WOMEN’S COLLEGE HOSPITAL MEDICAL DENTAL MIDWIFERY STAFF …€¦women’s college hospital ....

WOMEN’S COLLEGE HOSPITAL MEDICAL DENTAL MIDWIFERY STAFF BY-LAWS

AS AMENDED

MARCH 2006

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TABLE OF CONTENTS

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1. DEFINITIONS................................................................................................................... 2 1.1 INTERPRETATION.............................................................................................. 2 1.2 PROVISIONS........................................................................................................ 4

2. MEDICAL STAFF ............................................................................................................ 4 2.1 PURPOSE OF THE MEDICAL-DENTAL-MIDWIFERY STAFF

ORGANIZATION ................................................................................................. 4 2.2 APPOINTMENT OF MEDICAL STAFF............................................................. 4 2.3 APPOINTMENT TO HONORARY STAFF ........................................................ 4 2.4 APPOINTMENT TO MEDICAL STAFF............................................................. 4

2.4.1 Application for Appointment to the Medical Staff ................................. 4 2.4.2 Criteria for Appointment to the Medical Staff........................................ 7 2.4.3 Term........................................................................................................ 9

2.5 RE-APPOINTMENT............................................................................................. 9 2.5.1 Application for Re-Appointment and Performance Review................... 9 2.5.2 Criteria for Re-Appointment to the Medical Staff .................................. 9 2.5.3 Refusal to Re-Appoint .......................................................................... 10

2.6 PRIVILEGES....................................................................................................... 10 2.6.1 Application and Procedure for Processing Privileges........................... 11 2.6.2 Monitoring of Privileges ....................................................................... 11

2.7 CHANGE OF PRIVILEGES............................................................................... 12 2.7.1 Application For Change of Privileges................................................... 12

2.8 MID-TERM ACTION ......................................................................................... 12 2.8.1 Mid-Term Action .................................................................................. 12

2.9 MEDICAL STAFF GROUPS.............................................................................. 12 2.9.1 Medical Staff Groups............................................................................ 12 2.9.2 Active Medical Staff ............................................................................. 13 2.9.3 Associate Medical Staff ........................................................................ 14 2.9.4 Courtesy Medical Staff ......................................................................... 15 2.9.5 Locum Tenens....................................................................................... 17 2.9.6 Temporary Medical Staff ...................................................................... 17 2.9.7 Consultant Staff .................................................................................... 18 2.9.8 Clinical Associate Staff......................................................................... 19 2.9.9 Honorary Staff ...................................................................................... 20 2.9.10 Scientific and Affiliate Staff ................................................................. 21

2.10 MEDICAL STAFF DUTIES ............................................................................... 22 2.10.1 Duties, General ..................................................................................... 22 2.10.2 Chief of Staff......................................................................................... 23 2.10.3 Duties of the Chief of Staff ................................................................... 23 2.10.4 Monitoring Aberrant Practices.............................................................. 26 2.10.5 Viewing Therapeutic Actions, Operations or Procedures..................... 26 2.10.6 Transfer of Responsibility..................................................................... 26 2.10.7 Leave of Absence.................................................................................. 27

TABLE OF CONTENTS (continued)

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2.10.8 Relinquishment of Privileges................................................................ 27 2.10.9 Grievances............................................................................................. 27

2.11 MEDICAL STAFF DEPARTMENTS ................................................................ 28 2.11.1 Departments .......................................................................................... 28 2.11.2 Chief of the Department........................................................................ 29 2.11.3 Duties of Chief of the Department........................................................ 30 2.11.4 Services in a Department ...................................................................... 34 2.11.5 Head of Division ................................................................................... 34

2.12 MEETINGS – MEDICAL – DENTAL – MIDWIFERY STAFF....................... 36 2.12.1 Meetings of the Medical-Dental-Midwifery Staff ................................ 36 2.12.2 Notice of Annual Meetings................................................................... 36 2.12.3 Notice of Regular Meetings .................................................................. 36 2.12.4 Special Meetings................................................................................... 36 2.12.5 Quorum ................................................................................................. 37 2.12.6 Order of Business.................................................................................. 37 2.12.7 Ballot Process........................................................................................ 38 2.12.8 Attendance at Regular Staff Meetings .................................................. 38 2.12.9 Department Meetings............................................................................ 38 2.12.10 Attendance at Department Meetings..................................................... 39 2.12.11 Payment of Membership Fees............................................................... 39

2.13 MEDICAL-DENTAL-MIDWIFERY STAFF ELECTED OFFICERS .............. 39 2.13.1 Eligibility For Office............................................................................. 39 2.13.2 Election Procedure ................................................................................ 39 2.13.3 Duties of the President of the Medical-Dental-Midwifery Staff .......... 40 2.13.4 Duties of the Vice-President of the Medical-Dental-Midwifery

Staff Association................................................................................... 41 2.13.5 Duties of the Secretary of the Medical-Dental-Midwifery Staff

Association............................................................................................ 42 2.13.6 Duties of the Treasurer of the Medical-Dental-Midwifery Staff

Association............................................................................................ 43 2.13.7 Program Convenor ................................................................................ 44

2.14 MEDICAL ADVISORY COMMITTEE............................................................. 44 2.14.1 Purpose of the Medical Advisory Committee....................................... 44 2.14.2 Membership of the Medical Advisory Committee ............................... 44 2.14.3 Duties of the Medical Advisory Committee ......................................... 45 2.14.4 Meetings and Reporting Relationship of the Medical Advisory

Committee............................................................................................. 46 2.14.5 Executive Committee of the Medical Advisory Committee................. 46 2.14.6 Quorum ................................................................................................. 47 2.14.7 Transition .............................................................................................. 47

2.15 MEDICAL STAFF COMMITTEES ESTABLISHED BY THE BOARD ......... 47 2.15.1 Medical Staff Committees .................................................................... 47 2.15.2 Appointment To Medical Staff Committees......................................... 48


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2.15.3 Medical Staff Committee Duties .......................................................... 48 2.15.4 Medical Staff Committee Chair ............................................................ 48 2.15.5 Medical Staff Committee Chair Duties................................................. 48 2.15.6 Credentials Committee Duties .............................................................. 49 2.15.7 Infection Control Committee Duties..................................................... 50 2.15.8 Medical Records Committee Duties ..................................................... 52 2.15.9 Medical Quality Assurance Committee Duties..................................... 53 2.15.10 Operating Room and Recovery Room Committee Duties.................... 55 2.15.11 Pharmacy and Therapeutics Committee Duties .................................... 57 2.15.12 Transfusion Review Committee Duties ................................................ 58 2.15.13 Utilization Committee Duties ............................................................... 59

3. DENTAL STAFF............................................................................................................. 61 3.1 APPOINTMENT OF DENTAL STAFF ............................................................. 61 3.2 APPOINTMENT TO DENTAL STAFF............................................................. 61

3.2.1 Application For Appointment to the Dental Staff................................. 61 3.2.2 Criteria for Appointment to the Dental Staff ........................................ 63 3.2.3 Term...................................................................................................... 64

3.3 RE-APPOINTMENT........................................................................................... 64 3.3.1 Application for Re-Appointment and Performance Review................. 64 3.3.2 Criteria for Re-Appointment to the Dental Staff .................................. 64 3.3.3 Refusal to Re-Appoint .......................................................................... 64

3.4 CHANGE OF PRIVILEGES............................................................................... 65 3.4.1 Application for Change of Privileges ................................................... 65


3.6 DENTAL STAFF DUTIES ................................................................................. 65 3.6.1 Dental Staff Duties................................................................................ 65 3.6.2 Monitoring Aberrant Practices.............................................................. 66 3.6.3 Viewing Therapeutic Actions, Operations or Procedures..................... 66 3.6.4 Transfer of Responsibility..................................................................... 66

3.7 DENTAL SERVICE............................................................................................ 67 3.7.1 Dental Service....................................................................................... 67 3.7.2 Head of Dental Services........................................................................ 67 3.7.3 Duties of the Head of Dental Services.................................................. 68

3.8 MEETINGS – DENTAL STAFF ........................................................................ 68 3.8.1 Attendance By Dental Staff at Medical Staff Meetings........................ 68

3.9 DENTAL STAFF ELIGIBILITY TO HOLD OFFICE....................................... 68 3.9.1 Eligibility to Hold a Medical Staff Office ............................................ 68

4. MIDWIFERY STAFF ..................................................................................................... 69 4.1 APPOINTMENT OF MIDWIFERY STAFF ...................................................... 69 4.2 APPOINTMENT TO MIDWIFERY STAFF...................................................... 69

4.2.1 Application for Appointment to Midwifery Staff ................................. 69 4.2.2 Criteria for Appointment to Midwifery Staff........................................ 71


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4.2.3 Term...................................................................................................... 72 4.3 RE-APPOINTMENT........................................................................................... 72

4.3.1 Application for Re-Appointment and Performance Review................. 72 4.3.2 Criteria for Re-Appointment to the Midwifery Staff ............................ 72 4.3.3 Refusal to Re-Appoint .......................................................................... 72

4.4 CHANGE OF PRIVILEGES............................................................................... 73 4.4.1 Application for Change of Privileges ................................................... 73


4.6 MIDWIFERY STAFF GROUPS......................................................................... 73 4.6.1 Midwifery Staff Groups........................................................................ 73 4.6.2 Active Midwifery Staff ......................................................................... 73 4.6.3 Associate Midwifery Staff .................................................................... 74 4.6.4 Courtesy Midwifery Staff ..................................................................... 75 4.6.5 Locum Tenens....................................................................................... 76 4.6.6 Temporary Midwifery Staff .................................................................. 76

4.7 MIDWIFERY STAFF DUTIES .......................................................................... 77 4.7.1 Midwifery Staff Duties ......................................................................... 77 4.7.2 Monitoring Aberrant Practices.............................................................. 78 4.7.3 Viewing Deliveries, Therapeutic Actions or Procedures...................... 78 4.7.4 Transfer of Responsibility..................................................................... 78

4.8 MIDWIFERY STAFF ......................................................................................... 79 4.8.1 Midwifery Staff: Function within the Medical Staff Department ........ 79 4.8.2 Head Midwife ....................................................................................... 79 4.8.3 Duties of Head Midwife........................................................................ 79

4.9 MEETINGS – MIDWIFERY STAFF ................................................................. 79 4.9.1 Attendance by Midwifery Staff at Medical Staff Meetings.................. 79 4.9.2 Transition .............................................................................................. 80

4.10 MIDWIFERY STAFF ELIGIBILITY FOR OFFICE ......................................... 80 4.10.1 Eligibility to Hold a Medical Staff Office ............................................ 80

5. EXTENDED CLASS NURSING STAFF....................................................................... 80 5.1 APPOINTMENT OF EXTENDED CLASS NURSING STAFF........................ 80 5.2 APPOINTMENT TO EXTENDED CLASS NURSING STAFF ....................... 80

5.2.1 Application for Appointment to Extended Class Nursing Staff ........... 80 5.2.2 Criteria for Appointment to the Extended Class Nursing Staff ............ 82 5.2.3 Term...................................................................................................... 83

5.3 RE-APPOINTMENT........................................................................................... 83 5.3.1 Application for Re-Appointment and Performance Review................. 83 5.3.2 Criteria for Re-Appointment to the Extended Class Nursing Staff ...... 84 5.3.3 Refusal to Re-Appoint .......................................................................... 84


5.5 EXTENDED CLASS NURSING STAFF GROUPS .......................................... 84


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5.5.1 Extended Class Nursing Staff Groups .................................................. 84 5.5.2 Courtesy Extended Class Nursing Staff................................................ 85 5.5.3 Locum Tenens Extended Class Nursing Staff ...................................... 85

5.6 EXTENDED CLASS NURSING STAFF DUTIES............................................ 85 5.6.1 Extended Class Nursing Staff Duties.................................................... 85 5.6.2 Monitoring Aberrant Practices.............................................................. 86 5.6.3 Viewing Therapeutic Actions or Procedures ........................................ 86 5.6.4 Transfer of Responsibility..................................................................... 86

5.7 EXTENDED CLASS NURSING STAFF........................................................... 87 5.7.1 Extended Class Nursing Staff: Function Within Medical Staff

Department............................................................................................ 87 5.8 MEETINGS ......................................................................................................... 87

5.8.1 Attendance by Extended Class Nursing Staff at Medical Staff Meetings................................................................................................ 87

5.9 EXTENDED CLASS NURSING STAFF ELIGIBILITY FOR OFFICE........... 88 5.9.1 Eligibility to Hold a Medical Staff Office ............................................ 88

6. MEDICAL ADVISORY COMMITTEE AND BOARD PROCESS FOR APPLICATIONS, RE-APPLICATIONS, CHANGES IN PRIVILEGES AND MID-TERM ACTION ..................................................................................................... 88 6.1 THE MEDICAL ADVISORY COMMITTEE MEETING ................................. 88

6.1.1 The Medical Advisory Committee Meeting ......................................... 88 6.2 THE BOARD HEARING.................................................................................... 89

6.2.1 The Board Hearing................................................................................ 89 7. MID-TERM ACTION ..................................................................................................... 91

7.1 NON-IMMEDIATE MID-TERM ACTION ....................................................... 91 7.1.1 Preliminary Steps in Mid-Term Review ............................................... 91 7.1.2 Request to the Medical Advisory Committee for

Recommendations for Mid-Term Action.............................................. 92 7.1.3 The Medical Advisory Committee Meeting ......................................... 93

7.2 INTERMEDIATE MID-TERM ACTION IN AN EMERGENCY SITUATION ........................................................................................................ 94 7.2.1 Immediate Steps.................................................................................... 94 7.2.2 The Medical Advisory Committee Meeting ......................................... 95 7.2.3 The Board Hearing................................................................................ 96

8. AMENDMENTS TO MEDICAL STAFF, DENTAL STAFF, MIDWIFERY STAFF AND EXTENDED CLASS NURSING STAFF BYLAWS .............................. 98 8.1 AMENDMENTS TO BY-LAWS........................................................................ 98

PREAMBLE

WHEREAS Women’s College Hospital has been reconstituted as an independent health care facility following the de-amalgamation of Sunnybrook and Women’s College Health Sciences Centre; and

WHEREAS Women’s College Hospital is a non-profit corporation organized under the laws of the Province of Ontario to serve as a full-service academic ambulatory care center, providing patient care, education and research with all of its activities subject to the ultimate authority of the Women’s College Hospital Board; and

WHEREAS a transitional period will exist from the time of the official declaration of independent governance until relocation of the Perinatal and Gynaecology Program including all component departments, divisions and activities to Sunnybrook Health Sciences Centre during which a formal relationship between Women’s College Hospital and Sunnybrook Health Sciences Centre will be required; and

WHEREAS during the transitional period, the Perinatal and Gynaecology Program will be governed by and resourced from Sunnybrook Health Sciences Centre and the Sunnybrook Health Sciences Centre medical advisory committee and administration will have primary responsibility for the quality of care provided within the program; and

WHEREAS during the transitional period, the Perinatal and Gynaecology Program will advise the Women’s College Hospital medical advisory committee and the Women’s College Hospital Board with respect to aspects of medical, dental and midwifery care in the program at Women’s College Hospital, including quality of care matters, and will provide simultaneously to both the Women’s College Hospital medical advisory committee and the Sunnybrook Health Sciences Centre medical advisory committee all reports prepared for and to be provided to Sunnybrook Health Sciences Centre medical advisory committee and to both the Women’s College Hospital Board and the Sunnybrook Health Sciences Centre Board all reports prepared for and to be provided to the Sunnybrook Health Sciences Centre Board regarding the program; and

WHEREAS it is the expressed wish of the medical, dental and midwifery staff that they be organized, within the laws, regulations, customs and generally recognized professional standards that govern hospitals, into a collegial body that constitutes Women’s College Hospital’s medical, dental and midwifery staff, providing mutual education, consultation and clinical support for its members; and

WHEREAS Women’s College Hospital’s Board and management require a source of collective advice from the professionals practicing at the Women’s College Hospital to aid in the development and regulation of institutional policy, planning, coordination of services and governance; and

WHEREAS dedication to this purpose requires a cooperative effort among the professional peers practicing at Women’s College Hospital and between them and Women’s College Hospital Board and management, with well-defined lines of communication, responsibility and authority throughout the organization;

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NOW THEREFORE be it resolved that the physician, dentist and midwife practitioners practicing at Women’s College Hospital hereby organize themselves into a Medical-Dental-Midwifery Staff (as hereinafter defined) in conformity with the bylaws, rules and policies of Women’s College Hospital and physician, dentist and midwife practitioners working at Women’s College Hospital are to be governed by these Medical-Dental-Midwifery Staff By-laws for all their activities relating to Women’s College Hospital.

1. DEFINITIONS

1.1 INTERPRETATION

(1) In these By-laws,

“Affiliation Agreement” means the agreement between the University and the Hospital pertaining to the status of the Hospital as a teaching hospital of the University of Toronto.

“Academic Financial Plan” means a financial plan developed by each Department or Division (as applicable) with opportunity for input from Active and Associate Staff members of the Department or Division, to support the academic mission of the Hospital and consistent with University guidelines, where they exist, and approved by the University Chair of the Department, and the University Head of the Division, where appropriate, and the Chief of the Department, and the Head of the Division, where appropriate. The plan allows members of the Department or Division to financially contribute to the academic endeavours of the Department or Division.

“Board” means the Board of the Hospital.

“By-laws” means these by-laws entitled Women’s College Hospital Medical Dental Midwifery Staff By-laws.

“Chief Executive Officer” means the President and Chief Executive Officer (CEO) of the Hospital.

“De-amalgamation” means the effective date of the transfer of the Transferred Programs and Services from Sunnybrook and Women’s College Health Sciences Centre to the Hospital.

“Department” means a major area of medical practice identified in section 2.11.1.

“Dental Staff” means the dental practitioners appointed by the Board.

“Division” means a unit of a Department of the Medical Staff and Dental Staff.

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“Head Midwife” means the member of the Hospital Midwifery Staff who has been designated by the Board as the “Head Midwife”.

“Hospital” means Women’s College Hospital.

“Hospital Management Regulation” means Ont. Reg. 965.

“Impact Analysis” means the process by which the impact of all appointments to the Medical-Dental-Midwifery Staff on the Hospital’s resources is assessed.

“Medical Staff” means medical practitioners who are granted privileges by the Board.

“Memorandum of Agreement” means the memorandum of agreement between the applicant for the Medical Staff and the Chief of the relevant Department and/or the University Chair and Chief Executive Officer, on behalf of the Hospital, which is required for all new appointments and re-appointments to the Medical Staff and which clearly stipulates the expectations and the obligations agreed to by the applicant and the Hospital.

“Medical-Dental-Midwifery Staff” means the Medical Staff, the Dental Staff and the Midwifery Staff of the Hospital.

“Mid-Term” means during the period of appointment.

“Midwife” means an active member of the College of Midwives of Ontario.

“Midwifery Staff” means midwives appointed by the Board.

“Programs and Services” means the clinical activities transferred to and located at the Hospital and on the Hospital property.

“Public Hospitals Act” means the Public Hospitals Act (Revised Statutes of Ontario, 1990, Chapter P.40) and the Regulations promulgated thereunder.

“Rules of the Hospital” means the rules and regulations of the Hospital for the Medical-Dental-Midwifery Staff.

“Transition Period” means the period beginning on the effective date of the De-Amalgamation until relocation of the Perinatal and Gynaecology Program from the Hospital property to the Bayview site of Sunnybrook Health Sciences Centre.

“University” or “U of T” means The University of Toronto.

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1.2 PROVISIONS

(1) Where these By-laws provide that an action may be taken by the Chief Executive Officer, such action may from time to time be taken by a delegate of the Chief Executive Officer.

