Medical Staff Bylaws

MEDICAL STAFF BYLAWS
TABLE OF CONTENTS

DEFINITIONS
.2

MEDICAL STAFF ORGANIZATION
Purpose of the Medical Staff
Organization3
Responsibilities of the Medical Staff
Organization.3
Membership of the Medical
Staff4
Appointment and
Reappointments.10
Professional
Conduct.14

CLINICAL DEPARTMENTS AND
DIVISIONS.18
Responsibilities...
.18
Functions of Clinical
Departments/Divisions20
Duties of the Medical
Director..20
Duties of the Associate Medical
Director22
Duties of the Chief of the
OPD22
Duties of the Director of Medical
Education.23
Duties of the Director of
Research..23

MEDICAL STAFF
COMMITTEES..25
Standing Committees of the Medical
Staff.25
Medical Executive
Committee26
Bylaws
Team27
Credentials
Committee28
Department Chairs
Committee..28
Ophthalmology Division
Chiefs..28
Promotions
Committee29
Education
Committee29
Fellowship
Team..30
Medical Library
Team31
Research
Council..31
Human Ethics Committee/Institutional Review
Board..32
Morbidity and Mortality
Committee..32
Medical Care
Committee33
Pharmacy and Therapeutics
Committee..33
Nursing/Pharmacy
Team34

MEDICAL STAFF
MEETINGS.36
AMMENDMENTS TO AND ADOPTION OF MEDICAL STAFF
BYLAWS38
RULES AND
REGULATIONS39
ADOPTED BY THE MEDICAL
STAFF.41

DEFINITIONS

The term HOSPITAL means Hospital.

The Supervisor General represents the Ministry of Health and is the final governing authority of the
Hospital.

The Supervisor General is the individual responsible for the overall management of the Hospital.

The Supervisor General Assistant is the individual who reports to the Supervisor General Deputy
and participates in the daily operation of the hospital.

The term Medical Director means the physician, appointed by the Supervisor General, who shall
oversee the carrying out of medical programs and policies.

The term Medical Staff means all persons holding MD or equivalent degree who are privileged to
treat patients within their licensure in HOSPITAL.

The term Clinical Department Chair means a member of the Medical Staff designated by the
Medical Director to assume medical administrative responsibilities for one of the Medical
Departments.

The term Ophthalmology Division Chief means a member of the Medical Staff designated by the
Medical Director to assume medical administrative responsibilities within a recognized
subspecialty or organizational section.

Medical Staff Bylaws means the set of Bylaws governing the medical administration of HOSPITAL.

The term Medical Staff Year means the Gregorian calendar year beginning January 1 and ending
December 31.

The term Quorum of the Medical Staff Committees means at least 50% of the Committee
members, including those excused or on leave, who must be present at the outset of each
meeting.

MEC shall refer to Medical Staff Executive Committee.

Nothing contained in these Bylaws, Rules and Regulations can supersede, replace or modify any of
the provisions of the Employment Contracts between members of the Medical Staff and
HOSPITAL.

These Bylaws are meant to clarify the professional environment at HOSPITAL.

The Bylaws Committee is proud of the achievements and standards maintained at HOSPITAL.

Suggestions for improving the Bylaws are welcomed. Written recommendations may be submitted
at regular or special meetings of the Medical Staff or directly to the Bylaws Team.

Purpose of the Medical Staff Organization:

There shall be a single organized, self-governing Medical Staff that has overall responsibility for the
quality of professional services provided by individuals with clinical privileges, maintaining the
medical education and research programs, and ensuring ethical conduct and professional practice
of its members, as well as the responsibility of accounting to the Supervisor General.

The Medical Staff has the following characteristics:

It includes fully licensed physicians permitted to provide patient care services in the
Hospital.
All Medical Staff members have delineated clinical privileges that define the scope of patient
care services they may provide independently or with supervision in the Hospital.
All Medical Staff members are subject to Medical Staff bylaws, rules and regulations, and
policies and procedures, and are subject to review as part of the organizations performance
improvement activities.

Responsibilities of the Medical Staff Organization:

The responsibilities of the Medical Staff are to:

Develop and adopt bylaws and policies and procedures to establish a framework of self-
governance of Medical Staff activities and accountability to the Supervisor General. Medical
staff bylaws are adopted by the Medical Staff and approved by the Supervisor General
before becoming effective. Neither body may unilaterally amend the Medical Staff bylaws.
Medical Staff bylaws. Medical Staff bylaws create a framework within which the Medical
Staff members can act with a reasonable degree of freedom and confidence.
Organize committees to accomplish the functions of the Medical Staff. The responsibilities of
the Committees are to:
o Make recommendations of individuals for Medical Staff membership and
reappointment.
o Review credentials and delineate clinical privileges for eligible individuals in order
to ensure that all patients admitted and treated in the facilities of HOSPITAL shall
receive high quality medical care.
o Ensure the participation of Medical Staff members in organization performance
improvement activities.
o Determine the mechanisms of fair-hearing procedures and the means of reduction
or termination of Medical Staff membership or delineated clinical privileges.
o The Medical Staff committees will report the Medical Executive Committee which
will receive and act on reports and recommendations from Medical Staff
committees, clinical departments, and assigned activity groups and be responsible
for making its recommendations directly to the Supervisor General approval.
o
Membership of the Medical Staff:

Basic Qualifications for Membership:

Only those physicians holding appropriate current licensure and offering documentation of their
academic achievements, experience, training, demonstrated competence, adherence to the ethics of
the profession, good reputation, ability to work with others and of physical and mental health
sufficient to carry out the privileges granted, will be eligible for appointment to the Medical Staff.
All physicians appointed to the Medical Staff must be graduates of an acceptable medical school and
must have completed post-graduate medical education and certification appropriate to their
professional activities at HOSPITAL unless appointed as a fellow of resident.

All qualified candidates for Medical Staff appointment must have the Supervisor Generals approval
for employment.

Principles Regulating Professional Practice:

Membership on the Medical Staff or the exercise of temporary privileges shall be extended only to
professionally competent physicians who continuously meet the qualifications, standards, and
requirements set forth in these bylaws. Appointment to, and membership on the Staff shall confer
on member only such clinical privileges and prerogatives as have been granted by the Credentials
Committee and approved by the Medical Executive Committee, Medical Director, and Supervisor
General in accordance with these Bylaws. No physician shall admit or provide services to patients in
the hospital unless he/she is a member of the Medical Staff or has been granted temporary
privileges in accordance with the procedure set forth on providing services to a patient under the
conditions outlined under Appointment and Reappointment Process.

Categories of Medical Staff:

Physicians may be appointed to the Medical Staff as Faculty or Trainees.

There are four categories of Faculty:
Active Staff/Permanent
Active Staff/Temporary
Collaborating Staff
Visiting Staff
There are two categories of Trainees:
Fellow/Associate Staff
Resident/Assistant Staff

Faculty Staff:

1. Active Staff/Permanent:

Active Staff/Permanent shall consist of physicians who work full-time at HOSPITAL, are not
in training, meet the qualifications for membership as set forth in these bylaws, and have
been appointed to the Medical Staff for a period of one year or greater. Members of the
Active Staff/Permanent are responsible for the continuous care of patients treated at
HOSPITAL, including emergency service care, on-call responsibilities, and consultation
assignments. Members of the Active Staff/Permanent assume clinical responsibilities, as
designated by the Medical Director, Department Chairs, Chief of the Outpatient Department,
and Ophthalmology Division Chiefs, based upon the recommendations and approval of the
Credentials Committee, Medical Executive Committee, Medical Director, and Supervisor
General. They are eligible to serve on Medical Staff committees, hold office, vote, and shall
be required to attend 75% of Medical Staff meetings, excluding those missed due to leave,
illness, emergency patient care, or other reasons excused by the Medical Director.

