-MAC shall be accountable to the Board through the President & CEO;

 

      7.4        The HA-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.

 

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

 

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

 

      7.7        HA-MAC must:

 

                   7.7.1     be responsible, through ZMAC(s), for oversight of the ethical conduct and professional practice of the members of the zone medical staff;

 

                   7.7.2     be responsible, through ZMAC(s) for the supervision, quality, organization and delivery of all services provided by the Medical Staff including patient care, teaching and research;

 

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

 

                   7.7.4     make recommendations to NSHA’s Board concerning appointments, reappointments, discipline, and privileges of the medical staff;

 

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

 

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

 

                   7.7.7     advise the Board of such committees as it considers necessary for the proper governance of the HA-MAC and must set their terms of reference and appoint the members and chairs of such committees including but not limited to the Zone Credentials Committee as defined in Section 7.8 below.

 

      7.8        Zone Credentials Committee

 

                   7.8.1     There shall be a Zone Credentials Committee formed for each of the four zones.

 

                   7.8.2     The Zone Credentials Committees are committees of the HA-MAC and consists of the following persons appointed by the HA-MAC on the recommendation of the applicable ZMAC:

 

                                 7.8.2.1     the Zone Medical Executive Director who will serve as chair (or his/her delegate); and

 

                                 7.8.2.2     four other members appointed by the HA-MAC from the medical staff applicable to the relevant zone and who broadly represent the geographic and medical staff specialty-based demographics of the zone.

 

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

 

                   7.8.4     Each Zone Credentials Committee shall:

 

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

 

                                 7.8.4.2     review mediated resolutions arising out of the mediation processes outlined in Part C of these by-laws and where required pursuant to these by-laws; and

 

                                 7.8.4.3     perform such other functions as set out in these by-laws or in the rules and regulations.

 

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

 

                   7.8.6     The HA-MAC retains the authority at any time to appoint new or replace members of the Zone Credentials Committee where no quorum is available, where a conflict of interest may exist, or for any other reason where a member of the Zone Credentials Committee is not available to act.

 

8    ZMAC(s)

 

      8.1        There must be a ZMAC for each zone of the HA.

 

      8.2        ZMAC(s) are committees of the HA-MAC established to advise HA-MACs on matters concerning the provision of quality patient care, teaching and research within the management zone as prescribed by the mandate of [the] HA.

 

      8.3        The ZMAC(s) must consist of the following:

 

                   8.3.1     the Zone Medical Executive Director who must act as chair;

 

                   8.3.2     any other members, as may be outlined in the rules and regulations, reflecting representation of the leadership of the zone departments and programs of care as determined by the HA VP Medicine after consultation with the Zone Medical Executive Director and the Zone Executive Director and as documented in the rules and regulations;

 

                   8.3.3     the applicable medical site leads for the applicable zone;

 

                   8.3.4     a designated representative of the ZMSA;

 

                   8.3.5     the Zone Executive Operations Director(s); and

 

                   8.3.6     the HA VP Medicine ex officio and other non-voting representatives from the zone clinical directors/managers as may be provided for in the rules and regulations.

 

      8.4        The chair of the ZMAC is accountable to the HA-MAC through the HA VP Medicine.

 

      8.5        The ZMAC 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.

 

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

 

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

 

      8.8        ZMAC must:

 

                   8.8.1     be responsible through the Zone Department [Heads]/[Zone] Division Heads and the medical site leads for oversight of the ethical conduct and professional practice of the members of the zone medical staff;

 

                   8.8.2     be responsible, through the Zone Department [Heads]/[Zone] Division Heads and the medical site leads for the supervision, quality, organization and delivery of all services provided by the medical staff including patient care, teaching and research for the applicable zone;

 

                   8.8.3     consider, coordinate, and recommend to the HA-MAC the rules & [and] regulations and policies as they apply to the medical staff as a whole or to individual departments, or divisions;

 

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

 

                   8.8.5     consider and make recommendations on such matters as may be referred to it by the HA-MAC; and

 

                   8.8.6     advise the HA-MAC of such committees as it considers necessary for the proper governance of the ZMAC and must set their terms of reference and appoint the members and chairs of such committees.