(2) Where these By-laws provide that an action may be taken by the Chief of the Department, such action may from time to time be taken by a delegate of the Chief of the Department.

2. MEDICAL STAFF

2.1 PURPOSE OF THE MEDICAL-DENTAL-MIDWIFERY STAFF ORGANIZATION1

(1) The purposes of the Medical-Dental-Midwifery Staff organization, in addition to fulfilling the responsibilities established by the laws of Ontario and these By-laws, are,

(a) to provide a structure whereby the members of the Medical-Dental-Midwifery Staff participate in the Hospital's planning, policy setting, and decision making;

(b) to serve as a quality assurance system for medical, dental and midwifery care rendered to patients by the Medical-Dental-Midwifery Staff; and

(c) to provide a structure and process to ensure that all patients receive medical, dental or midwifery care.

2.2 APPOINTMENT OF MEDICAL STAFF

(1) On an annual basis, the Board shall appoint a Medical Staff for the Hospital.

2.3 APPOINTMENT TO HONORARY STAFF

(2) Notwithstanding the other requirements of these By-laws, a person who is not a physician may be honoured by appointment to the Honorary Staff pursuant to subsection 2.9.9.

2.4 APPOINTMENT TO MEDICAL STAFF

2.4.1 Application for Appointment to the Medical Staff

(1) An application for appointment to the Medical Staff shall be processed in accordance with the provisions of the Public Hospitals Act2, other applicable legislation and these By-laws.

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(2) On request, the Chief Executive Officer shall supply the appropriate

application form, a copy of these By-laws, the Rules of the Hospital and the Public Hospitals Act to each physician who expresses in writing the intention to apply for appointment to the Medical Staff.

(3) An applicant for appointment to the Medical Staff shall submit one (1) original written application to the Chief Executive Officer.

(4) An application for an appointment to the Medical Staff shall contain,

(a) a statement by the applicant that he or she has read the Public Hospitals Act, the Hospital Management Regulation, these By-laws and Rules of the Hospital;

(b) an undertaking that, if he or she is appointed to the Medical Staff of the Hospital, he or she will govern himself or herself in accordance with the requirements set out in the By-laws and Rules of the Hospital;

(c) a copy of the applicant’s certificate of Registration with the College of Physicians and Surgeons of Ontario;

(d) evidence of current immunization status as suggested in the Communicable Disease Surveillance Protocols jointly published by the Ontario Hospital Association and the Ontario Medical Association;

(e) evidence of medical practice protection coverage satisfactory to the Board and a record of past claims history;

(f) a list of the privileges which are requested;

(g) an up-to-date curriculum vitae;

(h) a list of three (3) appropriate referees;

(i) information of any previous disciplinary proceeding where there was an adverse finding;

(j) information on any criminal proceedings or convictions which may impact the ability of the applicant to practice;

(k) information of any civil suit where the applicant is or was a defendant where there was a finding of negligence or battery or where such suit was settled with the payment of monies to the other party;

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(l) a signed consent authorizing any medical regulatory body,

including the College of Physicians and Surgeons, or referee to provide a report on,

(i) any action taken by its disciplinary or fitness to practice committee, and

(ii) whether his or her privileges have been temporarily or permanently curtailed or cancelled by any medical regulatory body or by another hospital because of incompetence, negligence, incapacity or any act of professional misconduct; and

(m) a current certificate of Professional Conduct from the College of Physicians and Surgeons of Ontario and consent to the release of information from the Registrar of the College;

(n) a signed consent authorizing the release of information by the chief executive officer and/or chief of staff of any hospital where the applicant is presently and /or previously held an appointment to staff; and

(o) an executed Memorandum of Agreement.

(5) All Active, Associate and Clinical Associate Staff:

(a) who are members of a U of T Faculty of Medicine conforming practice plan shall continue to participate in such plan after the date these By-laws are passed;

(b) who are not members of a U of T Faculty of Medicine conforming practice plan on or before the date these By-laws are passed and who spend a major part of their professional time at the Hospital shall become participants in such plan; or

(c) first appointed after the date these By-laws are passed must participate in a U of T Faculty of Medicine conforming practice plan as a condition of appointment.

Any other Active or Associate Staff member may participate in a U of T Faculty of Medicine conforming practice plan.

(6) Each applicant shall visit the Hospital for an interview with the Chief of the Department acting as the delegate of the Chief Executive Officer, and with appropriate members of the Medical Staff.

(7) The Chief Executive Officer shall retain a copy of the application and shall refer the original application immediately to the Medical Advisory

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Committee through its Chair who shall keep a record of each application received and then refer the original application forthwith to the Chair of the Credentials Committee.

(8) The Credentials Committee shall investigate each application submitted to it by the Medical Advisory Committee to ensure the applicant meets the criteria set for appointment to the Medical Staff as set out in section 2.4.2 and shall make a written report to the Medical Advisory Committee at its next regular meeting.

(9) The Chief of the relevant Department shall forward to the Chair of the Credentials Committee a written statement indicating recommendations, including the rank and category proposed for the applicant and, where required, a summary of the essential terms of the Memorandum of Agreement referred to in subsection 2.4.1(4)(o) of these By-laws including the expectations of the appointee.

(10) Each application and the report of the Credentials Committee shall be considered by the Medical Advisory Committee which shall make a recommendation thereon in writing to the Board and the applicant.

(11) The Hospital and the Medical Advisory Committee shall deal with the application in accordance with the Public Hospitals Act and the procedure set out in subsections 6.1.1(1) to (7) and 6.2.1(1) to (13) of these By-laws.

2.4.2 Criteria for Appointment to the Medical Staff

(1) Only an applicant qualified to practice medicine and who holds a current, valid certificate of Registration with the College of Physicians and Surgeons of Ontario is eligible to be a member of and appointed to the Medical Staff of the Hospital except as otherwise provided for in these By-laws.

(2) The applicant will have,

(a) a certificate of Registration with the College of Physicians and Surgeons of Ontario;

(b) a current certificate of Professional Conduct from the College of Physicians and Surgeons of Ontario;

(c) if applying to the category of Active, Associate, Locum Tenens, Clinical Associate or Temporary Staff, be a Fellow of the Royal College of Physicians and Surgeons or Certificant of the College of Family Physicians of Canada for Active and Associate Staff and a Member or Certificant of the College of Family Practice for all other staff categories in the Department of Family Practice or a Fellow/Certificant of such other accrediting body as may be

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(d) a current appointment in the Faculty of Medicine University of Toronto if applying to the Active Medical Staff or Associate Medical Staff category;

(e) a demonstrated ability to provide patient care at an appropriate level of quality and efficiency;

(f) a demonstrated ability to communicate, work with and relate to all members of the Medical-Dental-Midwifery Staff, extended class nursing staff and Hospital staff in a co-operative and professional manner;

(g) a demonstrated ability to communicate and relate appropriately with patients and patients' relatives;

(h) a willingness to participate in the discharge of staff obligations appropriate to membership group;

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

(j) evidence of medical practice protection coverage satisfactory to the Board;

(k) a report on, among other things, the experience, competence and reputation of the applicant from the chief of staff, chief of the department, or other such persons as is appropriate to contact, in the hospitals in which the applicant trained or held an appointment; and

(l) in the case of a certified specialist, a report from the chief of the department in which training was completed, and/or a report from the chief of the department in which he or she last practiced.

(3) The applicant must agree to govern himself or herself in accordance with the requirements set out in these By-laws, the Rules of the Hospital and Hospital policies and the ethical standards of the profession.

(4) The applicant must indicate to the Credentials Committee adequate control of any significant physical or behavioural impairment that affects skill, attitude or judgment.

(5) There is a Hospital and community need based on the Mission, Strategic and Staff Complement Plans of the Hospital for the services in the community.

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(6) There exists a Memorandum of Agreement between the applicant and the

Hospital.

2.4.3 Term

(1) Subject to subsection 2.4.3(2), each appointment to the Medical Staff shall be for one (1) year3, but, if the member has applied for re-appointment, shall continue in effect as specified in subsection 2.5.3(4).

(2) Notwithstanding any other provision of these By-laws, medical staff of Sunnybrook Women’s College Health Sciences Centre who are appointed by the Board on De-amalgamation to the Medical Staff will be appointed to the Medical Staff until July 1, 2006 and, if the member applies for re-appointment, such appointment shall continue in effect as specified in subsection 2.5.3(4).

2.5 RE-APPOINTMENT

2.5.1 Application for Re-Appointment and Performance Review

(1) Upon recommendation by the Medical Advisory Committee, the Board shall establish and approve a process for the annual performance review of each member of the Medical Staff.

(2) Each year each member of the Medical Staff shall make a written application for re-appointment to a group of the Medical Staff of the Hospital in the prescribed form.

(3) Where a member of the Medical Staff has applied for re-appointment, the Chief of the Department shall conduct a review of the applicant’s performance for the past year in accordance with the approved process once established under subsection 2.5.1(1), and shall make a written report to the Medical Advisory Committee in respect of the applicant’s performance for the past year4.

(4) The application for re-appointment to a group of the Medical Staff of the Hospital shall be processed in the same manner as set out in section 2.4.1.

2.5.2 Criteria for Re-Appointment to the Medical Staff

(1) In order to be eligible for re-appointment, the applicant shall,

(a) continue to meet the criteria set out in section 2.4.2; and

(b) have demonstrated an appropriate use of Hospital resources.

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2.5.3 Refusal to Re-Appoint

(1) Pursuant to the Public Hospitals Act,5 the Board may refuse to re-appoint a member of the Medical Staff.

(2) Following consultation with the Medical Advisory Committee, the Board may deny any appointment or re-appointment to the Medical Staff or any other appointment of a member of the Medical Staff to any office in the Hospital.

(3) The Chief Executive Officer or his or her delegate shall prepare and forward a detailed report to the College of Physicians and Surgeons of Ontario where,

(a) the application of a member for appointment or re-appointment to the Medical Staff is rejected by reason of incompetence, negligence or misconduct; or

(b) the privileges of a member of the Medical Staff are restricted or cancelled by reason of incompetence, negligence or misconduct; or

(c) a member voluntarily or involuntarily resigns from the Medical Staff during the course of investigation into his or her competence, negligence or misconduct.

(4) Where a member has applied under section 2.5.1 for re-appointment, his or her appointment shall be deemed to continue,

(a) until the re-appointment is granted; or

(b) where he or she is served with notice that the Board refuses to grant the re-appointment, until the time for giving notice requiring a hearing by the Health Professions Appeal and Review Board has expired and, where a hearing is required, until the decision of the Health Professions Appeal and Review Board has become final.

2.6 PRIVILEGES

(1) When physicians, dentists, and midwives are appointed to the Medical-Dental-Midwifery Staff and request privileges, they are normally granted privileges allowing them to perform all those procedures generally within the competence of a trained and certified specialist in their particular specialty. Privileges for very specialized procedures, or for new procedures not generally deemed to be within the competence of such a specialist, will be limited to those with extra training.

10 TOR_A2G:1733483.7

(2) Notwithstanding the extent of privileges granted, the size and scale of

activity will be limited by the availability of resources as determined by the Board.

2.6.1 Application and Procedure for Processing Privileges

(1) Each applicant for appointment to the Medical Staff who desires to perform any procedure within the Hospital, and any member of the Medical Staff who wishes to change privileges, or use technology and procedures new to the Hospital shall submit to the Chief of the Department and the Chief Executive Officer a statement of the privileges which are desired.

2.6.2 Monitoring of Privileges

(1) Members of the Medical-Dental-Midwifery Staff shall be assigned to a Department and may attend, investigate, and treat patients in the Hospital within the limits of the privileges granted to them by the Board. Notwithstanding the above, each member of the Medical-Dental-Midwifery Staff may only perform such medical or dental acts, operations, and procedures for which the member knows her/himself to be adequately trained and for which the member remains competent.

(2) Each member of the Medical-Dental-Midwifery Staff has an obligation to remain competent in every area for which the member has privileges and to discuss her/his level of competence with the Chief of the Department as part of the member’s annual review.

(3) In exercising responsibility for the quality of medical care in the Department, the Chief of each Department shall:

(a) recommend only those applications for privileges, in accordance with Article 2, sections 2.4.1, 2.4.2, 2.4.3 and 2.5.1 and 2.5.2 and which are believed to be within the competence of the applicant and recommend specific exclusions if there is a reason to do so.

(b) keep fully informed with regard to the level of competence of all members of the Medical-Dental-Midwifery Staff of the Department and be satisfied that such individuals within the Department do not exceed the privileges granted to them or their current competence.

(c) undertake a formal annual performance appraisal of all Active, Associate, and Clinical Associate Medical Staff members within the Department and of all Courtesy Medical Staff members within the Department who provide a significant professional contribution to the Hospital, and provide a written summary of that appraisal to the member.

11 TOR_A2G:1733483.7

(d) when he/she believes it necessary or desirable in the best interests

of patient care, to examine, or cause to be examined, and reported to him/her, the professional competence of any member of the Department. Such review may include any or all aspects of the care of any patient, and the use of simulated patients and other clinical simulation models.

2.7 CHANGE OF PRIVILEGES

2.7.1 Application For Change of Privileges

(1) Where a member of the Medical Staff wishes to change his or her privileges, the physician member shall make a written application, in the prescribed form, listing the change of privileges which is requested and shall submit evidence of appropriate training and competence in respect of the privileges being requested.

(2) An application for a change in privileges made by a member of the Medical Staff shall be processed in the same manner as set out in section 2.4.1.

2.8 MID-TERM ACTION

2.8.1 Mid-Term Action

(1) Pursuant to the Public Hospitals Act and in accordance with these By-laws, the Board at any time may revoke or suspend any appointment of a member of the Medical Staff or dismiss, suspend, restrict, cancel, substantially alter or otherwise deal with, the privileges of the member.

(2) Mid-Term action in respect of a member of the Medical Staff, shall be processed in accordance with, and in the same manner provided in Part 7 of these By-laws.

2.9 MEDICAL STAFF GROUPS

2.9.1 Medical Staff Groups

(1) The Medical Staff will be divided into the following groups6:

(a) Active;

(b) Associate;

(c) Courtesy;

(d) Locum Tenens;

(e) Temporary;

12 TOR_A2G:1733483.7

(f) Consultant;

(g) Clinical Associate;

(h) Honorary; and

(i) Scientific and Affiliate.

2.9.2 Active Medical Staff

(1) The Active Medical Staff category is intended for applicants who are engaged fulltime in academic activities or practice and have the Hospital as the site of their primary clinical appointment or who spend a major part of their professional time at the Hospital.

(2) The Active Medical Staff category will consist of:

(a) all active staff at Sunnybrook and Women’s College Health Sciences Centre who, for the year prior to De-amalgamation, were at the Hospital and who have spent a major part of their professional time in Programs at the Hospital.

(b) Medical Staff promoted from the Associate Medical Staff category after the date that these By-laws are passed; and

(c) Medical Staff transferring to the Medical Staff from another academic practice environment with, and who hold a similar appointment status in such, academic practice.

(3) Every physician applying for appointment to the Active Medical Staff should have completed, unless specifically exempted by the Board, a minimum period of one (1) year of satisfactory performance on the Associate Medical Staff.

(4) Each member of the Active Medical Staff is responsible for ensuring that medical care is provided to his or her patients in the Hospital.

(5) All Active Medical Staff members shall have admitting privileges unless otherwise specified in their appointment to the Medical Staff7.

(6) Active Medical Staff members shall be eligible to vote at Medical Staff meetings and at Medical-Dental-Midwifery Staff Association meetings, to hold office and to sit on any committee of the Medical Staff.

(7) Each member of the Active Medical Staff shall,

(a) undertake such duties in respect of those patients classed as emergency cases as may be specified by the Chief of Staff or by

13 TOR_A2G:1733483.7

the Chief of the Department to which the member has been assigned;

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

(c) act as a supervisor of a member of the Medical-Dental-Midwifery Staff, as and when requested by the Chief of Staff or the Chief of the Department, and act as a supervisor of the extended class nursing staff, for the diagnosing, prescribing for or treating out-patients, as and when requested by the Chief of Staff or the Chief of the Department; and

(d) be a member of the Faculty of Medicine, University of Toronto.

(8) Physicians with an active medical staff appointment at another hospital may be appointed to the Active Medical Staff if they spend a major part of their professional time in Programs at the Hospital.

2.9.3 Associate Medical Staff

(1) The Associate Medical Staff category is intended for applicants who will become eligible for Active Medical Staff after a probationary period.

(2) The Associate Medical Staff category shall consist of:

(a) Physicians appointed as Associate Medical Staff by the Board on the date that these By-laws are passed; and

(b) Medical Staff first appointed to the Associate Medical Staff category after the date that these By-laws are passed.

(3) Each Associate Medical Staff member shall exercise such clinical privileges as are granted by the Board upon recommendation of the Chief of the Department and Medical Advisory Committee, including admitting and/or treating patients at the Hospital consistent with the nature of the member's practice.

(4) An Associate Medical Staff member shall work for a probationary period under the supervision of an Active Medical Staff member named by the Chief of Staff on the recommendation of the Chief of the Department to which the Associate Medical Staff member has been assigned.

(5) An Active Medical Staff member assigned to supervise an Associate Medical Staff member shall carry out his or her duties in accordance with the Rules of the Hospital.

14 TOR_A2G:1733483.7

(6) After one (1) year, in considering the application for re-appointment to the

Medical Staff, the appointment of a physician to the Associate Medical Staff shall be reviewed by the Credentials Committee who shall report to the Medical Advisory Committee.

(7) The Medical Advisory Committee may recommend that the physician be appointed to the Active Medical Staff or may require the physician to be subject to a further probationary period and re-appointed as an Associate Medical Staff member for a period of not longer than six (6) months.

(8) The Chief of the Department, upon the request of an Associate Medical Staff member or a supervisor, may assign the Associate Medical Staff member to a different supervisor for a further probationary period.

(9) At any time an unfavourable report may cause the Medical Advisory Committee to consider making a recommendation to the Board that the appointment of the Associate Medical Staff member be terminated.

(10) No member of the Medical Staff shall be appointed to the Associate Medical Staff for more than eighteen (18) consecutive months.

(11) Each member of the Associate Medical Staff shall,

(a) attend patients, and undertake treatment and operative procedures under supervision in accordance with the kind and degree of privileges granted by the Board on the recommendation of the Medical Advisory Committee;

(b) undertake such duties in respect of those patients classed as emergency cases as may be specified by the Chief of the Department to which the physician has been assigned; and

(c) be a member of the Faculty of Medicine, University of Toronto.

(12) A member of the Associate Medical Staff is required to attend Medical Staff meetings as specified in these By-Laws

(13) A member of the Associate Medical Staff is not eligible to vote at Medical Staff meetings or Medical-Dental-Midwifery Staff Association meetings nor be elected a Medical Staff officer, but may be appointed to a committee of the Medical Advisory Committee.

2.9.4 Courtesy Medical Staff

(1) The Courtesy Medical Staff category is intended for applicants who:

(a) have an active medical staff appointment at another hospital;

15 TOR_A2G:1733483.7

(b) have a primary commitment to another organization or community;

(c) request limited access to Hospital resources or facilities; or

(d) provide special but limited clinical or academic expertise.

(2) Privileges granted to members of the Courtesy Medical Staff category shall be explicitly specified.

(3) The Medical Advisory Committee may recommend to the Board that the appointment be contingent upon the individual remaining on staff at the other hospital, or continuing with the primary commitment to the other organization or community.