2. Active Staff/Temporary:

Active Staff/Temporary shall consist of physicians who work full-time at HOSPITAL, are not
in training, and meet the qualifications of membership as set forth in these bylaws, and have
been appointed to the Medical Staff for a period of less than one year. These positions are
available to appropriately qualified physicians to fill vacancies, on an interim (locum
tenens) basis, in Clinical Departments or Ophthalmology Divisions. Members of the Active
Staff/Temporary are responsible for the continuous care of patients treated at HOSPITAL,
including emergency service care, on-call responsibilities, and consultation assignments
during their period of appointment. Members of the Active Staff/Temporary assume clinical
responsibilities, as designated by the Medical Director, Department Chairs, Chief of the
Outpatient Department, Ophthalmology Division Chiefs, based upon the recommendation
and approval of the Credentials Committee, Medical Executive Committee, Medical Director,
and Supervisor General.
Active Staff (Temporary) may attend the Medical Staff meeting (as invites) and maybe
appointed by the Medical Director to serve on Medical Staff committees. Active
Staff/Temporary will be subject to the same corrective action and appeal procedure as
members of the Active Staff.

3. Collaborating Staff:

Selected physicians who meet all qualifications for membership on the Active Staff may be
nominated by the Medical Director for appointment as Collaborating Staff. Such
appointment will be based upon the opportunity to contribute toward such goals as
facilitating professional linkages between HOSPITAL and collaborating institutions, as well
as patient care and educational activities. The duties of the members of the Collaborating
Staff will be individualized with respect to the purpose of the appointment. The process of
the initial appointment of the Medical Staff, reappointment of the Medical Staff, delineation
of clinical privileges (if requested), and renewal of delineation of clinical privileges
(granted), will be identical to that of the Active Staff. Members of the Collaborating Staff
may attend the Medical Staff meeting (as invitees) and may be appointed by the Medical
Director to serve on Medical Staff committees. Collaborating Staff will be subject to the same
corrective action and appeal procedures as members of the Active Staff.

4. Visiting Staff:

Visiting Physicians (e.g. Visiting Professors) are invited to HOSPITAL from time to time by
the Medical Director of the Director of Medical Education to undertake research, teaching,
consultation, or care of patients. Appointment to the Visiting Staff for the purpose of
involvement in any clinical care including examination and surgery must be initiated by the
Medical Director. Normally, Visiting Staff appointments will be for a specific period of time,
as designated by the Medical Director.

Trainee staff:

1. Fellow/Associate Staff:
A Physician who has completed Residency Training in an approved and recognized
residency-training program and is board certified or eligible bay be accepted by the
Fellowship Selection committee for a minimum of one year of subspecialty training
at HOSPITAL.

Physicians in the Fellowship Program will be assigned to an Ophthalmology Division
or Clinical Department for training in the subspecialty fellowship program that has
been designed and that will be executed under the direct supervision of the
Ophthalmology Division Chief Departmental Chair. Members of the Faculty Staff will
participate in supervision and educational activities of the Fellow s at HOSPITAL.
Participation in the educational programs of the Fellows is a mandatory activity of
the Faculty Staff and evaluation of such performance will be a part of the renewal
and reappointment process of Medical Staff members.

Fellows will be appointed as Associate Medical Staff contingent upon their
concomitant appointment as a Fellow by the Fellowship Selection Committee.
Fellows may have independent core clinical privileges granted at the time of initial
appointment or later in the fellowship year, as warranted by prior training and
experience. In addition, Fellows may have additional independent privileges
granted at the time of initial appointment or later in the fellowship year, as
warranted by documented proficiency, upon a specific request submitted to the
Credentials Committee and supported by the recommendation of the
Ophthalmology Division Chief and subsequently approved by the Medical Executive
Committee, Medical Director, and Supervisor General.

The Chief Fellow may attend the Medical Staff meeting (as an invitee). Fellows may
be appointed as non-voting members to Medical Staff Committees by the Medical
Director.

Fellows must discharge all the professional obligations as required by him/her.
These include being on an on-call roster for nights and weekends (including
holiday). They may be assigned to duty in any of the clinical and surgical activities
performed by active members of the Faculty Staff.

Fellows will be evaluated by Chief of the Ophthalmology Division, Fellowship
Committee, and Director of Medical Education. Continuation in the fellowship
program is contingent upon satisfactory performance of duties as judged by those
responsible for evaluating fellow performance. The Director of Medical Education
may make a recommendation to the Medical Director for dismissal from the training
program for consistently poor clinical performance or lack of satisfactory progress
toward satisfying the curriculum requirements of the specialty training program. If
the Medical Director concurs with the decision, the Fellow will be dismissed from
the program. The fellow may appeal the decision to the Supervisor General whose
ruling on the matter will be final.

Fellows who violate the standards of clinical practice or Medical Staff Bylaws may
be disciplined by the Director of Medical Education, with the approval of the Medical
Director. Disciplinary action includes, but it is not limited to the following: ; letter of
warning/reprimand; modification, reduction, or revocation of clinical privileges;
temporary suspension from clinical duties, or expulsion from the fellowship
training program. The Fellow may appeal the decision to the Supervisor General
whose ruling on the matter will be final.

Because Fellows may not be independently privileged for many of their clinical care
activities at HOSPITAL the following mechanisms of supervision are necessary:

*Each Fellow will be assigned to a specific member of the Faculty Staff
during each clinical rotation at HOSPITAL. A Fellow assigned to the
emergency room will report to the Chief/ER or Associate Chief/ER.

*The Faculty Staff member and the Ophthalmology Division Chief will be
responsible for evaluation of Fellow performance. All such evaluations, as
well as any identified deficiencies in performance, will be reported to the
Director of Medical Education.

*A Faculty Staff Member shall evaluate and countersign the history, physical
examination, and preoperative notes of all patients admitted by the Fellows
if the case is one for which the Fellow does not have independent clinical
privileges. The Faculty Staff member will also be responsible for evaluating
the findings, recommendations for therapy, and orders for treatment of all
patients treated by the Fellow for which the Fellow does not have
independent privileges.

*All surgical procedures (major and minor for which the Fellow does not
have independent privileges must be supervised by a Medical Staff member
(Faculty or Associate Staff) who has independent surgical privileges for the
procedure. The name of the Medical Staff member, as well as his level of
participation (assistant, observer), must be clearly stated in the medical
record.

*It is the responsibility of the Fellows Division Chief to ensure that the
Fellow completes the medical record s in a proper and timely fashion. The
Faculty Staff member is ultimately responsible for final medical record
completion and accuracy.

*Fellows may provide clinical care as Attending Physicians, subject to the
General Rules and Regulations for Medical Staff Participation in Care at
HOSPITAL (p.52), in conjunction with independent clinical privileges that
have been awarded by the Credentials Committee and approved by the
Medical Executive Committee, Medical Director, and Supervisor General. In
such cases, they have the responsibility for the overall care of patient,
including sick leave requests and medical record documentation.

2. Resident/Assistant Staff:

The Residency/Assistant Staff shall consist of members of the four-year Riyadh
Integrated Residency Program. Physicians will be accepted and appointed to the
Residency Staff by the Admissions Committee of the Riyadh Integrated Residency
Program Supervisory Committee.

Physicians in the Residency Program will be assigned to HOSPITAL in accordance
with the curriculum designed by the Riyadh Integrated Residency Program
Supervisory Committee in order to meet the educational requirements of the Saudi
Board of Ophthalmology. The Director of Medical Education and the Education
Committee will ensure that HOSPITAL-sponsored educational activities are
available to meet the mandated educational requirements of the Saudi Board of
Ophthalmology. The Faculty Staff will participate in supervision and educational
activities of the Resident Staff as designated by the Director of Medical Education.
Participation in the educational programs of the Resident Staff is a mandatory
activity of the Faculty Staff and evaluation of such performance will be a part of the
renewal and reappointment process of Medical Staff members.

Resident physicians will have no independent clinical privileges while on rotation at
HOSPITAL with the exception of limited privileges for performing minor treatment
procedures as approved by the Director/ER.

The Chief Resident may attend the Medical Staff members (as an invitee). Residents
may be appointed as non-voting members to Medical Staff Committees by the
Medical Director.

Resident Staff must discharge all of the professional obligations as required by
him/her. These include on an on-call roster for nights and weekends (including
Holiday). They may be assigned to duty in any of the clinical and surgical activities
performed by active members of the Faculty Staff.