 

9    Departmental organization

 

      9.1        The medical staff must be divided into zone departments and, if appropriate, zone divisions and programs as recommended by the HA-MAC upon consultation with the ZMAC and approved by the Board.

 

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

 

      9.3        Members must undertake their activities in accordance with the rules and regulations and HA policies and procedures.

 

      9.4        The Board, after seeking advice from the CEO and the HA VP Medicine may change the status of a zone department or division. Any such change must be reflected in the rules and regulations in a timely fashion.

 

      9.5        Each department must have a Zone Department Head appointed by the Zone Medical Executive Director and the terms of the appointment must be confirmed in writing.

 

10  Provincial programs of care

 

      10.1      The Board may establish provincial programs of care on the recommendation of the HA’s executive leadership team and the Board shall in its decision outline how such Provincial programs of care interact with the medical staff organization, HA-MAC and ZMACs under these by-laws.

 

      10.2      A Provincial program of care medical program director must:

 

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

 

                   10.2.2   be eligible to be a member of the HA-MAC.

 

11  ZMSA(s)

 

      11.1      There must be 4 ZMSAs which must have terms of reference and policies and processes which are defined by such ZMSAs.

 

      11.2      Members of the ZMSA must consist of members of the medical staff eligible for membership under these by-laws and who have such zone designated as the primary base for application of their privileges.

 

      11.3      Membership in the ZMSA does not convey, confer or imply any benefits, rights or privileges of membership in the medical staff.

 

      11.4      The purpose of the ZMSAs is to represent the interests of the medical staff to the NSHA’s executive management team and on the ZMAC and the HA-MAC.

 

      11.5      Dues to be paid to the ZMSA by the members of the medical staff must be determined from time to time by the ZMSA for the zone designated as the primary base for application of their privileges.

 

12  Leave of absence

 

      12.1      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 HA medical staff, apply for a leave in writing to the Zone Department Head stating the duration and purpose of the proposed absence.

 

                   12.1.1   Subject to 12.2, a leave of absence must not exceed 12 months;

 

                   12.1.2   The Zone Department Head must notify the ZMAC and the HA-MAC of his/her decision regarding the proposed absence; and

 

                   12.1.3   The HA-MAC must notify the Board of the absence.

 

      12.2      The member may, with reasonable notice, apply in writing to the Zone Department Head for an extension of a leave of absence granted under Section 12.1 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 staff.

 

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

 

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

 

                   12.3.2   Prior to the resumption the member must provide the Zone 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 practised medicine since the commencement of the leave of absence, if applicable.

 

      12.4      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.

 

      12.5      Where a Zone Department Head or [Zone] Division head applies for and receives a leave of absence, the Zone Medical Executive Director must appoint an acting head for that department or division on the recommendation of the Zone Department Head and with the approval of the HA VP Medicine.

 

13  Continuing professional review and development

 

 

      13.1      Each member must have and agree to a review for purposes of evaluating his/her performance and their ongoing appointment to the HA Medical Staff on an annual basis and otherwise as may be determined by the HA VP Medicine or the Zone Medical Executive Director in consultation with applicable Zone Department Head. Members who hold appointments with the university may also be subject to the university’s professional review and development processes.

 

      13.2      The applicable Zone Department Head shall conduct an annual review of a member. The annual review will include documentation from the Zone Department Head to the HA-VP Medicine confirming:

 

                   13.2.1   evidence of compliance with any continuing medical education requirements as may be required by the applicable Zone Department Head;

 

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

 

                   13.2.3   a determination as to compliance with Code of Ethics and workplace behaviour requirements as outlined in these by-laws, the rules and regulations and in the HA’s policies and procedures;

 

                   13.2.4   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;

 

                   13.2.5   information on any discipline actions taken by the member’s professional regulatory college or by the HA;

 

                   13.2.6   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;

 

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

 

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

 

                   13.2.9   a finding by the applicable Zone Department Head 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 by-laws and any other information known by or received by the department head in connection with the member’s privileges.

