Guelph General Hospital By-Law (By-Law 1-13) · Guelph General Hospital By-Law (By-Law 1-13) Approved by the Board of Directors and Confirmed by the Members on June , 2019 TABLE OF

Guelph General Hospital

By-Law

(By-Law 1-13)

Approved by the Board of Directors

and

Confirmed by the Members

on

June ●, 2019

TABLE OF CONTENTS

Table of Contents

Page

ARTICLE 1 DEFINITIONS AND INTERPRETATION .............................................................. 1

1.1 Definitions ........................................................................................................................ 1

1.2 Interpretation .................................................................................................................... 4

1.3 Rules of Order .................................................................................................................. 6

ARTICLE 2 BOARD OF DIRECTORS ........................................................................................ 7

2.1 Board Composition .......................................................................................................... 7

2.2 Qualifications of Directors ............................................................................................... 7

2.3 Term ................................................................................................................................. 8

2.4 Nominations for Appointment of Directors ..................................................................... 8

2.5 Attendance at Meetings .................................................................................................... 8

2.6 Vacancy and Termination of Office ................................................................................. 8

2.7 Responsibilities of the Board ........................................................................................... 9

2.8 No Remuneration ............................................................................................................. 9

2.9 Conflict of Interest ........................................................................................................... 9

2.10 Confidentiality and Public Relations .......................................................................... 10

2.11 Indemnification and Insurance ................................................................................... 10

ARTICLE 3 MEETINGS OF THE BOARD................................................................................ 11

3.1 Attendees ........................................................................................................................ 11

3.2 Regular Meetings of the Board ...................................................................................... 11

3.3 Special Meetings of the Board ....................................................................................... 12

3.4 Chair ............................................................................................................................... 12

3.5 Quorum........................................................................................................................... 12

3.6 Adjourned Meetings ....................................................................................................... 12

ARTICLE 4 MEMBERS .............................................................................................................. 12

4.1 Members ......................................................................................................................... 12

4.2 Annual Members’ Meetings ........................................................................................... 13

4.3 Special Members’ Meetings ........................................................................................... 13

4.4 Location of Members’ Meetings .................................................................................... 13

4.5 Notice of Members’ Meetings........................................................................................ 13

(ii)

4.6 Chair ............................................................................................................................... 14

4.7 Quorum........................................................................................................................... 14

4.8 Removal of Directors ..................................................................................................... 14

4.9 Financial Year of the Corporation .................................................................................. 14

ARTICLE 5 OFFICERS ............................................................................................................... 14

5.1 Officers ........................................................................................................................... 14

5.2 Role and Responsibilities of the Chair ........................................................................... 15

5.3 Role and Responsibilities of the Vice-Chair(s) of the Board ......................................... 15

5.4 Roles and Responsibilities of the Secretary ................................................................... 15

5.5 Roles and Responsibilities of Other Officers ................................................................. 15

ARTICLE 6 COMMITTEES OF THE BOARD .......................................................................... 16

6.1 Establishment of Standing and Special Committees of the Board ................................. 16

6.2 Functions, Duties, Responsibilities, and Powers of Committees ................................... 16

6.3 Call for Meetings of Standing and Special Committees ................................................ 17

6.4 Quorum for Meetings of Standing and Special Committees.......................................... 17

ARTICLE 7 CHIEF EXECUTIVE OFFICER ............................................................................. 17

7.1 Appointment of the Chief Executive Officer ................................................................. 17

ARTICLE 8 RECORDS ............................................................................................................... 17

8.1 Retention of Written Statements .................................................................................... 17

ARTICLE 9 FINANCIAL MATTERS ........................................................................................ 17

9.1 Banking Arrangements ................................................................................................... 17

9.2 Signing Officers ............................................................................................................. 18

9.3 Seal ................................................................................................................................. 18

9.4 Investments..................................................................................................................... 18

9.5 Auditor ........................................................................................................................... 18

ARTICLE 10 BORROWING POWERS ...................................................................................... 18

10.1 Borrowing Powers ...................................................................................................... 18

ARTICLE 11 MATTERS REQUIRED BY THE ACT AND EXCELLENT CARE FOR ALL ACT....................................................................................................................................................... 19

11.1 Required Committees and Programs .......................................................................... 19

11.2 Fiscal Advisory Committee ........................................................................................ 19

11.3 Chief Nursing Executive ............................................................................................ 19

11.4 Nurses and other Staff and Professionals on Committees .......................................... 19

11.5 Occupational Health and Safety Program .................................................................. 19

11.6 Health Surveillance Program ...................................................................................... 20

(iii)

11.7 Organ Donation .......................................................................................................... 20

ARTICLE 12 PROFESSIONAL STAFF ..................................................................................... 20

12.1 Professional Staff ........................................................................................................ 20

12.2 Clinical Policies .......................................................................................................... 21

12.3 Departmental Clinical Policies ................................................................................... 21

ARTICLE 13 APPOINTMENT AND RE-APPOINTMENT TO THE PROFESSIONAL STAFF....................................................................................................................................................... 21

13.1 Appointment and Reappointment ............................................................................... 21

13.2 Qualifications and Criteria for Appointment to the Professional Staff ...................... 22

13.3 Application for Appointment to the Professional Staff .............................................. 24

13.4 Procedure for Processing Applications for Professional Staff Appointments ............ 25

13.5 Re-appointment to the Professional Staff ................................................................... 26

13.6 Application for Change in Privileges ......................................................................... 28

ARTICLE 14 CATEGORIES OF THE PROFESSIONAL STAFF ............................................ 29

14.1 Professional Staff Categories ...................................................................................... 29

14.2 Active Staff ................................................................................................................. 29

14.3 Associate Staff ............................................................................................................ 30

14.4 Courtesy Staff ............................................................................................................. 32

14.5 Consulting Staff .......................................................................................................... 32

14.6 Locum Tenens Staff .................................................................................................... 33

14.7 Temporary Staff .......................................................................................................... 35

14.8 Telemedicine and Educational Staff ........................................................................... 36

14.9 Honorary Staff .......................................................................................................... 399

ARTICLE 15 PROFESSIONAL STAFF DUTIES AND RESPONSIBILITIES ........................ 39

15.1 Duties, General ........................................................................................................... 39

15.2 Transfer of Accountability .......................................................................................... 41

15.3 Leave of Absence ....................................................................................................... 42

ARTICLE 16 MONITORING, SUSPENSION, AND REVOCATION OF PRIVILEGES ........ 43

16.1 Monitoring Practices and Transfer of Responsibility ................................................. 43

16.2 Suspension or Restriction of Privileges, or Revocation of Appointment ................... 44

16.3 Immediate Action ....................................................................................................... 44

16.4 Non-Immediate Action ............................................................................................... 45

16.5 Referral to Medical Advisory Committee for Recommendations .............................. 46

16.6 Board Hearing............................................................................................................. 47

(iv)

ARTICLE 17 CHIEF OF STAFF ................................................................................................. 48

17.1 Appointment of Chief of Staff .................................................................................... 48

17.2 Duties of Chief of Staff .............................................................................................. 49

ARTICLE 18 PROFESSIONAL STAFF DEPARTMENTS ....................................................... 49

18.1 Professional Staff Departments and Divisions ........................................................... 49

18.2 Appointment of Chief of Department ......................................................................... 50

18.3 Appointment and Duties of Division Lead ................................................................. 50

18.4 Duties of Chief of Department ................................................................................... 50

18.5 Duties of Division Lead .............................................................................................. 50

ARTICLE 19 MEDICAL ADVISORY COMMITTEE ............................................................... 50

19.1 Composition of Medical Advisory Committee .......................................................... 50

19.2 Medical Advisory Committee Duties and Responsibilities ........................................ 51

19.3 Establishment of Committees of the Medical Advisory Committee .......................... 52

19.4 Quorum for Medical Advisory Committee and Sub-Committee Meeting ................. 52

ARTICLE 20 MEETINGS OF THE PROFESSIONAL STAFF ASSOCIATION ..................... 52

20.1 Regular, Annual and Special Meetings of the Professional Staff Association ........... 52

20.2 Quorum ....................................................................................................................... 53

20.3 Rules of Order ............................................................................................................ 53

ARTICLE 21 ELECTED OFFICERS OF THE PROFESSIONAL STAFF ASSOCIATION .... 53

21.1 Officers of the Professional Staff Association ........................................................... 53

21.2 Eligibility for Office ................................................................................................... 53

21.3 Nominations and Election Process ............................................................................. 53

21.4 President of the Professional Staff Association .......................................................... 54

21.5 Vice President of the Professional Staff Association ................................................. 54

21.6 Secretary of the Professional Staff Association ......................................................... 54

21.7 Succession Planning ................................................................................................... 55

ARTICLE 22 DENTAL STAFF ................................................................................................... 55

22.1 Criteria ........................................................................................................................ 55

22.2 Categories ................................................................................................................... 55

ARTICLE 23 EXTENDED CLASS NURSING STAFF ............................................................. 56

23.1 Categories ................................................................................................................... 56

23.2 Courtesy Staff ............................................................................................................. 56

23.3 Locum Tenens Staff .................................................................................................... 56

23.4 Duties .......................................................................................................................... 56

(v)

ARTICLE 24 AMENDMENTS ................................................................................................... 57

24.1 Amendment ................................................................................................................ 57

24.2 Effect of Amendment ................................................................................................. 57

24.3 Member Approval....................................................................................................... 57

24.4 Amendments to Professional Staff By-laws ............................................................... 57

PREAMBLE

WHEREAS it is the intent of the Corporation to serve the community, and whereas the mission of the Corporation is:

Together with our community and guided by our values, we provide quality, patient-centred health care;

WHEREAS the Board deems it expedient that By-Law No. 1-12 heretofore enacted be revoked and that the following By-Law No. 1-13 be adopted for regulating the affairs of the Corporation;

NOW THEREFORE be it enacted and it is hereby enacted that By-Law No. 1-12 heretofore enacted be revoked and that the following By-Law No. 1-13 be substituted in lieu thereof.

ARTICLE 1 DEFINITIONS AND INTERPRETATION

1.1 Definitions

In this By-Law and all other By-Laws of the Corporation:

(a) “Associates” in relation to an individual means the individual’s parents, siblings, spouse or common law partner, and includes any organization, agency, company, or individual (such as a business partner) with a formal business relationship to the individual;

(b) “Board” means the board of directors of the Corporation;

(c) “By-Law” means any by-law of the Corporation from time to time in effect;

(d) “Certification” means holding a certificate in a medical, surgical, dental or midwifery specialty issued by any professional body recognized by the Board after consultation with the Medical Advisory Committee;

(e) “Chair” means the Director elected by the Board to serve as Chair of the Board;

(f) “Chief Executive Officer” means, in addition to “administrator” as defined in the Public Hospitals Act, the person who has for the time being the direct and actual superintendence and charge of the Corporation and may be designated as President and Chief Executive Officer;

(g) “Chief Nursing Executive” means the senior employee appointed by the process established by the Chief Executive Officer and responsible to the Chief Executive Officer for the nursing functions and practices in the Hospital;

(h) “Chief of a Department” means the member of the Professional Staff who has been appointed by the Board to be responsible for the professional standards and

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quality of care and appropriate behaviour rendered by the members of that Department;

(i) “Chief of Staff” means the member of the Medical Staff who has been appointed by the Board to be responsible for the professional standards and quality of care and appropriate behaviour rendered by the members of the Professional Staff;

(j) “Clinical Policies” means the provisions approved by the Board concerning the practice and professional conduct of the members of the Medical Staff, Dental Staff, Midwifery Staff and Extended Class Nursing Staff in the Hospital both generally and within a particular Department;

(k) “College” means, as the case may be, the College of Physicians and Surgeons of Ontario, the Royal College of Dental Surgeons of Ontario, the College of Midwives of Ontario, and/or the College of Nurses of Ontario;

(l) “Committee” means a committee of the Board or as otherwise specified in this By-Law;

(m) “Corporation” means Guelph General Hospital with the head office located at 115 Delhi Street, Guelph, Ontario N1E 4J4;

(n) “Corporations Act” means the Corporations Act (Ontario) and, where the context requires, includes the regulations made under it;

(o) “CPSO” means the College of Physicians and Surgeons of Ontario;

(p) “Credentials Committee” means a subcommittee of the Medical Advisory Committee tasked with reviewing all applications and re-applications for privileges;

(q) “Day” means a calendar day;

(r) “Dental Staff” means those Dentists who are appointed by the Board and who are granted privileges to practise dentistry in the Hospital;

(s) “Dentist” means a dental practitioner in good standing with the Royal College of Dental Surgeons of Ontario;

(t) “Department” means an organizational unit of the Professional Staff to which members with a similar field of practice have been assigned;

(u) “Director” means a member of the Board;

(v) “Disruptive Behaviour” occurs when the use of inappropriate words, actions, or inactions by a Professional Staff member interferes with their ability to function well with others to the extent that the behaviour interferes with, or is likely to

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interfere with, quality health care delivery and/or patient or workplace safety and/or staff recruitment, retention and the cost of providing health care to patients;

(w) “Division” means an organizational unit of a Department;

(x) “Division Lead” means the Physician, Dentist, or Midwife appointed by the Board to be in charge of one of the organized Divisions of a Department;

(y) “Ex-officio” means membership “by virtue of the office” and includes all rights, responsibilities, and power to vote unless otherwise specified in the By-Law or Legislation;