Because the Resident Staff is not independently privileged the following
mechanisms of supervision are necessary:

*Each Resident will be assigned to a specific member of the Faculty Staff during each
clinical rotation at HOSPITAL. A Resident assigned to the emergency room will
report to the Chief/ER. The Faculty Staff member and the Ophthalmology Division
Chief will be responsible for evaluation of Resident performance. All such
evaluations, as well as any identified deficiencies in performance, will be reported to
the Director of Medical Education.

*A Faculty Staff member shall evaluate and countersign the history, physical
examination, and preoperative notes of all patients admitted by the Resident Staff.
The Faculty Staff member will also be responsible for evaluating the findings,
recommendations for therapy, and orders for treatment of all patients treated by
the Resident Staff.

*All surgical procedures (major and minor) must have the supervision of a Medical
Staff member (Faculty Staff or Associate Staff) who has independent surgical
privileges for the procedure with the exception of procedures approved for the
residents to perform independently in the minor treatment room. The name of the
Medical Staff member, as well as his level of participation (assistant, observer), must
be clearly stated in the medical record.

*It is the responsibility of the member of the Faculty Staff responsible for each
Resident rotation to ensure that the Resident completes the medical record in a
proper and timely fashion. The Division Chief is ultimately responsible for final
medical record completion and accuracy.

Appointments and Reappointments:

Application for Initial Appointment:

Application for membership on the Medical Staff must be submitted in writing. At the time of
application, the potential candidate will be provided with a complete copy of the HOSPITAL Medical
staff bylaws for review.

The Application must contain the following information:

Medical education and training documents.
Valid current license to practice medicine.
Summary of professional experience.
Three or more references from persons knowledgeable about the applicants competence
and character.
Specific request for staff assignment and delineation of clinical privileges.
Information relevant to voluntary or involuntary loss of previous licensure or reduction of
clinical privileges.
Involvement in any prior medical malpractice judgment, current malpractice suits, or any
previously successful or currently pending challenges to licensure or registration.

The completed application must be signed by the applicant. The applicant must sign a statement on
the application package that affirms the following:

The applicant has read and pledges to abide by the Medical Staff Bylaws and to honor the
policies and procedures established by HOSPITAL.
The applicant pledges to provide continuous care for all HOSPITAL patients.

Application Process:

The completed application package and privilege request forms, along with verification of training,
licensure, and certifications, will be reviewed by the Medical Director and the appropriate
Department Chair or Ophthalmology Division Chief to determine the suitability and need for the
candidates appointment to the Medical Staff. A decision will be made on the completed application
package within one month.

If the Medical Director determines that the application is acceptable for consideration for
appointment to the Medical Staff and that an appropriate need and opening for the position exists,
the application for appointment and delineation of clinical privileges will be sent to the Credentials
Committee for appropriate action and the Promotions Committee for determination of academic
rank. The credentials Committee and Promotions Committee will act upon the application within
one month.

Initial Appointment:

The Credentials Committee must approve or disapprove all applications for appointment to
the Medical Staff (with the exception of the Resident Staff category), as well as the
delineation of specific clinical privileges.

The decision to approve or disapprove an appointment to the Medical Staff, as well as the
delineation of specific clinical privileges, must be based upon an assessment of the quality of
medical care of the proposed candidate. For ophthalmologists, the request for clinical
privileges must be for specific procedures performed in each of the subspecialty Divisions
as well as specified medical and diagnostic interventions. For non-ophthalmologists, the
privileges will be stated with greater precision than broad terms like General Medicine,
General Radiology, General Anesthesia or General Pathology.

For new appointments to the Medical Staff will be based upon, not limited to the following:

Prior education, training, and clinical experience.
Board certification.
Subspecialty fellowship training and certification.
Clinical privileges previously and currently held at other hospitals.
Letters of recommendation from previous residency program directors, fellowship
program directors, department chairs / division chiefs at previous hospital and
university positions, and previous chiefs of staff.

The Medical Executive Committee must approve or disapprove the recommendations of the
Credentials Committee. If approved, the recommendations must be forwarded to the
Medical Director and Supervisor General for final approval. Following approval by the
Credentials Committee, these final approvals should be requested and obtained within one
month.

At the time of initial appointment, physicians will be awarded provisional privileges.
During this provisional period, the Division Chief or Medical Director (if the physician is
appointed as a Division Chief) will be responsible for organizing a proctoring program to
confirm the medical and surgical skills of the newly appointed physician. After three months
the individual responsible for proctoring program will submit a report to the Chair of the
Credentials Committee with a recommendation to approve the recommended privileges,
valid for two years, if performance is consistent with the recommended privileges. Concerns
about any of the recommended medical or surgical privileges must be communicated to the
Credentials Committee for further discussion.

Six months after initial appointment, the Director of Quality Management will provide the
Credentials Committee with a summary report of the clinical activities of the newly
appointed physician. This will be reviewed by the Credentials Committee and any identified
concerns regarding clinical performance will be discussed by the committee.

Appointments to the Medical Staff and delineation of clinical privileges must be renewed
every two years.

A comprehensive list of the specific clinical privileges awarded to each new member of the
Medical Staff must be provided to the patient care units (Outpatient Department, Operating
room, Nursing Administration) to allow personnel to determine whether or not the
diagnostic intervention and whether or not each physician provides services within the
scope of privileges granted.

In the event of an undue delay on the part of the Credentials Committee to appoint or
delineate clinical privileges of a new Medical Staff member, the Medical Director may act
upon the basis of documented evidence of the applicants professional and ethical
qualifications from reliable sources and grant a temporary appointment and delineation of
clinical privileges until the next meeting of the Credentials Committee.

Reappointments:

The Credentials Committee must review the reappointment of each individual to the
Medical Staff and the continuation of delineated privileges prior to the expiration of the
two-year term of appointment. Applications of reappointment will be processed in a similar
fashion to the initial appointment. The same process will be followed for reappointment of
current Medical Staff and for physicians who return to the Medical Staff after a period of
absence. In case of physicians who return after a period of absence, the review will include
their performance at the institutions in which they have held clinical privileges since their
last appointment, as a review of their previous HOSPITAL privileges and clinical
performance.

The reappointment to the Medical Staff and continuation of delineated clinical privileges
will be based upon an evaluation of quality of care provided by the individual physician
with respect to each specific clinical privilege as evidence by but not limited to the
following:

Evaluation of the Medical Director.
Written evaluation of the Department Chair and/or Ophthalmology Division Chief
on the physicians professional performance, judgment, technical skills, and health
status.
Peer-review by the other members of the Medical Staff as requested in writing by
the Chair of the Credentials Committee.
The physicians pattern of care, as demonstrated by reviews conducted by the
Quality Management Department, Pharmacy and Therapeutics Committee,
Morbidity and Mortality Committee, Infection Control Committee, Health
Information Management Committee, and Incident Reports submitted to the Risk
Management Coordinator.
Performance in Resident and Fellow supervision and educational activities.
Participation in the Performance Improvement Program of HOSPITAL.
Participation and attendance at Medical Staff and Performance Improvement
Committee meetings.
Participation in continuing medical education activities.
Valid cardiopulmonary resuscitation certification.
Any other relevant documentation such as completion of annual safety and infection
control, fire safety, laser (if applicable).
Participation in research.

Any decision of an adverse nature with respect to reappointment or voluntary or involuntary
revocation or suspension of previously delineated clinical privileges must be documented in the
Credentials Committee files. In addition, the physician must be granted fair hearing before the
Credentials Committee regarding any adverse decision regarding reappointment to the Medical
Staff or the continuation of a previously granted clinical privilege. Any action that results in
revocation, modification, or reduction of clinical of privileges must be approved by eight (8) of the
twelve members of the Credentials Committee. Any recommendation for a corrective action, below
the level of revoking, modifying, or reducing clinical privileges must be approved by six (6) of the
twelve members of the Credentials Committee.

The Credentials Committee must review, at its next regularly scheduled meeting, any interim
requests for delineation of additional clinical privileges for any Medical Staff member. Such a
request for additional clinical privileges must be initiated by a request from the individual
physician, supported by evidence of training and experience with the proposed privilege, and
approved by the appropriate Department Chair or Ophthalmology Division Chief, or the Medical
Director (in case of a Department Chair or Ophthalmology Division Chief).

All actions of the Credentials Committee on reappointment of Medical Staff, continuation of
delineated clinical privileges, or granting of additional clinical privileges must be approved by the
Medical Director and Supervisor General for final approval.