 

      13.3      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 probationary medical staff members, the member’s annual performance review must be a comprehensive performance and development review which must be developed by the HA VP Medicine with input from the HA-MAC and which must include, as a minimum, those items to be included in the annual review required under Section 13.2 and the additional requirements and considerations as are outlined in the medical staff rules and regulations.

 

      13.4      The comprehensive performance review required under Section 13.3 must occur in the year in which the member staff member is seeking re-appointment and in the year in which a probationary member is being considered for appointment to active medical staff with or without admitting privileges or assistant medical privilege categories.

 

      13.5      The applicable zone 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 staff privileges.

 

      13.6      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 by-laws must be invoked.

 

14  Ethics and ethical relationships

 

      14.1      The NSHA Code of Ethics and these by-laws must govern the professional conduct of members. In the absence of a NSHA 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.

 

15  Affiliation agreements

 

      15.1      Upon the effective date of these by-laws, 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 by-laws, the rules and regulations and [an] affiliation agreement, precedence must be given to these by-laws and the rules and regulations.

 

16  Rules & [and] regulations

 

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

 

                   16.1.1   the management of medical activities, programs of care, medical services provided through the HA, education and research; and

 

                   16.1.2   the conduct of the medical staff.

 

      16.2      Should there be any perception of or actual conflict between these by-laws 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 by-laws must take precedence.


Part C

 

1    HA-MAC hearing pool and HA-MAC hearing committee

 

      1.1        The HA-MAC hearing pool is composed of 8 members made up of:

 

                   1.1.1     1 member representing each zone and who are [is] not [a] members of their ZMAC; and

 

                   1.1.2      member from the ZMSA for each zone.

 

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

 

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

 

                   1.3.1     two members of the HA-MAC appointed by the HA-MAC, who are not the chair of the HA-MAC, the member’s Zone Medical Executive Director or the member’s Zone Department Head, and one of whom shall act as chair of the hearing committee; and

 

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

 

      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 7 [8].

 

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

 

      1.7        A member of a HA-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 HA 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 [sic] members of the hearing committee.

 

      1.12      Subject to Section 1.13, the HA-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 HA-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 where 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 & privileges–general

 

      3.1        Appointment of medical 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 staff in the manner provided for in these by-laws.

 

                   3.1.2     Any medical staff whose relationship with the HA is established solely through granting of privileges shall be subject to these by-laws with respect to variation, suspension, revocation or other non-renewal of privileges.

 

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

 

                                 3.1.3.1     all by-laws, 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 by-laws and granted to the member; and

 

                                 3.1.3.4     the NSHA Code of Ethics and these by-laws must govern the professional conduct of members. In the absence of a NSHA 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 staff shall be granted privileges appropriate to his/her role and practice, as determined by the processes established under these by-laws. When privileges are granted under these by-laws, 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, zones, 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 staff in accordance with these by-laws shall normally be for a period of 36 months. In the case of members of the medical staff who have privileges in effect at the time these by-laws 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 probationary appointment;

 

                                 3.2.3.2     specified in a decision made under these by-laws;

 

                                 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 HA VP Medicine; 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 HA VP Medicine and relevant zone 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 by-laws, 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 staff, shall, following consultation with the relevant Zone Medical Executive Director, the relevant Zone Department Head, and the HA VP Medicine assess the inquiry from the perspective of need and availability of resources, not from the perspective of the individual merit of the applicant. 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 by-laws.

 

                   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 by-laws, 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 under 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 Zone Medical Executive Director to administer and coordinate the credentials process.

 

                   3.3.6     The Zone Medical Executive Director, 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 Zone Department Head 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 HA VP Medicine, shall:

 

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

 

                                 3.3.7.2     recommend to the HA-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 HA-MAC; and

 

inform the appropriate Zone Medical Executive Director of its recommendation.

 

                   3.3.8     Upon receipt of the recommendation from the Credentials Committee, the HA-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 Zone Medical Executive Director, CEO and applicant of its disposition.