(z) “Extended Class Nursing Staff” means those Registered Nurses in the Extended Class (nurse practitioners) who are:

(i) employed by the Corporation and are authorized to diagnose, prescribe for, or treat Patients in the Hospital; and

(ii) not employed by the Corporation and to whom the Board has granted privileges to diagnose, prescribe for, or treat patients in the Hospital;

(aa) “Fellowship” means a membership in a professional medical or dental College recognized by the Board after consultation with the Medical Advisory Committee;

(bb) “Hospital” means the public hospital operated by the Corporation;

(cc) “Impact Analysis” means a study conducted by the Chief Executive Officer or designate, in consultation with the Chief of Staff and applicable Chief of Department to determine the impact upon the resources of the Corporation of the proposed or continued appointment of any person to the Professional Staff;

(dd) “Individual” means a natural person, other than a natural person in their capacity as trustee, executor, administrator, or other legal representative;

(ee) “Legislation” means relevant statutes and regulations that govern the Hospital;

(ff) “Medical Advisory Committee” means the committee established pursuant to Article 19;

(gg) “Medical Staff” means those Physicians who are appointed by the Board and who are granted privileges to practise medicine in the Hospital;

(hh) “Member” means a member of the Corporation;

(ii) “Midwife” means a midwife in good standing with the College of Midwives of Ontario;

(jj) “Midwifery Staff” means those Midwives who are appointed by the Board and who are granted privileges to practise midwifery in the Hospital;

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(kk) “Officer” means the Board officers set out in section 5.1(a);

(ll) “Oral and Maxillofacial Surgeon” means those members of the Dental Staff who hold a specialty certificate from the Royal College of Dental Surgeons of Ontario authorizing practice in oral and maxillofacial surgery;

(mm) “Patient” means any “in-patient” or “out-patient” of the Corporation;

(nn) “Physician” means a medical practitioner in good standing with the CPSO;

(oo) “Policies” means the Board, administrative, and Clinical Policies of the Corporation;

(pp) “Professional Staff” means the Medical Staff, Dental Staff, Midwifery Staff, and members of the Extended Class Nursing Staff who are not employees of the Corporation;

(qq) “Professional Staff Clinical Human Resource Plan” means the plan developed by the Chief of Staff in consultation with the Chief Executive Officer and Chiefs of Department based on the mission and strategic plan of the Corporation and on the needs of the community, which plan provides information and future projections of this information with respect to the management and appointment of Physicians, Dentists, Midwives, and Registered Nurses in the Extended Class;

(rr) “Public Hospitals Act” means the Public Hospitals Act (Ontario) and, where the context requires, includes the regulations made under it;

(ss) “Registered Nurses in the Extended Class” (nurse practitioners) means those members of the College of Nurses of Ontario, who are registered nurses and who hold an extended certificate of registration under the Nursing Act, 1991;

(tt) “Special Resolution” means a resolution passed by the Board and confirmed with or without variation by at least two thirds of the votes cast at a special meeting of the Members duly called for that purpose or at an annual meeting of the Members, or in lieu of such confirmation, by consent in writing of all Members entitled to vote at such meeting; and

(uu) “Specialist” means a practitioner with either a Certification or Fellowship.

1.2 Interpretation

This By-Law shall be interpreted in accordance with the following, unless the context otherwise specifies or requires:

(a) Any Director or Committee member may participate in a meeting of the Board, or of a Committee of the Board, by telephonic or electronic means that permit all participants to communicate adequately with each other during the meeting. A person so participating in a meeting is deemed to be present at the meeting. The

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provisions of this section (a) shall not apply to the Professional Staff portion of this By-Law.

(b) Subject to section (a) above, business arising at any meeting of the Members, the Board, or any Committee, Department, or Division established pursuant to this By-Law shall be decided by a majority of votes, unless otherwise required by statute.

(c) Except as provided in this By-Law, each Member, each Director, each Committee member, and each Department/Division member shall be entitled to one vote at any meeting of the Members, Board, Committee, or Department/Division respectively.

(d) Any ex-officio Director or Committee member entitled to vote shall be counted towards quorum. Non-voting Directors and Committee members shall not count towards quorum.

(e) Votes shall be taken in the usual way, by show of hands or voice vote, among all Members, Directors, and Committee members present and, in the event of a tie, the Chair shall vote at a meeting of the Members in order to break the tie.

(f) After a show of hands or voice vote has been taken on any question, the chair of the meeting may require, or any person entitled to vote on the question may demand, a poll thereon. A poll so required or demanded shall be taken in such manner as the chair of the meeting shall direct. A demand for a poll may be withdrawn at any time prior to the taking of the poll. Upon a poll, each individual present in person and entitled to vote at such meeting shall have one vote, and the result of the poll shall be the decision of the Members, the Board, or the Committee, as the case may be.

(g) Whenever a vote by show of hands or voice vote shall have been taken on a question, unless a poll is required or demanded, a declaration by the chair of the meeting that a motion has been carried and an entry to that effect in the minutes shall be admissible in evidence as prima facie proof of the fact without proof of the number or proportion of the votes recorded in favour of or against such motion.

(h) In accordance with the Public Hospitals Act, no Member shall be entitled to vote by proxy at a Members’ meeting.

(i) Words importing the singular number include the plural and vice versa; words importing one gender include the all genders; and words importing persons include individuals and entities.

(j) The headings used in this By-Law are inserted for reference purposes only and are not to be considered or taken into account in construing the terms or provisions hereof or to be deemed in any way to clarify, modify, or explain the effect of any such terms or provisions.

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(k) Any references herein to any Legislation or regulation shall be construed as a reference thereto as amended or re-enacted from time to time or as a reference to any successor thereto.

(l) All terms which are contained in this By-Law and which are defined in the Public Hospitals Act or the Corporations Act shall have the meanings given to such terms in the Public Hospitals Act or the Corporations Act.

(m) Minutes shall be kept for all meetings of the Members, the Board, or any Committee.

(n) The accidental omission to give any notice to any Member, Director, Officer, Committee member, or the auditor of the Corporation, or the non-receipt of any notice by any Member, Director, Officer, Committee member, or the auditor of the Corporation, or any error in any notice not affecting the substance of it, shall not invalidate any action taken at any meeting held pursuant to the notice or otherwise founded on it.

(o) Where any individual in an administrative or medical leadership role is assigned a duty under this By-Law, that individual may delegate, where necessary, such duty to a delegate under their leadership, provided that the leader so delegating remains ultimately responsible for the performance of the duty. Notwithstanding the foregoing, nothing in this section allows any individual who serves as a Director to delegate their duty to attend and vote at any Board meeting.

(p) Any reference in this By-Law to a requirement that the Corporation or a person provide information or a document in writing to another is satisfied by the provision of the information or document in an electronic form that is: accessible by the other person so as to be usable for subsequent reference; and is capable of being retained by the other person; however, this does not apply to notice requirements relating to Members unless such Members have consented in writing.

1.3 Rules of Order

Any questions of procedure at or for any meetings of the Members, of the Board, of any Committee, including the Medical Advisory Committee, of any Department/Division meeting, or of the Professional Staff Association, which have not been provided for in this By-Law, or by the Corporations Act, Public Hospitals Act, or Policies of the Hospital, shall be determined by the Chair in accordance with the rules of procedure adopted by the Board, or failing such adoption, adopted by the chair of the meeting.

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ARTICLE 2 BOARD OF DIRECTORS

2.1 Board Composition

The composition of the Board shall be as follows:

(a) Elected Voting Directors:

(i) The Board shall be comprised of no fewer than 12 and no more than 14 elected Directors. The number of Directors shall be determined from time to time by Special Resolution of the Board.

(b) Ex-officio Non-Voting Directors:

The following shall serve in an ex-officio capacity and shall not be entitled to vote at Board meetings:

(i) the Chair of the Medical Advisory Committee;

(ii) the President of the Professional Staff Association;

(iii) the CEO; and

(iv) the Chief Nursing Executive.

2.2 Qualifications of Directors

(a) No member of the Professional Staff or employee of the Hospital shall be eligible for appointment to the Board, other than those persons who are required to be on the Board by virtue of their respective offices as contemplated by the Public Hospitals Act.

(b) No spouse, common law partner, child, parent, brother, or sister of any person identified in section (a) above, nor the spouse or common law partner of any such child, parent, brother, or sister shall be eligible for appointment to the Board.

(c) No person may be appointed a Director before reaching 18 years of age.

(d) No person who has the status of bankrupt shall be a Director.

(e) No person who is not an Individual shall be a Director.

(f) No person who has been found under the Substitute Decisions Act, 1992 or under the Mental Health Act to be incapable of managing property shall be a Director.

(g) No person who has been found to be incapable by any court in Canada or elsewhere shall be a Director.

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2.3 Term

(a) Elected Directors shall be elected for a term not to exceed three years, provided that each Director shall hold office until the earlier of the date on which their office is vacated or until the end of the meeting at which their successor is elected or appointed. Four Directors shall retire from office each year subject to re-election as permitted by this By-Law. Except for the ex-officio Directors, no person may be elected or appointed for more terms than will constitute nine consecutive years of service, except a former Director may be re-elected or reappointed as a Director following a break in the continuous services of at least one year.

(b) Despite the foregoing:

(i) a Director may, by Board resolution, have their maximum term as a Director extended for the sole purpose of that Director succeeding to the office of Chair or serving as Chair; and

(ii) where a Director was appointed to fill an unexpired term of a Director, the partial unexpired term filled by the Director shall be excluded from the calculation of the maximum years of service.

2.4 Nominations for Appointment of Directors

Subject to all other provisions of this By-Law, nominations for appointment as a Director may be made only by the Board, on the recommendation of the Nominating Committee, in accordance with the Board Policy “Director Recruitment”.

2.5 Attendance at Meetings

A Director shall attend meetings of the Board and of Committees of the Board in accordance with the Board Policy “Attendance at Board and Committee Meetings”.

2.6 Vacancy and Termination of Office

(a) The office of an elected Director shall automatically be vacated if the Director:

(i) by notice in writing to the Secretary, resigns their office, which resignation shall be effective at the time it is received by the Secretary or at the time specified in the notice, whichever is later; or

(ii) fails to meet the qualifications set out in section 2.2.

(b) So long as there is a quorum of Directors in office:

(i) the remaining Directors may exercise all the powers of the Board; and

(ii) any vacancy occurring in the Board may be filled by a qualified person appointed for the remainder of the term by the Directors then in office. In

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the absence of a quorum of the Board, or if the vacancy has arisen from a failure of the Members to elect the number of Directors required to be elected at any Members’ meeting, the Board shall forthwith call a Members’ meeting to fill the vacancy. A Director so appointed or elected shall hold office for the unexpired portion of the vacated term.

2.7 Responsibilities of the Board

The Board shall be responsible for the governance and oversight of the management of the activities and affairs of the Corporation.

2.8 No Remuneration

The Directors shall serve as such without remuneration, and no Director shall directly or indirectly receive any profit from their position as such, provided that a Director may be paid reasonable expenses incurred by them in the performance of their duties as a Director.

2.9 Conflict of Interest

(a) Any Director, who is in any way, directly or indirectly, interested in a contract or proposed contract with the Corporation shall disclose in writing or have entered in the minutes, the nature and extent of such Director’s interest in such contract or proposed contract.

(b) The disclosure required by section 2.9(a), shall be made:

(i) at the meeting at which a proposed contract is first considered if the Director is present, and otherwise, at the first meeting after the Director becomes aware of the contract or proposed contract;

(ii) if the Director was not then interested in a proposed contract, at the first meeting after such Director becomes so interested; or

(iii) if the Director becomes interested after a contract is made, at the first meeting held after the Director becomes so interested.

(c) A Director referred to in section 2.9(a) is not liable to account for any profit made on the contract by the Director or by a corporate entity, business firm, or organization in which the Director has a material interest, provided:

(i) the Director disclosed the Director’s interest in accordance with section 2.9(b); and

(ii) the Director has not voted on the contract.

(d) A Director referred to in section (a) shall not vote on any resolution to approve the contract and shall not take part in the discussion or consideration of, or in any way

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attempt to influence the voting on, any question with respect thereto, and shall exit the meeting when the applicable issue is under consideration.

(e) For the purposes of this section, a general notice to the Board by a Director declaring that the person is a director or officer of or has a material interest in a body corporate, business firm, or organization and is to be regarded as interested in any contract made therewith, is a sufficient declaration of interest in relation to any contract so made.

(f) The provisions of this Article are in addition to any conflict of interest policy adopted by the Board from time to time.

2.10 Confidentiality and Public Relations

(a) Every Director, Officer, member of the Professional Staff, and employee of the Corporation shall respect the confidentiality of matters brought before the Board or before any Committee, subcommittee, or task force, or any matter dealt with in the course of the employee’s employment or of the Professional Staff member’s activities in the Corporation.

(b) The Board may give authority to one or more Directors, Officers, or employees of the Corporation to make statements to the news media or public about matters brought before the Board. Refer to the Board Policy “Communication with the Media and the Public”.

2.11 Indemnification and Insurance

(a) Subject to sections 2.11(c) and 2.11(d), the Corporation shall indemnify the Directors and Officers (and once the Ontario Not-for-profit Corporations Act is proclaimed in force the former Directors or Officers) against all costs, charges and expenses, including an amount paid to settle an action or satisfy a judgment, reasonably incurred by the individual in respect of any civil, criminal, administrative, investigative, or other action or proceeding in which the individual is involved because of that association with the Corporation, except for the costs, charges, or expenses as are occasioned by the individual’s own wilful neglect or default.