A comprehensive list of renewed or additional clinical privileges awarded to each member of the
Medical Staff must be approved to the patient care units (Outpatient Department, Operating Room,
and Nursing Administration) to allow personnel to determine whether or not diagnostic
intervention and whether or not the physician is privileged to perform each specific procedure,
medical intervention, or diagnostic intervention and whether or not each physician provides
services within the scope of privileges granted.

In the event of an undue delay on the part of the Credentials Committee to reappoint or renew
clinical privileges of a Medical Staff member, the Medical Director may act upon the basis of
documented evidence of the applicants professional and ethical qualifications from reliable sources
and grant a temporary reappointment and continuation of delineated clinical privileges until the
next meeting of the Credentials Committee.

Administrative Appointments:

Administrative appointments within the Medical Staff are made by the Medical Director.
Administrative appointments must be reviewed and renewed annually by the Medical Director.

The procedure for initial appointment to the Medical Staff, reappointment to the Medical Staff, and
delineation of clinical privileges is identical for individuals holding administrative appointments
and those not holding administrative appointments.

Emergency Clinical Privileges:

In case of an emergency, any member of the Medical staff shall be permitted and assisted to do
everything possible to save the life of a patient, using every necessary facility at HOSPITAL,
including the calling of any available consultation necessary or desirable. When an emergency
situation no longer exists, the care will be transferred to an appropriate credentialed member of the
Medical Staff. An emergency is defines as a condition in which serious permanent harm would
result to a patient, or in which the life of a patient is in imminent danger, and delay in administering
treatment would add to that danger.

Professional Conduct:

Whenever the activities or professional conduct of any Medical Staff member are such as to indicate
violation of the Bylaws, Rules and Regulations, departure from the principles of professional ethics,
or conduct that is unacceptable to the hospital and Medical Staff, corrective action against the
member may be requested by any member of the Medical Staff, Medical Director, or Supervisor
General. All requests for corrective action shall be made in writing to the MEC and supported by
specific evidence.

Upon receipt of such a request, it shall be the responsibility of the MEC to investigate the charges in
accordance with the following procedures.

The hearing must be within a period of seven days. Ten members of the MEC must be
present. If necessary, the Medical Director may appoint each replacement members for
physician on leave for the purpose of participating in the hearing.
The accused staff member shall be permitted a fair hearing by the MEC. This includes the
right to appear before the MEC to hear and address the specific charges.
If the individual requesting the corrective action is a member of the MEC, he/she may not
participate as a voting member and may serve only as a witness to the proceedings. The
Medical Director must nominate a replacement to the MEC to replace the excused member.
If the requesting member is the Medical Director, the Supervisor General must nominate a
replacement member to the MEC for these hearings and designate a permanent member of
the MEC to chair the proceedings.

Upon conclusion of the investigation, the MEC shall, in writing, record its recommendation as
follows:

Requires the approval of ten (10) of the 12 members of the MEC.
The terminated or suspended staff member will be notified in writing of this
decision by the Medical Director.
The terminated or suspended staff member shall have the right of appeal
(see: Appeal Procedures). He/she will be informed of this right in the letter
from the Medical Director informing the accused staff member of the MEC
recommendation.
The recommendation for termination of contract by the MEC will be
forwarded to the Supervisor General.

*Corrective action involving revocation, modification, or reduction of clinical privileges:

Requires the approval of eight (8) of the 12 members of the MEC.
Whenever clinical privileges are revoked, modified, or reduced, the accused
staff member shall be notified in writing by the Medical Director prior to
application of the suspension.
The staff member will have the right to appeal the decision of the MEC see
Appeal Procedures). He/she will be informed of this right in the letter from
the Medical Director informing the accused staff member of the MEC
recommendation.
The recommendation for corrective action will be forwarded to the
Supervisor General.
All requests and recommendations for corrective action shall be
implemented through the Clinical Department Chair, Chief of the Outpatient
Department, or Ophthalmology Division Chief, after notification by the
Medical Director.

*Corrective action not involving revocation, modification, or reduction of clinical privileges
(including , but not limited to, letter of warning, letter of reprimand, recommendation of remedial
courses or training):

Requires the approval of seven (7) of the 12 member s of the MEC.
The recommendation for corrective action will be forwarded to the staff
member by the Medical Director.
The staff member will have the right to appeal the decision of the MEC (see
Appeal Procedures). He/she will be informed of this right in the letter from
the Medical Director informing the staff member of the MEC
recommendation.
The recommendation for corrective action will be forwarded to the
Supervisor General.
All requests and recommendations for corrective action shall be
implemented through the Clinical Department Chair. Chief of the Outpatient
Department, or Ophthalmology Division Chief after notification by the
Medical Director.

Summary Suspension:

For conduct disruptive to hospital and Medical Staff function, or for other unacceptable behavior,
the Medical Director, or Supervisor General in consultation with two members of the MEC, shall
have authority to immediately suspend clinical and hospital privileges pending investigation.
Concurrent with the imposition of an immediate suspension, the Medical Director or designee shall
organize alternative medical coverage for the patient(s) of the suspended physician in the hospital
at the time of such suspension.

Whenever action must be taken immediately in the interests of patient care, the Medical Director in
consultation with any two members of the MEC shall have the authority to immediately suspend all
or any portion of the clinical privileges of a Physician. Such summary suspension shall become
effective upon imposition. Concurrent with the imposition of an immediate suspension, the Medical
Director or designee shall provide for alternative coverage for the patient(s) of the suspended
physician in the hospital at the time of such suspension.

Such summary of suspension of some or all clinical and/or hospital privileges imposed by the
Medical Director or Supervisor General, will be followed by a meeting of available MEC members to
be held within 72 hours of the summary suspension. The MEC will recommend approval,
modification, or rejection of the recommendations of the summary suspension in accordance with
procedures discussed above.
Automatic Suspension:

Automatic suspension or termination of clinical privileges shall ensue for any action that suspends
or terminates a Medical Staff members medical license.

It shall be the duty of the Department Chair/Divisional Chief to cooperate with the Medical Director
in enforcing all automatic suspensions.

Appeal Procedures:

If the MEC recommends (1) termination or suspension from the Medical Staff, (2) revocation,
reduction, or modification of clinical privileges, or (3) corrective action below the level of
revocation, reduction, or modification of clinical privileges, the staff member has the right to appeal
before the decision is finalized.

If the MEC recommends termination or suspension from the Medical Staff, the staff member has the
right to appeal the decision to the Supervisor General. Within three days of being informed of such
recommendation, the accused member must inform the Supervisor General in writing that he/she
wishes to make an appeal. If he/she fails to do so within the specified time, he/she shall be deemed
to have waived the right of appeal and the MEC decision will be final. If an appeal is filed, the
decision of the Supervisor General will be final.

If the MEC recommends corrective action resulting in revocation, reduction, or modification of
clinical privileges, the staff member has the right to appeal the decision to the Supervisor General
within seven days of being informed of such recommendation, the accused member must inform
the Supervisor General in writing that he/she wishes to make an appeal. If he/she fails to do so
within the specified time, he/she shall be deemed to have waived the right of appeal and the
decision of the MEC will be final. If an appeal is filed, the decision of the Supervisor General will be
final.

If the MEC recommends corrective action below the level of revocation, reduction, or modification
of clinical privileges, the staff member has the right to appeal the decision to the Supervisor
General. Within seven days of being informed of such recommendation, the accused member must
inform the Supervisor General in writing that he/she wishes to make an appeal.

If he/she fails to do so within the specified time, he/she shall be deemed to have waived the right of
appeal and the decision of the MEC will be final. If an appeal is filed, the decision of the Supervisor
General will be final.

Notwithstanding any of the above provisions, all physicians shall have protection as provided by
the HOSPITAL employment contract.

CLINICAL DEPARTMENTS AND DIVISIONS

The Medical Staff at HOSPITAL shall be organized into Clinical Departments and Ophthalmology
Divisions to facilitate professional activity for the delivery of quality patient care.