 

                   3.3.9     Where a variance is recommended by the HA-MAC, the HA-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 HA-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 2.8.

 

                   3.3.11   The Board shall review all recommendations from the Credentials Committee and HA-MAC.

 

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

 

                   3.3.13   The Board shall make the final decision on the application within forty-five (45) working days of receipt of the HA-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 Zone Medical Executive Director for information.

 

                   3.3.15   After the Board Chair has informed the CEO and the appropriate Zone Medical Executive Director 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 by-laws.

 

      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 Zone Medical Executive Director, whose office shall administer the reappointment process.

 

                   3.4.4     The Zone Medical Executive Director shall, within five (5) working days of receipt of the application, forward the application and all accompanying documentation to the applicant’s Zone Department Head.

 

                   3.4.5     The Zone Department Head 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 Zone Medical Executive Director;

 

                                 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 Zone Medical Executive Director; 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 (10) working days of receiving the application from the Zone Medical Executive Director 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 [mediated] 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 Zone Department Head’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 appropriate Zone Medical Executive Director (and/or the Vice-President of Research and Innovation for Scientists);

 

                                 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;

 

                                 3.4.10.2   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 3.4.14.3, or suggest a variance that is not acceptable to the applicant; and

 

[and] inform the Zone Medical Executive Director and the applicant of its decision.

 

                   3.4.11   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 HA-MAC within thirty (30) working days of the Credentials Committee’s receipt of the matter.

 

                   3.4.12   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.

 

                   3.4.13   Where the matter is referred to the HA-MAC in accordance with Section 3.4.11, the HA-MAC shall conduct any inquiries it deems necessary and shall consider:

 

                                 3.4.13.1   the application;

 

                                 3.4.13.2   the recommendation of the Credentials Committee;

 

                                 3.4.13.3   the recommendations forwarded to the Credentials Committee by the CEO, the Zone Medical Executive Director, and the Zone Department Head; and

 

                                 3.4.13.4   any information that it gains from its inquiries.

 

                   3.4.14   Upon completion of its review under Section 3.4.13, the HA-MAC shall:

 

                                 3.4.14.1   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 HA-MAC from the Credentials Committee, to the Board for a final decision;

 

                                 3.4.14.2   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;

 

                                 3.4.14.3   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 HA-MAC, in which event the matter shall be referred to the Credentials Committee for review and consideration of the HA-MAC recommendation. Should the Credentials Committee reject the HA-MAC recommendation or the recommendation is not acceptable to the applicant, the matter shall be referred to the Hearing Committee under 3.4.12 within twenty (20) working days of referral to the Credentials Committee;

 

and shall inform the Zone Medical Executive Director and the applicant of its decision.

 

                   3.4.15   Where a recommendation is made under Section 3.4.14.1 or 3.4.14.2, the Board shall conduct such inquiries it deems necessary and shall consider:

 

                                 3.4.15.1   the application;

 

                                 3.4.15.2   the recommendation of the Credentials Committee;

 

                                 3.4.15.3   the recommendation of the HA-MAC; and

 

                                 3.4.15.4   any information that it gains from its inquiries.

 

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

 

                   3.4.17   After the CEO has been notified of the Board’s decision, the CEO shall notify the applicant, the HA-MAC, the Credentials Committee, the HA VP Medicine and the Zone Medical Executive Director of such decision.

 

      3.5        Temporary appointments to the medical staff

 

                   3.5.1     Notwithstanding any other provisions in these by-laws, the CEO or designate, or the HA VP Medicine 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 with or without admitting 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 by-laws, or it is necessary to approve a temporary appointment to the medical 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 zone 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 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

 

                                 3.4.5.2     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 Zone Department Head at the earliest opportunity of such revocation 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 staff shall take into account the provisions of such an affiliation agreement.

 

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

 

      4.5        Notices

 

                   4.5.1     All notices in these by-laws 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 by-laws, 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 by-laws shall be governed by these by-laws.

 

                   4.7.2     Subject to Section 1.1.3, 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 by-laws shall be completed in accordance with the provisions of these by-laws and any deviation from the process set out in the former by-laws on account of this transition shall not be considered material.

