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MEDICAL STAFF BYLAWS2020073120201
TABLE OF CONTENTSPREAMBLE . 1ARTICLE 1 NAME AND DEFINITIONS . 1Section 1.1Name . 1Section 1.2Definitions . 1ARTICLE 2 PURPOSE AND RESPONSIBILITIES OF THE MEDICAL STAFF . 3Section 2.1Purpose and Responsibilities . 3ARTICLE 3 MEMBERSHIP . 4Section 3.1Eligibility and Qualifications . 4Section 3.2Ethics and Ethical Relations . 6Section 3.3Members’ Conduct Requirements . 6Section 3.3.1 Disruptive and Inappropriate Conduct . 6Section 3.4Clinical and Teaching Responsibilities . 7Section 3.4.2 Requirements for Histories and Physicals. 7Section 3.5Terms of Appointment . 8Section 3.6Provisional Appointment . 9Section 3.7Focused Professional Practice Evaluation . 9Section 3.8Leaves of Absence . 10ARTICLE 4 CATEGORIES OF MEMBERSHIP . 10Section 4.1Categories . 10Section 4.2Attending . 10Section 4.3Associate Attending . 11Section 4.4UCLA Community Practice Physician . 11Section 4.5Courtesy. 11Section 4.6Consultant . 11Section 4.7Teaching Only . 12Section 4.8Resident/House Staff . 12Section 4.8.1 Qualifications . 12Section 4.8.2 Appointment .13Section 4.9Medical Students. 13Section 4.10Administrative Staff . .13ARTICLE 5Section 5.1Section 5.2Section 5.2.1Section 5.2.2Section 5.2.3Section 5.2.4Section 5.2.5Section 5.2.6Section 5.2.7Section 5.3Section 5.4Section 5.4.1Section 5.4.2Section 5.4.3Section 5.4.4Section 5.4.5Section 5.4.6Section 5.4.7Section 5.4.8Section 5.5Section 5.6INITIAL APPOINTMENT, REAPPOINTMENT, AND TERMINATION . 14Basis for Initial Appointment . 14Procedure for Initial Appointment . 14Application Form . .14Content . . .14Incomplete Application .15Verification by the Medical Staff 16Chief of Service Recommendation .16Credentials Committee Recommendation .17Medical Staff Executive Committee Recommendation 17Basis for Reappointment . 17Procedure for Reappointment . 18Application Form. 18Content . 18Verification by the Medical Staff . 19Chief of Service Recommendation . 19Credentials Committee Recommendation. 20Medical Staff Executive Committee Recommendation . 20Failure to Timely Complete Reappointment Process . 20Failure to Meet Minimum Activity or Proctoring Requirements . 20Burden of Producing Information . 21Termination of Appointment and Other Discipline . 21073120202
Section 5.7Section 5.7.1Section 5.7.2Section 5.8ARTICLE 6Section 6.1Section 6.2Section 6.3Section 6.4Section 6.5Section 6.6Section 6.7Section 6.8Section 6.8.6Section 6.8.7Section 6.8.8Section 6.8.9Section 6.8.10Section 6.8.11Section 6.8.12ARTICLE 7Section 7.1Section 7.2Section 7.3Section 7.4Section 7.5Section 7.6Section 7.6.1Section 7.6.2Section 7.7Section 7.8Section 7.8.1Section 7.8.2Section 7.8.3Section 7.8.4Section 7.9Section 7.9.1Section 7.9.2Section 7.9.3Section 7.9.4Section 7.9.5Section 7.9.6Section 7.9.7Section 7.9.8Section 7.9.9Section 7.9.10Section 7.9.11Section 7.9.12Section 7.9.13Fees. 21Initial Application Processing Fee. 21Reappointment Application Processing Fee. 22Authorization and Release . 22CLINICAL PRIVILEGES. 22Exercise and Delineation of Privileges . 21Temporary Privileges . 22Special Academic Temporary Privileges . 24Temporary Privileges in the Event of a Disaster . 24Emergency Privileges . 25Special Conditions for Dentists . 25Special Conditions for Podiatrists . 26Allied Health Practitioners . 26Processing the Application . 27Duration of Appointment and Reappointment . 27General Duties. 27Prerogatives and Status. 28Termination and Suspension of Privileges and Grievance Procedure. 28Standardized Procedures . 29Development of Standardized Procedures . 29EVALUATION AND CORRECTIVE ACTION . 29Role of Medical Staff in Performance Improvement and Patient Safety Activities . 29Preliminary Review of Concern . 30Informal Corrective Activities . 30Informal Investigation. 30Formal Investigation . 