(4) The Courtesy Medical Staff category shall consist of:

(a) physicians appointed as Courtesy Medical Staff by the Board on the date that these By-laws are passed;

(b) Medical Staff appointed to the Courtesy Medical Staff category after the date that these By-laws are passed.

(5) A member of the Courtesy Medical Staff shall meet the criteria set out in section 2.4.2

(6) A Courtesy Medical Staff member

(a) shall not be eligible to vote at Medical Staff meetings or Medical-Dental-Midwifery Staff Association meetings, hold office or serve on a medical standing committee except as provided by resolution of the Medical Advisory Committee or the Board;

(b) may attend Medical Staff meetings, Medical-Dental-Midwifery Staff Association meetings and medical education programs;

(c) shall be required to fulfil any Departmental requirements as determined by the Chief of the Department to which the physician has been assigned;

(d) shall meet the obligations of the Memorandum of Agreement;

(e) if continuing a community practice, visit their patient in Hospital and have access to the clinical data concerning that patient and shall be identified as Courtesy Medical Staff Visiting privileges only.

16 TOR_A2G:1733483.7

2.9.5 Locum Tenens

(1) The Medical Advisory Committee upon the request of a member of the Medical Staff may recommend the appointment of a Locum Tenens as a planned replacement for that physician for a specified period of time.

(2) A Locum Tenens shall,

(a) have admitting privileges unless otherwise specified;

(b) work under the counsel and supervision of a member of the Active Medical Staff who has been assigned this responsibility by the Chief of Staff or his or her delegate;

(c) attend patients assigned to his or her care by the Active Medical Staff member by whom he or she is supervised, and shall treat them within the kind and degree of privileges granted by the Board on the recommendation of the Medical Advisory Committee; and

(d) undertake such duties in respect of those patients classed as emergency cases as may be specified by the Chief of Staff or by the Chief of the Department to which the physician has been assigned.

2.9.6 Temporary Medical Staff

(1) A temporary appointment of a physician to the Medical Staff may be made only for one of the following reasons:

(a) to meet a specific singular requirement by providing a consultation and/or operative procedure; or

(b) to meet an urgent unexpected need for a medical service8.

(2) Notwithstanding any other provision in these By-laws:

(a) the Chief Executive Officer, after consultation with the Chief of Staff or his or her delegate, may:

(i) grant a temporary appointment to a physician who is not a member of the Medical Staff 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; and

(ii) continue the appointment on the recommendation of the Medical Advisory Committee until the next meeting of the Board; and

17 TOR_A2G:1733483.7

(b) the Chief of Staff at the request of a Chief of the Department and

after consultation with the Chief Executive Officer or his or her delegate may:

(i) grant a temporary appointment to a physician who is not a member of the Medical Staff for a period of not more than three (3) months provided that:

(A) the physician meets criteria of Section 2.4.2 that are determined to be applicable by the Chief of Staff; and

(B) the physician’s credentials are reviewed by the Chief of Staff and the Chief of the Department prior to such appointment and determined by each to be satisfactory; and

(ii) renew the temporary appointment granted under subclause (b) (i) for an additional period of not more than three (3) months provided that a temporary appointment is only renewable once and that such renewal occurs within a twelve month period commencing on the date the physician first received his or her temporary medical appointment.

(3) A temporary appointment shall not be eligible to vote at Medical Staff meetings or Medical-Dental-Midwifery Staff Association meetings, hold office or serve on a medical standing committee except as provided by resolution of the Medical Advisory Committee or the Board.

2.9.7 Consultant Staff

(1) The Consultant Staff category is intended to recognize individuals with outstanding credentials or reputation and who may occasionally provide clinical or academic expertise.

(2) Privileges granted to members of the Consulting Staff category will be explicitly specified.

(3) The Consultant Staff category shall consist of:

(a) Physicians appointed as Consultant Staff by the Board on the date that these By-laws are passed; and

(b) Medical Staff appointed to the Consultant Staff category after the date that these By-laws are passed.

(4) A member of the Consultant Staff shall be responsible to the Chief of the Department to which the physician is assigned for all aspects of professional, clinical and academic matters within the Hospital.

18 TOR_A2G:1733483.7

(5) A member of the Consultant Staff shall meet the criteria set out in section

2.4.2.

(6) A member of the Consultant Staff shall exercise such clinical privileges as are granted by the Board upon recommendation of the Chief of the Department and the Medical Advisory Committee.

(7) Members of the Consultant Staff shall not:

(a) have admitting privileges;

(b) have regularly assigned duties or responsibilities unless specifically authorized by the Board on the recommendation of the Chief of the Department;

(c) be eligible to vote at Medical Staff meetings or Medical-Dental-Midwifery Staff Association meetings; or

(d) hold office or serve on a standing committee of the Medical Advisory Committee except as provided by resolution of the Medical Advisory Committee and the Board.

2.9.8 Clinical Associate Staff

(1) The Clinical Associate Staff category is intended to provide temporary appointments for a specific period of time to fulfil clinical and or academic needs as determined by the Chief of the Department. The Clinical Associate Staff category is for temporary appointments for physicians who are engaged fulltime in academic activities or practice and have the Hospital as the site of their primary clinical appointment or who spend a major part of their professional time at the Hospital.

(2) The Clinical Associate Staff Category shall consist of:

(a) all Clinical Associate Staff at Sunnybrook and Women’s College Health Sciences Centre who, for the year prior to De-amalgamation were at the Hospital and who have spent a major part of their professional time in the Programs at the Hospital; and

(b) Medical Staff appointed to the Clinical Associate Staff category after the date that these By-laws are passed.

(3) A member of the Clinical Associate Staff shall meet the criteria set out in section 2.4.2

(4) Each Clinical Associate Staff member shall exercise such clinical privileges as are granted by the Board upon recommendation Chief of the Department and Medical Advisory Committee, including admitting and/or

19 TOR_A2G:1733483.7

treating patients at the Hospital consistent with the nature or the member's practice.

(5) A Clinical Associate Staff member shall work under the supervision of an Active Medical Staff member named by the Chief of Staff on the recommendation of the Chief of the Department to which the Clinical Associate Staff member has been assigned.

(6) An Active Medical Staff member supervisor shall carry out the duties in accordance with the Rules of the Hospital.

(7) After one (1) year, in considering the application for re-appointment to the Medical Staff, the appointment of a physician to the Clinical Associate Staff shall be reviewed by the Credentials Committee who shall report to the Medical Advisory Committee.

(8) The Medical Advisory Committee may recommend that the physician be re-appointed to the Clinical Associate Staff for a further twelve (12) months.

(9) At any time an unfavourable report may cause the Medical Advisory Committee to consider making a recommendation to the Board that the appointment of the Clinical Associate Staff member be terminated.

(10) No member of the Medical Staff shall be appointed to the Clinical Associate Staff for a period of more than twenty-four (24) consecutive months.

(11) A Clinical Associate Staff member shall,

(a) attend patients, and undertake treatment and operative procedures under supervision in accordance with the kind and degree of privileges granted by the Board on the recommendation of the Medical Advisory Committee; and

(b) undertake such duties in respect of those patients classed as emergency cases as may be specified by the Chief of the Department to which the physician has been assigned.

(12) A member of the Clinical Associate Staff shall not be eligible to vote at Medical Staff meetings or Medical-Dental-Midwifery Staff Association meetings, but may be appointed to a committee of the Medical Advisory Committee.

20 TOR_A2G:1733483.7

2.9.9 Honorary Staff

(1) The Honorary Staff category is intended to provide a means by which physicians and other individuals may be recognized for their outstanding reputations, their contributions to the community or to the Hospital.

(2) The Honorary Staff category shall consist of:

(a) Members appointed as Honorary Staff by the Board on the date that these By-laws are passed; and

(b) Medical Staff appointed to the Honorary Staff category after the date that these By-laws are passed.

(3) A physician may be honoured by the Board with a position on the Honorary Staff of the Hospital because he or she,

(a) is a former member of the Medical Staff who has retired from active practice; or

(b) has an outstanding reputation or made an extraordinary accomplishment, although not necessarily a resident in the community.

(4) Each member of the Honorary Staff shall be appointed by the Board on the recommendation of the Medical Advisory Committee.

(5) Notwithstanding any other provision of these By-laws, membership on the Honorary Staff is not restricted to physicians.

(6) A member of the Honorary Staff may:

(a) have access to all educational activities in the Hospital; and

(b) have library privileges.

(7) A member of the Honorary Staff is not subject to the duties, responsibilities and does not have rights or privileges of any of the other categories of the Medical Staff except as noted in subsection 2.9.9(6)(a) and (b) above.

(8) Members of the Honorary Staff shall not,

(a) have regularly assigned duties or responsibilities9;

(b) be eligible to vote at Medical Staff meetings or Medical-Dental-Midwifery Staff Association meetings or to hold office or serve on a medical standing committee of the Medical Advisory Committee;

21 TOR_A2G:1733483.7

(c) be bound by the attendance requirements for Medical Staff

meetings; or

(d) have admitting privileges.

2.9.10 Scientific and Affiliate Staff

(1) Notwithstanding any other provisions of these By-laws, the Scientific and Affiliate Staff category is intended to provide cross appointments of non-medical scientific staff or other health professionals to the Medical Staff for academic purposes.

(2) The Scientific and Affiliate Staff shall consist of:

(a) Members appointed as Scientific and Affiliate Staff by the Board on the date these By-laws are passed; and

(b) Staff appointed to the Scientific and Affiliate Category after the date that these By-laws are passed.

(3) A member of the Scientific and Affiliate Staff shall be responsible to the Chief of the Department to which the member is assigned for all aspects of professional, clinical and academic matters within the Hospital.

(4) A member of the Scientific and Affiliate Staff shall not be eligible to vote at Medical Staff meetings or Medical-Dental-Midwifery Staff Association meetings, or hold office or serve on a medical standing committee of the Medical Advisory Committee except as provided by resolution of the Medical Advisory Committee and the Board;

2.10 MEDICAL STAFF DUTIES

2.10.1 Duties, General

(1) Each member of the Medical Staff is accountable to and shall recognize the authority of the Board through and with their Chief of the Department, the Chief of Staff, and the Chief Executive Officer.

(2) Each member of the Medical Staff shall,

(a) attend and treat patients within the limits of the privileges granted by the Board, unless the privileges are otherwise restricted;

(b) provide care at a level of quality and effectiveness generally recognized as appropriate;

22 TOR_A2G:1733483.7

(c) notify the Chief Executive Officer of any change in the Certificate

of Registration with the College of Physicians and Surgeons of Ontario;

(d) give such instruction as is required for the education of other members of the Medical-Dental-Midwifery Staff, extended class nursing staff and Hospital staff;

(e) abide by the Rules of the Hospital, these By-laws, the Public Hospitals Act and all other legislated requirements;

(f) co-operate with,

(i) the Chief of Staff and the Medical Advisory Committee;

(ii) the Chiefs of Department;

(iii) the Head of the applicable services; and

(iv) the Chief Executive Officer;

(g) notify patients and/or their families or other appropriate persons about their options with respect to tissue and organ transplantation10;

(h) perform such other duties as may be requested from time to time by, or under the authority of the Board, the Medical Advisory Committee or the Chief of Staff11;and

(i) prepare and complete records in a timely fashion.

(3) Each member of the Active and Associate Medical Staff groups and the Courtesy Medical Staff shall attend fifty percent (50%) of the regular Medical Staff meetings and fifty percent (50%) of the meetings of the Department of Medical Staff of which he or she is a member.

2.10.2 Chief of Staff

(1) The Board shall appoint a member of the Active Medical Staff to be the Chief of Staff after giving consideration to the recommendations of a Selection Committee, established by the Board for the purposes of appointing a Chief of Staff, which shall seek the advice of the Medical Advisory Committee.

(2) The membership of a Selection Committee may include,

(a) a Director of the Board, who shall be chair;

23 TOR_A2G:1733483.7

(b) two (2) members of the Medical Advisory Committee, one of

whom shall be the President of the Medical Staff;

(c) the Chief Nursing Executive;

(d) the Chief Executive Officer, or his or her delegate; and

(e) such other members as the Board deems advisable.

(3) Subject to annual confirmation by the Board, an appointment made under subsection 2.10.2 (1) of these By-laws shall be for a term of three (3) years, but the Chief of Staff shall hold office until a successor is appointed.

(4) The maximum number of terms under subsection 2.10.2 (3) of these By-Laws shall be two (2), provided however that following a break in the continuous service of at least one (1) year the same person may be re-appointed.

(5) The Board may at any time revoke or suspend the appointment of the Chief of Staff for cause.

2.10.3 Duties of the Chief of Staff

(1) The Chief of Staff shall,

(a) be accountable to the Board;

(b) organize the Medical-Dental-Midwifery Staff to ensure that the quality of the medical, dental and midwifery care given to all patients of the Hospital is in accordance with policies established by the Board, and organize the extended class nursing staff care to ensure that the quality of the extended class nursing care, with respect to diagnosing, prescribing for or treating out-patients of the Hospital, is in accordance with policies established by the Board;

(c) chair the Medical Advisory Committee12;

(d) advise the Medical Advisory Committee and the Board with respect to the quality of medical and dental diagnosis, care and treatment provided to the patients of the Hospital13, and the quality of midwifery assessment, care and treatment provided to the patients of the Hospital, and the quality of extended class nursing staff care with respect to diagnosing, prescribing for or treating out-patients of the Hospital;

(e) report regularly to the Board, and Medical Staff14 and the Medical-Dental-Midwifery Staff about the activities, recommendations and

24 TOR_A2G:1733483.7

actions of the Medical Advisory Committee and any other matters about which they should have knowledge;

(f) assign, or delegate the assignment of a member of the Medical-Dental-Midwifery Staff or extended class nursing staff;

(g) supervise the practice of medicine of any other member of the Medical Staff, the practice of dentistry of any other member of the Dental Staff, the practice of midwifery of any other member of the Midwifery Staff, or the practice of registered nurses in the extended class with respect to diagnosing, prescribing for or treating out-patients of any other member of the extended class nursing staff, as appropriate for any period of time;

(h) make a written report to the Chief of the appropriate Department;

(i) assign, or delegate the assignment of, a member of the Medical-Dental-Midwifery Staff or extended class nursing staff to discuss in detail with any other member of the Medical-Dental-Midwifery Staff or extended class nursing staff as appropriate, any matter which is of concern to the Chief of Staff and to report the discussion to the Chief of the appropriate Department;

(j) in consultation with the Chief Executive Officer, designate an alternate to act during an absence;

(k) be a member of the Board, the Chair of the Medical Advisory Committee, the Executive Committee of the Medical Advisory Committee, the Credentials Committee and such other committees as may be specified in these By-Laws or as the Board may deem appropriate;

(l) be responsible to the Board through and with the Chief Executive Officer for the appropriate utilization of resources by all medical, dental and midwifery departments and extended class nursing staff;

(m) report to the Medical Advisory Committee on activities of the Hospital including the utilization of resources and quality assurance;

(n) participate in the development of the Hospital's mission, objectives, and strategic plan;

(o) work with the Medical Advisory Committee to plan medical human resources and other needs of the Hospital in accordance with the Hospital's strategic plan;

(p) participate in Hospital resource allocation decisions;

25 TOR_A2G:1733483.7

(q) ensure a process for the regular review of the performance of the

Chiefs of the Departments;

(r) ensure there is a process for participation in continuing Medical-Dental-Midwifery Staff and extended class nursing staff education;

(s) receive and review recommendations from Chiefs of Department regarding changes in privileges;

(t) receive and review the performance evaluations and the recommendations from Chiefs of Department concerning re-appointments;

(u) ensure that the evaluations and recommendations are forwarded to the Medical Advisory Committee;

(v) notify the Credentials Committee of the completion of the evaluations and the completion of the recommendations;

(w) advise the Medical-Dental-Midwifery Staff and extended class nursing staff on current Hospital policies, objectives and rules including the Hospital Rules; and

(x) delegate appropriate responsibility to the Chiefs of the Departments.

2.10.4 Monitoring Aberrant Practices

(1) Where any member of the Medical-Dental-Midwifery Staff, extended class nursing staff or Hospital staff believes that a member of the Medical Staff, the Dental Staff, the Midwifery Staff or the extended class nursing staff is attempting to exceed his or her privileges or is temporarily incapable of providing a service that he or she is about to undertake, the belief shall be communicated immediately to the Chief of the Department, the Chief of Staff and to the Chief Executive Officer.

2.10.5 Viewing Therapeutic Actions, Operations or Procedures

(1) Any therapeutic action, operation or procedure performed in the Hospital may be viewed without the permission of the physician by,

(a) the Chief of Staff or delegate; or

(b) the Chief of the Department or delegate.

26 TOR_A2G:1733483.7

2.10.6 Transfer of Responsibility

(1) Pursuant to the Hospital Management Regulation15 whenever the responsibility for the care of a patient of a member of the Medical Staff is transferred to another member of the Medical Staff, a written notation by the Medical Staff member who is transferring the care over to another shall be made and signed on the patient's medical record and the name of the Medical Staff member assuming the responsibility shall be noted in the patient's medical record and the Medical Staff member assuming the responsibility shall be notified immediately.

(2) Where a supervisor of a member of the Medical Staff, the Chief of the Department, or the Chief of Staff becomes aware that, in his or her opinion a serious problem exists in the care or treatment of one or more patients or out-patients of a physician, the supervisor, Chief of the Department or Chief of Staff, as the case may be, shall forthwith discuss the condition, care and treatment of the patient or out-patient with the attending physician and if changes in the care or treatment satisfactory to the supervisor, Chief of the Department or Chief of Staff, as the case may be, are not made promptly, he or she shall assume forthwith the duty of investigating, prescribing for and treating the patient or out-patient, as the case may be, and shall notify the attending physician, the Chief Executive Officer and if possible, the patient or out-patient, that the member of the Medical Staff who was in attendance will cease forthwith to have any hospital privileges as the attending physician for the patient or out-patient.

(3) Where a supervisor of a member of the Medical Staff, the Chief of the Department or the Chief of Staff, as the case may be, is responsible under subsection 2.10.6 (2) is unable to discuss the problem with the attending physician as required by subsection 2.10.6 (2), the supervisor, the Chief of the Department or the Chief of Staff, as the case may be, shall proceed with his or her duties as prescribed in this subsection 2.10.6 (2) as if he or she had had the discussion with the attending physician.

(4) Where a supervisor of a member of the Medical Staff, the Chief of the Department or Chief of Staff, as the case may be, has cause to take over the care of a patient, then pursuant to the Public Hospitals Act, 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 mentally incompetent, the patient’s substitute decision maker, shall be notified as soon as possible.

2.10.7 Leave of Absence

(1) Medical Staff members may apply for a leave of absence, sabbatical leave or leave for other reasons in accordance with the Hospital’s policies and procedures. Where the Board, on recommendation of the Medical

27 TOR_A2G:1733483.7

Advisory Committee, has granted a leave of absence of not more than one year to a member of the Medical Staff, such member shall be eligible for re-appointment to the Medical Staff as applicable pursuant to Article 2, section 2.5.2, provided that the member applies for such re-appointment within one year of the commencement of the member’s leave of absence.

2.10.8 Relinquishment of Privileges

(1) If a member of the Medical Staff wishes to relinquish his or her privileges, he or she shall endeavour to take efforts to provide not less than ninety (90) days notice to the Chief of the Department.

2.10.9 Grievances

(1) If a member of the Medical Staff has a grievance not otherwise dealt with in the By-laws, the member shall be entitled to give written notice of the details thereof to the Chair of the Medical Advisory Committee and/or President of the Medical-Dental-Midwifery Staff Association. The Chair of the Medical Advisory Committee and/or President of the Medical-Dental-Midwifery Staff Association will discuss the grievance with the Chief of the relevant Department and with the Chief Executive Officer

(2) If the matter is not resolved after a reasonable period, the member may write to the Chair of the Medical Advisory Committee requesting that the matter be brought before the next meeting of the Medical Advisory Committee which is held not earlier than thirty (30) days after the date that such request is submitted to the Chair of the Medical Advisory Committee.