Responsibilities:

Each Clinical Departments will have a Clinical Department and each Ophthalmology Division will
have a Division Chief appointed by the Medical Director. Appointments will be for a one-year
period, beginning on 1 January of each calendar year. Reappointments will be considered and made
annually by the Medical Director based upon performance of the incumbent, performance of other
applicants for the position, and the institutional needs. All administrative appointments will be
submitted to the Supervisor General for approval.

The removal and replacement of a Clinical department Chair or Division Chief between annual
appointment / reappointment may be done upon the recommendation of the Medical Director,
with approval of the MEC and Supervisor General of the Hospital.

Individuals appointed to these positions will possess the clinical, academic, and administrative
competence necessary to fulfill the responsibilities of their position, based upon review of previous
training and professional practice prior to and during their tenure at HOSPITAL.

The responsibilities of the Clinical Department Chair or Division Chief shall include, but not be
limited to:

Monitoring of all clinical related activities of the department/division.
All administrative related activities of the department/division unless otherwise provided
for by the Hospital.
Continued surveillance of the professional performance of all individuals in the
department/division who have delineated clinical privileges. This includes, but is not
limited to, assessment of each member after 90 days of initial employment, and at the time
of each 2-year reappointment to the Medical Staff.
Recommendation to the Credentials Committee the criteria for clinical privileges that are
relevant to the department/division.
Assess and recommend to the MEC off-site sources for needed patient care services not
provided by the department /division of HOSPITAL.
Coordination and integration of intradepartmental services to facilitate the patient care,
teaching, and research mission of HOSPITAL.
Coordination and integration of intradepartmental/interdivisional services through
appropriate meetings and communication with members of the department/division.
Coordination and integration of intradepartmental/interdivisional services through
participation in the Department Chair/Division Chiefs Committees.
Development of department/division policy and procedures that guide and support the
provision of services.
Make recommendations to the Medical Director regarding the sufficient number of
qualified and competent persons to provide the care and services of the
department/division.
Determine the qualification and competence of department/division personnel who are not
licensed independent practitioners and who provide patient care services.
Continually assess and improve the quality of care and services provided.
Maintain appropriate quality-improvement programs within the department/division.
Provide orientation and continuous education of all members of the department/division.
Participation in department/division planning (budgets, staffing, etc.) and assisting in the
preparation of all required reports.
The Clinical Department Chairs of Medicine and Ophthalmology will assure that emergency
service patient care is appropriately performed and documented, and further, assure that
orientation, scheduling and such other physician activities are integrated into emergency
service care as may be required.
The Chair of the Medicine Department (or designee) will serve as the Medical Coordinator
for the Internal and External Emergency Plan.

Each member of the Medical Staff will be assigned to a Clinical Department at the time of initial
appointment. If assigned to the Department of Ophthalmology, the Medical Staff will also be
assigned to an Ophthalmology Division. Depending upon qualifications and the needs of the
institution, a member of the Medical Staff may be assigned to multiple departments/divisions.

The Clinical Departments are:

Anesthesia
Diagnostic Imaging
Medicine (Internal Medicine/Pediatrics)
Ophthalmology
Research

The Ophthalmology Divisions are:

Anterior Segment/External Disease
Emergency Room
Glaucoma
Neuro-Ophthalmology
Ocuplastics and Orbit
Pediatric Ophthalmology and Strabismus
Uveitis
Vitreoretinal

The formation, elimination, subdivision, or combination of Clinical Department and Ophthalmology
Divisions may be made upon the recommendation of the Medical Director, with approval of the
MEC.

Functions of Clinical Departments/Divisions:

The primary responsibility delegated to each Clinical Department /Division is to implement and
conduct specific review and evaluation activities that contribute to the presentation and
improvement of the quality and efficiency of patient care provided. Such activities shall be subject
to MEC review and approval.

The general functions of each Clinical Department/Division shall include:

Review, analysis, and evaluation of clinical work performed.
Recommendation of clinical aspects of patient care, risk management and safety issues for
monitoring to the Performance Improvement Committee.
Preparation of written reports to the MEC on a regularly scheduled basis concerning:
*Findings of the Clinical Departments review, evaluation and monitoring activities.
*Recommendations for maintaining and improving the quality of care provided in
the Clinical Department.
Preparation of written reports to the Credentials Committee on a regularly scheduled basis
concerning:
*Requests for continuation, or modification of delineated clinical privileges of
Department/Division.

Meetings at least six times per year or more as required for the purpose of receiving,
reviewing, and considering the evaluation and monitoring activities, and of performing
receiving reports on other staff and department functions.

Duties of the Medical Director:

The Medical Director must be an Ophthalmologist who shall serve as the Chief Administrative
Officer of the Medical Staff to:

Act in coordination and cooperation with the Supervisor General on all matters of mutual
concern within HOSPITAL.
Receive, interpret, and communicate the policies of HOSPITAL to the Medical Staff through
the MEC and Medical Staff meetings.
Receive, interpret, and communicate issues related to performance and maintenance of
quality care to the Supervisor General. This includes, but is not limited to recommendations
regarding Medical Staff requirements, equipment, needs, educational issues, etc.
Represent the view, policies, needs, and grievances of the Medical Staff to the Supervisor
General.
Call, preside at, an e responsible for the agenda of all general meetings of the Medical staff.
Serve as Clinical Department Chair of the Ophthalmology Department.
Serve as Chair of the following committees:
o Medical Executive Committee
o Department Chairs Committee
o Promotions Committee
o Bylaws Team
Serve as Member of the following committees:
o Credentials Committee
o Research Council
o Performance Improvement Committee
Be responsible for initiating disciplinary action for active Medical staff members in
accordance with the Medical Staff bylaws and for insuring Medical Staff compliance with
procedural safeguards in all instances when corrective action has been requested against a
physician.
Be responsible for the enforcement of Medical Staff Bylaws and Department/Division
policies and procedures.
Be responsible for recruitment of physicians to the Medical Staff and submission of
proposed appointments to the Credentials Committee, Promotions Committee and MEC and
the Supervisor General.
Appoint Department Chairs and Ophthalmology Division Chiefs on an annual basis.
Appoint Chair and Committee Members of al standing Medical Staff committees, in
accordance with the Medical Staff bylaws.
Recommend Medical Staff appointments to physician positions on Performance
Improvement committees.
Be responsible, through the Medical Education Department, for the coordination of
continuing medical education programs, fellowship training programs, and the residency
education program conducted at HOSPITAL as part of the Riyadh Residency Program.
Be responsible, through the Director of Research, for the Research Program and HOSPITAL.
Ensure maintenance of all established and approved medical and surgical services by active
Medical Staff members as monitored by the MEC; ensure that all members of the Medical
Staff participate in continuous performance-improvement activities as monitored by the
Performance Improvement Committee; and ensure effective communication be maintained
between the MEC, the Hospital Management and Operation Committee (HMOC), and
Supervisor General (Governing Authority).
Be spokesman for the Medical Staff in its external professional and public relations.
Recommend a member of the full-time HOSPITAL Department of Ophthalmology to serve as
Acting Medical Director and Associate Medical Director are on leave subject to approval by
the supervisor General.
Practice medicine in accordance with qualifications as time permits.