 

                   4.7.3     Where a reappointment process, or a special review process or an immediate suspension/variation process has been initiated prior to the effective date of these by-laws and a recommendation has been made by the DMAC ISC under the former by-laws, but no hearing has yet been held under those bylaws by the Board by the effective date of these by-laws, unless the matter is otherwise resolved, a hearing will be held by the Board, or a subcommittee appointed by the Board for that purpose, pursuant to Section 11 and subsections 7.14.5, 8.9 or 9.5 of the former by-laws, as the case may be. In that event the decision of the Board, or subcommittee thereof, shall be final and binding and, for greater certainty, there shall be no appeal to a Provincial appeal board.

 

5    Revocation/suspension/variation regarding medical 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 HA or failure to meet the requirements of any of the by-laws or the rules and regulations.

 

      5.2        The CEO, the HA VP Medicine, a Zone Medical Executive Director, referred to in this Section as “the person initiating the complaint” may file a complaint in writing to the Zone Department Head, 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 Zone Department Head may initiate a complaint in writing to the Zone Medical Executive Director 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 Zone Department Head (or the Zone Medical Executive Director, as relevant), 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 Zone Department Head (or the Zone Medical Executive Director, as relevant) finds that the grounds for the complaint are unfounded, the Zone Department Head shall notify the person initiating the complaint, the member, and the ZMSA that the complaint is being dismissed.

 

      5.7        In the case where the Zone Department Head (or the Zone Medical Executive Director, 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 Zone Department Head (or the Zone Medical Executive Director, as relevant) shall attempt to resolve the issues through informal mediation as detailed in the HA’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 Zone Department Head shall document the result in the member’s file.

 

      5.9        In the case where the Zone Department Head 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 Zone Department Head 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 Zone Department Head 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 HA-MAC.

 

      5.13      Where the HA-MAC agrees with the facilitated mediated resolution, the Chair of the HA-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 HA-MAC and the Board shall proceed under Section 5.15.

 

      5.14      Where the HA-MAC does not agree with the facilitated mediated resolution, the HA-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 HA-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 Zone Department Head and the HA-MAC of the decision.

 

6    Immediate action regarding privileges

 

      6.1        The CEO or designate, or a Zone Department Head 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 a HA or by services provided through the HA;

 

                   6.1.2     is reasonably likely to be detrimental to safety or to the delivery of care in the HA or by services provided through the HA; 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 HA-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 Zone Medical Executive Director and the Zone Department Head of the suspension or variance, and at such time, or when the CEO becomes aware of the initiation of immediate action by the Zone Department Head, whichever is the later, the CEO shall, within 48 hours appoint a HA Representative to commence the facilitated mediated process.

 

      6.5        If no facilitated mediated resolution is achieved under the facilitated mediated 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 HA-MAC.

 

      6.7        Where the HA-MAC agrees with the facilitated mediated resolution, the Chair of the HA-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 HA-MAC.

 

      6.8        Where the HA-MAC does not agree with the facilitated mediated resolution, the HA-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 HA-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 Zone Department Head, the relevant Zone Division Head, if applicable, and the HA-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 a HA 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 HA representative selected by the CEO or designate (who must not be the Zone Department Head 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 ZMSA member of the zone that the member works in and appointed by the ZMSA Executive; and

 

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

 

      7.3        The HA representative shall facilitate the facilitated mediation process unless the HA 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 HA representative to the relevant committee under these by-laws, 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 by-laws.

 

      7.9        Where the facilitated mediation process is not successful and a matter is referred to a hearing committee under these by-laws, 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 HA representative appointed for the particular hearing.

 

      8.3        In a proceeding before a hearing committee, the HA 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 HA 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 HA 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 by-laws.

 

      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 by-laws.

 

      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 by-laws 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 8.7 [8.11], the hearing committee may, in its discretion, allow the introduction of evidence that would be otherwise inadmissible under Section 8.7 [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 by-laws 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 8.11, 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;

 

                                 8.20.3.5   a reprimand;

 

                                 8.20.2.6   placement of the member on probation with respect to his/her medical 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 HA-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 by-laws.