(3) The grievance will be considered by the Medical Advisory Committee at the next meeting as described in subsection 2.10.9(2) and the member shall be entitled to make a presentation to the Medical Advisory Committee at that meeting.

(4) The decision of the Medical Advisory Committee will be final and binding.

2.11 MEDICAL STAFF DEPARTMENTS

2.11.1 Departments

(1) Members of the Medical Staff shall be appointed to one of the following professional Departments:

(a) Anaesthesia;

(b) Anatomic Pathology;

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(c) Clinical Pathology;

(d) Family and Community Medicine;

(e) Medical Imaging;

(f) Medicine;

(g) Microbiology;

(h) Newborn and Developmental Paediatrics;

(i) Obstetrics and Gynaecology;

(j) Psychiatry; and

(k) Surgery.

(2) Whenever a separate Department is established, physicians and where appropriate, dentists, midwives and registered nurses in the extended class and patients related to such a Department shall come under the jurisdiction of that Department.

(3) The Board, after considering the advice of the Medical Advisory Committee, at any time, may establish or disband Departments of the Medical Staff.

(4) During the Transition Period, members of the Departments of Newborn and Developmental Paediatrics and Obstetrics and Gynaecology may have their primary appointments with Sunnybrook Health Sciences Centre and will acquire secondary appointments.

(5) The Department of Surgery may include the disciplines of ophthalmology, otolaryngology and orthopaedic surgery within its Divisions, upon the recommendation of the Medical Advisory Committee and upon approval of the Board.

2.11.2 Chief of the Department

(1) The Board shall appoint as Chief of the Department a physician from that Department who is on the Active Medical Staff after giving consideration to the recommendations of a Search Committee established for such purpose by the Chief Executive Officer and following the process identified in the Affiliation Agreement and the Board’s procedures for a Search Committee.

(2) The membership of a Search Committee shall include,

(a) a Director;

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(b) the Dean of the Faculty of Medicine at the University or her/his

representative;

(c) the Chair of the relevant University department (where applicable);

(d) the Chief of Staff;

(e) a member of the Medical Advisory Committee;

(f) the Chief Nursing Executive;

(g) the Chief Executive Officer or his or her delegate; and

(h) a member of the Department.

(3) Subject to annual confirmation of the Board, the appointment of a Chief of the Department shall be for a term of five (5) years to commence on July 1 which term is renewable.

(4) The maximum number of terms under subsection 2.11.2 (3) of these By-Laws shall be two (2), provided however that following a break in the continuous service of at least one (1) year the same person may be re-appointed to Chief of the Department.

(5) The Board may at any time revoke or suspend the appointment of the Chief of a Department for cause.

(6) During the Transition Period, the Chiefs of the Departments of Newborn and Developmental Paediatrics and Obstetrics and Gynaecology will receive their primary appointments from Sunnybrook Health Sciences Centre and will acquire secondary appointments at the Hospital.

2.11.3 Duties of Chief of the Department

2.11.3.1 Function

(1) The Chief of the Department is responsible for the development and maintenance of quality patient care, education and research in the Department and management of the affairs of the Department within and outside of the Hospital.

2.11.3.2 Responsible to

(1) The Chief of the Department is responsible to:

(a) the Board through the Medical Advisory Committee with respect to medical diagnosis, care and treatment of patients in his or her Department;

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(b) the Deans of the Faculties of Medicine or Dentistry at the

University, through the Departmental Chair, for academic matters related to the University; and

(c) the Chief Executive Officer, or delegate, on matters of planning, management and administration of the Department.

2.11.3.3 Responsibilities

(1) Specific responsibilities of the Chief of the Department with respect to the following include:

(a) Patient Care:

(i) Supervise the professional care provided to in-patients and out-patients of the Hospital, by all members of the Medical-Dental-Midwifery Staff, the extended class nursing staff and all other members of the staff of the Department;

(ii) Advise the Medical Advisory Committee with respect to the quality of medical diagnosis, care and treatment provided to in-patients and out-patients of the Department;

(iii) Advise the Medical Advisory Committee and the Chief Executive Officer of any patient in the Department who is not receiving the most appropriate treatment and care;

(iv) Ensure that a quality assurance program exists within the Department and undertake quality improvement; and

(v) Organize the Medical-Dental-Midwifery Staff, the extended class nursing staff and all other staff within the Department to ensure the provision of care to all patients treated by members of the Department.

(b) Planning:

(i) Participate in the ongoing formulation of the mission, strategic plan, objectives and goals of the Hospital;

(ii) Undertake human resource planning for the Department, consistent with the Hospital's strategic plan; and

(iii) Review proposals from each program for new appointments to the Medical-Dental-Midwifery Staff and the extended class nursing staff and make recommendations for approval to the Medical Advisory Committee within the context of

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approved medical, dental, midwifery and extended class nursing staffing plans.

(c) Staff Responsibilities:

(i) Recruit qualified Medical Staff, in accordance with Article 2, section 2.4.2 and ensure that ongoing practice patterns, including resource and income considerations, are consistent with and further the realization of the mission, objectives and goals of the Hospital and the academic objectives of the University;

(ii) Ensure orientation of new Medical-Dental-Midwifery Staff members;

(iii) Encourage, support, motivate and supervise members of the Department, and foster an atmosphere of collegiality;

(iv) Implement disciplinary measures where members of the Department contravene the requirements of the By-laws, the Rules of the Hospital and Department policies, procedures and rules;

(v) Be fully informed as to the level of competence of all members of the Department and be satisfied that such individuals do not exceed the privileges granted to them or their current competence;

(vi) Review the performance and privileges of the members of the Department annually based on the structured review process approved by the Board and make such recommendations to the Medical Advisory Committee concerning re-appointment;

(vii) Recommend to the Medical Advisory Committee and the Board the appointment of a Head for each separate Division where these exist within the Department;

(viii) Delegate responsibility to the Head of each Division within the Department, as appropriate, and supervise that individual's activities; and

(ix) Develop and regularly update policies and rules for the Department.

(d) Education:

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(i) Organize and co-ordinate within the Department

educational programs for undergraduate, postgraduate and practising physicians and other health professionals in co-operation with the Hospital's Medical Education Department/Committees and with the University of Toronto and other affiliated academic institutions; and

(ii) Ensure that members of the Department undertake continuing education.

(e) Research:

(i) Encourage, support and monitor research consistent with the Hospital's vision and policies for research.

(f) Management:

(i) Advise Hospital management committees regarding effective utilization of Hospital resources related to clinical practice, while ensuring patient care and consistency with departmental academic objectives;

(ii) Be responsible for any agreements made with, or commitments to, the University by the Department as defined in the Affiliation Agreement between the Hospital and the University;

(iii) Ensure the Department's activities are consistent with any contractual arrangements with the Hospital and the University;

(iv) Organize the activities and functions of the Department and hold regular meetings with members of the Department to inform and seek input on Hospital and University policies and procedures, rules, goals and objectives, strategic planning activities and resource allocation;

(v) Maintain a written record of departmental meetings;

(vi) Develop and implement policies and programs within the Department, and allocate resources;

(vii) Report to the Medical Advisory Committee, including written reports as necessary, recommendations on policies affecting medical care and the allocation of resources, such reports to include an annual report for each academic year; and

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(viii) Represent the Department on the Medical Advisory

Committee.

2.11.3.4 Search Process

(1) The Chief of the Department shall be appointed by the Board on the recommendation of a Search Committee struck by the Chief Executive Officer in accordance with the Affiliation Agreement.

(2) The Chair of the Search Committee shall be a member of the Board and shall be appointed by the Board.

(3) The search process shall include candidate selection on the basis of defined criteria.

2.11.3.5 Term

(1) The term of office is five (5) years to commence on July 1, subject to annual review and confirmation in accordance with the Memorandum of Agreement between the member and the Hospital and renewable as defined in the Affiliation Agreement.

2.11.3.6 Review

(1) Pursuant to the Affiliation Agreement, a five year review of the Department and the Chief of the Department will occur during the final year of the initial appointment. Based on the review, re-appointment of the Chief of the Department may occur for a second five year term or a term as determined by the Board not to exceed five years, in accordance with the process as identified in the Affiliation Agreement.

(2) In Departments where the same Chief has served two consecutive five (5) year terms, pursuant to the Affiliation Agreement, there shall be a formal search for the position of Chief of the Department, set up during the ninth year. The existing Chief of the Department may apply.

(3) Under extraordinary circumstances after serving ten years, the Chief may be given consideration for an additional appointment and the Search Committee may recommend to the Board and the University that the incumbent should be appointed without going through a more extensive search process. The Board and the University shall decide whether to accept the recommendation of the Search Committee or ask the Search Committee to conduct a broader search.

2.11.4 Services in a Department

(1) When warranted by the professional resources of the Department, the Board, on the advice of the Medical Advisory Committee, after

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considering the recommendation of the Chief of the Department, may divide the Department into Divisions.

2.11.5 Head of Division

(1) When Divisions are established under a Department, the Board, on the advice of the Medical Advisory Committee, after considering the recommendation of the Chief of the Department, shall appoint a Head of Division for each service who shall be responsible to the Chief of the Department for the quality of medical, and where appropriate, dental and midwifery care, rendered to patients in that Division.

2.11.5.1 Duties of the Head of the Division

(1) The Head of a Division is responsible for the development and maintenance of quality patient care, education and research in the Division and management of the affairs of the Division within and outside the Hospital.

(2) The Head of the Division is responsible to the Chief of the Department.

(3) Specific responsibilities of the Head of the Division include:

(a) To act as a delegate of the Chief of the Department and to assume such duties and responsibilities as assigned;

(b) To fulfil the responsibilities outlined in subsections 2.11.3.1, 2.11.3.2 and 2.11.3.3(a) as they pertain to the Division and/or members of the Division; and

(c) To fulfil such other responsibilities as may be delegated by the Chief of the Department.

2.11.5.2 Search Process

(1) The Head of the Division shall be appointed by the Board on the recommendation of a Search Committee struck by the Chief of the Department in accordance with the Affiliation Agreement. The search process shall include candidate selection on the basis of defined criteria.

2.11.5.3 Term

(1) The term of office for a Head of the Division is five (5) years to commence on July 1, subject to annual review and confirmation in accordance with the Memorandum of Agreement between the member and the Hospital, and renewable in accordance with these By-laws and the Affiliation Agreement.

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2.11.5.4 Review

(1) Pursuant to the Affiliation Agreement, a five year review of the Division and the Head of the Division will occur during the final year of the initial appointment. Based on the review, re-appointment may occur for a second five-year term or a term as determined by the Board not to exceed five years, in accordance with the process as identified in the Affiliation Agreement.

(2) In Divisions where the same Head has served two consecutive five (5) year terms, pursuant to the Affiliation Agreement, there shall be a formal search for the position of Head of the Division, set up during the ninth year. The existing Head of the Division may apply.

(3) Under extraordinary circumstances after serving ten years, the Head of the Division may be given consideration for an additional appointment and the Search Committee may recommend to the Board and the University that the incumbent should be appointed without going through a more extensive search process. The Board and the University shall decide whether to accept the recommendation of the Search Committee or ask the Search Committee to conduct a broader search.

(4) Notwithstanding the above, in the case of a very small Division, it may be impractical to appoint a new Head of the Division based on a ten (10) year rotation policy. Hence, in cases where Divisions have five or fewer physicians, the Hospital and the University may agree to waive the requirements of the ten (10) year rotation policy.

2.12 MEETINGS – MEDICAL – DENTAL – MIDWIFERY STAFF

(1) The Medical-Dental-Midwifery Staff Association is the organized body of the Medical-Dental-Midwifery Staff and extended class nursing staff who hold appointments in the Hospital.

2.12.1 Meetings of the Medical-Dental-Midwifery Staff

(1) The Medical-Dental-Midwifery Staff shall hold at least four (4) meetings in each fiscal year of the hospital, one of which shall be the annual meeting16 and the Medical Staff meetings required pursuant to the Public Hospitals Act including the annual meeting are to be convened during such meetings.

(2) The first meeting of the Medical-Dental-Midwifery Staff shall be at a time and place fixed by the Board.

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2.12.2 Notice of Annual Meetings

(1) A written notice of each annual meeting of the Medical-Dental-Midwifery Staff shall be posted electronically and in the Hospital’s Doctor’s Lounge by the Secretary of the Medical-Dental-Midwifery Staff Association at least ten (10) days before the meeting.

2.12.3 Notice of Regular Meetings

(1) A written notice of each regular meeting of the Medical-Dental-Midwifery Staff shall be posted electronically and in the Hospital’s Doctor’s Lounge by the Secretary of the Medical-Dental-Midwifery Staff Association at least five (5) days before the meeting.

2.12.4 Special Meetings

(1) The President of the Medical-Dental-Midwifery Staff Association may call a special meeting.

(2) Special meetings shall be called by the President of the Medical-Dental-Midwifery Staff Association on the written request of any 10 members of,

(i) the Active Medical Staff; or

(ii) a Department17.

(3) Notice of such special meetings shall be as required for a regular meeting, except in cases of emergency, and shall state the nature of the business for which the special meeting is called.

(4) The usual period of time required for giving notice of any special meeting shall be waived in cases of emergency, subject to ratification of this action by the majority of the Active Medical Staff present and eligible to vote at the special meeting, as the first item of business at the meeting.

2.12.5 Quorum

(1) Twenty percent (20%) of the Active Medical Staff members entitled to vote shall constitute a quorum18 at any annual, general or special meeting of the Medical-Dental-Midwifery Staff Association.

2.12.6 Order of Business

(1) The order of business at the Annual General Meeting of the Medical-Dental-Midwifery Staff shall be:

(a) review and adopt the minutes of the previous meeting;

(b) business arising from the minutes and new business;

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(c) the report of the President of the Medical-Dental-Midwifery Staff

Association;

(d) the report of the Treasurer of the Medical-Dental-Midwifery Staff Association;

(e) the report of the Chief of Staff including:

(i) reports of the standing committees of the Medical Advisory Committee,

(ii) reports of special committees of the Medical Advisory Committee, and

(iii) reports of the Chiefs of Departments;

(f) the election of the members of the Executive of the Medical-Dental-Midwifery Staff Association including the President, Vice-President, Secretary, Treasurer and Program Convenor;

(g) other business; and

(h) adjournment.

(2) The order of business at any general meetings of the Medical-Dental-Midwifery Staff Association shall be:

(a) review and adopt the minutes of the last regular meeting;

(b) business arising from the minutes and unfinished business;

(c) announcements of interest to the Medical-Dental-Midwifery Staff;

(d) educational presentations and discussions;

(e) new business; and

(f) adjournment.

(3) The order of business at special meetings of the Medical-Dental-Midwifery Staff Association shall be:

(a) reading of the notice calling the meeting;

(b) the business for which the meeting was called; and

(c) adjournment.

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2.12.7 Ballot Process

(1) A secret ballot by all members of the Active Medical Staff present and entitled to vote shall be held at the Annual Meeting of the Medical-Dental-Midwifery Staff Association to elect the officers of the Medical-Dental-Midwifery Staff Association. No proxy votes or advanced votes shall be allowed.

2.12.8 Attendance at Regular Staff Meetings

(1) Each member of the Active Medical Staff and the Associate Medical Staff shall attend at least fifty per cent (50%) of the general Medical-Dental-Midwifery Staff Association meetings.

2.12.9 Department Meetings

(1) Department meetings shall be held in accordance with subsections 2.11.3.1(1)(f)(iv) and (v) of these By-laws.

(2) Quorum at a Department meeting is not less than thirty three percent (33%) of Active Medical Staff entitled to vote.

2.12.10 Attendance at Department Meetings

(1) Each member of the Active and Associate Medical Staff groups shall attend at least fifty percent (50%) of the meetings of the Department of which he or she is a member.

2.12.11 Payment of Membership Fees

(1) All physicians, with the exception of Consultant Staff and the Honorary Staff, appointed to the Medical Staff of the Hospital are required to pay an annual membership fee to the Medical-Dental-Midwifery Staff Association.

(2) Failure to pay dues will be followed by three (3) written notices of fees followed by one written notice by registered mail. Upon failure to pay after written notification, the President of the Medical-Dental-Midwifery Staff Association will report these physicians to the Chair of the Medical Advisory Committee and the Chief Executive Officer who will suspend their privileges until the dues are paid.

2.13 MEDICAL-DENTAL-MIDWIFERY STAFF ELECTED OFFICERS

2.13.1 Eligibility For Office

(1) Only members of the Active Medical Staff may be elected or appointed to any position or office in the Medical-Dental-Midwifery Staff Association.

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2.13.2 Election Procedure

(1) A Nominating Committee shall be appointed by the Active Medical Staff at each annual meeting and shall consist of three (3) members of the Active Medical Staff: the then current President of the Medical-Dental-Midwifery Staff Association, who chairs the committee, and two (2) members of the Active Medical Staff elected by the Active Medical Staff members at the general meeting of the Medical-Dental-Midwifery Staff Association preceding the Annual General Meeting.

(2) At least thirty days before the annual meeting of the Medical-Dental-Midwifery Staff, the Nominating Committee shall post electronically and in the Doctors’ Lounge of the Hospital19 a list of the names of those who are nominated for the offices of the Medical-Dental-Midwifery Staff which are to be filled by election in accordance with these By-laws and the Public Hospitals Act.

(3) Any further nominations shall be made in writing to the Secretary of the Medical-Dental-Midwifery Staff within fourteen (14) days after the posting of the names referred to in subsection 2.13.2 (2) of these By-laws.

(4) Further nominations referred to in subsection 2.13.2 (3) of these By-laws shall be signed by two (2) members of the Active Medical Staff who are entitled to vote and the nominee shall have signified in writing on the nomination acceptance of the nomination. Such nominations shall then be posted alongside the list referred to in subsection 2.13.2 (2) of these By-laws.

2.13.3 Duties of the President of the Medical-Dental-Midwifery Staff

(1) The role of the President of the Medical-Dental-Midwifery Staff is to represent the interests of the Medical-Dental-Midwifery Staff to the Board and the Hospital, in accordance with the Public Hospitals Act.

(2) The President of the Medical-Dental-Midwifery Staff is responsible to the Medical-Dental-Midwifery Staff.

(3) Specific responsibilities of the President of the Medical-Dental-Midwifery Staff Association include the following:

(a) To act as an advocate by supporting, promoting and advancing the rights and privileges of physicians, dentists and midwives both as individuals and as a collective body;

(b) To provide leadership to the collegial body of the Medical-Dental-Midwifery Staff;

40 TOR_A2G:1733483.7

(c) To facilitate the process of developing a Medical-Dental-

Midwifery Staff position on issues and to convey that position to the appropriate body;

(d) To act as a member of the Board and as a member of such committees of the Board as deemed appropriate by the Board;

(e) To act as liaison between the Medical-Dental-Midwifery Staff Association and both the Chief Executive Officer and the Board;

(f) To be an ex officio member of the Joint Conference Committee and the Finance Committee;

(g) To act as a member of the Medical Advisory Committee and such other Hospital committees as deemed appropriate by the Board;

(h) To preside at all meetings of the Medical Staff Association and the Medical-Dental-Midwifery Staff Association; and

(i) To communicate with and to inform the Medical-Dental-Midwifery Staff Association of all issues pertaining to their interests.