Duties of the Associate Medical Director

The Associate Medical Director must be an ophthalmologist and a member of the HOSPITAL
Medical Staff and will:

Work directly with the Medical Director on issues related to the
administrative management of the Medical Staff.
During the absence of the Medical Director, act in coordination with the
Supervisor General on all matters of mutual concern within HOSPITAL.
During the absence of the Medical Director carry out all the designated
duties and responsibilities of the Medical Director.
Serve as Chair of the following committee:
Serve as member of the following committees:
o Research Council
o Education Committee
o Bylaws Team
Practice medicine in accordance with qualifications according to a schedule
approved by the Medical Director.
Duties of the Chief of the OPD
The Chief of the OPD must be an ophthalmologist and a member of the HOSPITAL Medical Staff will:
Work directly with the Medical Director on issues related to patient care
provided y the Medical Staff as follows:
o Act in coordination and cooperation with the Medical Director on all
physician related activities within the Outpatient Department and
Operating Room.
o Be responsible for all ophthalmologists schedules in the ambulatory
services and in the operating room, subject to approval by the
Medical Director.
o Be responsible for ensuring that an appropriate on-call schedule for
general and subspecialty ophthalmology services is prepared and
implemented at all times.
o Participate in Outpatient Department planning (budgets, staffing,
etc.) and assist in preparation of all relevant and requested reports.
o Ensure that regular review and evaluation of the quality and
appropriateness of patient care rendered within the clinical services
is carried out through designated mechanisms.
Serve as Chair of the following committees:
o Division Chiefs
Serve as member of the following committees:
o Bylaws Team
Duties of Director of Medical Education:
The Director of Medical Education must be an ophthalmologist and a member of the
HOSPITAL Medical Staff and will:
Act in coordination and cooperation with the Medical Director on all matters
of educational activity within HOSPITAL.
Be responsible to develop, plan and implement subspecialty fellowship
programs at HOSPITAL. This will be done in consultation with the
Ophthalmology Division Chiefs but the final plan will be the responsibility of
the Director of Education, subject to approval by the Medical Director.
Be responsible to develop, plan and implement residency training programs
and activities at HOSPITAL. This is done in cooperation with the
Ophthalmology Division Chiefs and Integrated Residency Steering
Committee and is ultimately subject to approval by the Medical Director and
the Saudi Council foe Health Specialties.
Be responsible for coordinating medical instruction as needed by Clinical
Departments and Ophthalmology Divisions at HOSPITAL.
Plan the continuing medical education activities for the Medical Staff
including Grand Rounds, the Annual Symposium and other symposia.
Serve as the Chair of the following committees/teams:
o Fellowship Selection Team
o Medical Library Team
Serve as Member of the following committees:
o Bylaws Team
Duties of the Director of Research:
The Director of Research at HOSPITAL must be an ophthalmologist and a member of the
HOSPITAL Medical staff and will:
Be responsible for the overall direction of the Research Department. Prepare
the yearly research program and budget; subject to approval by the, ensure
quality of research activities by periodic assessment of ongoing studies;
supervise all work-related matters for the Department and evaluate the
performance of all full time and part time members of the Research
Department in accordance with Hospital and Departmental Personnel
Policies.
Be responsible for the recruitment program of the Research Department
under the guidance of the Medical Director.
Appoint administrative officers (Associate/Assistant Director of Research)
of the Research Department, Chief Research Associate, Chief of Coordination
Section, Chief of Laboratory Section and Administrative Assistant, subject to
the approval of the Medical Director.
Receive and review research applications prepared by staff members. Assist
the applicant in improving the quality of the application and recommend
finally whether or not the research proposal should be sent to the Research
Council for final consideration and funding.
Act as Chair of the Research Council.
Engage actively on research (basic, clinical or both) in the course of regular
professional activities and participate in patient care as a member of Medical
Staff and practice clinical medicine in accordance with qualifications as
permits or as necessary.
Establish and maintain a system for the operation and supervision of the
research laboratories and work with the Medical Director in long-range
planning for additional research facilities and equipment. Pursue the
progressive growth of investigative work at HOSPITAL by submitting
proposals for extramural funding, stimulating investigative studies by the
Medical Staff members, and by appropriate promotional efforts.
Serve as a Member of the following committees:
o Bylaws Team
o Human Ethics Committee/ Institutional Review Board
Practice medicine in accordance with qualifications and as time permits.

MEDICAL STAFF COMMITEES
There shall be a Medical Executive Committee (MEC) and such other standing and special
committees of the staff responsible to the MEC, as may be necessary and desirable to
perform Medical Staff functions. The MEC may, by resolution and upon approval by the
Medical Director, establish additional Medical Staff committees to execute such functions.
Each standing committee of the Medical Staff may commission ad hoc teams as necessary to
accomplish specific tasks.
All meetings shall be conducted in accordance with Roberts Rules of Order. Minutes must
be recorded and submitted to the MEC via the Medical Director.
STANDING COMMITTEES OF THE MEDICAL STAFF
The following will be the standing committees/teams of the Medical Staff that will report to
the Medical Executive Committee:
Bylaws Team
Credentials Committee
Department Chairs Committee
Ophthalmology Division Chiefs Committee
Promotions Committee
Education Committee
o Fellowship Team
o Medical Library Team
Research Council
Human Ethics Committee/ Institutional Review Board
Morbidity and Mortality Committee
Medical Care Committee
Pharmacy and Therapeutics Committee
o Nursing /Pharmacy Team
The Medical Executive Committee will provide the Performance Improvement Committee
with a monthly report submitted on the first Saturday of the month summarizing the
activities of all Medical Staff committees.
Medical Staff Committee members and chairs shall be appointed by the Medical Director
annually in accordance with the membership charters established in the Bylaws.
Appointments begin in January each year.
Vacancies shall be filled by appointment by the Medical Director for the remainder of any
unfilled team. The Supervisor General is an ex officio member of all Medical Staff
Committees.
Members of the Medical Staff, who are members of standing Medical Staff or Performance
Improvement Committees by virtue of their administrative appointment, must instruct the
person acting for them during their leave to attend their committee meetings. For other
committee memberships, it will be at the discretion of the Chair of the committee as to
whether or not a replacement should be designated to replace a Medical Staff member who
is on leave.
A committee chair may request that the Medical Director replace a member who does not
satisfactorily discharge his/her responsibilities to the committee if the member is an
obligatory appointee by virtue of an administrative position, he/she may not be removed
from the committee. If the member is an at large appointee, the Medical Director has the
option of selecting a suitable replacement. If the member has been elected to the committee
by the Medical Staff, the Medical Director may appoint a substitute member pending a new
election by the Medical Staff. The removed committee member is eligible to run for
reelection, but in such a case, the committee chair may express his grievance regarding
deficiencies in committee performance. If re-elected by the Medical Staff he/she must be
reinstated to the committee.
The following are committees which report to the Performance Improvement Committee
and on which the Medical Staff shall have representation. The Medical Director will
nominate candidates for appointment to these committees to Hospital Administration.
Performance Improvement Committee
o HOSPITAL JCIA Team
o Staff Development Team
Health Information Management Committee
o Closed/open Chart Review Team
Operative and Other Invasive Procedures Committee
Infection Control Committee
Environment of Care Committee
o Data Analysis and Reporting Team (DART)
Health Education Committee
o Inpatient Education Team
o Outpatient Education Team

MEDICAL EXECUTIVE COMMITTEE (MEC)
Members are:
Medical Director (Chair)
Associate Medical Director
Chief of OPD
Director of Research
Director of Medical Education
Two non-ophthalmologists appointed by the Medical Director representing
and selected from the Clinical Departments of Pathology, Anesthesia,
Diagnostic Imaging and Medicine.
Two ophthalmologists appointed by the Medical Director to be selected at
large from entire Medical Staff.
Two members at large, one ophthalmologist and one non-ophthalmologists
elected annually by the Medical Staff.
Director of Quality Management (invitee)
Supervisor General ( ex officio)
Duties are to:
Directly communicate via the Medical Director on all matters of professional
practice activities at HOSPITAL with the Hospital Executive Committee and
Supervisor General.
Act on behalf of the Medical Staff in intervals between Medical Staff
meetings.
Receive, review and act on reports and recommendations from Medical Staff
committees, Clinical Departments/ Divisions and assigned activity groups;
document its conclusions, recommendations directly to the Hospital
Executive Committee and Supervisor General for approval.
Review the minutes of the meetings of all Medical Staff Committees. Discuss
and take action on relevant issues raised in the meetings of Medical Staff
Committees that have not been referred to the MEC, as per item 3 (above).
Ensure the participation of the entire Medical Staff in Resident and Fellow
supervision and educational activities.
Delineate the structure and function of Medical staff committees, in
compliance with the bylaws.
Reports findings and recommendations to the Medical Director, Hospital
Executive Committee and Supervisor General.
The Medical Executive Committee shall meet at least nine times per year.