 

      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


 

      1.1        Act means the Health Authorities Act, S.N.S. 2014, c. 32;

 

      1.2        affiliation agreements mean Board-authorized written agreements describing the relationship between the Nova Scotia Health Authority with academic institutions;

 

      1.3        appeal panel means an appeal panel of the Board established in Section 2 of Part C of these by-laws;

 

      1.4        Board means the Board of Directors of a health authority;

 

      1.5        CEO means the person appointed by the Board to be the Chief Executive Officer of the HA;

 

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

 

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

 

      1.8        facilitated mediation process means the mediation process as outlined in Section 6 of Part C;

 

      1.9        facilitated mediation [mediated] resolution means an agreement entered into by the parties to a facilitated mediation process;

 

      1.10      former by-laws means the by-laws in effect at or for the nine district health authorities which existed until March 31, 2015, and under the Health Authorities Act, S.N.S. 2000, c.6;

 

      1.11      HA means a health authority established under the Act and includes the Nova Scotia Health Authority;

 

      1.12      HA VP Medicine means the NSHA’s Vice-President Medicine & Integrated Health Services as defined in Part B Section 3.0 of these by-laws;

 

      1.13      HA-MAC means the Health Authority Medical Advisory Committee for the HA as defined in Section 7 of Part B of these by-laws;

 

      1.14      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;

 

      1.15      hearing committee means the committee of the HA-MAC acting as the hearing committee;

 

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

 

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

 

      1.18      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;

 

      1.19      medical site lead means a person recommended for appointment to the role of medical site lead for a facility/community by the Zone Medical Executive Director and approved by the HA VP Medicine, who co-leads with the site administrative lead and who is accountable to the Zone [Medical] Executive Medical Director;

 

      1.20      medical 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 staff, who have privileges granted by the Board;

 

      1.21      member means a member of the medical staff;

 

      1.22      party means:

 

                   1.22.1   the HA and its representatives, or

 

                   1.22.2   the member;

 

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

 

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

 

      1.25      programs of care means a plan or system for health care services operated by a health authority;

 

      1.26      rules and regulations mean the rules and regulations established pursuant to Part B Section 16 of these by-laws;

 

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

 

      1.28      university department head 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 HA’s care facilities, services or programs;

 

      1.29      working day means those working days of the week excluding weekends and statutory holidays;

 

      1.30      zone means a management zone for the Provincial health authority established under subsection 60(1) of the Act;

 

      1.31      zone department means a clinical organizational unit established under Part B, Section 9 that is structured on a zone-wide or IWK wide basis consisting of members with related fields of practice;

 

      1.32      Zone Department Head means a person appointed to that role by the Zone Medical Executive Director and approved by the Vice-President of Medicine to co-lead a management zone based medical department with an administrative co-lead and who is accountable to the Vice-president of Medicine for medical practitioner professional based issues and to Zone Medical Executive Director for care and operational issues at the zone level;

 

      1.33      zone division means a sub-section or portion of a zone department;

 

      1.34      Zone Division Head means a person recommended for that role by the Zone Department Head and approved by the Vice-president of Medicine to be the senior medical administrator of a division, and who is accountable to the Zone Department Head;

 

      1.35      Zone Medical Executive Director means a person recommended for appointment by the HA VP Medicine and approved by the President & CEO to co-lead at the zone level, with the Zone Executive Director and is accountable to the HA VP Medicine;

 

      1.36      Zone Operations Executive Director means a person employed by the NSHA who co-leads with the Zone Executive Medical Executive Director at the zone level and is accountable to an Integrated Vice-president of the NSHA;

 

      1.37      ZMAC means the medical advisory committee for a zone as defined in Part B, Section 8;

 

      1.38      ZMSA means the medical staff association for a zone as defined in Part B, Section 11;

 

      1.39      Zone Credentials Committee mean a committee of the HA-MAC for each of the zones known as the zone’s Credentials Committee as further defined in Part B, Section 7.9.