2.13.3.1 Appointment and Term – President of the Medical-Dental-Midwifery Staff Association

(1) The President of the Medical-Dental-Midwifery Staff Association shall be elected by the Active Medical Staff present and eligible to vote. The President of the Medical-Dental-Midwifery Staff shall also be President of the Medical Staff.

(2) The term of office for the President of the Medical-Dental-Midwifery Staff Association shall be one (1) year, renewable once.

2.13.4 Duties of the Vice-President of the Medical-Dental-Midwifery Staff Association

(1) The role of the Vice-President of the Medical-Dental-Midwifery Staff Association is to assist the President of the Medical-Dental-Midwifery Staff Association in the performance of his/her duties and to assume the role and powers of the President of the Medical-Dental-Midwifery Staff Association during that individual's absence or inability to attend to his/her duties. It is expected that the Vice-President of the Medical-Dental-Midwifery Staff Association will succeed the President of the Medical-Dental-Midwifery Staff Association at the end of their respective terms.

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(2) The Vice-President of the Medical-Dental-Midwifery Staff Association is

responsible to the Medical-Dental-Midwifery Staff. (3) Specific responsibilities of the Vice-President of the Medical-Dental-

Midwifery Staff Association include the following:

(a) To act in the capacity of the President of the Medical-Dental-Midwifery Staff Association in that individual's absence;

(b) To perform such duties as the President of the Medical-Dental-Midwifery Staff Association may delegate;

(c) To act as a member of the Medical Advisory Committee; and

(d) To act as a member of the Board and as a member of such committees of the Board as deemed appropriate by the Board.

2.13.4.1 Appointment and Term – Vice-President of the Medical-Dental-Midwifery Staff Association

(1) The Vice-President of the Medical-Dental-Midwifery Staff Association shall be elected by the Active Medical Staff present and eligible to vote. The Vice-President of the Medical-Dental-Midwifery Staff Association shall also be the Vice-President of the Medical Staff.

(2) The term of office for the Vice-President of the Medical-Dental-Midwifery Staff Association shall be one (1) year, renewable once.

2.13.5 Duties of the Secretary of the Medical-Dental-Midwifery Staff Association

(1) The role of the Secretary of the Medical-Dental-Midwifery Staff Association is to assist the President of the Medical-Dental-Midwifery Staff Association in the performance of his/her duties and to act in the place of the Vice-President of the Medical Medical-Dental-Midwifery Association in that individual's absence, or to act in the place of the President of the Medical-Dental-Midwifery Staff Association in the absence of both the Vice-President and President of the Medical-Dental-Midwifery Staff Association.

(2) The Secretary of the Medical-Dental-Midwifery Staff Association is responsible to the Medical-Dental-Midwifery Staff.

(3) Specific responsibilities of the Secretary of the Medical-Dental-Midwifery Staff Association include the following:

(a) To attend to the correspondence of the Medical-Dental-Midwifery Staff Association;

42 TOR_A2G:1733483.7

(b) To give notice of Medical-Dental-Midwifery Staff Association

meetings in accordance with the Public Hospitals Act and these By-laws;

(c) To ensure that minutes are kept at Medical-Dental-Midwifery Staff Association meetings;

(d) To ensure that a record of the attendance at each meeting of the Medical-Dental-Midwifery Staff Association is made;

(e) Receive the record of attendance for each meeting of each Department of the Medical Staff;

(f) Make the attendance records available to the Medical Advisory Committee;

(g) Perform the duties of the Treasurer for Medical Staff funds and be accountable therefore, when a Treasurer of the Medical-Dental-Midwifery Staff has not been elected20;

(h) Act in the place of the Vice-President of the Medical-Dental-Midwifery Staff Association, performing his or her duties and possessing his or her powers in the absence or disability of the Vice-President;

(i) To act in the capacity of the President of the Medical-Dental-Midwifery Staff Association in the absence of the President and Vice-President; and

(j) To act as a member of the Medical Advisory Committee.

2.13.5.1 Appointment and Term – Secretary of the Medical-Dental-Midwifery Staff Association

(1) The Secretary of the Medical-Dental-Midwifery Staff Association shall be elected by the Active Medical Staff present and eligible to vote. The Secretary of the Medical-Dental-Midwifery Staff Association will also be the Secretary of the Medical Staff.

(2) The term of office for the Secretary of the Medical-Dental-Midwifery Staff Association shall be one (1) year, renewable once.

2.13.6 Duties of the Treasurer of the Medical-Dental-Midwifery Staff Association

(1) The role of the Treasurer of the Medical-Dental-Midwifery Staff Association is to oversee and be accountable for the financial matters of the Medical-Dental-Midwifery Staff Association.

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(2) The Treasurer of the Medical-Dental-Midwifery Staff Association is

responsible to the Medical-Dental-Midwifery Staff Association.

(3) Specific responsibilities of the Treasurer of the Medical-Dental-Midwifery Staff Association include the following:

(a) To hold the funds of the Medical-Dental-Midwifery Staff Association at the direction of the Officers of the Medical-Dental-Midwifery Staff Association.

(b) To disburse Medical-Dental-Midwifery Staff Association funds at the direction of the Officers of the Medical-Dental-Midwifery Staff Association.

2.13.6.1 Appointment and Term – Treasurer of the Medical-Dental-Midwifery Staff Association

(1) The Treasurer of the Medical-Dental-Midwifery Staff Association shall be elected by the Active Medical Staff present and eligible to vote.

(2) The term of office for the Treasurer of the Medical-Dental-Midwifery Staff Association shall be one (1) year, renewable once.

2.13.7 Program Convenor

(1) The role of the Program Convenor of the Medical-Dental-Midwifery Staff Association is to plan the social and educational activities for the Medical-Dental-Midwifery Staff Association.

(2) The Program Convenor of the Medical-Dental-Midwifery Staff Association is responsible to the Medical-Dental-Midwifery Staff.

2.13.7.1 Appointment and Term – Program Convenor of the Medical-Dental- Midwifery Staff Association

(1) The Program Convenor of the Medical-Dental-Midwifery Staff Association shall be elected by the Active Medical Staff present and eligible to vote.

(2) The term of office for the Program Convenor of the Medical-Dental-Midwifery Staff Association shall be one (1) year, renewable once.

2.14 MEDICAL ADVISORY COMMITTEE

2.14.1 Purpose of the Medical Advisory Committee

(1) All medical, dental and midwifery programs and services at the Hospital shall report to the Medical Advisory Committee.

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(2) The purpose of the Medical Advisory Committee shall be to advise the

Board concerning, and to supervise on behalf of the Board:

(a) all aspects of medical, dental and midwifery care appropriate to a teaching hospital of a University; and

(b) compliance with the requirements of the Public Hospitals Act.

2.14.2 Membership of the Medical Advisory Committee

(1) The Medical Advisory Committee21 membership shall include:

(a) the Chief of Staff22, who shall be Chair;

(b) all Chiefs of Medical and Dental Departments;

(c) the President of the Medical Staff;

(d) the Vice-President of the Medical Staff; and

(e) the Secretary of the Medical Staff;

Ex-Officio and non-voting members of the Medical Advisory Committee shall include:

(a) the Chief Executive Officer;

(b) the Chief Nursing Executive;

(c) the Head Midwife;

(d) two (2) representatives from other health professional groups selected by those groups;

(e) the Director of the Centre for Research in Women’s Health;

(f) others as determined from time to time by the Medical Advisory Committee

2.14.3 Duties of the Medical Advisory Committee

(1) The Medical Advisory Committee shall elect from among themselves a Vice-Chair and a Secretary to the Medical Advisory Committee.

(2) The Medical Advisory Committee shall perform the functions as set out in the Hospital Management Regulation23.

(3) The Medical Advisory Committee shall,

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(a) receive and consider the report of the Credentials Committee and

other reports that may be provided by any other medical standing committees of the Medical Advisory Committee;

(b) in considering a recommendation for appointment or re-appointment, review,

(i) the need of the Hospital for such an appointment or re-appointment;

(ii) the impact such an appointment or re-appointment would have on available Hospital and community resources; and

(iii) in the case of a recommendation for appointment or re-appointment, specify the privileges which it recommends the applicant be granted.

(c) develop a medical, dental, midwifery and extended class nursing staff human resources plan.

(d) through the Chief of Staff, the Medical Advisory Committee shall advise the Board on:

(i) medical, dental, midwifery and extended class nursing staff quality assurance;

(ii) academic affairs;

(iii) clinical role of the Hospital; and

(iv) medical, dental, midwifery and extended class nursing staff human resources plan.

(e) make recommendations to the Board concerning by-laws, rules and regulations respecting the Medical-Dental-Midwifery Staff and the extended class nursing staff;

(f) make recommendations to the Board concerning dismissal, suspension or restriction of Hospital privileges of any member of the Medical-Dental-Midwifery Staff and the extended class nursing staff; and

(g) make recommendations to the Board regarding every application for appointment or re-appointment of the Medical-Dental-Midwifery Staff and extended class nursing staff.

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2.14.4 Meetings and Reporting Relationship of the Medical Advisory Committee

(1) The Medical Advisory Committee shall hold a minimum of ten (10) monthly meetings in each fiscal year.

(2) The Medical Advisory Committee shall report to the Board.

2.14.5 Executive Committee of the Medical Advisory Committee

(1) The Executive Committee of the Medical Advisory Committee shall consist of:

(a) the Chief of Staff, who shall be Chair;

(b) the President of the Medical Staff;

(c) the Vice-Chair of the Medical Advisory Committee;

(d) the Past Vice-Chair of the Medical Advisory Committee; and

(e) one other who shall be a Chief of a Department.

(2) The Chief Executive Officer and the Chief Nursing Executive shall be invited to attend meetings of the Executive Committee of the Medical Advisory Committee but shall not have a vote.

(3) The Executive Committee of the Medical Advisory Committee shall,

(a) act as an advisory committee to the Medical Advisory Committee on issues brought to the Medical Advisory Committee or referred to the Executive Committee by the Board or the Chief Executive Officer;

(b) exercise the full powers of the Medical Advisory Committee in all urgent matters reporting every action at the next meeting of the Medical Advisory Committee;

(c) report at each meeting of the Medical Advisory Committee; and

(d) meet monthly or at the call of the Chair of the Executive Committee.

2.14.6 Quorum

(1) A quorum at any meeting of the Medical Advisory Committee or a standing committee or any other committee of the Medical Advisory Committee shall be a majority of the Medical Staff appointees to that committee unless otherwise addressed in these By-laws.

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2.14.7 Transition

(1) During the Transition Period, primary responsibility for quality of care provided by members of the Departments of Newborn and Developmental Paediatrics and Obstetrics and Gynaecology will rest with Sunnybrook Health Sciences Centre. As such, the medical advisory committee of Sunnybrook Health Sciences Centre and its subcommittees will hold the primary responsibility for overseeing the quality of medical care provided by members of these departments. The Chiefs of these departments will also be members of the Medical Advisory Committee of the Hospital and will advise the Medical Advisory Committee of the Hospital with respect to aspects of medical and midwifery care occurring at the Hospital, including quality of care matters, and will provide simultaneously to both the Medical Advisory Committee and the Sunnybrook Health Sciences Centre medical advisory committee all reports prepared for and to be provided to Sunnybrook Health Sciences Centre medical advisory committee regarding the departments.

2.15 MEDICAL STAFF COMMITTEES ESTABLISHED BY THE BOARD

2.15.1 Medical Staff Committees

(1) The following Medical Staff Committees are hereby established:

(a) Credentials Committee;

(b) Infection Control Committee;

(c) Medical Records Committee;

(d) Medical Quality Assurance/Patient Care Committee;

(e) Operating Room Committee;

(f) Pharmacy and Therapeutics Committee

(g) Transfusion Review Committee;

(h) Utilization Committee; and

(i) Such other Committees as may be established by the Board.

2.15.2 Appointment To Medical Staff Committees

(1) Pursuant to the Hospital Management Regulation24, the Medical Advisory Committee shall appoint the medical members of all Medical Staff Committees provided for in these By-laws. Other non-medical staff

48 TOR_A2G:1733483.7

members of Medical Staff Committees shall be appointed by the Board or in accordance with these By-laws.

2.15.3 Medical Staff Committee Duties

(1) In addition to the specific duties of each Medical Staff Committee as set out in these By-laws, all Medical Staff Committees shall,

(a) meet as directed by the Medical Advisory Committee;

(b) present a written report including any recommendations of each meeting to the next meeting of the Medical Advisory Committee; and

(c) present a written annual report to the Medical Advisory Committee one month prior to the Annual General Meeting of the Hospital.

2.15.4 Medical Staff Committee Chair

(1) The Medical Advisory Committee shall appoint the Chair of each Medical Staff Committee.

2.15.5 Medical Staff Committee Chair Duties

(1) For each Medical Staff Committee the Chair of such Medical Staff Committee shall,

(a) chair the Medical Staff Committee meetings;

(b) call meetings of the Medical Staff Committee;

(c) at the request of the Medical Advisory Committee, be present to discuss all or part of any report of the Medical Staff Committee; and

(d) carry out such further and other duties as may be requested by the Medical Advisory Committee from time to time.

2.15.6 Credentials Committee Duties

(1) The Credentials Committee shall ensure that a record of the qualifications and professional career of every member of the Medical-Dental-Midwifery Staff and extended class nursing staff is maintained.

(2) The Credentials Committee shall establish the authenticity of and investigate the qualifications of each applicant for appointment and re-appointment to the Medical-Dental-Midwifery Staff and extended class nursing staff and each applicant for a change in privileges.

49 TOR_A2G:1733483.7

(3) The Credentials Committee shall ensure that,

(a) each applicant for appointment to the Medical Staff meets the criteria as set out at section 2.4.2;

(b) each applicant for appointment to the Dental Staff meets the criteria as set out at section 3.2.2;

(c) each applicant for appointment to the Midwifery Staff meets the criteria as set out at section 4.2.2;

(d) each applicant for appointment to the extended class nursing staff meets the criteria as set out at section 5.2.2;

(e) each applicant for re-appointment to the Medical Staff meets the criteria as set out at section 2.5.2;

(f) each applicant for re-appointment to the Dental Staff meets the criteria as set out at section 3.3.2;

(g) each applicant for re-appointment to the Midwifery Staff meets the criteria set out at section 4.3.2;

(h) each applicant for re-appointment to the extended class nursing staff meets the criteria as set out at section 5.3.2; and

(i) each applicant for a change in privileges continues to meet the criteria for re-appointment set out respectively for physicians at section 2.5.2, dentists at section 3.3.2, midwives at section 4.3.2, extended nursing staff at section 5.3.2.

(4) The Credentials Committee shall consider reports of the interviews with the applicant.

(5) The Credentials Committee shall consult with the appropriate Chief of the Department.

(6) The Credentials Committee shall receive notification from the Chief of Staff when the performance evaluations and the recommendations for re-appointments have been completed.

(7) The Credentials Committee shall submit a written report to the Medical Advisory Committee at or before its next regular meeting regarding all applications referred by the Medical Advisory Committee to the Credentials Committee since the last regular meeting of the Medical Advisory Committee. The report shall include the kind and extent of privileges requested by the applicant, and, if necessary, a request that the application be deferred for further investigation.

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(8) The Credentials Committee shall perform any other duties requested by

the Medical Advisory Committee.

(9) Membership of the Credentials Committee shall include,

(a) the Chief of Staff;

(b) the Vice-Chair, Medical Advisory Committee;

(c) the Secretary, Medical Advisory Committee;

(d) the President of the Medical Staff;

(e) Medical and Dental Department Chiefs;

(f) the Chief Executive Officer; and

(g) others as determined by the Medical Advisory Committee.

2.15.7 Infection Control Committee Duties

(1) The Infection Control Committee shall make recommendations to the Medical Advisory Committee on infection control matters related to,

(a) the Occupational Health and Safety Program;

(b) immunization programs;

(c) visitor restrictions or instructions both in general terms and in special circumstances;

(d) patient restrictions or instructions;

(e) educational programs for all persons carrying on activities in the Hospital;

(f) isolation procedures;

(g) aseptic and antiseptic techniques; and

(h) environmental sanitation in the Hospital.

(2) The Infection Control Committee shall make recommendations to the Chief Executive Officer with respect to,

(a) infection control matters related to the Occupational Health and Safety Program; and

51 TOR_A2G:1733483.7

(b) infection control matters related to the Health Surveillance

Program.

(3) The Infection Control Committee shall follow-up and evaluate the results of each of its recommendations made under subsections 2.15.7 (1) and 2.15.7 (2) of these By-laws.

(4) The Infection Control Committee shall develop, monitor and evaluate an infection control system which includes a reporting system by which all infections, including post discharge infections will come to the Infection Control Committee's attention.

(5) The Infection Control Committee shall review reports from all departments and programs in the Hospital.

(6) The Infection Control Committee meet at least quarterly and at the call of the Infection Control Committee Chair as required.

(7) Additionally, the Infection Control Committee shall perform such other duties as may from time to time be requested by the Medical Advisory Committee.

(8) Membership of the Infection Control Committee shall include the following:

(a) Hospital epidemiologist;

(b) Infectious disease physician;

(c) Medical microbiologist(s);

(d) Infection prevention & control practitioners/co-ordinators;

(e) A senior representative from each of the following programs, departments or staff functions:

(i) Nursing;

(ii) Staff nurse;

(iii) Manager;

(iv) Operating Room;

(v) Occupational Health & Safety;

(vi) Anaesthesiology;

(vii) Respiratory Therapy;

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(viii) Pharmacy;

(ix) Environmental Services; and

(x) Administration;

(f) 2 Medical/Dental Department Chiefs; and

(g) Other representation as determined by the Medical Advisory Committee.

2.15.8 Medical Records Committee Duties

(1) The Medical Records Committee shall recommend procedures to the Medical Advisory Committee to ensure that the provisions of the Hospital Management Regulation, these By-laws and the Rules of the Hospital are observed, including,

(a) the development of rules to govern the completion of medical records;

(b) a review of medical records for completeness and quality of recording;

(c) a report in writing to each regular meeting of the Medical Advisory Committee with respect to:

(i) the review of the medical records and the results thereof, and

(ii) the names of members of the Medical-Dental-Midwifery Staff and extended class nursing staff who are delinquent with respect to the rules governing medical records;

(d) a review and revision of forms as they pertain to Medical-Dental-Midwifery Staff record keeping; and

(e) the retention of medical records and notes, charts and other material relating to patient care.

(2) The Medical Record Committee shall perform any other duties pertaining to medical record keeping as may be requested by the Medical Advisory Committee.

(3) Membership of the Medical Record Committee shall include:

(a) representatives from each of the following Departments:

(i) Anaesthesia;

53 TOR_A2G:1733483.7

(ii) Family and Community Medicine;

(iii) Medicine;

(iv) Newborn and Developmental Paediatrics;

(v) Obstetrics and Gynaecology;

(vi) Psychiatry; and

(vii) Surgery;

(b) two (2) Representatives from Health Data Resources; and

(c) others as determined by the Medical Advisory Committee.