BYLAWS TEAM
The Bylaws Team shall be chaired by the Medical Director and shall consist of all of the
membership of the Medical Executive Committee. By definition, actions approved by the
Bylaws team will be considered approved by the Medical Executive Committee.
The Bylaws Team will conduct annual reviews of the Bylaws, Rules and Regulations,
policies, forms, etc.
The Bylaws Team will review all requested changes in the existing Bylaws as submitted by
any member of the Medical Staff, or Supervisor General of HOSPITAL.
All changes approved by the Bylaws Team will be submitted to the Supervisor General of
HOSPITAL.
The Bylaws Team shall meet at least once a year or as needed.
CREDENTIALS COMMITTEE
The Credentials Committee shall be chaired by the Associate Medical Director for
Administrative Affairs and consist of all the membership of the Medical Executive
Committee. By definition, actions approved by the Credentials Committee will be
considered approved by the Medical Executive Committee.
Duties are to:
Review the credentials of applicants for Medical Staff membership and make
recommendations for appointment and delineation of clinical privileges to
the Medical Executive Committee.
Review information available regarding the competency and suitability of
staff members and make recommendations for reappointment and
continuation or modification of clinical privileges to the Medical Executive
Committee.
The Credentials Committee shall meet at least ten times per year.

DEPARTMENT CHAIRS COMMITTEE
Members are:
Medical director (chair)
Chair, Medicine Department
Chair, Anesthesia Department
Chair, Diagnostic Imaging Department
Chair, Pathology Department
Director, Outreach Program
Supervisor General (ex officio).
Duties are to:
Review and act upon matters of mutual interest and concern that affect
interdepartmental functions.
Make recommendations to the Medical Executive Committee.
The Departmental Chairs shall meet at least four times per year.
OPHTHALMOLOGY DIVISION CHIEFS COMMITTEE
Members are:
Chief, OPD
Chief, Anterior Segment Division
Chief, Emergency Room
Chief, Glaucoma Division
Chief, Neuro-ophthalmology Division
Chief, MCED
Chief, Oculoplastics and Orbit Division
Chief, Pediatric Ophthalmology and Strabismus
Chief, Uveitis Division
Chief, Vitreoretinal Division
Director, Outreach Program
Chief, Optometry Division (invitee)
Director of Surgical Services (invitee)
Supervisor General ( ex officio)
Medical Director (ex officio)

Duties are to:
Review and act upon matters of mutual interest and concern that affect
interdivisional functions.
The Division Chiefs shall meet at least six times per year.
PROMOTIONS COMMITTEE
Members are:
Up to five members of the Medical Staff who hold the rank of Senior
Academic Consultant will be appointed by the Medical Director on a
rotational basis.
Supervisor General (ex officio)
Duties are to:
To review the academic accomplishments of all members of the Medical Staff
on a semi-annual basis to consider potential candidates for promotion to
Senior Consultant and Senior Academic Consultant.
The Promotions Committee shall meet at least two times per year.
EDUCATION COMMITTEE
Members are:
Director of Research
Director of Residency Training Program or designee
Director of Education
Duties are to:
Develop and plan programs of continuing education relevant to medical care
delivered at HOSPITAL.
Develop and plan programs of Fellow and Resident education at HOSPITAL.
Evaluate the effectiveness of educational programs implemented.
Act upon continuing education recommendations from the MEC, the Clinical
Department Chair (s), Division Chief(s) or the Staff.
Approve applications and priorities, either by committee action o delegated
responsibility, for use of medical television.
Review the medical library services in terms of the informational,
educational, and research-related needs of the medical and hospital staff.
Oversee the functions of the Fellowship Selection Team and the Medical
Library Team.
The Medical Education Committee shall meet at last four times a year.
FELLOWSHIP TEAM
Members are:
Director of Medical Education (Chair)
Ophthalmology Division Chiefs from the following services:
o Anterior Segment/External disease
o Glaucoma
o Neuro-Ophthalmology
o Oculoplastics
o Pediatrics
o Uveitis
o Vitreoretinal
Duties are to:
Report to the Medical Education Committee
To review all applications for formally approved HOSPITAL Fellowship
Programs
To recommend successful candidates to the Medical Director for
appointment to established Fellowship Programs at HOSPITAL.
The Fellowship Team shall meet at least once annually.
MEDICAL LIBRARY TEAM
Members are:
Director of Residency Training Program or designee
HOSPITAL Librarian.
A representative from each Ophthalmology Division, Medicine, Anesthesia,
and Diagnostic Imaging.
Nursing Services Representative.
Representative from the Research Department.
Duties are to:
Report to the Medical Education Committee.
Review and approve requests for purchase of books, journals, videocassettes
and other sources of information for the HOSPITAL Medical Library.
Plan growth and development of the Library to enhance patient care,
teaching and research resources.
The Medical Library Team shall meet at least once annually.
RESEARCH COUNCIL
Members are:
Director of Research (Chair)
Associate Director of Research
Medical Director
Six members appointed by the Director of Research for 2-year terms
Two members (one ophthalmologist and one non-ophthalmologist) elected
by secret ballot by the Medical Staff
Duties are to:
Develop, revise ad implement policies and procedures pertaining to
research activities at HOSPITAL.
Receive, review and act on research applications from staff members, as well
as from collaborators from other institutions.
Assist investigators in improving the quality of research.
Settle disputes between investigators on participation and authorship
related to all research projects.
Ensure medical staff participation in performing research.
Evaluate medical staff performance in research.
Make recommendations on future planning of clinical and basic research
and allocation of resources.
The Research Council shall meet at least nine times a year.
HUMAN ETHICS COMMITTEE/ INSTITUTIONAL REVIEW BOARD
Members are:
At least five HOSPITAL physician members, representative of both genders,
four of whom must be Medical Staff Ophthalmologists and one of whom
must be a Medical Staff member from another department. The Director of
Research and the Associate Director of Research may be among the
membership. One of the ophthalmologists must be the Chair.
At least two members, representing both genders, from HOSPITAL who are
not physicians and are selected from the Nursing Services, Health
Educational Services, or Social Services
At least one member who is not employed by HOSPITAL.
At least one of three members who are not members of the HOSPITAL
Medical Staff must have a non-scientific background.
Duties are to:
Review cases as per criteria recommended to the committee by department
chairs and division chiefs and reviewed annually and coordinated through
the Quality Management Department.
Investigate adverse outcomes of medical and surgical therapy, possibly
inappropriate or unnecessary surgery, unexpected surgical cancellations,
unusual patterns of practice, excessive complications and instances in which
patients are required unexpectedly to return to surgery during the same
hospital stay.
Identify and investigate questions of appropriateness of clinical and surgical
privileges.
Report findings and recommendations to the Credential Committee, MEC,
and Medical Director.
The Morbidity and Mortality Committee shall meet at least nine times a year.
MEDICAL CARE COMMITTEE
Members are:
Chair, Internal Medicine Department (Chair)
Chair, Department of Anesthesia
Consultant Pediatrician
Chief or Associate Chief of Emergency Room
Chief, Employee Health
Ophthalmologist
Associate Administrator, Nursing Services or designee
Director of Quality Management (invitee)

Duties are to:
Ensure high quality of non-ophthalmic medical care for patients in all
hospital areas and hospital staff and their dependents.
Oversees all CLS related activities throughout the hospital
Reviews every Code Blue to ensure satisfactory standard.
Receives and acts on reports from Cardiac Life Support.
The Medical Care Committee shall meet at least six times a year.
PHARMACY & THERAPEUTICS COMMITTEE
Members are:
Medical Staff Member (Chair)
Food and Nutrition Service Member
Medical Staff Member, Medicine Department
Medical Staff Member, Anesthesiologist
Medical Staff Member, Anterior Segment
Medical Staff Member, Glaucoma
Medical Staff Member, Vitreoretinal
Medical Staff Member, Pathologist
Nursing Services Member (Unit Manager)
Pharmacy Member
Medical (ex officio)
Duties are to:
Receive, assess and appropriately act on reports and findings related to the
prescribing or ordering, preparing and dispensing, administration and
monitoring the effects on patients of medications and blood/blood products
used for patient care at HOSPITAL.
Review and approve a HOSPITAL Hospital Formulary, which will be
maintained on a current basis.
Review Pharmacy Monitoring System.
Review the medication errors monthly summary report.
Assist in development and evaluation of all HOSPITAL Policies and
Procedures related to the use of medication and blood/blood components at
HOSPITAL.
The Chair report a summary of activities to the Medical Executive
Committee every other month.
The Pharmacy and Therapeutics Committee shall meet at least six times a year.
NURSING/PHARMACY TEAM
Members are:
Team Leader: Nursing Services Member (unit Manager)
Recorder: Selected Team Member
Employee Health representative
Infection Control/Risk Management Coordinator
Nurse Services representative from patient care units
Nursing Services representative from ACS
Nursing Services representative from OR/PARR
Pharmacist, Inpatient Area
Pharmacist, Outpatient Area
Pre-hospitalization representative
Short Stay Unit representative

Duties are to:
To receive P & T Committee actions as they relate to the purpose of the
Nursing/Pharmacy Team
To review, assess and liaise with other caregivers to implement actions to
improve medication distribution and pharmaceutical care to our patients.
To review the medications errors monthly summary report and submit
report of action (s) to the P&T Committee.
The Nursing/Pharmacy Team will meet every other month before the P&T meeting.