(b) The Corporation shall advance money to the Director or Officer for the costs, charges, and expenses of an action or proceeding referred to in that section, but the individual shall repay the money if the individual does not fulfil the conditions set out in section 2.11(c).

(c) The Corporation shall not indemnify an individual under section 2.11(a) unless:

(i) the individual acted honestly and in good faith with a view to the best interests of the Corporation; and

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(ii) if the matter is a criminal or administrative proceeding that is enforced by a monetary penalty, the individual had reasonable grounds for believing that their conduct was lawful.

(d) The indemnity provided for in section 2.11(a) shall not apply to any liability which a Director or Officer may sustain or incur as the result of any act or omission as a member of the Professional Staff.

(e) The Corporation shall purchase and maintain insurance for the benefit of an individual referred to in section 2.11(a) against any liability incurred by the individual in the individual’s capacity as a Director or Officer and covered by the indemnification provisions in this By-Law.

ARTICLE 3 MEETINGS OF THE BOARD

3.1 Attendees

(a) The press and public may attend open meetings of the Board. The Board may move to a closed meeting to discuss confidential issues. See Board Policy “Open and Closed Meetings and Confidentiality”. All matters discussed at a closed meeting are confidential and may not be disclosed outside the Board unless the Board has agreed that such disclosure is appropriate or necessary.

(b) Members of the public and invited guests who attend Board meetings shall not interfere with the orderly conduct of the meeting. The Chair shall control all meetings of the Board and may expel any person for improper conduct at a meeting of the Board.

3.2 Regular Meetings of the Board

(a) At the beginning of each Board year a list of the dates for all regularly scheduled Board meetings shall be prepared, and the list of the meetings shall be given to the Directors and shall be made available to the public, and no other notice shall be required for any regular meeting.

(b) The Board shall meet at the head office of the Corporation or such other place, as the Board may from time to time determine.

(c) The Secretary shall give notice of the meeting to the Directors if the meeting is to be held at another time or day or at a place other than the head office. If such notice is to be given, it shall be delivered, e-mailed, faxed, or telephoned to each Director at least 24 hours in advance of the meeting or shall be mailed to each Director at least five days in advance of the meeting. Notice of time and place of the meeting shall be made available to the public.

(d) A meeting of the Board may be held without notice, immediately following the annual Members’ meeting.

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(e) The declaration of the Secretary or Chair that notice has been given pursuant to the By-Law shall be sufficient and conclusive evidence of the giving of such notice.

3.3 Special Meetings of the Board

(a) The Chair may call special meetings of the Board.

(b) The Secretary shall call a special meeting of the Board if three Directors so request in writing.

(c) Notice of a special meeting of the Board shall specify the purpose of the meeting, may be delivered, e-mailed, faxed, or telephoned to each Director, and shall be given at least 24 hours in advance of the meeting.

(d) If a special meeting of the Board is called that is not a closed session of the Board, as soon as the meeting is called, notice of time and place of the meeting also shall be made available to the public.

3.4 Chair

Board meetings shall be chaired by:

(a) the Chair;

(b) one of the Vice-Chairs, if the Chair is absent or unable to act; or

(c) a Director elected by the Directors present if the Chair and Vice-Chair are both absent or unable to act.

3.5 Quorum

A quorum for any meeting of the Board shall be a majority of the Directors entitled to vote.

3.6 Adjourned Meetings

If, within one-half hour after the time appointed for a Board meeting, a quorum is not present, the meeting shall stand adjourned until a day within two weeks to be determined by the Chair. At least 48 hours’ notice of the rescheduled meeting shall be given.

ARTICLE 4 MEMBERS

4.1 Members

The Members shall consist of the Directors from time to time, who shall be ex-officio Members for so long as they serve as Directors. Membership is not transferrable and ceases upon the Member ceasing to be a Director. No fees shall be payable by the Members.

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4.2 Annual Members’ Meetings

The annual meeting shall be held between the 1st day of April and the 31st day of July in each year on a day fixed by the Board.

4.3 Special Members’ Meetings

(a) The Chair may call a special Members’ meeting.

(b) The notice of a Members’ meeting at which special business is to be transacted must state the nature of that business in sufficient detail to permit a Member to form a reasoned judgment on the business and state the text of any special resolution to be submitted to the meeting.

4.4 Location of Members’ Meetings

Annual and special meetings of Members may be held at the head office of the Corporation or at any place in the Province of Ontario as the Board may determine.

4.5 Notice of Members’ Meetings

(a) Notice of the annual meeting shall be given to each Member by one of the following methods:

(i) by prepaid registered mail at least ten days but not more than 50 days in advance of the meeting, to the address shown on the records of the Corporation;

(ii) by electronic communication (including facsimile and e-mail) at least ten days but not more than 50 days in advance of the meeting to the electronic address shown on the records of the Corporation, provided the Member has consented to receiving notices in such manner; or

(iii) by publication once a week for two consecutive weeks next preceding the meeting in a newspaper circulated in the municipality or municipalities in which Members reside as shown by their addresses on the records of the Corporation.

(b) A Member or any other person entitled to notice of a meeting of Members may waive notice of any meeting of Members. Attendance of any Member at a meeting of Members shall constitute a waiver of notice of the meeting, except where such Member attends such meeting for the express purpose of objecting to the transaction of any business on the grounds that the meeting is not lawfully called. Meetings of Members, held without notice, shall be deemed to be duly called and held if all of the Members waive notice of the meeting and consent to the transaction of such business as may have come before it, subject to a quorum being present at such meeting.

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4.6 Chair

(a) The chair of a Members’ meeting shall be:

(i) the Chair; or

(ii) one of the Vice-Chairs of the Board, if the Chair is absent; or

(iii) a chair elected by the Members present if the Chair and the Vice-Chair are absent.

(b) If, within one-half hour after the time appointed for a Members’ meeting, a quorum is not present, the meeting shall stand adjourned until a day within two weeks to be determined by the Chair. At least 48 hours’ notice of the rescheduled meeting shall be given.

4.7 Quorum

A quorum for any Members’ meeting shall be a majority of the Members.

4.8 Removal of Directors

(a) The office of an elected Director may be vacated by a resolution of the Members if:

(i) a Director does not comply with the Board attendance Policy;

(ii) a Director fails to comply with the Legislation, the By-law and Policies, including without limitation, the confidentiality and conflict of interest provisions contained in this By-Law; and/or

(iii) for any other reason deemed appropriate by the Members.

(b) At the next annual meeting in addition to the election of Directors to fill the vacancies caused by expiry of Directors’ terms, the meeting shall elect an additional Director to fill the unexpired term created by any vacancy referred to in section 4.8(a) above as per the Board Recruitment Policy.

4.9 Financial Year of the Corporation

The financial year of the Corporation shall end with the 31st day of March in each year.

ARTICLE 5 OFFICERS

5.1 Officers

(a) The following shall be the Officers:

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(i) the Chair;

(ii) one or more Vice-Chairs of the Board;

(iii) the Secretary of the Board; and

(iv) such other Officers as the Board may determine.

(b) The Directors shall appoint the Chair and Vice-Chair(s) of the Board from among themselves at the meeting immediately following each annual meeting at which the Directors are elected or at such other times when a vacancy occurs, in accordance with the Board Policy.

(c) The Chief Executive Officer shall serve as the Secretary, until the Board determines otherwise.

(d) Any Officer shall cease to hold office upon resolution of the Board.

(e) No Director may serve as Chair or Vice-Chair of the Board for longer than two consecutive years. An additional one year may be served upon Board resolution as per Board Policy.

5.2 Role and Responsibilities of the Chair

The roles and responsibilities of the Chair shall be set out in Board Policy.

5.3 Role and Responsibilities of the Vice-Chair(s) of the Board

The Vice-Chair of the Board shall have all the powers and perform all the responsibilities of the Chair in the absence or disability of the Chair and perform any other duties assigned by the Chair or the Board. Where two or more vice-chairs are appointed, they shall be designated First Vice-Chair, Second Vice-Chair, and so on. The Chair, or failing the Chair, the Board, shall designate which of the Vice-Chairs of the Board shall perform the duties and exercise the powers of the Chair in the Chair’s absence or disability.

5.4 Roles and Responsibilities of the Secretary

The Secretary shall carry out the duties of the secretary of the Corporation generally and shall attend or cause a recording secretary to attend meetings of the Members, Board, and Board Committees to act as a clerk thereof and to record all votes and minutes of all proceedings in the books to be kept for that purpose. The Secretary shall give or cause to be given notice of all meetings of the Members, the Board, and the Board Committees, and shall perform such other duties as may be prescribed by the By-law or the Board.

5.5 Roles and Responsibilities of Other Officers

The powers and duties of all other Officers shall be such as the Board may from time to time determine.

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ARTICLE 6 COMMITTEES OF THE BOARD

6.1 Establishment of Standing and Special Committees of the Board

The Board may establish Committees from time to time. The Board shall determine the duties of such Committees. The Board Committees shall be:

(a) standing committees, being those committees whose duties are normally continuous; and

(b) special committees, being those committees appointed for specific duties whose mandate shall expire with the completion of the tasks assigned.

The Board shall appoint the members of each Committee, the chair of the Committee and, if desirable, the vice chair thereof as per Board Policy. The members and the chair and vice chair of a Committee shall hold their office at the will of the Board. Each chair of a standing Committee shall be a member of the Board. Unless otherwise provided, the Chair and Chief Executive Officer shall be ex-officio members of all Committees.

6.2 Functions, Duties, Responsibilities, and Powers of Committees

The functions, duties, responsibilities, and powers of Committees shall be provided in the resolution of the Board by which such Committee is established or in terms of reference adopted by the Board.

(a) The Committees and structure will also support the annual objectives of the Board as identified by the Board. See the Board Policy “Board Committee Composition, Vice-Chair Position and Committee Chair Appointments”.

(b) The Board may by resolution dissolve any special Committee at any time.

(c) The Board’s standing and special Committees report to the Board.

(d) With the exception of Medical Advisory Committee, the membership of which is set out in this By-Law, the Board may appoint additional members who are not Directors to all Committees, and those persons shall be entitled to vote, but the number of non-Directors shall not exceed the number of Directors on a Committee. Participation by any non-Director on a Committee is conditional on such individual signing an acknowledgement that they:

(i) are a fiduciary of the Corporation and must place the interests of the Corporation above their own interests;

(ii) has read and understood the Conflict of Interest and confidentiality requirements of this By-Law, which apply to all such individuals; and

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(iii) agrees to participate in the Board’s orientation and continuing education program, as requested.

6.3 Call for Meetings of Standing and Special Committees

(a) Meetings of Committees, subcommittees, or task forces, including the Fiscal Advisory Committee, shall be held at the call of the Chair, the chair of the Committee or at the request of any two members of the Committee.

(b) The Medical Advisory Committee shall hold at least ten monthly meetings in each financial year of the Corporation.

6.4 Quorum for Meetings of Standing and Special Committees

A quorum for any meeting of a Committee, subcommittee, or task force of the Board, shall be a majority of the members of the Committee, subcommittee, or task force entitled to vote.

ARTICLE 7 CHIEF EXECUTIVE OFFICER

7.1 Appointment of the Chief Executive Officer

(a) The Chief Executive Officer shall be appointed by the Board in accordance with its approved selection process as per the CEO Recruitment Policy.

(b) The Board may at any time revoke or suspend the appointment of the Chief Executive Officer as per the CEO Agreement.

ARTICLE 8 RECORDS

8.1 Retention of Written Statements

The Chief Executive Officer shall cause to be retained for at least two (2) years, all written statements made in respect of the destruction of medical records, notes, charts, and other material relating to patient care and photographs thereof.

ARTICLE 9 FINANCIAL MATTERS

9.1 Banking Arrangements

The banking business of the Corporation or any part of it shall be transacted with such banks, trust companies, or other financial institutions as the Board may determine from time to time.

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9.2 Signing Officers

The Chair or Vice-Chair and the Chief Executive Officer jointly shall sign on behalf of the Corporation all contracts, agreements, conveyances, mortgages, or other documents, as may be required by law or as authorized by the Board as per the Board Policy “Signing Officers”.

In addition, the Board may from time to time direct the manner in which and the person or persons by whom any particular instrument or class of instruments or documents may or shall be signed. Any signing officer may affix the seal of the Corporation to any instrument or document, and may certify a copy of any instrument, resolution, By-Law, or other document of the Corporation to be a true copy.

9.3 Seal

The seal of the Corporation shall be in the form impressed hereon.

9.4 Investments

The Board may invest in any investments that are authorized by the Corporation’s investment Policy.

9.5 Auditor

(a) The Members shall at each annual meeting appoint an auditor who shall not be a member of the Board or an Officer or employee of the Corporation or a partner or employee of any such person, and who is duly licensed under the Public Accounting Act, 2004 (Ontario), to hold office until the next annual meeting, provided that the Board may fill any casual vacancy in the office of auditor.

(b) The auditor shall have all the rights and privileges as set out in the Corporations Act and shall perform the audit function as prescribed therein.

(c) In addition to making the report at the annual meeting, the auditor shall from time to time report to the Board on the audit work with any necessary recommendations.

(d) The Board shall fix the remuneration of the auditor.