2.15.9 Medical Quality Assurance Committee Duties

(1) The duties of the Medical Quality Assurance Committee shall be to:

(a) develop a Medical Quality Assurance Program which includes mechanisms to,

(i) monitor trends and activities;

(ii) identify potential problem areas; and

(iii) develop action plans and provide follow-up;

(b) report to the Medical Advisory Committee and to the Quality Assurance Committee of the Board;

(c) receive reports from, and monitor the functioning of, Medical Staff Committees reporting to the Medical Advisory Committee;

(d) monitor the functioning of the Medical Advisory Committee;

(e) review, evaluate and make recommendations on the following matters affecting the Medical-Dental-Midwifery Staff and extended class nursing staff:

(i) privileges;

(ii) human resources planning, Impact Analysis;

(iii) program, departmental and service activities;

(iv) process for handling complaints; and

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(f) develop processes:

(i) to ensure accountability of Medical Departments for medical quality of care issues;

(ii) to assess the measures undertaken to monitor the quality of medical care;

(iii) to ensure measures are undertaken for the improvement of medical care;

(iv) to receive regular reports from Medical Departments concerning quality of medical care;

(v) to receive reports from Medical Advisory Committee subcommittees regarding particular aspects of the quality of medical care;

(vi) to submit recommendations to the Medical Advisory Committee for approval;

(vii) to address other issues of quality of medical care not covered by the above actions; and

(viii) to assume other duties and responsibilities as requested by the Medical Advisory Committee; and

(g) assure that other department medical, dental, midwifery and extended class nursing audits are undertaken as necessary.

(2) Membership of the Medical Quality Assurance Committee shall include:

(a) Medical Advisory Committee Executive Committee;

(b) other individuals as determined by the Medical Advisory Committee; and

(c) Ex officio members including:

(i) the Chief Executive Officer or delegate;

(ii) the Chair, Pharmacy and Therapeutics Committee;

(iii) the Chair, Infection Prevention and Control Committee;

(iv) the Chief Nursing Officer; and

(v) others at the invitation of Chair of the Quality Assurance Committee.

55 TOR_A2G:1733483.7

2.15.10 Operating Room and Recovery Room Committee Duties

(1) Specific duties of the Operating Room and Recovery Room Committee shall include:

(a) To advise the Medical Advisory Committee of the resource impact of proposed privileges for individual physicians and surgeons;

(b) To establish policies, rules and regulations as related to clinical practice in the Operating Room, Recovery Room and Post Care Unit, such as booking, scheduling, utilization, and quality control and to recommend such policies, rules and regulations and revisions of same to the Medical Advisory Committee;

(c) To set standards of patient care and to ensure that adequate programs of quality assurance as related to clinical practice are developed; and to monitor such programs on a regular basis;

(d) To review both capital and operating budget for the Operating Room, Recovery Room and Post Care Unit;

(e) To investigate and advise Hospital management on new technology as related to clinical practice;

(f) To prioritize the need for new and replacement equipment;

(g) To be a forum for program and facilities planning as related to the Operating Room, Recovery Room and Post Care Unit function;

(h) To promote information services with a view to enhancing the efficiency and effectiveness of patient care in the Operating Room, Recovery Room and Post Care Unit;

(i) To advise the Medical Advisory Committee with respect to any matter referred to it by the Medical Advisory Committee or the Medical Advisory Committee Executive Committee; and

(j) To assume other duties and responsibilities as assigned by the Medical Advisory Committee.

(2) Membership of the Operating Room and Recovery Room Committee shall include:

(a) a representative from each of the following Departments:

(i) Anaesthesia;

(ii) Medicine;

56 TOR_A2G:1733483.7

(iii) Obstetrics and Gynaecology;

(iv) Anatomic Pathology;

(b) 3 members from the Department of Surgery as determined by the Divisions of Surgery;

(c) OR Management Team:

(i) Operations Director Operating Room and Related Services Patient Service Unit;

(ii) Head, Department of Surgery; and

(iii) Nursing Director, Surgical Daycare/ Pre-Admission Clinic;

(d) Recovery Room Nurse;

(e) OR Nurse;

(f) members of the diagnostic and laboratory departments;

(g) a representative from Infection Control; and

(h) other individuals as determined by the Medical Advisory Committee.

2.15.11 Pharmacy and Therapeutics Committee Duties

(1) The Pharmacy and Therapeutics Committee shall,

(a) serve in an advisory capacity to the Medical-Dental-Midwifery Staff and extended class nursing staff by assessing regularly the appropriateness and adequacy of medication-related policies and make policy recommendations to the Medical Advisory Committee regarding drug utilization to ensure safe, effective and economical use of drugs;

(b) evaluate drug utilization, new drugs and current therapeutics and develop a formulary which is suited to the Hospital's needs, and periodically assess the effectiveness of and adherence to the formulary;

(c) develop a procedure for the use of non-formulary drugs and mechanisms for their evaluation;

(d) periodically analyze a summary of medication errors and their causative factors and make appropriate recommendations

57 TOR_A2G:1733483.7

regarding prevention to the Medical-Dental-Midwifery Staff and extended class nursing staff, and nursing and/or pharmacy staffs;

(e) develop an adverse drug reaction reporting program, review all these reports and ensure that a summary is circulated to Medical-Dental-Midwifery Staff, extended class nursing staff and nursing and pharmacy staffs when the need arises;

(f) develop protocols governing programs such as total parenteral nutrition, investigational drugs, self-medication, or ensure that such protocols have been developed after appropriate committee review;

(g) identify and/or arrange appropriate educational programs for the Medical-Dental-Midwifery Staff extended class nursing staff and Hospital staff to enhance their knowledge of drug therapy and practices;

(h) perform such other duties as the Medical Advisory Committee may request; and

(i) meet quarterly or more frequently at the call of the Pharmacy and Therapeutics Committee Chair.

(2) Membership of the Pharmacy and Therapeutics Committee shall include:

(a) the Director, Clinical Pharmacology, or delegate;

(b) the Chief, Pharmacy;

(c) the Coordinator, Drug Information;

(d) the Drug Use Evaluation Pharmacist;

(e) representatives of Medical Departments as determined by the Medical Advisory Committee; and

(f) other individuals as determined by the Medical Advisory Committee.

2.15.12 Transfusion Review Committee Duties

(1) The role of the Transfusion Review Committee shall be to recommend policies and practices in blood and component transfusion, and to review and report on utilization, quality management and adverse reactions to transfusion, and to review and report on utilization, quality management and practice in tissue banking.

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(2) Specifically, the Transfusion Review Committee shall:

(a) review and report on utilization and quality management;

(b) review at regular intervals utilization of blood and blood components;

(c) audit surgical blood utilization and review the surgical blood order schedule;

(d) review workload units, outdating of blood and wastage, and results of external quality assurance program surveys;

(e) review adverse reactions to transfusion;

(f) establish and survey transfusion policies and practices, including:

(i) Patient/specimen/transfusion product identification;

(ii) Guidelines/indications for various components;

(iii) Transfusion protocols;

(iv) Methods of administration of blood (e.g. use of filters); and

(v) Maintenance of records of transfusion.

(g) receive for informational purposes, data on blood and blood component utilization;

(h) maintain liaison with the Canadian National Blood Transfusion Service;

(i) maintain and surveillance of an autologous blood donation service;

(j) maintain a manual of blood transfusion practice;

(k) recommend appropriate education programs in blood transfusion practice;

(l) be supportive of the development of research endeavors in blood transfusion; and

(m) assume other duties and responsibilities as requested by the Medical Advisory Committee.

(3) Membership of the Transfusion Review Committee shall include:

(a) Representatives from the Departments of:

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(i) Clinical Pathology;

(ii) Anaesthesia;

(iii) Medicine;

(iv) Obstetrics and Gynaecology;

(v) Newborn and Developmental Pediatrics; and

(vi) Surgery;

(b) Representatives from Nursing; and

(c) Ex-officio members:

(i) Charge Technologist, Blood Bank;

(ii) Technical Specialist, Tissue Bank; and

(iii) Transfusion Surveillance Officer.

2.15.13 Utilization Committee Duties

(1) The Utilization Committee shall,

(a) review utilization patterns in the Hospital and identify where improvements in utilization patterns could be achieved;

(b) monitor overall trends in admissions, length of stay and day program volumes and provide appropriate information to Chiefs of the Departments;

(c) review the reports from each Medical Department’s utilization review;

(d) ensure that the Chiefs of the Medical Departments are educated about utilization review issues and about their responsibility for reporting regularly to their Departments on utilization trends;

(e) report findings and make recommendations to the Medical Advisory Committee and Hospital management on a regular basis but at least quarterly;

(f) monitor response to those Utilization Committee recommendations which are approved by the Medical Advisory Committee and Hospital management and report back on progress achieved;

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(g) report annually to the Medical Staff on the Utilization Committee's

activities;

(h) comment on the resource implications of proposed additions to the Medical Staff; and

(i) perform such other duties as may be requested from time to time by the Medical Advisory Committee.

(2) Membership of the Utilization Committee shall include:

(a) Representatives from each Medical and Dental Department;

(b) Ex-Officio:

(i) Health Records representative;

(ii) Data Base Support representative;

(iii) IT representative;

(iv) Chief Executive Officer or delegate from senior management;

(v) the Chief Nursing Officer; and

(vi) Other individuals as determined by the Medical Advisory Committee.

3. DENTAL STAFF

3.1 APPOINTMENT OF DENTAL STAFF

(1) The Board, on the advice of the Medical Advisory Committee, may appoint, annually, one or more dentists to the Dental Staff of the Hospital and shall delineate the privileges for each dentist.

3.2 APPOINTMENT TO DENTAL STAFF

3.2.1 Application For Appointment to the Dental Staff

(1) An application for appointment to the Dental Staff shall be processed consistent with the provisions of the Public Hospitals Act and these By-laws.

(2) On request, the Chief Executive Officer shall supply a copy of these By-laws, the Rules of the Hospital, the Public Hospitals Act to each dentist who expresses in writing the intention to apply for appointment to the Dental Staff.

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(3) An applicant for appointment to the Dental Staff shall submit one original

written application to the Chief Executive Officer.

(4) Each application from appointment to the Dental Staff shall contain,

(a) a statement by the applicant that he or she has read the Public Hospitals Act, the Hospital Management Regulation, these By-laws and the Rules of the Hospital;

(b) an undertaking that, if he or she is appointed to the Dental Staff of the Hospital, he or she will govern himself or herself in accordance with the requirements set out in these By-laws and the Rules of the Hospital;

(c) a copy of the applicant’s Certificate of Registration or Specialty Certificate of Registration with the Royal College of Dental Surgeons of Ontario;

(d) evidence of dental practice protection coverage satisfactory to the Board and a record of past claims history;

(e) a list of the privileges which are requested;

(f) an up-to-date curriculum vitae;

(g) a list of three (3) appropriate referees;

(h) information of any previous disciplinary proceeding where there was an adverse finding;

(i) information on any criminal proceedings or convictions which may impact the ability of the applicant to practice;

(j) information of any civil suit where the applicant is or was a defendant there was a finding of negligence or battery or where such suit was settled with the payment of monies to the other party;

(k) a signed consent authorizing any dental regulatory body, including the Royal College of Dental Surgeons of Ontario, or referee to provide a report on,


(ii) whether his or her privileges have been temporarily or permanently curtailed or cancelled by any dental regulatory body or by another hospital because of incompetence,

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negligence, incapacity or any act of professional misconduct; and

(l) a signed consent authorizing the release of information by the chief executive officer or chief of staff of any hospital where the applicant is presently and/or previously held an appointment on staff.

(5) Each applicant shall visit the Hospital for an interview with appropriate members of the Dental Staff and Medical Staff and the Chief Executive Officer or his or her delegate.

(6) The Chief Executive Officer shall retain a copy of the application and shall refer the original application immediately to the Medical Advisory Committee through its Chair who shall keep a record of each application received and then refer the original application to the Chair of the Credentials Committee.

(7) Each application shall be considered by the Medical Advisory Committee which shall make a recommendation thereon in writing to the Board.


3.2.2 Criteria for Appointment to the Dental Staff

(1) Only an applicant qualified to practice dentistry and who holds a current, valid certificate of Registration with the Royal College of Dental Surgeons of Ontario, or an applicant qualified to practice a dental specialty recognized by the Royal College of Dental Surgeons of Ontario and who holds a current, valid Specialty Certificate of Registration with the Royal College of Dental Surgeons of Ontario, is eligible to be a member of and appointed to the Dental Staff of the Hospital.


(a) a current valid Certificate of Registration with the Royal College of Dental Surgeons of Ontario, and in the case of an oral 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;

(b) a demonstrated ability to provide patient care at an appropriate level of quality and efficiency;

(c) a demonstrated ability to communicate, work with and relate to all members of the Medical-Dental-Midwifery Staff, extended class

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nursing staff and Hospital staff in a co-operative and professional manner;

(d) a demonstrated ability to communicate and relate appropriately with patients and patients' relatives;

(e) a willingness to participate in the discharge of staff obligations appropriate to the Dental Staff;

(f) adequate training and experience for the privileges requested;

(g) evidence of dental practice protection coverage satisfactory to the Board; and

(h) a report on, among other things, the experience, competence and reputation of the applicant from the chief of staff or chief of the department in the last hospital in which the applicant trained or held an appointment.

(3) The applicant must agree to govern himself or herself in accordance with the requirements set out in these By-laws, the Rules of the Hospital and the Hospital policies and the ethical standards of the profession.


(5) There is a need for the services in the Hospital and in the community.

3.2.3 Term

(1) Each appointment to the Dental Staff shall be for one (1) year, but shall continue in effect until the Board has made appointments for the ensuing year.

3.3 RE-APPOINTMENT


(1) Upon recommendation by the Medical Advisory Committee, the Board shall establish and approve a process for the annual performance review of each member of the Dental Staff.

(2) Each year each member of the Dental Staff shall make a written application for re-appointment to the Dental Staff of the Hospital in the prescribed form.

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(3) Where a member of the Dental Staff has applied for re-appointment, the

Chief of the Department shall conduct a review of the applicant’s performance for the past year in accordance with the approved process once established under subsection 3.3.1(1), and shall make a written report to the Medical Advisory Committee in respect of the applicant’s performance for the past year25.

(4) The application for re-appointment to the Dental Staff of the Hospital shall be processed in the same manner as set out in section 3.2.1.

3.3.2 Criteria for Re-Appointment to the Dental Staff


(a) continue to meet the criteria set out in section 3.2.2; and



(2) In a manner consistent with the provisions of the Public Hospitals Act, the Board may refuse to re-appoint a member of the Dental Staff.


3.4.1 Application for Change of Privileges

(1) Where a member of the Dental Staff wishes to change his or her privileges, the member shall make a written application, in the prescribed form, listing the change of privileges which is requested and shall submit evidence of appropriate training and competence in respect of the privileges being requested.

(2) An application for a change in privileges made by a member of the Dental Staff shall be processed in the same manner as set out in section 3.2.1.

3.5 MID-TERM ACTION


(1) In a manner consistent with the Public Hospitals Act and these By-laws, the Board at any time may revoke or suspend any appointment of a member of the Dental Staff, or dismiss, suspend, restrict, cancel, substantially alter or otherwise deal with the privileges of the member.

(2) Mid-Term action in respect of a member of the Dental Staff, shall be processed in accordance with, and in the same manner provided in Part 7 of these By-laws.

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3.6 DENTAL STAFF DUTIES

3.6.1 Dental Staff Duties

(1) Each member of the Dental Staff is accountable to and shall recognize the authority of the Board through and with their Chief of the Department, the Chief of Staff, and the Chief Executive Officer.

(2) Each member of the Dental Staff shall,

(a) attend and treat patients within the limits of the privileges granted by the Board unless the privileges are otherwise restricted;

(b) notify the Chief Executive Officer of any change in the Certificate of Registration with the Royal College of Dental Surgeons of Ontario, and in the case of an oral and maxillofacial surgeon, the Specialty Certificate of Registration with the Royal College of Dental Surgeons of Ontario;

(c) give such instruction as is required for the education of other members of the Medical-Dental-Midwifery Staff, extended class nursing staff and Hospital staff;

(d) abide by the Rules of the Hospital, these By-laws, the Public Hospitals Act and all other legislated requirements;

(e) perform such other duties as may be requested from time to time by, or under the authority of the Board, the Medical Advisory Committee or the Chief of Staff; and

(f) provide consultations on patients as are required.

(3) Every member of the Dental Staff who is an oral and maxillofacial surgeon and who holds a valid Specialty Certificate from the Royal College of Dental Surgeons of Ontario authorizing practice in oral and maxillofacial surgery shall have admitting privileges unless otherwise specified in their appointment to the Dental Staff.

(4) Every member of the Dental Staff shall co-operate with,

(a) the Chief of Staff and the Medical Advisory Committee;

(b) the Head of Dental Service;

(c) the Chief of the Department of Surgery; and

(d) the Chief Executive Officer.

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(1) Each member of the Dental Staff shall comply with the requirements of section 2.10.4.

3.6.3 Viewing Therapeutic Actions, Operations or Procedures

(1) Any therapeutic action, operation or procedure performed in the Hospital may be viewed without the permission of the member of the Dental Staff by,


(b) the Chief of the Department, or delegate.


(1) Pursuant to the Hospital Management Regulation26 whenever the responsibility for the care of a patient of a member of the Dental Staff is transferred to another member of the Dental Staff or Medical Staff, a written notation by the Dental Staff member who is transferring the care over to another shall be made and signed on the patient's medical record and the name of the Dental Staff or Medical Staff member assuming the responsibility shall be noted in the patient's medical record and the Dental Staff or Medical Staff member assuming the responsibility shall be notified immediately.

(2) Where a supervisor of a member of the Dental Staff, the Chief of the Department, or the Chief of Staff becomes aware that, in his or her opinion a serious problem exists in the care or treatment of one or more patients or out-patients of a dentist, the supervisor, Chief of the Department or Chief of Staff, as the case may be, shall forthwith discuss the condition, care and treatment of the patient or out-patient with the attending dentist and if changes in the care or treatment satisfactory to the supervisor, Chief of the Department or Chief of Staff, as the case may be, are not made promptly, he or she shall assume forthwith the duty of investigating, prescribing for and treating the patient or out-patient, as the case may be, and shall notify the attending dentist, the Chief Executive Officer and if possible, the patient or out-patient, that the member of the Dental Staff who was in attendance will cease forthwith to have any hospital privileges as the attending dentist for the patient or out-patient.

(3) Where a supervisor of a member of the Dental Staff, the Chief of the Department or the Chief of Staff, as the case may be, is responsible under subsection 3.6.4 (2) is unable to discuss the problem with the attending dentist as required by subsection 3.6.4 (2), the supervisor, the Chief of the Department or the Chief of Staff, as the case may be, shall proceed with

67 TOR_A2G:1733483.7

his or her duties as prescribed in this subsection 3.6.4 (2) as if he or she had had the discussion with the attending dentist.

(4) Where a supervisor of a member of the Dental Staff, the Chief of the Department or Chief of Staff, as the case may be, has cause to take over the care of a patient, the Chief Executive Officer, the attending dentist and the patient, shall be notified as soon as possible or, in the case where the patient is mentally incompetent, the patient’s substitute decision maker, shall be notified as soon as possible.

3.7 DENTAL SERVICE

3.7.1 Dental Service

(1) The Dental Staff shall function as a service within the Department of Surgery.

3.7.2 Head of Dental Services

(1) Where the Board has appointed more than one (1) dentist to the Dental Staff, the Board shall appoint as Chief of Dentistry a dentist who is on the active staff, after giving consideration to the recommendations of a Search Committee established for that purpose by the Chief Executive Officer and following the process as identified in the Affiliation Agreement and the Board of Directors procedure for a Search Committee.

(2) The membership of a Search Committee shall include,

(a) a Director;

(b) the Dean of the Faculty of Dentistry at the University or her/his representative;

(c) the Chair of the University Department of Dentistry

(d) the Chief of Staff;

(e) a member of the Medical Advisory Committee;

(f) a member of the Department of Surgery;

(g) the Chief Nursing Executive;

(h) the Chief Executive Officer or his or her delegate; and

(i) a member of the Department.

(3) The Chair of the Search Committee shall be a member of the Board and shall be appointed by the Board.

