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Approved and Effective as of8 February 2021THE ALBERTA HEALTH SERVICES MEDICALSTAFF BYLAWS
Alberta Health Services Medical Staff BylawsTable of ContentsDEFINITIONS 2PART 1 – GENERAL PROVISIONS . 61.01.11.21.31.41.51.6General. 6Objectives . 6Binding Effect . 6Records and Disclosure. 6Advisor . 6Medical Staff Rules . 6Bylaws Review and Amendments . 6PART 2 – MEDICAL ORGANIZATIONAL STRUCTURE OF AHS . l. 10Chief Medical Officer . 10Associate Chief Medical Officer(s) . 11Zone Medical Directors . 11Associate Zone Medical Directors . 11Facility and Community Medical Directors . 11Zone Clinical Departments . 11Zone Clinical Department Heads . 14Provincial Practitioner Executive Committee . 15Medical Staff Bylaws and Rules Review Committee . 15Zone Medical Administrative Committees. 15Zone Application Review Committees . 16Zone Medical Staff Associations . 16PART 3 - THE PROCESS FOR MEDICAL STAFF APPOINTMENTS AND CLINICAL PRIVILEGES . 173.03.13.23.33.43.53.63.73.83.9General. 17Medical Staff Appointments . 17Clinical Privileges . 18Appointment and Privileges Procedure . 19Application Process . 19Request to Change a Medical Staff Appointment and Clinical Privileges . 21Unfavourable Recommendations . 22Decisions of the Chief Medical Officer . 24Exceptional and Urgent Situations . 24Agreements With Other Providers . 24PART 4 - RESPONSIBILITIES AND ACCOUNTABILITY OF AHS AND THE MEDICAL STAFF . 264.04.14.2General. 26Joint Responsibilities and Accountability . 26Individual Practitioner Responsibilities and Accountability . 28PART 5 – PERIODIC REVIEW. 31PART 6 - TRIGGERED INITIAL ASSESSMENT AND TRIGGERED REVIEW. 326.06.16.26.36.46.56.66.76.86.96.106.11General. 32Concerns . 32Procedural Fairness . 33Triggered Initial Assessment. 34Consensual Resolution Process . 35Hearing . 36Appeal of the Hearing Committee Process . 38Immediate Action . 38Decisions of the Chief Medical Officer . 39Notification of the Complainant . 40Practitioner-Initiated Reviews . 40Disposition of Records . 40PART 7 – TRANSITION PROVISIONS . 41Page 1
Alberta Health Services Medical Staff BylawsDEFINITIONSIn this document the following words have the meanings set opposite to them:Academic PhysicianA physician Practitioner who also possesses an appointment as a FullTime Faculty or Clinical Faculty member with either the Faculty ofMedicine & Dentistry of the University of Alberta or the Faculty ofMedicine of the University of Calgary.Active StaffThe Practitioners who are appointed to the Active Staff categorypursuant to these Bylaws.AdvisorA person, lay or professional, who provides guidance, support, or counselto a Practitioner pursuant to these Bylaws.Affected PractitionerA Practitioner who is the subject of a Triggered Initial Assessment,Triggered Review or Immediate Action.AHS AgentA person, other than an AHS employee, Senior Officer or board member,who is authorized to bind AHS, purports to bind AHS or who directly orindirectly controls AHS funds.AHS Code of ConductThe code of conduct established by AHS.AHS Conflict of Interest BylawThe conflict of interest bylaw established by AHS.AHS Programs and ProfessionalServicesDiagnostic and treatment services and programs operated by or for AHSto which Practitioners with relevant Clinical Privileges can refer Patients.AHS RepresentativeAn AHS employee, Senior Officer, Agent or board member.AHS Senior OfficerThe Chief Executive Officer, president or vice-presidents of AHS, anyother executive directly accountable to the Chief Executive Officer orpresident of AHS, and any other person so designated by the ChiefExecutive Officer or board of AHS.Alberta Health ServicesThe health authority established pursuant to applicable legislation for theProvince of Alberta.ApplicationThe forms and process used to apply for a Medical Staff Appointmentand Clinical Privileges in the manner specified in these Medical StaffBylaws and the Medical Staff Rules.Bylaws and Rules Review CommitteeA committee established as such pursuant to these Bylaws.Chief Executive Officer or CEOThe chief executive officer appointed by the Chief Executive Officer tobe responsible for the function of Medical Affairs within AHS.Chief Medical Officer or CMOThe CMO is the most senior medical administrative leader appointed bythe CEO to be responsible for the function of Medical Affairs within AHS.CollegeThe relevant regulatory body which governs the Practitioner.Community Physician, Dentist, Oral &Maxillofacial Surgeon or PodiatristA Physician, Dentist, Oral & Maxillofacial Surgeon or Podiatrist with ascope of practice limited to community office or clinic practice.Community StaffThe Practitioners who are appointed to the Community Staff categorypursuant to these Bylaws.Page 2