ARTICLE 10 BORROWING POWERS

10.1 Borrowing Powers

The Board may, from time to time, on behalf of the Corporation, without authorization of the Members:

(a) borrow money on the credit of the Corporation;

(b) issue, sell, or pledge securities (including bonds, debentures, notes, or other similar obligations, secured or unsecured) of the Corporation; and

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(c) charge, mortgage, hypothecate, or pledge all or any of the real or personal property of the Corporation, including book debts and unpaid calls, rights and powers, franchises and undertakings, to secure any securities or for any money borrowed, or other debt, or any other obligation or liability of the Corporation.

ARTICLE 11 MATTERS REQUIRED BY THE ACT AND EXCELLENT CARE FOR ALL ACT

11.1 Required Committees and Programs

The Board shall ensure that the Corporation establishes such committees and undertakes such programs as are required under the Legislation, including a medical advisory committee, a quality committee, and a fiscal advisory committee.

11.2 Fiscal Advisory Committee

The Chief Executive Officer shall appoint the members of the fiscal advisory committee required to be established pursuant to the regulations under the Public Hospitals Act.

11.3 Chief Nursing Executive

The Chief Executive Officer shall ensure there are appropriate procedures in place for the appointment of the Chief Nursing Executive.

11.4 Nurses and other Staff and Professionals on Committees

The Chief Executive Officer shall from time to time approve a process for the participation of the Chief Nursing Executive, nurse managers, and staff nurses, staff, and other professionals of the Corporation in decision making related to administrative, financial, operational, and planning matters, and for the election or appointment of the Chief Nursing Executive, staff nurses or nurse managers, and other staff and professionals of the Corporation to those administrative committees approved by the Chief Executive Officer to have a nurse, staff, or professional representation.

11.5 Occupational Health and Safety Program

Pursuant to the regulations under the Public Hospitals Act, there shall be an Occupational Health and Safety Program for the Corporation, which shall include procedures with respect to: (i) a safe and healthy work environment; (ii) the safe use of substances, equipment, and medical devices; (iii) safe and healthy work practices; (iv) the prevention of accidents to persons on the premises; and (v) the elimination of undue risks and the minimizing of hazards inherent in the Corporation environment.

The person designated by the Chief Executive Officer to be in charge of occupational health and safety in the Corporation shall be responsible to the Chief Executive Officer or their delegate for the implementation of the Occupational Health and Safety Program. The Chief Executive Officer shall report to the Board as necessary on matters in respect of the Occupational Health and Safety Program.

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11.6 Health Surveillance Program

Pursuant to the regulations under the Public Hospitals Act, there shall be a Health Surveillance Program for the Corporation, which shall: (i) be in respect of all persons carrying on activities in the Corporation; and (ii) include a communicable disease surveillance program.

The person designated by the Chief Executive Officer to be in charge of health surveillance in the Corporation shall be responsible to the Chief Executive Officer or their delegate for the implementation of the Health Surveillance Program. The Chief Executive Officer shall report to the Board as necessary on matters in respect of the Health Surveillance Program.

11.7 Organ Donation

Pursuant to the regulations under the Public Hospitals Act, the Board shall approve procedures to encourage the donation of organs and tissues including: (a) procedures to identify potential donors; and (b) procedures to make potential donors and their families aware of the options of organ and tissue donations, and shall ensure that such procedures are implemented in the Corporation.

ARTICLE 12 PROFESSIONAL STAFF

12.1 Professional Staff

Articles 12 through 23 govern the Professional Staff practising within the Hospital, as contemplated by the regulations under the Public Hospitals Act. The purposes of these Articles are to:

(a) outline clearly and succinctly the purposes and functions of the Professional Staff Association;

(b) identify specific organizational units necessary to allocate the work of carrying out those functions;

(c) identify the process for the selection of the Chief of Staff (as per Board Policy), Chiefs of Department, and Division Leads, and for the election of the Professional Staff Association officers;

(d) provide the Professional Staff with a Medical Advisory Committee which has defined responsibility, authority, and accountability and that is designed to ensure that each Professional Staff member exercises responsibility and authority commensurate with the member’s contribution to patient care and fulfills like accountability obligations;

(e) provide a mechanism for accountability to the Board to promote best patient care, workplace safety, and professional and ethical behaviour of each individual member of the Professional Staff; and

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(f) create a Professional Staff Association structure that will advocate the interests of and support the rights and privileges of the Professional Staff as provided herein.

12.2 Clinical Policies

The Board, after consulting with the Professional Staff and considering the recommendation of the Medical Advisory Committee, may make Clinical Policies as it deems necessary, including those for patient care and safety and the conduct of members of the Professional Staff.

12.3 Departmental Clinical Policies

Each Department and Division will construct written Clinical Policies specific to their functioning in the Hospital as they deem necessary to supervise the patient care provided by the Professional Staff, to ensure workplace safety, and to ensure the behaviour of the members of the Professional Staff is consistent with the Public Hospitals Act, the By-law, the mission, vision and values of the Hospital, as well as the strategic plan. The Chief of Department or Division Lead, as may be appropriate, will consult and seek the comments of the members of their Department or Division in developing these Clinical Policies. Such Clinical Policies shall become effective when approved by the Medical Advisory Committee and the Board.

ARTICLE 13 APPOINTMENT AND RE-APPOINTMENT TO THE PROFESSIONAL STAFF

13.1 Appointment and Reappointment

(a) The Board, after considering the recommendations of the Medical Advisory Committee, shall appoint annually a Medical Staff and may appoint a Dental Staff, Midwifery Staff, and the non-employed members of the Extended Class Nursing Staff, and shall grant such privileges as it deems appropriate to each member of the Professional Staff so appointed. Unless revoked by the Board, appointments to the Professional Staff shall be for the period from July 1st, or any date thereafter, of any year until June 30th of the following year or for such shorter period of time as the Board may determine.

(b) Where a member of the Professional Staff has applied for reappointment within the time prescribed by the Medical Advisory Committee, the current appointment shall continue:

(i) until the reappointment is granted or not granted by the Board unless

(ii) the reappointment is not granted by the Board and there is a right of appeal to the Health Professionals Appeal and Review Board (HPARB). In such cases, the appointment shall continue until the time for giving notice of a hearing by the HPARB has expired or where a hearing is required, until the decision of the HPARB has become final.

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(c) All applications for appointment and reappointment to the Professional Staff shall be processed in accordance with the provisions of this By-law and the Public Hospitals Act.

(d) The Board may, at any time, make, or revoke any appointment to the Professional Staff or suspend or restrict the privileges of any member of the Professional Staff in accordance with the provisions of this By-law and the Public Hospitals Act. Applications for privileges relating to a service that the Hospital has ceased or ceases to provide pursuant to section 44 of the Public Hospitals Act shall not be considered and shall not be subject to the procedure for processing applications for Professional Staff appointments set out in Article 13.

13.2 Qualifications and Criteria for Appointment to the Professional Staff

(a) Only applicants who meet the qualifications and satisfy the criteria set out in this By-Law are eligible to be a member of, and appointed to, the Professional Staff.

(b) An applicant for appointment to the Professional Staff must meet the following qualifications:

(i) have adequate training and experience for the privileges requested;

(ii) have a demonstrated ability to:

a provide patient care at an appropriate level of quality and efficiency;

b work and communicate with, and relate to, others in a co-operative, collegial, and professional manner;

c communicate with, and relate appropriately to, patients and patients’ relatives and/or substitute decision makers;

d participate in the discharge of staff, committee and, if applicable, teaching responsibilities, and other duties appropriate to staff category;

e demonstrate an ability to communicate fluently in English, both written and orally;

f meet an appropriate standard of ethical conduct and behaviour; and

g govern themselves in accordance with the requirements set out in this By-Law, the Hospital’s mission, vision and values, and Policies;

(iii) have maintained the level of continuing professional education required by the applicable regulatory College;

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(iv) have up-to-date inoculations, screenings, and tests as may be required by the occupational health and safety policies and practices of the Hospital, the Public Hospitals Act or other legislation;

(v) demonstrate adequate control of any significant physical or behavioural impairment affecting skill, attitude, or judgment that might impact negatively on patient care or the operations of the Corporation; and

(vi) have current membership in the Canadian Medical Protective Association or professional practice liability coverage appropriate to the scope and nature of the intended practice.

(c) In addition to the qualifications set out in section 13.2(b), an applicant for appointment to the Medical Staff must meet the following qualifications:

(i) be qualified to practice medicine and licensed pursuant to the laws of Ontario and have a Certificate of Registration in good standing with the College of Physicians and Surgeons of Ontario or an equivalent certificate from their most recent licensing body; and

(ii) have a current Certificate of Professional Conduct from the College of Physicians and Surgeons of Ontario or the equivalent certificate from their most recent licensing body.

(d) In addition to the qualifications set out in section 13.2(b), an applicant for appointment to the Dental Staff must meet the following qualifications:

(i) be qualified to practice dentistry and licensed pursuant to the laws of Ontario and have a letter of good standing from the Royal College of Dental Surgeons of Ontario or the equivalent letter from their most recent licensing body; and

(ii) have a current Certificate of Professional Conduct from the Royal College of Dental Surgeons or the equivalent certificate from their most recent licensing body.

(e) In addition to the qualifications set out in section 13.2(b), an applicant for appointment to the Midwifery Staff must meet the following qualifications:

(i) be qualified to practice midwifery and be licensed pursuant to the laws of Ontario and have a Certificate of Registration in good standing with the College of Midwives of Ontario or an equivalent certificate from their most recent licensing body; and

(ii) have a current Certificate of Professional Conduct from the College of Midwives of Ontario or the equivalent certificate from their most recent licensing body.

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(f) In addition to the qualifications set out in section 13.2(b), an applicant for appointment to the Extended Class Nursing Staff must meet the following qualifications:

(i) be qualified to practice as a nurse in the extended class and hold a current, valid Annual Registration Payment Card as a registered nurse in the extended class with the College of Nurses of Ontario; and

(ii) have a letter of good standing from the Ontario College of Nurses or their most recent licensing body.

(g) All appointments, other than Locum 1 and Locum 2, will require an Impact Analysis demonstrating that the Hospital has the resources to accommodate the applicant and that the applicant meets the needs of the respective Department as described in the Professional Staff Clinical Human Resource Plan.

(h) In addition to any other provisions of the By-Law, including the qualifications set out in sections 13.2(b), the Board may refuse to appoint any applicant to the Professional Staff on any of the following grounds:

(i) the appointment is not consistent with the need for service, as determined by the Board from time to time;

(ii) the Professional Staff Clinical Human Resource Plan and/or the Impact Analysis of the Corporation does not demonstrate sufficient resources to accommodate the applicant; or

(iii) the appointment is not consistent with the strategic plan, mission, vision and values of the Corporation.

(i) Each applicant shall, where requested, visit the Hospital for an interview with the Chief of Staff, Chief of Department and, where appropriate, other members of the Professional Staff, the Chief Executive Officer and other members of the Hospital staff.

13.3 Application for Appointment to the Professional Staff

(a) The Chief Executive Officer shall supply a copy of, or information on how to access a form of the application and the mission, vision and values and strategic plan of the Corporation, the By-Law and the Clinical Policies and other appropriate Policies, to each Physician, Dentist, Midwife or Registered Nurse in the Extended Class who expresses in writing an intention to apply for appointment to the Professional Staff.

(b) An applicant for appointment to the Professional Staff shall submit to the Chief Executive Officer one original application in the prescribed form together with signed consents to enable the Hospital to make inquiries of the applicable College and other hospitals, institutions, and facilities where the applicant has previously

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provided professional services or received professional training to allow the Hospital to fully investigate the qualifications and suitability of the applicant.

13.4 Procedure for Processing Applications for Professional Staff Appointments

(a) The Chief Executive Officer, on receipt of a completed application on the prescribed forms, will deliver each original application forthwith to the Medical Advisory Committee through the Chair of the Medical Advisory Committee, who shall keep a record of each application received and then refer the original application forthwith to the chair of the Credentials Committee with a copy to the Chief of the relevant Department.

(b) The Credentials Committee shall review all materials in the application, receive the recommendation of the Chief of the relevant Department, ensure all required information has been provided, investigate the professional competence and verify the qualifications of the applicant, consider whether the qualifications and criteria required by this By-Law are met and shall submit a report as to its assessment and recommendation to the Medical Advisory Committee at its next regular meeting.

(c) The Medical Advisory Committee will receive and consider the report and recommendations of the Credentials Committee, review the application with reference to the Professional Staff Clinical Human Resource Plan and Impact Analysis and send its recommendation in writing to the Board within 60 days of the date of receipt by the Chief Executive Officer of the completed application, as outlined in the Public Hospitals Act. The Medical Advisory Committee may make its recommendation to the Board later than 60 days after the receipt of the completed application if, prior to the expiry of the 60-day period, it indicates in writing to the Board and the applicant that a final recommendation cannot yet be made and includes written reasons for the delay. The applicant may, in the application, waive the 60-day response time referenced above.

(d) Where the Medical Advisory Committee recommends the appointment, it shall specify the category of appointment and the specific privileges it recommends the applicant be granted.

(e) Where the Medical Advisory Committee does not recommend appointment or where the recommended appointment or privileges differ from those requested, the Medical Advisory Committee shall inform the applicant that they are entitled to:

(i) written reasons for the recommendation if a request is received by the Medical Advisory Committee within seven days of the receipt by the applicant of notice of the recommendation; and

(ii) a hearing before the Board if a written request is received by the Board and the Medical Advisory Committee within seven days of the receipt by the applicant of the written reasons referred to above.