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(4) Subject to annual confirmation of the Board, the appointment of a Chief of

Department shall be for a term of five (5) years to commence on July 1 subject to annual confirmation which term is renewable.

3.7.3 Duties of the Head of Dental Services

(1) The Head of Dental Service shall supervise the professional care given by all members of the Dental Staff and shall be responsible to the Chief of the Department of Surgery for the quality of care rendered to patients by members of the Dental Staff.

3.8 MEETINGS – DENTAL STAFF

3.8.1 Attendance By Dental Staff at Medical Staff Meetings

(1) A member of the Dental Staff is not eligible to vote. A member of the Dental Staff may attend Medical Staff meetings.

3.9 DENTAL STAFF ELIGIBILITY TO HOLD OFFICE

3.9.1 Eligibility to Hold a Medical Staff Office

(1) A member of the Dental Staff is not eligible to hold an office or position other than Head of Dental Service.

4. MIDWIFERY STAFF

4.1 APPOINTMENT OF MIDWIFERY STAFF

(1) The Board, on the advice of the Medical Advisory Committee, may appoint, annually, one or more midwives to the Midwifery Staff of the Hospital and shall delineate the privileges for each midwife.

4.2 APPOINTMENT TO MIDWIFERY STAFF

4.2.1 Application for Appointment to Midwifery Staff

(1) An application for appointment to the Midwifery Staff shall be processed consistent with the provisions of the Public Hospitals Act and these By-laws.

(2) On request, the Chief Executive Officer shall supply a copy of these By-laws, the Rules of the Hospital and the Public Hospitals Act to each midwife who expresses in writing the intention to apply for appointment to the Midwifery Staff.

(3) An applicant for appointment to the Midwifery Staff shall submit one (1) original written application to the Chief Executive Officer.

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(4) Each application for appointment to the Midwifery Staff shall contain,

(a) a statement by the applicant that he or she has read the Public Hospitals Act, and the Hospital Management Regulation, these By-laws and the Rules of the Hospital;

(b) an undertaking that, if he or she is appointed to the Midwifery Staff of the Hospital, he or she will govern himself or herself in accordance with the requirements set out in these By-laws and the Rules of the Hospital;

(c) a copy of the applicant’s certificate of Registration with the College of Midwives of Ontario;

(d) evidence of midwifery practice protection coverage satisfactory to the Board and a record of past claims history;

(e) a list of the privileges which are requested;

(f) an up-to-date curriculum vitae;

(g) a list of three (3) appropriate referees, including one (1) from a physician who is active in obstetrics and who has worked with the midwife;

(h) information of any previous disciplinary proceeding where there was an adverse finding;

(i) information on any criminal proceedings or convictions which may impact the ability of the applicant to practice;

(j) information of any civil suit where the applicant is or was named as a defendant where there was a finding of negligence or battery or where such suit was settled with payment of monies to the other party;

(k) a signed consent authorizing any midwifery regulatory body including the College of Midwives of Ontario or referee to provide a report on,


(ii) whether his or her privileges have been curtailed or cancelled by any midwifery regulatory body or by another hospital because of incompetence, negligence, incapacity or any act of professional misconduct; and

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(l) a current certificate of Professional Conduct from the College of

Midwives of Ontario and consent to the release of information from the Registrar of the College.

(m) A signed consent authorizing the release of information by the Chief Executive Officer or Chief of Staff of any hospital where the applicant is presently and/or previously held an appointment on staff.

(5) Each applicant shall visit the Hospital for an interview with appropriate members of the Medical Staff and Midwifery Staff and the Chief Executive Officer or his or her delegate.

(6) The Chief Executive Officer shall retain a copy of the application and shall refer the original application immediately to the Medical Advisory Committee through its Chair who shall keep a record of each application received and than refer the original application forthwith to the Chair of the Credentials Committee.



4.2.2 Criteria for Appointment to Midwifery Staff

(1) Only an applicant qualified to practice midwifery and who holds a current, valid Certificate of Registration with the College of Midwives of Ontario is eligible to be a member of and appointed to the Midwifery Staff of the Hospital.


(a) a certificate of Registration with the College of Midwives of Ontario;

(b) a current certificate of Professional Conduct from the College of Midwives of Ontario;

(c) a demonstrated ability to provide patient care at an appropriate level of quality and efficiency;

(d) demonstrated ability to communicate, work with and relate to all members of the Medical-Dental-Midwifery Staff, extended class nursing staff and Hospital staff in a co-operative and professional manner;

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(e) a demonstrated ability to communicate and relate appropriately

with patients and patients' relatives;

(f) a willingness to participate in the discharge of staff obligations appropriate to his or her membership group;

(g) adequate training and experience for the privileges requested;

(h) evidence of midwifery practice protection coverage satisfactory to the Board; and

(i) a report on, among other things, the experience, competence and reputation of the applicant from the chief of staff or the chief of the department in the last hospital or facility in which the applicant trained or held an appointment, if possible, or where such report is not available, a report from any other physician where the physician has had direct knowledge of the midwife's experience, competence and reputation.

(3) The applicant must agree to govern himself or herself in accordance with the requirements set out in these By-laws, the Rules of the Hospital and the Hospital policies and the ethical standards of the profession.



4.2.3 Term

(1) Each appointment to the Midwifery Staff shall be for one (1) year, but shall continue in effect until the Board has made appointments for the ensuing year.

4.3 RE-APPOINTMENT


(1) Upon recommendation by the Medical Advisory Committee, the Board shall establish and approve a process for the annual performance review of each member of the Midwifery Staff.

(2) Each year each member of the Midwifery Staff shall make a written application for re-appointment to a group of the Midwifery Staff of the Hospital in the prescribed form.

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(3) Where a member of the Midwifery Staff has applied for re-appointment,

the Chief of the Department of Obstetrics and Gynaecology shall conduct a review of the applicant’s performance for the past year in accordance with the approved process once established under subsection 4.3.1(1), and shall make a written report to the Medical Advisory Committee in respect of the applicant’s performance for the past year27.

(4) The application for re-appointment to a group of the Midwifery Staff of the Hospital shall be processed in the same manner as set out in section 4.2.1.

4.3.2 Criteria for Re-Appointment to the Midwifery Staff


(a) continue to meet the criteria set out at section 4.2.2; and



(1) In a manner consistent with the provisions of the Public Hospitals Act 28, the Board may refuse to re-appoint a member of the Midwifery Staff.


4.4.1 Application for Change of Privileges

(1) Where a member of the Midwifery Staff wishes to change his or her privileges the midwife shall make a written application, in the prescribed form, listing the change of privileges which is requested and shall submit evidence of appropriate training and competence in respect of the privileges being requested.

(2) An application for a change in privileges made by a member of the Midwifery Staff shall be processed in the same manner as set out in section 4.2.1.

4.5 MID-TERM ACTION


(1) In a manner consistent with the Public Hospitals Act and these By-laws, the Board at any time may revoke or suspend any appointment of a member of the Midwifery Staff, or dismiss, suspend, restrict, cancel, substantially alter or otherwise deal with the privileges of the member.

73 TOR_A2G:1733483.7

(2) Mid-term action in respect of a member of the Midwifery Staff, shall be

processed in accordance with, and in the same manner provided in Part 7 of these By-laws.

4.6 MIDWIFERY STAFF GROUPS

4.6.1 Midwifery Staff Groups

(1) The Midwifery Staff shall be divided into the following groups:

(a) Active;

(b) Associate;

(c) Courtesy;

(d) Locum Tenens; and

(e) Temporary.

4.6.2 Active Midwifery Staff

(1) The Active Midwifery Staff shall consist of those midwives who have been appointed as Active Midwifery Staff by the Board.

(2) Except where approved by the Board, no midwife with an active midwifery staff appointment at another hospital shall be appointed to the Active Midwifery Staff29.

(3) Every midwife applying for appointment to the Active Midwifery Staff may be assigned to the Associate Midwifery Staff for a probationary period if the Board so requires.

(4) Each member of the Active Midwifery Staff is responsible for ensuring that midwifery care is provided to his or her patients in the Hospital.

(5) All Active Midwifery Staff members shall have admitting privileges unless otherwise specified in their appointment to the Midwifery Staff.

(6) Each member of the Active Midwifery Staff shall,

(a) undertake such duties in respect of those patients classed as emergency cases as may be specified by the Chief of Staff or by the Chief of Obstetrics and Gynaecology to which the midwife has been assigned;

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

74 TOR_A2G:1733483.7

(c) act as a supervisor of a member of the Midwifery Staff when

requested by the Chief of Staff or the Chief of the Department of Obstetrics and Gynaecology.

4.6.3 Associate Midwifery Staff

(1) Each Associate Midwifery Staff member shall have admitting privileges unless otherwise specified in the appointment.

(2) An Associate Midwifery Staff member shall work for a probationary period under the supervision of an Active Medical Staff or an Active Midwifery Staff member named by the Chief of Staff on the recommendation of the Chief of the Department of Obstetrics and Gynaecology.

(3) A supervisor of and Associate Midwifery Staff member shall carry out the duties in accordance with the Rules of the Hospital.

(4) After one (1) year, in considering the application for re-appointment to the Midwifery Staff, the appointment of a midwife to the Associate Midwifery Staff shall be reviewed by the Credentials Committee who shall report to the Medical Advisory Committee.

(5) The Medical Advisory Committee may recommend that the midwife be appointed to the Active Midwifery Staff or may require the midwife to be subject to a further probationary period and re-appointed to the Associate Midwifery Staff for a period of time not longer than six (6) months.

(6) The Chief of the Department of Obstetrics and Gynaecology, upon the request of an Associate Midwifery Staff member or a supervisor of an Associate Midwifery Staff member, may assign the Associate Midwifery Staff member to a different supervisor for a further probationary period.

(7) At any time an unfavourable report may cause the Medical Advisory Committee to consider making a recommendation to the Board that the appointment of the Associate Midwifery Staff member be terminated.

(8) No member of the Midwifery Staff shall be appointed to the Associate Midwifery Staff for more than eighteen (18) consecutive months.

(9) An Associate Midwifery Staff member shall,

(a) attend patients, and undertake treatment and procedures under supervision in accordance with the kind and degree of privileges granted by the Board on the recommendation of the Medical Advisory Committee; and

75 TOR_A2G:1733483.7

(b) undertake such duties in respect of those patients classed as

emergency cases as may be specified by the Chief of the Department of Obstetrics and Gynaecology to which the midwife has been assigned.

4.6.4 Courtesy Midwifery Staff

(1) The Board may grant a midwife an appointment to the Courtesy Midwifery Staff30 in one or more of the following circumstances:

(a) the applicant has an active midwifery staff commitment at another hospital; or

(b) the applicant lives at such a remote distance from the Hospital that it limits full participation in Active Midwifery Staff duties, but he or she wishes to maintain an affiliation with the Hospital; or

(c) the applicant has a primary commitment to, or contractual relationship with, another community or organization; or

(d) the applicant requests access to limited Hospital resources or out-patient programs or facilities; or

(e) where the Board deems it otherwise advisable.

(2) The Board may grant a midwife an appointment to the Courtesy Midwifery Staff with such privileges as the Board deems advisable.

(3) Privileges to admit patients shall be granted under specified circumstances and the circumstances leading to an appointment under this subsection shall be specified by the midwife on each application for re-appointment.

4.6.5 Locum Tenens

(1) The Medical Advisory Committee upon the request of a member of the Midwifery Staff may recommend the appointment of a Locum Tenens as a planned replacement for that midwife for a specified period of time.


(a) have admitting privileges unless otherwise specified;

(b) work under the counsel and supervision of a member of the Active Medical Staff or the Active Midwifery Staff who has been assigned this responsibility by the Chief of Staff or his or her delegate;

76 TOR_A2G:1733483.7

(c) attend patients assigned to his or her care by the member of the

Active Medical Staff or the Active Midwifery Staff by whom he or she is supervised, and shall treat them within the professional privileges granted by the Board on the recommendation of the Medical Advisory Committee; and

(d) undertake such duties in respect of those patients classed as emergency cases as may be specified by the Chief of Staff or by the Chief of the Department of Obstetrics and Gynaecology.

4.6.6 Temporary Midwifery Staff

(1) A temporary appointment of a midwife to the Midwifery Staff may be made only for one of the following reasons:

(a) to meet a specific singular requirement by providing a consultation and/or procedure; or

(b) to meet an urgent unexpected need for a midwifery service.

(2) Notwithstanding any other provision in these By-laws, the Chief Executive Officer, after consultation with the Chief of Staff or his or her delegate, may,

(a) grant a temporary appointment to a midwife who is not a member of the Midwifery Staff 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; and

(b) continue the appointment on the recommendation of the Medical Advisory Committee until the next meeting of the Board.

(3) A temporary appointment shall not have privileges to admit patients.

4.7 MIDWIFERY STAFF DUTIES

4.7.1 Midwifery Staff Duties

(1) Each member of the Midwifery Staff is accountable to and shall recognize the authority of the Board through and with the Chief of the Department of Obstetrics and Gynaecology, the Chief of Staff, and the Chief Executive Officer.

(2) Each member of the Midwifery Staff shall,

(a) attend and treat patients within the limits of the privileges granted by the Board, unless the privileges are otherwise restricted;

77 TOR_A2G:1733483.7

(b) notify the Chief Executive Officer of any change in the certificate

of Registration with the College of Midwives of Ontario;

(c) give such instruction as is required for the education of other members of the Medical-Dental-Midwifery Staff, extended class nursing staff and Hospital staff;

(d) abide by Rules of the Hospital, these By-laws, the Public Hospitals Act and all other legislated requirements;

(e) 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; and

(f) provide consultations on patients as required.

(3) Every member of the Midwifery Staff shall co-operate with,

(a) the Chief of Staff and the Medical Advisory Committee;

(b) the Head Midwife;

(c) the Chief of the Department of Obstetrics and Gynaecology31; and

(d) the Chief Executive Officer.

(4) Each member of the Active and Associate Midwifery Staff Groups and the Courtesy Midwifery Staff where required shall attend at least seventy percent (70%) of the meetings of the Department of Obstetrics and Gynaecology.


(1) Each member of the Midwifery Staff shall comply with the requirements of section 2.10.4.

4.7.3 Viewing Deliveries, Therapeutic Actions or Procedures

(1) Any delivery, therapeutic action or procedure performed in the Hospital may be viewed without the permission of the midwife by,


(b) the Chief of the Department of Obstetrics and Gynaecology, or delegate.

78 TOR_A2G:1733483.7


(1) Pursuant to the Hospital Management Regulation32 whenever the responsibility for the care of a patient of a midwife is transferred to another member of the Midwifery Staff or the Medical Staff, a written notation by the Midwifery Staff member who is transferring the care over to another shall be made and signed on the patient's medical record and the name of the Midwifery Staff member or Medical Staff member assuming the responsibility shall be noted in the patient's medical record and the midwife or the Medical Staff member assuming the responsibility shall be notified immediately.

(2) Where a supervisor of a midwife, the Chief of the Department of Obstetrics and Gynaecology, or the Chief of Staff becomes aware that, in his or her opinion a serious problem exists in the care or treatment of one or more patients or out-patients of a midwife, the supervisor, Chief of the Department of Obstetrics and Gynaecology or Chief of Staff, as the case may be, shall forthwith discuss the condition, care and treatment of the patient or out-patient with the attending midwife and if changes in the care or treatment satisfactory to the supervisor, Chief of the Department of Obstetrics and Gynaecology or Chief of Staff, as the case may be, are not made promptly, he or she shall assume forthwith the duty of investigating, prescribing for and treating the patient or out-patient, as the case may be, and shall notify the attending midwife, the Chief Executive Officer and if possible, the patient or out-patient, that the member of the Midwifery Staff who was in attendance will cease forthwith to have any hospital privileges as the attending midwife for the patient or out-patient.

(3) Where a supervisor of a midwife, the Chief of the Department of Obstetrics and Gynaecology or the Chief of Staff, as the case may be, is responsible under subsection 4.7.4 (2) is unable to discuss the problem with the attending midwife as required by subsection 4.7.4 (2), the supervisor, Chief of the Department of Obstetrics and Gynaecology or Chief of Staff, as the case may be, shall proceed with his or her duties as prescribed in this subsection 4.7.4 (2) as if he or she had had the discussion with the attending midwife.

(4) Where a supervisor of a midwife, the Chief of the Department of Obstetrics and Gynaecology or the Chief of Staff, as the case may be, has cause to take over the care of a patient, the Chief Executive Officer, the attending midwife and the patient, shall be notified as soon as possible or, in the case where the patient is mentally incompetent, the patient’s substitute decision maker shall be notified as soon as possible.

79 TOR_A2G:1733483.7

4.8 MIDWIFERY STAFF

4.8.1 Midwifery Staff: Function within the Medical Staff Department

(1) The midwifery staff shall function within the Department of Obstetrics and Gynaecology33.

4.8.2 Head Midwife

(1) Where the Board has appointed more than one (1) midwife to the Midwifery Staff, one (1) of the members of the Midwifery Staff shall, subject to annual confirmation by the Board, be appointed by the Board upon the recommendation of the Medical Advisory Committee for a term of three (3) years to be the Head Midwife upon the recommendation of the Chief of the Department of Obstetrics and Gynaecology34.

(2) The Board may at any time revoke or suspend the appointment of the Head Midwife.

4.8.3 Duties of Head Midwife

(1) The Head Midwife shall supervise the professional care given by all members of the Midwifery Staff and shall be responsible to the Chief of the Department of Obstetrics and Gynaecology35 for the quality of care rendered to patients by members of the Midwifery Staff.

4.9 MEETINGS – MIDWIFERY STAFF

4.9.1 Attendance by Midwifery Staff at Medical Staff Meetings

(2) A member of the Midwifery Staff shall not be eligible to vote. A member of the Midwifery Staff may attend Medical Staff meetings.

4.9.2 Transition

(1) During the Transition Period, primary responsibility for quality of care provided by Midwifery Staff will rest with Sunnybrook Health Sciences Centre. As such, the medical advisory committee of Sunnybrook Health Sciences Centre and its subcommittees will hold the primary responsibility for overseeing the quality of medical care provided the Midwifery Staff. The head midwife of Sunnybrook Health Sciences Centre will also be a member of the Medical Advisory Committee of the Hospital and will advise the Medical Advisory Committee of the Hospital with respect to aspects of midwifery care occurring at the Hospital, including quality of care matters, and will provide simultaneously to both the Medical Advisory Committee and the Sunnybrook Health Sciences Centre medical advisory committee all reports prepared for and to be provided to

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Sunnybrook Health Sciences Centre medical advisory committee regarding such care.

4.10 MIDWIFERY STAFF ELIGIBILITY FOR OFFICE


(1) A member of the midwifery staff is not eligible to hold an office other than Head Midwife or an office of the Medical Staff.

5. EXTENDED CLASS NURSING STAFF36

5.1 APPOINTMENT OF EXTENDED CLASS NURSING STAFF37

(1) The Board, on the advice of the Medical Advisory Committee, may appoint, annually, one or more registered nurses in the extended class who are not employees of the Hospital to the extended class nursing staff of the Hospital and shall delineate the privileges with respect to diagnosing, prescribing for or treating out-patients in the Hospitals38.

5.2 APPOINTMENT TO EXTENDED CLASS NURSING STAFF

5.2.1 Application for Appointment to Extended Class Nursing Staff

(1) An application for appointment to the extended class nursing staff shall be processed consistent with the provisions of the Public Hospitals Act and these By-laws.

(2) On request, the Chief Executive Officer shall supply a copy of the By-laws, the Rules of the Hospital and the Public Hospitals Act to each registered nurse in the extended class who expresses in writing the intention to apply for appointment to the extended class nursing staff.