31Medical Staff Executive Committee Action. . 32No Action, Deferred Action, or Informal Corrective Activities: . 32Formal Corrective Actions: . 33Investigatory Leave . 33Summary Restriction or Suspension. 34Initiation of Summary Restriction of Suspension . 34Duration of Summary Restriction or Suspension . 35Medical Staff Executive Committee Action . 35Scope of Summary Restriction or Suspension .35Automatic Suspension or Limitation . 36Licensure . 36Drug Enforcement Administration (DEA) Registration . 36Medical Records . 37Cancellation of Professional Liability Insurance . 37Failure to Pay Fees/Fines . 37Other Regulatory or Mandated Training Requirements .37Exclusion from Government Programs . 38Felony Conviction . 38Automatic Termination . 38Medical Staff Executive Committee Deliberation and Procedural Rights . 38Notice of Automatic Suspension or Limitation . 38Scope of Automatic Suspension or Action . 39Joint Evaluation and Corrective Action Among University of California Peer ReviewBodies . 39Section 7.10 Failure to Respond or Appear . 39ARTICLE 8 HEARINGS AND APPEAL PROCEDURES . 40Section 8.1General Provisions 40Section 8.1.1 Intent .40073120203
Section 8.1.2Section 8.1.3Section 8.1.4Section 8.1.5Section 8.2Section 8.3Section 8.4Section 8.5Section 8.5.1Section 8.5.2Section 8.5.3Section 8.5.4Section 8.5.5Section 8.5.6Section 8.5.7Section 8.6Section 8.6.1Section 8.6.2Section 8.6.3Section 8.7Section 8.7.1Section 8.7.2Section 8.7.3Section 8.7.4Section 8.7.5Section 8.8Section 8.8.1Section 8.8.2Section 8.8.3Section 8.8.4Section 8.8.5Section 8.8.6Section 8.8.7Section 8.8.8Section 8.9Section 8.9.1Section 8.9.2Section 8.9.3Section 8.9.4Section 8.9.5Section 8.9.6Section 8.9.7Section 8.9.8Section 8.10Section 8.11Section 8.11.1Section 8.11.2Section 8.11.3Section 8.11.4Section 8.11.5Section 8.12Section 8.12.1Section 8.1307312020Exhaustion of Remedies . 40Intra-Organizational Remedies . 40Definitions . 41Substantial Compliance . 41Grounds for Hearing 41Notice of Action or Recommendation .41Request for Hearing . 42Hearing Procedure .42Time and Place for Hearing . 42Notice of Reasons/Charges . 42Arbitrator . 43Hearing Committee . 44Voir Dire Examination . 44Representation . 45Failure to Appear or Proceed; Non-Cooperation or Disruption . 45Discovery . 45Rights of Inspection and Copying. . 45Limits on Discovery . 46Ruling on Discovery Disputes . 46Pre-Hearing .46Pre-hearing Document Exchange. 46Exchange of Witness Lists . 46Objections to Introduction of Evidence Previously Not Produced for the MedicalStaff 47Expert Witnesses. 47Pre-Hearing Conference .47Hearing . 47Record of Hearing . 48Attendance. 48Rights of the Participants. 48Rules of Evidence . 48Burdens of Presenting Evidence and Proof . 48Adjournment and Conclusion . 49Basis for Decision . 49Decision of the Arbitrator or Hearing Committee . 49Appeal . 49Time for Appeal . 49Burden of Producing Hearing Record . 50Waiver of Appellate Rights . 50Grounds for Appeal . 50Appeal Board . 50Time, Place and Notice . 51Appeal Procedure . 51Decision. 51Right to One Hearing .51Exceptions to Hearing Rights .51Exclusive Contracts . 51Allied Health Professionals . 51Failure to Meet the Minimum Qualifications . 52Failure to Meet Minimum Activity Requirements . 52Denial of Termination of Temporary Privileges . 52Joint Hearings and Appeals . 52Joint Hearings . 52Applicability of Corrective Actions Among UCLA Clinical Sites . 534
ARTICLE 9CLINICAL SERVICES . 53Section 9.1Organization of Clinical Services . 53Section 9.2Clinical Services .
THE MEDICAL STAFF OF THE RONALD REAGAN UCLA MEDICAL CENTER BYLAWS . PREAMBLE . These Bylaws and accompanying Rules and Regulations are adopted to provide a framework for self-governance for the organization of the Medical Staff of the Ronald Reagan UCLA Medical Center. Subject to the authority and approval of the Governing Body, the Medical .