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(f) Where the applicant does not request a hearing by the Board, the Board may implement the recommendation of the Medical Advisory Committee.

(g) Where an applicant requests a hearing by the Board, it shall be dealt with in accordance with the applicable provisions of the Public Hospitals Act and this By-Law.

(h) The Board shall consider the Medical Advisory Committee recommendations within the time frame specified by the Public Hospitals Act.

(i) The Board, in determining whether to make any appointment or reappointment to the Professional Staff or approve any request for a change in privileges shall take into account the recommendation of the Medical Advisory Committee and such other considerations, in its discretion, considers relevant including, but not limited to, the Professional Staff Clinical Human Resource Plan, Impact Analysis, strategic plan and the Corporation’s ability to operate within its resources.

13.5 Re-appointment to the Professional Staff

(a) Each year, each member of the Professional Staff desiring reappointment to the Professional Staff shall make application on the prescribed form to the Chief Executive Officer on or before March 31st.

(b) Each application for reappointment to the Professional Staff shall contain the following information:

(i) a restatement or confirmation of the undertakings and acknowledgements requested as part of an application for appointment;

(ii) either:

a a declaration that all information on file at the Hospital from the applicant’s most recent application is up-to-date, accurate, and unamended as of the date of the current application; or

b a description of all material changes to the information on file at the Hospital since the applicant’s most recent application, including without limitation: an updated curriculum vitae including any additional professional qualifications acquired by the applicant since the previous application and information regarding any completed disciplinary or malpractice proceedings, restriction in privileges, or suspensions during the past year;

(c) a report of the Chief(s) of the relevant Department(s), as the case may be, in accordance with a performance evaluation process approved by the Board from time to time, which report shall include the Chief of Department’s recommendation with respect to reappointment with the Hospital taking into consideration the following:

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(i) if the applicant is a Physician, satisfaction of the College’s requirements for continuing medical education using guidelines developed by the College of Family Physicians of Canada (Mainpro) and the Royal College of Physicians & Surgeons of Canada (Mocomp) or other guidelines issued by these colleges, or CPSO, or an educational program pre-approved by the Chief of Department as being equivalent for those applicants who are not bound by College requirements;

(ii) demonstration of professional attitudes and behaviours including communication skills with patient and staff;

(iii) record of all documented patient and staff complaints during the past year relating to the applicant’s quality of care and/or impact on workplace safety;

(iv) ability to work in a collegial, professional and non-disruptive manner with the Board, Chief Executive Officer, Vice-Presidents, the Chief Nursing Executive, the Chief of Staff, Chiefs of Department, Division Leads, other members of the Medical Advisory Committee, and other members of the Professional Staff, the nursing staff, other healthcare practitioners and learners within the Hospital and other employees of the Corporation;

(v) satisfactory discharge of “on-call” responsibilities, if any;

(vi) if applicable, teaching performance;

(vii) staff and committee responsibilities;

(viii) quality of care performance including, but not limited to, complications, infection rate, mortality rates, and any indications of performance that are available to the Chief of Department;

(ix) discharge of clinical, teaching, and research responsibilities;

(x) ability to supervise staff;

(xi) monitoring of patients, together with evidence of appropriate and completed records of personal health information;

(xii) resource utilization that demonstrates appropriate use of Hospital’s resources in accordance with the Professional Staff Clinical Human Resource Plan and the Policies of the Corporation;

(xiii) compliance with the Public Hospitals Act, applicable legislation, the By-Law, mission, vision and values, and Policies; and

(xiv) such other information that the Board may require, from time to time, having given consideration to the recommendations of the Medical Advisory Committee;

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(d) For greater certainty, the Chief of Department is only required to conduct such a detailed report in respect of each applicant’s reapplication on a three yearly basis so that in each credentialing year, at a minimum, the Chief of Department shall submit the report contemplated above in respect of one third of the members of the Department.

(i) where the Department has a Division of which the applicant is a member, the Division Lead shall make a recommendation to the Chief of Department, which recommendation shall be considered by the Chief of Department in their report; and

(ii) the Chief of Department shall, at least every third year, conduct a 360 degree performance evaluation of the applicant by canvassing senior management, nursing staff, and other Hospital staff regarding whether they have any concerns about the applicant’s quality of care, behaviour, or ability to comply with Clinical Policies that may impact the re-appointment of the applicant.

(e) the category of appointment requested and a request for either the continuation of, or any change in, existing privileges;

(f) if requested, a current Certificate of Professional Conduct or equivalent from the appropriate College or licensing body. An obligation exists to disclose any and all information that is, or could be, on the public register of the College of which the member is affiliated and to provide ongoing disclosure of any change in such information.

(g) such other information that the Board may require, respecting competence, capacity and conduct, having given consideration to the recommendation of the Medical Advisory Committee.

In the case of any application for reappointment in which the applicant requests additional privileges, each application for reappointment shall identify any required professional qualifications and confirm that the applicant holds such qualifications.

Application for reappointment shall be dealt with in accordance with the Public Hospitals Act and section 13.5 of this By-Law.

13.6 Application for Change in Privileges

(a) Each member of the Professional Staff who wishes to change their privileges, shall submit, on the prescribed form, to the Chief Executive Officer, an application listing the change of privileges requested, and providing evidence of appropriate training and competence and such other matters as the Board may require.

(b) The Chief Executive Officer shall refer any such application forthwith to the Medical Advisory Committee through the Chief of Staff, who shall keep a copy of

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each application received and shall then refer the original application forthwith to the Chair of the Credentials Committee and the Chief of the relevant Department.

(c) The Credentials Committee shall investigate the professional competence, verify the qualifications of the applicant for the privileges requested, receive the report of the Chief of Department, and shall submit a report of its findings to the Medical Advisory Committee at its next regular meeting. The report shall contain a list of privileges, if any, that it recommends that the applicant be granted.

ARTICLE 14 CATEGORIES OF THE PROFESSIONAL STAFF

14.1 Professional Staff Categories

(a) The Medical Staff, Dental Staff, and Midwifery Staff shall be divided into the following categories:

(i) Active;

(ii) Associate;

(iii) Courtesy;

(iv) Consulting;

(v) Locum Tenens;

(vi) Telemedicine and Educational

(vii) Honorary Staff; and

(viii) such categories as may be determined by the Board from time to time having given consideration to the recommendation of the Medical Advisory Committee.

(b) The Extended Class Nursing Staff may be divided into such categories as the Board may from time to time determine having given consideration to the recommendation of the Medical Advisory Committee.

(c) All new staff appointments relative to the Active and Consulting categories will be made to the Locum 3 category, unless waived by the Board on the recommendation of the Credentials Committee and the Medical Advisory Committee.

14.2 Active Staff

(a) The Active Staff shall consist of those Physicians, Dentists, and Midwives appointed to the Active Staff by the Board and who have completed satisfactory service as Locum 3 and Associate Staff of at least one year of both Locum 3 and

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Associate positions or who the Board, on the recommendation of the Medical Advisory Committee, appoints directly to the Active Staff.

(b) Each member of the Active Staff shall:

(i) have admitting privileges unless otherwise specified in their appointment and must have cared for at least one patient as the most responsible practitioner (MRP) during the preceding year;

(ii) attend patients and undertake treatment and operative procedures only in accordance with the kind and degree of privileges granted by the Board;

(iii) be responsible to the Chief of Department to which they have been assigned for all aspects of patient care;

(iv) act as a mentor to other members of the Medical Staff, Dental Staff, Midwifery Staff, or Extended Class Nursing Staff when requested by the Chief of Staff or the Chief of the Department to which they have been assigned;

(v) fulfil such on-call requirements as may be established by each Department or Division in accordance with the Professional Staff Clinical Human Resource Plan, and Policies;

(vi) perform such other duties as may be prescribed by the Medical Advisory Committee or requested by the Chief of Staff or Chief of the relevant Department from time to time;

(vii) if a Physician, be entitled to attend and vote at Professional Staff Association meetings and be eligible to be an elected or appointed officer of the Professional Staff Association; and

(viii) if a Dentist, Midwife, or Registered Nurse in the Extended Class, be entitled to attend Professional Staff Association meetings but shall not have a vote or be an elected or appointed officer of the Professional Staff Association.

14.3 Associate Staff

(a) The Associate Staff shall consist of Physicians, Dentists, and Midwives who are appointed to this category for a further probationary period of one year following the Locum 3 period to provide the Hospital with an opportunity to conduct a more thorough evaluation of the member’s qualifications, skill, expertise, behaviours, and collegiality in order to determine whether the applicant should be appointed as an Active or Consulting Staff member with an expectation, subject to the Legislation and the By-Law, of continued yearly appointments at the Hospital.

(b) Each member of the Associate Staff shall:

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(i) have admitting privileges unless otherwise specified in their appointment and must have cared for at least one patient as the most responsible practitioner (MRP) during the preceding year;

(ii) work under the mentorship of an Active Staff member named by the Chief of Staff to whom they have been assigned;

(iii) undertake such duties in respect of patients as may be specified by the Chief of Staff and, if appropriate, by the Chief of the relevant Department to which they have been assigned;

(iv) fulfil such on call requirements as may be established by each Department or Division and in accordance with the Professional Staff Clinical Human Resource Plan and the Clinical Policies;

(v) perform such other duties as may be prescribed by the Medical Advisory Committee or requested by the Chief of Staff or Chief of the relevant Department from time to time;

(vi) if a Physician, be entitled to attend Professional Staff Association meetings but shall not have a vote or be an elected or appointed officer of the Professional Staff Association; and

(vii) if a Dentist, Midwife, or Registered Nurse in the Extended Class, be entitled to attend Professional Staff Association meetings but shall not have a vote or be an elected or appointed officer of the Professional Staff Association.

(c) At six month intervals following the appointment of an Associate Staff member to the Professional Staff, the Active Staff member by whom the Associate Staff member has been supervised shall complete a performance evaluation and shall make a written report to the Chief of Staff, concerning:

(i) the knowledge and skill that has been shown by the Associate Staff member;

(ii) the nature and quality of their work in the Corporation; and

(iii) their performance and compliance with the criteria set out in Article 13. The Chief of Staff shall forward such report to the Credentials Committee.

(d) Upon receipt of the report, the appointment of the member of the Associate Staff shall be reviewed by the Credentials Committee, which shall make a recommendation to the Medical Advisory Committee.

(e) If any report made is not favourable to the Associate Staff member, the Medical Advisory Committee may recommend to the Board the appointment of the Associate Staff member be terminated at the end of the current application period.

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(f) No member of the Associate Staff shall be recommended for appointment to the Active Staff unless they have been a member of the Associate Staff for at least one year. In no event shall an appointment to the Associate Staff be continued for more than two years.

(g) Notwithstanding the two year limit, any international medical graduate shall remain in the Associate Staff category until such time as they have met the requirements of the CPSO/CFPC and/or the RCPS(C) allowing them to practice independently.

14.4 Courtesy Staff

(a) The Courtesy Staff shall consist of those Physicians, Dentists, and Midwives appointed by the Board to the Courtesy Staff in one or more of the following circumstances:

(i) the applicant meets a specific service need of the Corporation; or

(ii) where the Board deems it otherwise advisable and in the best interests of the Corporation.

(b) Members of the Courtesy Staff shall:

(i) have such limited privileges as may be granted by the Board on an individual basis;


(iii) be responsible to the Chief of Department to which they have been assigned for all aspects of patient care; and

(iv) be entitled to attend Professional Staff Association meetings but shall not have a vote or be an elected or appointed officer of the Professional Staff Association.

14.5 Consulting Staff

(a) The Consulting Staff shall consist of those Physicians appointed by the Board to the Consulting Staff in one or more of the following circumstances:

(i) the applicant meets a specific service need of the Corporation; or

(ii) where the Board deems it otherwise advisable and in the best interests of the Corporation.

(b) Members of the Consulting Staff shall:

(i) have such privileges as may be granted by the Board on an individual basis because of special knowledge, skills, and/or experience and are Specialists

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with a Fellowship in their specialty; or are Specialists with Certification in their specialty;


(iii) not admit but may treat patients admitted by the Active or Associate Staff; and may see patients in the Emergency Department or Ambulatory Care Unit if requested;

(iv) be responsible to the Chief of Department to which they have been assigned for all aspects of patient care; and

(v) be entitled to attend Professional Staff Association meetings but shall not have a vote or be an elected or appointed officer of the Professional Staff Association.

14.6 Locum Tenens Staff

(a) The Locum Tenens Staff shall consist of those Physicians, Dentists, or Midwives who have been admitted to the Locum Tenens Staff by the Board in order to meet specific clinical needs for a defined period of time in one or more of the following circumstances:

(i) to be a planned replacement for a Physician, Dentist, or Midwife for specified period of time; or

(ii) to provide episodic or limited surgical or consulting services.

(b) The appointment of a Physician, Dentist, or Midwife as a member of the Locum Tenens Staff may be for up to one year subject to renewal for a further period of up to one additional year. The Board, having considered the recommendation of the Medical Advisory Committee may permit renewal beyond two years in exceptional circumstances.

(c) A Locum Tenens Staff member shall:

(i) have admitting privileges unless otherwise specified in their appointment;

(ii) work under the mentorship of a Professional Staff member assigned by the Chief of Staff or Chief of Department/Division Lead; and

(iii) attend patients and undertake treatment and operative procedures only in accordance with the kind and degree of privileges granted by the Board.