Alberta Health Services Medical Staff BylawsComplainantA Patient or his/her legal representative(s), a member of the public, oranother Practitioner(s) who initiate(s) a Concern.ConcernA written complaint or concern from any individual or group ofindividuals about a Practitioner's professional performance and/orconduct, either in general or in relation to a specific event or episode ofcare provided to a specific Patient.Consensual ResolutionA consensual and confidential process to resolve a Concern. ConsensualResolution includes the Affected Practitioner, the relevant AHS medicaladministrative leader(s), and any other relevant person(s).Dentist or Oral & MaxillofacialSurgeonA person licensed in independent practice and in good standing with theAlberta Dental Association and College pursuant to the Health ProfessionsAct (Alberta).FacilitiesApproved hospitals, continuing care facilities, community health, urgentcare, and public health centres, and any other facilities operated byAHS.HearingThe process of addressing Concerns where a Triggered Initial Assessmentand Consensual Resolution have not resolved the matter or are notconsidered appropriate means to resolve the matter.Hearing CommitteeA committee established as such pursuant to these Bylaws.Immediate ActionAn immediate suspension or restriction of a Practitioner’s Medical StaffAppointment and/or Clinical Privileges without first conducting aTriggered Review pursuant to these Bylaws.Immediate Action Review CommitteeA committee established as such pursuant to these Bylaws.In WritingThe requirement for documents to be submitted in writing can be met byreturning the document through e-mail from a secure AHS or otherenterprise organization e-mail system requiring sign-in and verification.The requirement may also be met in situations where an individual haschosen or requested AHS communicate with them using another electronicformat or address. In certain specific situations, original paper copies ofdocuments will be required because of legislative or other legalrequirements.Medical Affairs OfficeAn operational and organizational office of the Executive Vice President& Chief Medical Officer portfolio.Medical DirectorThe Practitioner who is the medical administrative leader of a Zone (ZoneMedical Director); one or more Facilities (Facility Medical Director), oneor more communities (Community Medical Director), an AHS provincialportfolio or program (Senior Medical Director or Medical Director); or aZone program (Zone Program Medical Director).Medical Organizational StructureThe medical organizational structure of AHS aligned with these Bylawsand the Rules.Medical StaffCollectively, all Practitioners who possess a Medical Staff Appointmentpursuant to these Bylaws.Medical Staff Appointment orAppointmentThe admission of a Practitioner to the AHS Medical Staff.Page 3
Alberta Health Services Medical Staff BylawsMedical Staff Letter of OfferAn offer to join the Medical Staff which specifies the category ofAppointment, assignment to a Zone(s) Clinical Department(s), delineationof specific Clinical Privileges (if applicable), and the details of majorresponsibilities and roles.MinisterThe member of the Executive Council of Alberta who is charged withcarrying out the statutory responsibilities conferred on him as Minister ofHealth and Wellness.PatientAn individual receiving health services from a Practitioner.Periodic ReviewA periodic review of the professional performance and all mattersrelevant to the Appointment and Clinical Privileges of a Practitioner withan Appointment in the Active and Locum Tenens Staff categories.PhysicianA person with a practice permit not requiring supervision from theCollege of Physicians and Surgeons of Alberta pursuant to the HealthProfessions Act (Alberta).PodiatristA person with a practice permit not requiring supervision from theAlberta Podiatry Association pursuant to the Podiatry Act/HealthProfessions Act (Alberta).PoliciesAdministrative and operational objectives, plans, values, principles,practices and standards established by AHS with respect to its operationsand Facilities, programs and services.PractitionerA Physician, Dentist, Oral & Maxillofacial Surgeon; Podiatrist, or aScientist Leader, who has an AHS Medical Staff Appointment.Practitioner Workforce PlanAn AHS plan which provides projections and direction with respect to therecruitment, retention and organization of an appropriate number, mixand location of Practitioners with the required skill sets.Primary Zone Clinical DepartmentThe Zone Clinical Department in which a Practitioner undertakes themajority of his/her Medical Staff responsibilities and roles, and throughwhich changes in Appointment, Periodic Reviews, and other administrativeactions pursuant to these Bylaws will be managed.Probationary StaffThe Practitioners who are appointed to the Probationary Staff categorypursuant to these Bylaws.ProcedureA diagnostic or therapeutic intervention for which a grant of ClinicalPrivileges is required.Professional Codes of ConductThe Code of Conduct established by the College of Physicians andSurgeons of Alberta, the Code of Conduct established by the AlbertaPodiatry Association, and the Code of Ethics established by the AlbertaDental Association and College.Provincial Practitioner ExecutiveCommittee or PPECA committee established as such pursuant to these Bylaws.Request to ChangeA request to change the category of Appointment and/or the ClinicalPrivileges of a Practitioner pursuant to these Bylaws.RulesThe specific provisions established as Medical Staff Rules pursuant tothese Bylaws.Scientist LeaderA person other than a Physician, Dentist, Oral & Maxillofacial Surgeon orPodiatrist who holds a doctorate degree in a recognized health-relatedscientific or biomedical discipline, and who is an AHS medicaladministrative leader responsible for, and accountable to, Physician,Dentist, Oral & Maxillofacial Surgeon and/or Podiatrist Practitioners.Page 4
Alberta Health Services Medical Staff BylawsSites of Clinical ActivityThe locations and programs, listed in the grant of Clinical Privileges,where a Practitioner may perform Procedures, or provide care orservices to Patients. The Sites of Clinical Activity may include Zones,Facilities, specific AHS Programs and Professional Services withinFacilities, and/or Telemedicine.TelemedicineThe provision of services for Patients, including the performance ofProcedures, via telecommunication technologies, when the Patient and thePractitioner are geographically separated. This may includePractitioners in Alberta, as well as those outside Alberta who are on theTelemedicine Register of the College of Physicians and Surgeons ofAlberta.Temporary StaffThe Practitioners who are appointed to the Temporary Staff categorypursuant to these Bylaws.Triggered Initial AssessmentAn investigation and initial assessment of a Concern or otherinformation/complaints about a Practitioner.Triggered ReviewA review undertaken in response to a Concern about a Practitioner'sprofessional performance and/or conduct.Universal Programs and ProfessionalServicesThose diagnostic and therapeutic services and programs available, withintheir respective scope of practice, to all Alberta Physicians, Dentists, Oral& Maxillofacial Surgeons and Podiatrists without the need for an AHSMedical Staff Appointment or grant of Clinical Privileges.ZoneA geographically defined organizational and operational sub-unit ofAHS, the boundaries of which may be revised from time-to-time by AHS.Zone Application Review Committee orZARCA committee established as such pursuant to these Bylaws.Zone Clinical Department or ZCDAn organizational unit of Practitioners established by the Zone MedicalDirector and Zone Medical Administrative Committee to which membersof the Zone Medical Staff are assigned.Zone Clinical Department Head orZCDHThe Practitioner who is the leader of a Zone Clinical Department.Zone Clinical Department Site ChiefThe Practitioner who is the leader of Zone Clinical members at aparticular Facility or Site.Zone Clinical SectionAn organizat
an Appointment in the Active and Locum Tenens Staff categories. . Podiatry Association, and the Code of Ethics established by the Alberta Dental Association and College. Provincial Practitioner Executive Committee or PPEC