MEDICAL STAFF MEETINGS
Meetings of the full Medical Staff shall be held at least quarterly. The December meeting
shall be the annual meeting.
All meetings shall be conducted in accordance with Roberts Rules of Order.
Members of the Active Medical Staff/Permanent attend the Medical Staff meeting. Majority
of the members of the Active Medical Staff/ Permanent present at the outset constitute a
quorum.
Members of the Active Staff/Temporary and Collaborative Staff may attend the Medical Staff
Meeting as invitees.
The Chief Fellow/ Associate Staff and Chief Resident/ Assistant Staff may attend the Medical
Staff Meeting as invitees.
The Chief of Optometry and the Chief of Orthoptics may attend the Medical Staff Meeting as
invitees.
Hospital Administrators who present the mandatory reports at the meeting (see below)
may attend the Medical Staff Meeting as invitees.
Each member of the Active Medical/Permanent Staff shall be required to attend at least
75% of all regular Medical Staff and Committee meetings in each year. A member who is
compelled to b absent from any regular staff meeting shall promptly submit to the Medical
Director, in writing, the reason(s) for such absence. Unless excused by the MEC, failure to
meet the foregoing annual attendance requirements shall be grounds for corrective action,
which might include revocation of clinical privileges.
The Medical Director, the Associate Medical Director, or any two of the Clinical Department
Chairs or Division Chiefs may call a Special Meeting at any time, designating the time and
place of such special meeting. No business shall be transacted at any Special Meeting except
that stated in the notice calling the meeting.
Minutes of each regular and special staff meeting of a Committee or of a Department shall
be prepared and include a record of the attendance of members and the vote taken on each
matter. The minutes shall be signed by the presiding officer ad forwarded to the MEC for
approval. The minutes shall be read at the next Committee meeting unless waived and
approved. Each Committee and Service shall maintain a permanent file of the minutes of
each meeting in the Medical Directors office.
The agenda of any special Medical Staff meeting shall be:
Reading of the notice calling the meeting
Transaction of business for which the meeting was called
Adjournment

The agenda of a regular Medical Staff meeting shall include:

Call to order
Approval of the minutes if the last regular and/or special meeting
Reports from Hospital Administration
o Supervisor General (or representative)
o Administrator/Patient Care Services (or representative)
o Administrator/Administrative Services (or representative)
o Associate Administrator for Nursing Services (or
representative)
o Associate Administrator for Administrative Services (or
representative)
o Director of Management Information Services (or
representative)
o Director of Quality Management (or representative)
o Pharmacy Director (or representative)
o Medical Records Director (or representative)
Reports from Department Chairs:
o Anesthesia
o Diagnostic Imaging
o Medicine
o Ophthalmology
o Pathology
Report from the Outreach Department
Report from the Research Department
Report from Medical Education
Old Business
New Business
Adjournment

AMENDMENTS TO AND ADOPTION
OF MEDICAL STAFF BYLAWS
Neither the Medical Staff nor the Supervisor General of HOSPITAL may unilaterally amend, appeal,
or revise the Medical Staff bylaws.
Any member of the Medical Staff or the Supervisor General may propose changes to the bylaws, by
submitting the proposed change(s) in writing for consideration at the next meeting of the Bylaws
Team. Approval or disapproval will by majority vote of the Bylaws Team. All approved changes will
be forwarded to the Supervisor General for final approval.
In addition, a proposal for a Medical Staff bylaws change(s) may be made at any regularly scheduled
or special meeting of the Medical Staff. If such a motion is made, seconded, and approved by a
majority vote of members, it shall be forwarded to the Supervisor General for final approval.

RULES AND REGULATIONS
General rules and regulations for medical staff participation in care at HOSPITAL:
The Medical Staff operation is governed by the Joint commission International Standards for
Hospitals (JCIA), the Hospital Plan for Patient Care, the HOSPITAL Performance Improvement and
Quality Management Plan, the HOSPITAL Strategic Plan and Hospital Policies and Procedures, in
their latest revisions. The Medical Staff must conduct all aspects of professional practice in
accordance with these standards in a manner consistent with the hospital mission of patient care,
teaching and research. A declaration of this intention must be signed at the time of initial
appointment and reappointment to the Medical Staff.
Upon appointment to the Medical Staff the physician must sign a declaration that they are familiar
with the contents of the Medical Staff By-Laws and agree to abide by them in all aspects of their
professional activities at HOSPITAL.
Upon reappointment to the Medical Staff, the physician must sign a declaration that they are
familiar with the most current version of the Medical Staff By-Laws and agree to abide by them in
all aspects of their professional activities at HOSPITAL.
Every patient at HOSPITAL will be treated by a member of the Medical Staff. The responsibilities of
the Medical Staff member include but are not limited to the following:
Provide care within the scope of delineated clinical privileges and area of expertise.
Assure timely, adequate professional care for his patients in the hospital by being
available or by having available an eligible alternative physician with whom prior
arrangements have been made.
Obtain appropriate medical, anesthetic, diagnostic imaging, ophthalmic subspecialty
consultation when indicated.
Maintain complete and accurate medical records, including documentation of the
plan of care and follow-up plan at each physician encounter, whether in the
outpatient or inpatient setting.
Communicate with other HOSPITAL Medical Staff, as needed, to provide optimal
patient care.
Communicate with referring physicians/agencies regarding the condition and
clinical course of the patient and to obtain any information needed to provide
optimal care.
Communicate with relatives regarding the condition and clinical course of the
patient, and to obtain any information needed to provide optimal care.
Be available by telephone or beeper during regular clinic hours and when assigned
to on call duties after regular working hours.
Do everything possible within the scope of professional experience and skill to save
a patients life or save a patient from serious harm in the event of an emergency.
Maintain patient confidentiality during participation in clinical care, teaching,
research and participation in Quality Management activities.
Every patient admitted to the hospital must have one member of the Medical Staff designated as the
Attending Physician, whether the patient is admitted for surgical or non-surgical care.
The Attending physician has ultimate responsibility for the care of the patient.
He/she can and must obtain consultation from other members of the Medical Staff
and obtain assistance from personnel from non-Medical Staff departments
whenever the clinical situation warrants.
For surgical cases, the Attending Physician must personally perform, supervise the
performance of the procedure by another physician, or observe the performance of
the procedure by another physician.
For non-surgical cases, the Attending Physician must personally manage or directly
supervise the medical care of the patient.
The responsibilities of the Attending are in effect until the patient has been formally
transferred to another member of the Medical Staff who has agreed to assume the
responsibility as the patients Attending Physician.
Any member of the Medical Staff may become involved in the care of a patient at the request of the
Attending Physician as either a Consulting Physician or Prescribing Physician.
A Consultant Physician is individual from whom the Attending Physician requests an opinion
regarding a specific issue/s related to the care of the patient. The Attending Physician has the
option to accept or reject the recommendation of the Consulting Physician. By mutual agreement,
the Attending Physician may request the Consulting Physician to assume responsibility for the care
of the patient as the Attending Physician. In such a case the transfer of responsibility must be
clearly documented in the medical record.
A Prescribing Physician is an individual whom the Attending Physician requests to assume the
responsibility for providing moderate or deep sedation, local anesthesia or general anesthesia for
the purpose of conducting an examination or procedure on a patient. The Prescribing Physician is
responsible for the sedation or anesthesia-related aspects of the case. The Attending Physician
remains for the overall care of the patient.

Medical Staff Bylaws

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MEDICAL STAFF BYLAWS

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