(d) Notwithstanding section 14.6(b), the term of a Locum Tenens Staff member may be extended:

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(i) if the Board considers it to be necessary to cover an extended leave of absence or departmental vacancy or other unexpected need; or

(ii) if the Physician is on a roster of Locum Tenens Staff members that the Hospital calls upon from time to time to, on an ongoing basis, fill unplanned or unexpected vacancies.

(iii) The Physician shall be required to specify the time period and Department/Division that they would like to be appointed to.

(e) The Locum Tenens Staff members shall be categorized as falling within one of the following three sub-categories:

(i) Defined Short-Term:

a the appointment is for a defined term of less than 12 months to typically fill either an approved short term leave of absence or for recruitment purposes; and

b the appointment has no impact on Hospital resources.

(ii) Intermittent Ongoing:

a the appointment is to assist a Department in filling gaps in the call schedule.

(iii) Defined Long-Term

a the appointment is to fill a specified long-term leave of absence that spans more than one credentialing term or for a long-term departmental trial period for a potential new Active Staff member of a Department.

(f) Locum Tenens Staff shall be entitled to attend Professional Staff Association meetings but shall not have a vote or be an elected or appointed officer of the Professional Staff Association.

(g) The aggregate period of appointment shall not exceed 12 months and shall terminate no later than June 30th.

(h) The Locum Tenens Staff appointment is a discrete appointment which does not create any resource entitlements which carry forward in the subsequent annual applications for reappointment to the Professional Staff.

(i) In the event that the Physician is replacing a specified member of the Medical Staff, the Physician shall be required to substitute for the absent practitioner in any of the practitioner’s regularly scheduled on-call duties.

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14.7 Temporary Staff

(a) The Temporary Staff shall consist of those Physicians, Dentists, and Midwives who:

(i) have been granted a temporary appointment and temporary privileges by the Chief Executive Officer, upon the recommendation of either the applicable Chief of Department or the Chief of Staff, in order to meet a specific singular requirement by providing a consultation and/or operative procedure, or to meet an urgent unexpected need for a medical service; or

(ii) are new applicants awaiting approval and have been granted a temporary appointment and temporary privileges by the Chief Executive Officer , upon the recommendation of either the applicable Chief of Department or the Chief of Staff, provided that:

a as soon as is practical, evidence is obtained that the applicant is in good standing with the College and has appropriate professional liability coverage or membership in the Canadian Protective Medical Association;

b if applicable, a letter of recommendation is obtained from the applicant’s chief of department; and

c the Chief Executive Officer may revoke the appointment at any time (following consultation with the Chief of Staff).

(b) Temporary Staff members:

(i) may exercise any privileges as granted by the Chief Executive Officer;

(ii) shall be appointed for no longer than three months, provided that such appointment shall not extend beyond the date of the next meeting of the Medical Advisory Committee at which time the action taken shall be reported, however, the Chief Executive Officer may continue a temporary appointment and temporary privileges on the recommendation of the Medical Advisory Committee, until the next meeting of the Board;

(iii) may attend staff, departmental, and committee meetings as required; and

(iv) be entitled to attend Professional Staff Association meetings but shall not have a vote, or be an elected or appointed officer of the Professional Staff Association.

(c) The Board may, after receiving the recommendation of the Medical Advisory Committee, continue a temporary appointment for such period of time and on such terms as the Board determines.

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(d) If the term of the temporary appointment has been completed before the next Board meeting, the appointment shall be reported to the Board.

(e) Temporary Staff members shall:

(i) work under the counsel and supervision of the Chief of Department or Medical Staff member who has been assigned this responsibility by the Chief of the Department to which the Physician has been assigned; and

(ii) undertake such duties in respect of those patients classes as emergency cases as my be specified by the Chief of Staff or by the Chief of the Department to which the Physician has been assigned.

(f) The Temporary Staff appointment is a discrete appointment which does not create any resource entitlements which carry forward in the subsequent annual applications for reappointment to the Medical Staff.

14.8 Telemedicine and Educational Staff

(a) The category of Telemedicine and Educational Staff has been created to streamline the credentialing process so that:

(i) the Hospital’s patients may benefit from the specialised consulting expertise and services of Physicians whose primary practices are at other hospitals, but which will be provided to the Hospital via telemedicine on an occasional and as-needed basis and would not otherwise be available to patients in the Hospital; or

(ii) the Hospital wishes to grant privileges to a Physician who shall teach new leading clinical/operative procedures or refinements and such Physician would not otherwise be available to the Professional Staff.

(b) For the purposes of this section 14.8, “telemedicine” shall mean the use of telecommunications technologies to create audio/visual linkages between a Physician located outside of the Hospital to a patient of the Hospital, in actual or stored time.

(c) The Telemedicine and Educational Staff shall consist of Physicians who:

(i) hold Active Staff privileges at another public hospital in Ontario;

(ii) provide telemedicine consultations to patients, which consultation leads to a physician/patient relationship, at the request of a Physician who holds Active Staff or Associate Staff privileges at the Hospital; or

(iii) teach and/or learn and perform new leading clinical/operative technologies or procedures or refinements of existing practices, through personally

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performing, as a teacher or learner, such techniques or procedures on patients; and

(iv) have been granted limited privileges, as set out in this section, to conduct such consultations.

(d) Telemedicine and Educational Staff privileges may be granted to a Physician where:

(i) the Hospital does not have the volume of practice to require the specialized services on a full-time basis; or

(ii) access to the Physician’s skills would contribute to the health and welfare of members of the community;

(iii) the Chief of Department or Chief of Staff request(s) that a Physician be granted privileges to teach a new leading clinical/operative technique or procedure; and

(iv) it is highly unlikely or impractical to expect the Physician to formally apply for privileges at the Hospital.

(e) In the ordinary course, the appointment process shall follow the process set out in Article 13 of this By-Law.

(f) Notwithstanding any of the other provisions contained in this By-Law, a Physician may be granted Telemedicine and Educational Staff privileges by the Chief Executive Officer upon the recommendation of either the applicable Chief of Department or the Chief of Staff, provided that:

(i) a letter is obtained from the Chief of Staff or Chief of Department at the hospital where the Physician holds active Medical Staff privileges stating that the Physician is in good standing at the hospital and outlining the extent of the privileges and any restrictions thereon;

(ii) evidence is obtained that the applicant is in good standing with the College and has appropriate professional liability coverage or membership in the Canadian Medical Protective Association;

(iii) the Chief of Staff or Chief of Department will undertake a search of the CPSO’s website to check as to whether the Physician has a licence to practice medicine in the province of Ontario and whether there are pending, ongoing or completed proceedings or investigations before the CPSO’s Discipline, Fitness to Practice, or Quality Assurance Committee(s) or any other regulatory/governing body in any jurisdiction and its equivalent committees, including any matters that are being appealed; and

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(iv) in respective of educational privileges, the letter referred to in section 14.8(f)(i) must also confirm that the Chief of Staff or Chief of Department confirm that the Physician has the required skills and expertise to teach the clinical/operative procedure.

(g) If there is no outstanding referral or adverse finding against the Physician, the Chief Executive Officer may grant privileges to the Physician.

(h) If there is an outstanding referral or adverse finding against the Physician, then this streamlined process will not be available and the Physician will have to comply with the standard application process.

(i) Unless appointed pursuant to the process set out in Article 13 of this By-Law, the Chief Executive Officer may revoke the Physician’s privileges at any time (following consultation with the Chief of Staff).

(j) Telemedicine and Educational Staff members:

(i) will not have regularly assigned duties or responsibilities;

(ii) will be entitled to attend Professional Staff Association meetings but shall not have a vote or be an elected or appointed officer of the Professional Staff Association;

(iii) will not be bound by attendance requirements for Medical Staff Association meetings;

(iv) may not be appointed to a committee of the Professional Staff Association; and

(v) may not admit or discharge patients, but may treat patients admitted by the Active or Associate Staff by telemedicine consultation only.

(k) Telemedicine and Educational Staff members shall:

(i) provide telemedicine consultations when requested from the Active or Associate Staff;

(ii) teach new leading clinical/operative technologies or procedures or refinements of existing practices, through personally performing such techniques or procedures on patients;

(iii) prepare and complete records of personal health information in accordance with the Policies as may be established from time to time, the Legislation and accepted industry and professional standards;

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(iv) undertake appropriate follow-up on a timely basis, including, without limitation, providing timely communication with all patients’ referring Physicians and obtaining consultations on patients, where appropriate; and

(v) comply with applicable CPSO policies, including the policy on telemedicine.

(l) The Telemedicine and Educational Staff appointment is a discrete appointment which does not create any resource entitlements which carry forward in the subsequent annual applications for reappointment to the Medical Staff; and

14.9 Honorary Staff

(a) The Honorary Staff shall consist of physicians, dentists and midwives who have been honoured by the Board, on the recommendation of the Medical Advisory Committee, for such term as the Board deems appropriate, because they are:

(i) a former member of the Professional Staff who have an outstanding reputation; or

(ii) have made an extraordinary accomplishment, although not necessarily a resident in the community.

(b) Honorary Staff members:

(i) cannot admit, treat, perform diagnostic procedures, or discharge patients;

(ii) will not have regularly assigned duties or responsibilities;

(iii) will be entitled to attend Department and Professional Staff Association meetings but shall not have a vote or be an elected or appointed officer of the Professional Staff Association.

ARTICLE 15 PROFESSIONAL STAFF DUTIES AND RESPONSIBILITIES

15.1 Duties, General

(a) Each member of the Professional Staff is accountable to and shall recognize the authority of the Board through and with the Chief of Staff, Chief Executive Officer, Chief of Department and Division Lead.

(b) Each member of the Professional Staff has an individual responsibility to the Corporation and the Board to:

(i) ensure the highest professional standard of care is provided to patients under their care that is consistent with sound healthcare resource utilization practices;

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(ii) practise at the highest professional and ethical standards within the limits of the privileges provided;

(iii) provide care, which is within the member’s scope of competence, to patients in emergency situations to the best of the member’s ability, whether the member is privileged to perform the procedure or treatment or not;

(iv) maintain involvement in continuing medical and interdisciplinary professional education;

(v) contribute to academic activities within the parameters of a mutual agreement as determined within the Department in which the Professional Staff member is appointed;

(vi) comply with the Public Hospitals Act, the Legislation, and the By-Law, mission and Policies of the Corporation;

(vii) participate in continuous quality improvement and patient and workplace safety initiatives, as appropriate;

(viii) prepare and complete records of personal health information in accordance with the Policies as may be established from time to time, the Legislation, and accepted professional standards;

(ix) provide the member’s Chief of Department with three months’ notice of the members’ intention to resign, take leave of absence, or reduce one’s privileges;

(x) advise the Chief of Department and/or Chief of Staff immediately of any material changes to the information required to be provided by the member to the Hospital upon re-application. An obligation exists to disclose any and all information that is, or could be, on the public register of the College of which the member is affiliated and to provide ongoing disclosure of any change in such information;

(xi) forthwith advise the Chief of Staff of the commencement of any College disciplinary proceedings, proceedings to restrict or suspend privileges at other hospitals, settled actions, malpractice actions, or any pending claim related to a criminal or patient care or other issue that might impact the reputation of the Hospital or the quality of care provided in the Hospital;

(xii) comply with any specific conditions attached to the exercise of the member’s privileges;

(xiii) work and cooperate with others in a manner consistent with the Hospital’s mission, vision and values;

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(xiv) notify the Board in writing through the Chief Executive Officer of any additional professional degrees or qualifications obtained by the member or of any change in the licence to practice made by the College or change in professional liability insurance;

(xv) file a report with the Chief Executive Officer if the Professional Staff member has reasonable grounds to believe that another member of the same or different College is incompetent or incapacitated;

(xvi) serve as required on various Hospital and Professional Staff Association committees;

(xvii) provide timely communication with all patients’ referring physicians;

(xviii) obtain consultations on patients, where appropriate;

(xix) when requested by a fellow Professional Staff member, provide timely consultations;

(xx) notify patients and/or their families or other appropriate individuals about their options with respect to tissue and organ transplantation;

(xxi) not undertake any conduct that would be prejudicial to the Hospital’s reputation or standing in the community, including making prejudicial or adverse public statements with respect to the Hospital’s operations which have not first been addressed through the proper communication channels identified above and such official channels have not satisfactorily resolved the Professional Staff member’s concerns;

(xxii) co-operate with any request that their practice be monitored pursuant to section 16.1 of this By-Law;

(xxiii) in undertaking clinical research or clinical investigation, abide by the policies of the Research and Ethics Committee;

(xxiv) when requested by the Chief of Staff or Chief of Department, supervise and/or mentor a designated member of Professional Staff; and

(xxv) pay such Professional Staff Association dues as may be prescribed from time to time by resolution of the Professional Staff Association.

15.2 Transfer of Accountability

(a) A Professional Staff member who has assumed responsibility for a patient’s care shall remain responsible for that patient until the patient’s discharge from the Hospital or until the care of the patient is transferred to another Professional Staff member.

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(b) Subject to section (c) below, the transfer of care from one Professional Staff member to another must be done as an order and clearly indicated on the patient’s Hospital chart. The Professional Staff member must confirm in the chart that:

(i) they have directly spoken to the Professional Staff member to whom they are transferring the patient care (the “Accepting Professional Staff Member”);

(ii) the Accepting Professional Staff Member has directly confirmed to the Professional Staff member that the Accepting Professional Member has accepted the transfer; and

(iii) they have communicated the patient’s vital information to the Accepting Professional Staff Member.

(c) Where a Department adopts a Policy of transferring responsibility for all in-patients of the Department or a Division to another member of the Department or Division at regular intervals, such Policy shall be in writing and any such transfers shall be communicated in writing to all appropriate staff. Under such circumstances, a transfer order on the patient’s chart is not required.

(d) Where the Chief of Staff or the Chief of Department has cause to take over the care of a patient, the Chief Executive Officer, the attending Physician, and the patient, shall be notified as soon as possible or, in the case where the patient is not mentally competent, the patient’s substitute decision maker, shall be notified as soon as possible.

15.3 Leave of Absence

(a) Subject to section (c) below, when a member of the Professional Staff temporarily plans to cease practice in the community for a period of 12 months or less, application for a leave of absence from the Professional Staff may be made for medical or parental leave, education, training or sabbatical or other reasons. Such application, stating the effective dates and reasons, shall be made to the Chief of Staff who in turn shall forward the application to the Medical Advisory Committee for consideration at its next regular meeting. The Medical Advisory Committee shall make its recommendation to the Board in respect of the leave that pertains to the current application term. Any request for a leave of absence that extends beyond the current application term must be requested in the Professional Staff member’s reapplication for appointment.

(b) If such leave of absence is granted, the Professional Staff member may make application for re-appointment to the Professional Staff upon their return in accordance with the By-Law and, in such event, the Board may waive the usual requirement that the applicant apply to the Associate Staff, after considering the recommendations of the Medical Advisory Committee.

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(c) Notwithstanding other provisions contained in the By-Law, in the event the leave of absence is for any reason other than medical or parental leave, the granting of the leave is conditional upon:

(i) the Professional Staff member co-ordinating locum to cover their clinical responsibilities; and

(ii) the Chief of Department confirming in writing to the Chief of Staff that the absence will not negatively impact the Department’s ability to meet its on-call responsibilities.

(d) Upon the Professional Staff member’s return from a leave of absence, the Chief of Staff and Professional Staff member shall be required to jointly sign an agreed-upon transition plan that will be considered by the Credentials Committee to ensure the member’s clinical competencies were not prejudiced during their absence.

ARTICLE 16 MONITORING, SUSPENSION, AND REVOCATION OF PRIVILEGES

16.1 Monitoring Practices and Transfer of Responsibility

(a) Any aspect of patient care or Professional Staff conduct being carried out in the Corporation may be reviewed without the approval of the member of the Professional Staff responsible for such care by the Chief of Staff, Chief of Department or Division Lead.

(b) Where any member of the Professional Staff or Corporation staff reasonably believes that a member of the Professional Staff is incompetent, attempting to exceed their privileges, incapable of providing a service that they are about to undertake, or acting in a manner that exposes or is reasonably likely to expose any patient, health care provider, employee or any other person at the Hospital to harm or injury, such individual shall communicate that belief forthwith to one of the Chief of Staff, Chief of the relevant Department, Division Lead AND the Chief Executive Officer, so that appropriate action can be taken.

(c) The Chief of a Department, on notice to the Chief of Staff where they believe it to be in the best interest of the patient, shall have the authority to examine the condition and scrutinize the treatment of any patient in their Department and to make recommendations to the attending Professional Staff member or any Professional Staff member involved in the patient’s care and, if necessary, to the Medical Advisory Committee. If it is not practical to give prior notice to the Chief of Staff, notice shall be given as soon as possible.

(d) If the Chief of Staff or Chief of a Department and/or their delegate, in their opinion, believes a serious problem exists in the diagnosis, care, or treatment of a patient, the officer shall forthwith discuss the condition, diagnosis, care, and treatment of the patient with the attending member of the Professional Staff. If the diagnosis, care, or treatment are not satisfactory to the Chief of Staff or the Chief of

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Department and/or their delegate, as the case may be, they shall forthwith assume the duty of investigating, diagnosing, prescribing for, and/or treating the patient.

(e) Where the Chief of Staff or Chief of a Department and/or their delegate has cause to take over the care of a patient, the Chief Executive Officer, Chief of Staff, or Chief of the Department, as the case may be, and one other member of the Medical Advisory Committee, the attending member of the Professional Staff, and the patient or the patient’s substitute decision maker shall be notified in accordance with the Public Hospitals Act. The Chief of Staff or the Chief of Department shall file a written report with the Medical Advisory Committee within 48 hours of their action.

(f) Where the Medical Advisory Committee concurs in the opinion of the Chief of Staff or Chief of Department and/or their delegate who has taken action under section 16.1(d) that the action was necessary, the Medical Advisory Committee shall forthwith make a detailed written report to the Chief Executive Officer and the Board of the problem and the action taken.

16.2 Suspension or Restriction of Privileges, or Revocation of Appointment

(a) The Board may, at any time, in a manner consistent with the Public Hospitals Act and this By-law, revoke any appointment of a member of the Professional Staff or suspend, restrict, or otherwise deal with the Privileges of a member of the Professional Staff.

(b) Any administrative or leadership appointment of the member of the Professional Staff will automatically terminate upon the restriction or suspension of privileges or the revocation of appointment, unless otherwise determined by the Board.

(c) Where an application for appointment or reappointment is denied or, the privileges of a member of the Professional Staff have been restricted or suspended, or the appointment of a member of the Professional Staff has been revoked, by reason of incompetence, negligence or misconduct, or the member resigns from the Professional Staff during the course of an investigation into their competence, negligence or misconduct, the Chief Executive Officer shall prepare and forward a detailed written report to the member’s regulatory body as soon as possible, and not later than 30 days.

16.3 Immediate Action

(a) The Chief Executive Officer, Chief of Staff, or Chief of a Department may temporarily restrict or suspend the privileges of any member of the Professional Staff, in circumstances where in their opinion the member’s conduct, performance, or competence:

(i) exposes or is reasonably likely to expose any patient, health care provider, employee, or any other person at the Hospital to harm or injury; or

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(ii) is or is reasonably likely to be detrimental to patient safety or to the delivery of quality patient care within the Hospital, or

(iii) is, or is reasonably likely to constitute Disruptive Behaviour; or

(iv) results in the imposition of sanctions by the College; or

(v) fails to comply with the By-Laws, Policies, the Public Hospitals Act or any other relevant law,

AND immediate action must be taken to protect patients, health care providers, employees and any other person at the Hospital from harm or injury.

(b) Before the Chief Executive Officer, Chief of Staff or Chief of a Department takes action authorized in section 16.3(a), they shall first consult with one of the other of them. If such prior consultation is not possible or practicable under the circumstances, the person who takes the action authorized in section 16.3(a) shall provide immediate notice to the others. The person who takes the action authorized in section 16.3(a) shall forthwith submit a written report on the action taken with all relevant materials and/or information to the Medical Advisory Committee.

Refer to Board Policy “Immediate Mid-Term Action in an Emergency Situation – Role of the Medical Advisory Committee”.

16.4 Non-Immediate Action

(a) The Chief Executive Officer, Chief of Staff, or Chief of a Department may recommend to the Medical Advisory Committee that the privileges of any member of the Professional Staff be restricted or suspended or that the appointment be revoked in any circumstances where in their opinion the member’s conduct, performance, or competence:

(i) fails to meet or comply with the criteria for annual reappointment; or

(ii) exposes or is reasonably likely to expose any patient, health care provider, employee or any other person at the Hospital to harm or injury; or

(iii) is, or is reasonably likely to be, detrimental to patient safety or to the delivery of quality patient care within the Hospital or impact negatively on the operations of the Hospital; or

(iv) fails to comply with the By-Law, Policies, Public Hospitals Act or any other relevant law.

(b) Prior to making a recommendation as referred to in section 16.4(a), an investigation will be conducted. Where an investigation is conducted it may be assigned to an individual within the Hospital other than the Medical Advisory Committee or to an external consultant.

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Refer to Board Policy “Non-Immediate Mid-Term Action – Role of the Medical Advisory Committee”.

16.5 Referral to Medical Advisory Committee for Recommendations

(a) Following the temporary restriction or suspension of privileges under section 16.3, or the recommendation to the Medical Advisory Committee for the restriction or suspension of privileges or the revocation of an appointment of a member of the Professional Staff under section 16.4, the following process shall be followed;

(i) the Chief of the Department of which the individual is a member or an appropriate alternate designated by the Chief of Staff or Chief Executive Officer shall forthwith submit to the Medical Advisory Committee a written report on the action taken, or recommendation, as the case may be, with all relevant materials and/or information;

(ii) a date for consideration of the matter will be set, not more than ten days from the time the written report is received by the Medical Advisory Committee;

(iii) as soon as possible, and in any event, at least 48 hours prior to the Medical Advisory Committee meeting, the Medical Advisory Committee shall provide the member with a written notice of:

a the time and place of the meeting;

b the purpose of the meeting; and

c a statement of the matter to be considered by the Medical Advisory Committee together with any relevant documentation.

(b) The date for the Medical Advisory Committee to consider the matter under s.16.5(a)(ii) may be extended by,

(i) an additional five days in the case of a referral under s.16.3; or

(ii) any number of days in the case of a referral under s.16.4,

if the Medical Advisory Committee considers it necessary to do so.

(c) The Medical Advisory Committee may:

(i) set aside the restriction or suspension of privileges; or

(ii) recommend to the Board a revocation of the appointment or a restriction or suspension of privileges on such terms as it deems appropriate. Notwithstanding the above, the Medical Advisory Committee may also refer the matter to a committee of the Medical Advisory Committee.

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(d) If the Medical Advisory Committee recommends the continuation of the restriction or suspension of privileges or recommends a revocation of appointment and/or makes further recommendations concerning the matters considered at its meeting, the Medical Advisory Committee shall within 24 hours of the Medical Advisory Committee meeting provide the member with written notice of the Medical Advisory Committee's recommendation.

(e) The written notice shall inform the member they are entitled to:

(i) written reasons for the recommendation if a request is received by the Medical Advisory Committee within seven days of the member’s receipt of the notice of the recommendation; and

(ii) a hearing before the Board if a written request is received by the Board and the Medical Advisory Committee within seven days of the receipt by the member of the written reasons requested.

(f) If the member requests written reasons for the recommendation under s.16.5(e), the Medical Advisory Committee shall provide the written reasons to the member within 48 hours of receipt of the request.

16.6 Board Hearing

(a) A hearing by the Board shall be held when one of the following occurs:

(i) the Medical Advisory Committee recommends to the Board that an application for appointment, reappointment, or requested privileges not be granted and the applicant requests a hearing in accordance with the Public Hospitals Act; or

(ii) the Medical Advisory Committee makes a recommendation to the Board that the privileges of a member of the Professional Staff be restricted or suspended or an appointment be revoked and the member requests a hearing.

Refer to Board Policy “Board Hearing”.

(b) The parties to the Board hearing are the applicant or member, the Medical Advisory Committee and such other persons as the Board may specify.

(c) The applicant or member requiring a hearing and the Medical Advisory Committee shall be afforded an opportunity to examine, prior to the hearing, any written or documentary evidence that will be produced, or any reports the contents of which will be used in evidence.

(d) Members of the Board holding the hearing will not have taken part in any investigation or consideration of the subject matter of the hearing and will not communicate directly or indirectly in relation to the subject matter of the hearing

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with any person or with any party or their representative, except upon notice to and an opportunity for all parties to participate. Despite the foregoing, the Board may obtain legal advice.

(e) The findings of fact of the Board pursuant to a hearing will be based exclusively on evidence admissible or matters that may be noticed under the Statutory Powers Procedure Act.

(f) No member of the Board will participate in a decision of the Board pursuant to a hearing unless they are present throughout the hearing and heard the evidence and argument of the parties and, except with the consent of the parties, no decision of the Board will be given unless all members so present participate in the decision.

(g) The Board shall make a decision to follow, amend, or not follow the recommendation of the Medical Advisory Committee. The Board, in determining whether to make any appointment or reappointment to the Medical Staff or approve any request for a change in privileges shall take into account the recommendation of the Medical Advisory Committee and such other considerations it, in its discretion, considers relevant. The Board shall consider only the reasons of the Medical Advisory Committee that have been given to the member in support of its recommendation.

(h) A written copy of the decision of the Board will be provided to the applicant or member and to the Medical Advisory Committee.

(i) Service of a notice to the parties may be made personally or by registered mail addressed to the person to be served at their last known address and, where notice is served by registered mail, it will be deemed that the notice was served on the third day after the day of mailing unless the person to be served establishes that they did not, acting in good faith, through absence, accident, illness or other causes beyond their control, receive it until a later date.

ARTICLE 17 CHIEF OF STAFF

17.1 Appointment of Chief of Staff

(a) The Board shall appoint a Physician to be the Chief of Staff in accordance with the Board Policy relating to the selection of the Chief of Staff.

(b) The Board may, at any time, revoke or suspend the appointment of the Chief of Staff.

(c) In the event of a revocation or suspension, the Board may appoint an acting Chief of Staff until such time as the selection process set out in section 17.1(a) is complied with.

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17.2 Duties of Chief of Staff

(a) The Chief of Staff shall:

(i) be an ex-officio, non-voting member of the Board;

(ii) be the Chair of the Medical Advisory Committee;

(iii) be an ex-officio member of all Medical Advisory Committee sub-committees;

(iv) perform such duties as may be set out in the Board Policy “Duties of the Chief of Staff”; and

(v) report regularly to the Board on the work and recommendations of the Medical Advisory Committee.

(b) The Chief of Staff shall, in consultation with the Chief Executive Officer, designate an alternate to act during their absence.

ARTICLE 18 PROFESSIONAL STAFF DEPARTMENTS

18.1 Professional Staff Departments and Divisions

(a) The Professional Staff may be organized into such Departments as may be approved by the Board from time to time.

(b) A Department may be divided into such Divisions as may be approved by the Board from time to time.

(c) Each Professional Staff member will be appointed to a minimum of one of the Departments. Appointment may extend to one or more additional Departments.

(d) Any Department shall function in accordance with the Clinical Policies of the Hospital.

(e) Quorum for Department meetings shall be 30% of the Active Staff members. It is expected that all Department members will endeavor to attend Department meetings on a regular basis.

(f) The Board may, at any time, after consultation with the Medical Advisory Committee, create such additional Departments or Divisions, amalgamate Departments or Divisions, or disband Departments or Divisions.

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18.2 Appointment of Chief of Department

The Board shall appoint a Chief of each Department. The Board shall receive and consider the input of the appropriate Professional Staff before it makes an appointment of a Chief of a Department.

18.3 Appointment and Duties of Division Lead

The Board may appoint a Division Lead or may delegate to the Chief of Staff and Medical Advisory Committee the authority to appoint one or more Division Lead.

18.4 Duties of Chief of Department

A Chief of Department shall:

(a) perform such duties as may be set out in the Board Policy “Duties of the Chief of Department”.

18.5 Duties of Division Lead

The Division Lead, if appointed, is the delegate of the Chief of the Department. The Division Lead has responsibilities and duties similar to those of the Chief of the Department as determined by the Chief of the Department.

ARTICLE 19 MEDICAL ADVISORY COMMITTEE

19.1 Composition of Medical Advisory Committee

(a) The Medical Advisory Committee shall consist of the following voting members:

(i) the Chief of Staff, who is the Chair of the Medical Advisory Committee;

(ii) the Chiefs of Department;

(iii) the President, Vice President and Secretary of the Professional Staff Association; and

(iv) such other members of the Medical Staff as may be appointed by the Board from time to time.

(b) In addition, the following shall be entitled to attend the meetings of the Medical Advisory Committee without a vote:

(i) the Chief Executive Officer;

(ii) the Chief Nursing Executive; and

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(iii) the Director, Quality and Professional Practice.

19.2 Medical Advisory Committee Duties and Responsibilities

The Medical Advisory Committee shall, perform the duties and undertake the responsibilities set out in the Public Hospitals Act and its regulations, including:

(a) make recommendations to the Board concerning the following matters:

(i) every application for appointment or reappointment to the Professional Staff and any request for a change in privileges;

(ii) the privileges to be granted to each member of the Professional Staff;

(iii) the By-Laws and Clinical Policies respecting the Medical Staff, Dental Staff, Midwifery Staff, and Extended Class Nursing Staff;

(iv) the revocation of appointment, or the suspension or restriction of privileges, of any member of the Professional Staff;

(v) the quality of care provided in the Hospital by the Medical Staff, Dental Staff, Midwifery Staff and Extended Class Nursing Staff;

(b) supervise the clinical practice of medicine, dentistry, midwifery and extended class nursing in the Hospital;

(c) appoint the Medical Staff members of all committees established under section 19.3;

(d) receive reports of the committees of the Medical Advisory Committee;

(e) advise the Board on any matters referred to the Medical Advisory Committee by the Board;

(f) where the Medical Advisory Committee identifies systemic or recurring quality of care issues in making its recommendations to the Board under section 2(a)(v) of the Hospital Management Regulation (965) under the Public Hospitals Act, the Medical Advisory Committee shall make recommendations about those issues to the Hospital’s quality committee established under section 3(1) of the Excellent Care for All Act;

(g) assist the Chief Executive Officer is the development of a Professional Staff Clinical Human Resource Plan that takes into account the services provided by all Professional Staff members; and

(h) facilitate the development and maintenance of Clinical Policies, ethical guidelines and procedures of the Professional Staff.

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19.3 Establishment of Committees of the Medical Advisory Committee

(a) The Board may, on the recommendation of the Medical Advisory Committee, establish such standing and special sub-committees of the Medical Advisory Committee as may be necessary or advisable from time to time for the Medical Advisory Committee to perform its duties under the Public Hospitals Act or the By-Law.

(b) The terms of reference and composition for any standing or special sub-committees of the Medical Advisory Committee may be set out in the Clinical Policies or in a resolution of the Board, on recommendation of the Medical Advisory Committee. The Medical Staff members of any such subcommittee of the Medical Advisory Committee shall be appointed by the Medical Advisory Committee and other committee members may be appointed by the Board.

19.4 Quorum for Medical Advisory Committee and Sub-Committee Meeting

A quorum for any meeting of the Medical Advisory Committee, or a sub-committee thereof, shall be a majority of the members entitled to vote.

ARTICLE 20 MEETINGS OF THE PROFESSIONAL STAFF ASSOCIATION

20.1 Regular, Annual and Special Meetings of the Professional Staff Association

(a) At least four meetings of the Professional Staff Association will be held each year, one of which shall be the annual meeting.

(b) The President of the Professional Staff Association may call a special meeting. Special meetings shall be called by the President of the Professional Staff Association on the written request of any five members of the Active Staff entitled to vote.

(c) A written notice of each meeting of the Professional Staff Association (including the annual meeting or any special meeting) shall be given by the Secretary of the Professional Staff Association to the Professional Staff at least 14 days in advance of the meeting by posting a notice of the meeting in a conspicuous place in the Hospital. Notice of special meetings shall state the nature of the business for which the special meeting is called.

(d) The period of time required for giving notice of any special meeting may be waived in cases of emergency by the majority of those members of the Professional Staff Association present and entitled to vote at the special meeting, as the first item of business of the meeting.

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20.2 Quorum

Five members of the Medical Staff entitled to vote and present in person shall constitute a quorum at any annual, regular, or special meeting of the Professional Staff Association.

20.3 Rules of Order

The procedures for meetings of the Professional Staff Association not provided for in this By-Law shall be governed by the rules of order adopted by the Board.

ARTICLE 21 ELECTED OFFICERS OF THE PROFESSIONAL STAFF ASSOCIATION

21.1 Officers of the Professional Staff Association

(a) The officers of the Professional Staff Association will be:

(i) the President;

(ii) the Vice President; and

(iii) the Secretary.

(b) The officers of the Professional Staff Association shall be elected annually for a term of one year by a majority vote of the voting members of the Professional Staff Association in attendance and voting at a meeting of the Professional Staff Association.

(c) The officers of the Professional Staff Association may serve consecutive years in office.

(d) The officers of the Professional Staff Association may be removed from office prior to the expiry of their term by a majority vote of the voting members of the Professional Staff Association in attendance and voting at a meeting of the Professional Staff Association called for such purpose.

21.2 Eligibility for Office

Only Physicians who are members of the Active Staff may be elected or appointed to any position or office of the Professional Staff Association.

21.3 Nominations and Election Process

(a) A nominating committee shall be constituted through a process approved by the Professional Staff Association on recommendation of the officers of the Professional Staff Association.

(b) At least 10 days before the annual meeting of the Professional Staff Association, the nominating committee shall circulate or post in a conspicuous place at each site

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of the Corporation, a list of the names of those who are nominated to stand for the offices of the Professional Staff Association that are to be filled by election, in accordance with the Regulations under the Public Hospitals Act and this By-Law.

(c) Any further nominations shall be made in writing to the Secretary of the Professional Staff Association up to five days before the annual meeting of the Professional Staff Association.

21.4 President of the Professional Staff Association

(a) The President of the Professional Staff Association shall:

(i) preside at meetings of the Professional Staff Association;

(ii) act as a liaison between the Professional Staff, the Chief Executive Officer, the Chief of Staff and the Board with respect to matters concerning the Professional Staff;

a advocate fair process in the treatment of individual members of the Professional Staff.

b be a member of the Medical Advisory Committee; and

c be an ex-officio Director of the Board and as a Director, fulfill fiduciary duties to the Corporation.

21.5 Vice President of the Professional Staff Association

(a) The Vice President of the Professional Staff Association shall:

(i) in the absence or disability of the President of the Professional Staff Association, act in place of the President, perform their duties and possess their powers;

(ii) perform such duties as the President of the Professional Staff Association may delegate to them; and

(iii) be a member of the Medical Advisory Committee; and

(iv) attend meetings of the Board as a guest

21.6 Secretary of the Professional Staff Association

(a) The Secretary of the Professional Staff Association will:

(i) attend to the correspondence of the Professional Staff Association;

(ii) ensure notice is given and that minutes and attendance record are kept of Professional Staff Association meetings;

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(iii) maintain the funds and financial records of the Professional Staff Association and provide a financial report at the annual meeting of the Professional Staff Association;

(iv) disburse funds at the direction of the Professional Staff Association, as determined by a majority vote of the Professional Staff Association members entitled to vote who are present and vote at a Professional Staff Association meeting;

(v) be a member of the Medical Advisory Committee; and

(vi) in the absence or disability of the Vice President of the Professional Staff Association, act in place of the Vice President, perform their duties and possess their powers.

21.7 Succession Planning

In the ordinary course, it is the expectation of the Professional Staff Association that, for succession planning purposes, at each annual meeting there will be a motion confirming the Professional Staff Association’s intended succession plan, namely that the Professional Staff Association’s elected representatives begin their respective terms in office as Secretary/Treasurer and through subsequent annual meetings are successively elected to the office of the Vice-President and then President of the Professional Staff Association.

If the position of any elected Professional Staff Association officer becomes vacant during the term, it may be filled by a vote of the majority of the voting members of the Professional Staff Association present and voting at a regular meeting of the Professional Staff Association or at a special meeting called for that purpose. The Professional Staff member so elected to office shall fill the office until the next annual meeting.

ARTICLE 22 DENTAL STAFF

22.1 Criteria

In addition to the criteria set out in section 13.2 of this By-Law, in the case of an Oral and Maxillofacial Surgeon, a current valid specialty certificate of registration from the Royal College of Dental Surgeons of Ontario authorizing practice in oral and maxillofacial surgery.

22.2 Categories

(a) A Dentist in the Active Staff category who is an Oral and Maxillofacial Surgeon may be granted in-patient and/or out-patient Admitting Privileges, unless otherwise specified in his appointment.

(b) A Dentist in the Active Staff category may be granted in-patient and/or out-patient Admitting Privileges in association with a Physician who is a member of the Active Staff, unless otherwise specified in his appointment.

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ARTICLE 23 EXTENDED CLASS NURSING STAFF

23.1 Categories

Registered Nurses in the Extended Class may be divided into the following groups:

(a) courtesy; and

(b) locum tenens.

23.2 Courtesy Staff

The Board may grant a Registered Nurse in the Extended Class an appointment to the Courtesy Staff to access the Hospital’s diagnostic services in respect of patients in their private practice.

23.3 Locum Tenens Staff

(a) The Medical Advisory Committee upon the request of a member of the Extended Class Nursing Staff may recommend the appointment of a locum tenens as a planned replacement for that Registered Nurse in the Extended Class for a specified period of time.

(b) A locum tenens shall have access to the Hospital’s diagnostic services in respect of patients in their private practice.

23.4 Duties

(a) Each non-employed member of the Extended Class Nursing Staff shall:

(i) notify the Chief Executive Officer of any change in the class of registration on the Annual Registration Payment Card from the College of Nurses of Ontario;

(ii) give such instruction as is required for the education of other members of the Medical Staff, Midwifery Staff, and Hospital staff;

(iii) abide by the Policies, this By-Law, the Public Hospitals Act and the Regulations thereunder and all other legislative requirements; and

(iv) perform such other duties as may be prescribed from time to time by, or under the authority of the Board, the Medical Advisory Committee, or the Chief of Staff.

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ARTICLE 24 AMENDMENTS

24.1 Amendment

Subject to applicable legislation, this By-Law may be repealed or amended by By-Law enacted by a Board resolution and sanctioned by at least a majority of the Members voting at a meeting duly called for the purpose of considering the By-Law.

24.2 Effect of Amendment

Subject to the Corporations Act, a By-Law or an amendment to a By-Law passed by the Board has full force and effect from the time the motion was passed or from such future time as may be specified in the motion.

24.3 Member Approval

A By-Law or an amendment to a By-Law passed by the Board shall be presented for confirmation at the next annual meeting or to a general Members’ meeting called for that purpose. The notice of the annual or general meeting shall refer to the By-Law or amendment to be presented. The Members may confirm the By-Law as presented or reject or amend it and, if rejected, it thereupon ceases to have effect and, if amended, it takes effect as amended. In any case of rejection, amendment, or refusal to approve the By-Law or part of the By-Law in force and effect in accordance with this section, no act done or right acquired under any By-Law is prejudicially affected by any rejection, amendment, or refusal to approve.

24.4 Amendments to Professional Staff By-laws

Prior to submitting amendments to this By-Law to the approval processes described above:

(a) notice specifying the proposed By-Law or amendments thereto shall be made available for review by the Professional Staff;

(b) the Professional Staff shall be afforded an opportunity to comment on the proposed amendment(s); and

(c) the Medical Advisory Committee may make recommendations to the Board concerning the proposed amendment.

TOR01: 7817163: v7

Documents

Guelph General Hospital By-Law (By-Law 1-13) · Guelph General Hospital By-Law (By-Law 1-13) Approved by the Board of Directors and Confirmed by the Members on June , 2019 TABLE OF