(3) An applicant for appointment to the extended class nursing staff shall submit one (1) original written application to the Chief Executive Officer.

(4) Each application shall contain,

(a) a statement by the applicant that he or she has read the Public Hospitals Act, the Hospital Management Regulation, the By-laws and the Rules of the Hospital;

(b) an undertaking that, if he or she is appointed to the extended class nursing staff of the Hospital, he or she will govern himself or herself in accordance with the requirements set out in the Public Hospitals Act, the Hospital Management Regulations, these By-laws, the Rules of the Hospital, the legislated scope of practice and the ethical standards of the profession;

81 TOR_A2G:1733483.7

(c) evidence of appropriate protection coverage for practice as a

registered nurse in the extended class satisfactory to the Board and a record of past claims history;

(d) a list of the privileges which are requested;

(e) an up-to-date curriculum vitae;

(f) a list of three (3) appropriate referees, including one (1) from a physician who has worked with the registered nurse in the extended class;

(g) information of any previous disciplinary proceeding where there was an adverse finding;

(h) information on any criminal proceedings or convictions which may impact the ability of the applicant to practice;

(i) information of any civil suit where the applicant is or was a defendant where there was a finding of negligence or battery or where such suit was settled with the payment of monies to the other party;

(j) a signed consent authorizing the College of Nurses of Ontario, and any other governing regulatory body or referee, to provide a report on,

(i) any action taken by its disciplinary or fitness to practise committee, and

(ii) whether his or her privileges have been temporarily or permanently curtailed or cancelled by the College of Nurses of Ontario, or by any other governing regulatory body, or by another hospital because of incompetence, negligence, incapacity or any act of professional misconduct; and

(k) a current Annual Registration Payment Card from the College of Nurses of Ontario and consent to the release of information from the Registrar of the College; and

(l) a signed consent authorizing the release of information by the chief executive officer and/or chief of staff of any hospital where the applicant is presently and/or previously held an appointment to staff.

(5) Each applicant shall visit the Hospital for an interview with appropriate members of the Medical Staff and the extended class nursing staff or a

82 TOR_A2G:1733483.7

nursing professional practice leader familiar with the extended class nursing staff role, and the Chief Executive Officer or his or her delegate.

(6) The Chief Executive Officer shall retain a copy of the application and shall refer the original application immediately to the Medical Advisory Committee through its Chair who shall keep a record of each application received and than refer the original application to the Chair of the Credentials Committee.



5.2.2 Criteria for Appointment to the Extended Class Nursing Staff

(1) Only an applicant qualified to practise as a registered nurse in the extended class and who holds a current, valid Annual Registration Payment Card as a registered nurse in the extended class with the College of Nurses of Ontario and is not an employee of the Hospital is eligible to be a member of and appointed to the extended class nursing staff of the Hospital.


(a) A current Annual Registration Payment Card as a registered nurse in the extended class with the College of Nurses of Ontario;

(b) a demonstrated ability to provide patient care at an appropriate level of quality and efficiency;

(c) a demonstrated ability to communicate, work with and relate to all members of the extended class nursing staff, the Medical-Dental-Midwifery Staff and Hospital staff in a co-operative and professional manner;

(d) a demonstrated ability to communicate and relate appropriately with patients and patients' relatives;

(e) a willingness to participate in the discharge of staff obligations appropriate to his or her membership group;

(f) adequate training and experience for the privileges requested;

(g) evidence of appropriate protection coverage for practice as a registered nurse in the extended class satisfactory to the Board; and

83 TOR_A2G:1733483.7

(h) a report on, among other things, the experience, competence and

reputation of the applicant from the chief of staff or the chief of the department in the last hospital or facility in which the applicant trained or held an appointment, if possible, or where such report is not available, a report from any other physician where the physician has had direct knowledge of the registered nurse in the extended class experience, competence and reputation39.

(3) The applicant must agree to govern himself or herself in accordance with the requirements set out in these By-laws, the Rules of the Hospital and the Hospital policies, the legislated scope of practice and the ethical standards of the profession.



5.2.3 Term

(1) Each appointment to the extended class nursing staff shall be for one (1) year, but shall continue in effect until the Board has made appointments for the ensuing year.

5.3 RE-APPOINTMENT


(1) Upon recommendation by the Medical Advisory Committee, the Board shall establish and approve a process for the annual performance review of each member of the extended class nursing staff.

(2) Each year each member of the extended class nursing staff shall make a written application for re-appointment to a group of the extended class nursing staff of the Hospital in the prescribed form.

(3) Where a member of the extended class nursing staff has applied for re-appointment, the Chief of the Department shall conduct a review of the applicant’s performance for the past year in accordance with the approved process once established under subsection 5.3.1(1), and shall make a written report to the Medical Advisory Committee in respect of the applicant’s performance for the past year40.

(4) The application for re-appointment to a group of the extended class nursing staff of the Hospital shall be processed in the same manner as set out in section 5.2.1.

84 TOR_A2G:1733483.7

5.3.2 Criteria for Re-Appointment to the Extended Class Nursing Staff


(a) continue to meet the criteria set out at section 5.2.2; and



(1) In a manner consistent with the provisions of the Public Hospitals Act, the Board may refuse to re-appoint a member of the extended class nursing staff.

5.4 MID-TERM ACTION


(1) In a manner consistent with the Public Hospitals Act and these By-laws, the Board at any time may revoke or suspend any appointment of a registered nurse in the extended class or dismiss, suspend, restrict or otherwise deal with the privileges of the member.

(2) Mid-term action in respect of a member of the extended class nursing staff, shall be processed in accordance with, and in the same manner provided in Part 7 of these By-laws.

5.5 EXTENDED CLASS NURSING STAFF GROUPS

5.5.1 Extended Class Nursing Staff Groups

(1) Extended class nursing staff may be divided into the following groups:

(a) Courtesy; and

(b) Locum Tenens.

5.5.2 Courtesy Extended Class Nursing Staff

(1) The Board may grant a registered nurse in the extended class, who is not an employee of the Hospital, an appointment to the courtesy extended class nursing staff to register out-patients in the Hospital to diagnose, prescribe for or treat such out-patients.

5.5.3 Locum Tenens Extended Class Nursing Staff

(1) The Medical Advisory Committee upon the request of a member of the extended class nursing staff may recommend the appointment of a locum

85 TOR_A2G:1733483.7

tenens as a planned replacement for that registered nurse in the extended class for a specified period of time.


(a) register out-patients in the Hospital to diagnose, prescribe for or treat such out-patients; and

(b) work under the counsel and supervision of a member of the Active Medical Staff or courtesy extended class nursing staff who has been assigned this responsibility by the Chief of Staff or his or her delegate.

5.6 EXTENDED CLASS NURSING STAFF DUTIES

5.6.1 Extended Class Nursing Staff Duties

(1) Each member of the extended class nursing staff is accountable to and shall recognize the authority of the Board through and with their Chief of the Department, the Chief of Staff and the Chief Executive Officer.

(2) Each member of the extended class nursing staff shall,

(a) register a person as an out-patient for purposes of diagnosing, prescribing for or treating out-patients in the Hospital;

(b) 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;

(c) give such instruction as is required for the education of other members of the extended class nursing staff, Medical-Dental-Midwifery Staff, and Hospital staff;

(d) abide by the Rules of the Hospital, these By-laws, the Public Hospitals Act and all other legislated requirements; and

(e) co-operate with,

(i) the Chief of Staff and the Medical Advisory Committee;

(ii) the Chief of Family and Community Medicine41; and

(iii) the Chief Executive Officer.

(f) perform such other duties as may be requested 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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(1) Each member of the extended class nursing staff shall comply with the requirements of section 2.10.4.

5.6.3 Viewing Therapeutic Actions or Procedures

(1) Any therapeutic action or procedure performed in the Hospital may be viewed without the permission of a member of the extended class nursing staff by,


(b) the Chief of the Department.


(1) Pursuant to the Hospital Management Regulation42 whenever the responsibility for the care of an out-patient of a member of the extended class nursing staff is transferred to another member of the extended class nursing staff or the Medical Staff, a written notation by the extended class nursing staff member who is transferring the care over to another member or the Medical Staff shall be made and signed on the patient's medical record and the name of the extended class nursing staff member or Medical Staff member assuming the responsibility shall be noted in the patient's medical record and the member of the extended class nursing staff or the Medical Staff member assuming the responsibility shall be notified immediately.

(2) Where a supervisor of a member of the extended class nursing staff, the Chief of Family and Community Medicine, or the Chief of Staff becomes aware that, in his or her opinion a serious problem exists in the care or treatment of one or more out-patients of a member of the extended class nursing staff, the supervisor, Chief of Family and Community Medicine or Chief of Staff, as the case may be, shall forthwith discuss the condition, care and treatment of the out-patient with the attending member of the extended class nursing staff and if changes in the care or treatment satisfactory to the supervisor, Chief of Family and Community Medicine or Chief of Staff, as the case may be, are not made promptly, he or she shall notify the attending member of the extended class nursing staff, the Chief Executive Officer and if possible, the out-patient, that the member of the extended class nursing staff who was in attendance will cease forthwith to have any hospital privileges as the attending member of the extended class nursing staff for the out-patient.

(3) Where a supervisor, Chief of Family and Community Medicine or Chief of Staff, as the case may be, is responsible under subsection 5.6.4 (2) is unable to discuss the problem with the attending member of the extended

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class nursing staff as required by subsection 5.6.4 (2), the supervisor, Chief of Family and Community Medicine or Chief of Staff, as the case may be, shall proceed with his or her duties as prescribed in this subsection 5.6.4 (2) as if he or she had had the discussion with the attending member of the extended class nursing staff.

(4) Where a supervisor, the Chief of Family and Community Medicine or Chief of Staff, as the case may be, has cause to take over the care of an out-patient of a member of the extended class nursing staff, the Chief Executive Officer, the attending member of the extended class nursing staff and the patient, shall be notified as soon as possible or, in the case where the patient is mentally incompetent, the patient’s substitute decision maker, shall be notified as soon as possible.

5.7 EXTENDED CLASS NURSING STAFF

5.7.1 Extended Class Nursing Staff: Function Within Medical Staff Department

(1) The extended class nursing staff shall function within the Department of Family and Community Medicine.

5.8 MEETINGS

5.8.1 Attendance by Extended Class Nursing Staff at Medical Staff Meetings

(1) A member of the extended class nursing staff is not eligible to vote. A member of the extended class nursing staff may attend Medical Staff meetings.

5.9 EXTENDED CLASS NURSING STAFF ELIGIBILITY FOR OFFICE


(1) A member of the extended class nursing staff is not eligible to hold an office of the Medical-Dental-Midwifery Staff.

6. MEDICAL ADVISORY COMMITTEE AND BOARD PROCESS FOR APPLICATIONS, RE-APPLICATIONS, CHANGES IN PRIVILEGES AND MID-TERM ACTION

6.1 THE MEDICAL ADVISORY COMMITTEE MEETING

6.1.1 The Medical Advisory Committee Meeting

(1) In the case of an application for appointment, re-appointment or change in privileges, within sixty (60) days from the date of the application, the Medical Advisory Committee shall give written notice to the Board and the applicant or member, as the case may be, of its recommendation43.

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(2) In the case of Mid-Term action, within fourteen (14) days from the date of

the Medical Advisory Committee meeting, the Medical Advisory Committee shall give written notice to the Board and the member of its recommendation.

(3) The notice referred to in subsection 6.1.1 (1) and 6.1.1 (2) shall,

(a) include the written reasons for the recommendation; and

(b) inform the applicant or member, as the case may be, that he or she is entitled to a hearing before the Board if a written request is received by the Board and the Medical Advisory Committee within seven (7) days of the receipt by the applicant or member, as the case may be, of the written reasons under clause (a)44.

(4) The time period to provide the written notice required in subsection 6.1.1 (1) or 6.1.1 (2) may be extended, if, prior to the expiry of the time period, the Medical Advisory Committee gives written notice to the Board and the applicant or member, as the case may be, that the final recommendation cannot yet be made and provides written reasons therefor45.

(5) Service of a notice to the applicant or member may be made personally or by registered mail addressed to the person to be served at his or her last known address and, where the notice is served by registered mail, it shall be deemed that the notice was served on the third day after the day of mailing unless the person to be served establishes that he or she did not, acting in good faith, through absence, accident, illness or other cause beyond his or her control receive it until a later date46.

(6) Where the applicant or member does not require a hearing by the Board, the Board may implement the recommendation of the Medical Advisory Committee47.

(7) Where the applicant or member requires a hearing by the Board, the Board shall appoint a place and a time for the hearing48.

(8) Where the member continues in his or her duties at the Hospital and the Chief of the Department believes the member's work should be scrutinized, the applicant or member's work shall be scrutinized in a manner to be determined by the Chief of the Department.

(9) If at any time it becomes apparent that the member's conduct, performance or competence is such that it exposes, or is reasonably likely to expose patient(s) to harm or injury and immediate action must be taken to protect the patients, then the procedures under immediate measures in an emergency situation shall be invoked49.

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6.2 THE BOARD HEARING

6.2.1 The Board Hearing

(1) The Board shall name a place and time for the hearing50.

(2) The Board hearing shall be held within fourteen (14) days of the Board receiving the notice from the applicant or member requesting a hearing.

(3) The Board shall give written notice of the hearing to the applicant or member and to the Chair (or substitute) of the Medical Advisory Committee at least seven (7) days before the hearing date.

(4) The notice of the Board hearing shall include,

(a) the place and time of the hearing;

(b) the purpose of the hearing;

(c) a statement that the applicant or member and the Medical Advisory Committee shall be afforded an opportunity to examine prior to the hearing, any written or documentary evidence that will be provided or any report, the contents of which will be given in evidence at the hearing;

(d) a statement that the applicant or member may proceed in person or be represented by counsel, and that in his or her absence the Board may proceed with the hearing and that the applicant or member will not be entitled to any further notice of the proceeding;

(e) a statement that the applicant or member may call witnesses and tender documents in evidence in support of his or her case; and

(f) a statement that the time for the hearing may be extended by the Board.

(5) The parties to the Board hearing are the applicant or member, the Medical Advisory Committee and such other persons as the Board may specify51.

(6) The applicant or member requiring a hearing before the Board shall be afforded an opportunity to examine, prior to the hearing, any written or documentary evidence that will be produced, or any report the contents of which will be given in evidence at the hearing52.

(7) Members of the Board holding the hearing shall not have taken part in any investigation or consideration of the subject matter of the hearing before the hearing and shall not communicate directly or indirectly in relation to the subject matter of the hearing with any person or with any party or his

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or her representative, except upon notice to and an opportunity for all parties to participate53,54.

(8) The findings of fact of the Board pursuant to a hearing shall be based exclusively on evidence admissible or matters that may be noticed under sections 15 and 16 of the Statutory Powers Procedure Act55.

(9) The Board shall consider only the reasons of the Medical Advisory Committee that have been given to the applicant or member in support of its recommendation. Where through error or inadvertence, certain reasons have been omitted in the statement delivered to the applicant or member, the Board may consider those reasons only if those reasons are given by the Medical Advisory Committee in writing to both the applicant or member, as the case may be, and the Board and the applicant or member is given a reasonable time to review the reasons and to prepare a case to meet those additional reasons56.

(10) No member of the Board shall participate in a decision of the Board pursuant to a hearing unless he or she was 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 shall be given unless all applicant or members so present participate in the decision57, 58.

(11) The Board shall make a decision to either follow or not follow the recommendation of the Medical Advisory Committee.

(12) A written copy of the decision of the Board and the written reasons for the decision shall be provided to the applicant or member, as the case may be, and to the Medical Advisory Committee Secretary59 within seven (7) days of the decision.

(13) Service of the notice of the decision and the written reasons to the applicant or member may be made personally or by registered mail addressed to the applicant or member at his or her last known address and, where the notice is served by registered mail, it shall be deemed that the notice was served on the third day after the day of mailing unless the person to be served establishes that he or she did not, acting in good faith, through absence, accident, illness or other cause beyond his or her control receive it until a later date60, 61.

7. MID-TERM ACTION

7.1 NON-IMMEDIATE MID-TERM ACTION

7.1.1 Preliminary Steps in Mid-Term Review

7.1.1.1 Criteria for Initiation

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(1) Mid-Term action may be initiated wherever the member is alleged to have

engaged in, made or exhibited acts, statements, demeanour or professional conduct, either within or outside of the Hospital, and the same exposes, or is reasonably likely to expose patients to harm or injury, or the same is, or is reasonably likely to be, detrimental to patient safety or to the delivery of quality patient care within the Hospital, or the same is, or is reasonably likely to be, detrimental to Hospital operations; or the same is, or is reasonably likely to constitute abuse; or the same results in the imposition of sanctions by the professional College of the member; or the same is contrary to the By-laws, Hospital policies, the Rules of the Hospital, the Public Hospitals Act or any other relevant law or legislated requirement.

7.1.1.2 Initiation

(1) Where information is provided to the Chief Executive Officer, Chief of Staff, or Chief of the Department which raises concerns about any of the matters in subsection 7.1.1.1(1), the information shall be in writing and shall be directed to the Chief Executive Officer, Chief of Staff, Chief of the Department.

(2) If either of the Chief Executive Officer, Chief of Staff, or Chief of the Department receives information about the conduct, performance or competence of a member, he or she shall inform the other individuals.

7.1.1.3 Initial Interview

(1) An interview shall be arranged with the member62.

(2) The member shall be advised of the information about his or her conduct, performance or competence and shall be given a reasonable opportunity to present relevant information on his or her own behalf.

(3) A written record shall be maintained reflecting the substance of the interview and copies shall be sent to the member, the Chief Executive Officer, the Chief of Staff, and Chief of the Department.

(4) If the member fails or declines to participate in the interview after being given a reasonable opportunity, the appropriate action may be initiated63.

7.1.1.4 Investigation

(1) The Chief of Staff, Chief of the Department or Chief Executive Officer shall determine whether a further investigation is necessary64.

(2) The investigation may be assigned to an individual(s) within the Hospital, the Medical Advisory Committee, a body within the Hospital other than the Medical Advisory Committee or an external consultant.

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(3) Upon completion of the investigation, the individual or body who

conducted the investigation shall forward a written report to the Chief Executive Officer, Chief of Staff, and the Chief of the Department The member should be provided with a copy of the written report.

(4) The Chief of Staff, Chief of the Department and Chief Executive Officer, shall review the report and determine whether any further action may be required.

7.1.2 Request to the Medical Advisory Committee for Recommendations for Mid-Term Action

(1) Where it is determined that further action may be required and the matter relates to the dismissal, suspension or restriction of a member's Hospital privileges and/or the quality of medical care or dental care in the Hospital, the matter shall be referred to the Medical Advisory Committee who shall make a recommendation to the Board65.

(2) All requests for a recommendation for Mid-Term action must be submitted to the Medical Advisory Committee in writing and supported by reference to the specific activities or conduct which constitute grounds for the request.

(3) Where the matter is referred to the Medical Advisory Committee, a copy of any reports made by a body or consultant with respect to the matter shall be forwarded to the Medical Advisory Committee.

(4) The Medical Advisory Committee may initiate further investigation itself, establish an Ad Hoc Committee to conduct the investigation, refer the matter to an external consultant, dismiss the matter for lack of merit or determine to have a meeting of the Medical Advisory Committee66.

(5) Where the Medical Advisory Committee establishes an Ad Hoc Committee to conduct the investigation or refers the matter to an external consultant, that individual or body shall forward a written report of the investigation to the Medical Advisory Committee as soon as practicable after the completion of the investigation.

(6) Upon completion of its own investigation or upon receipt of the report by the body that conducted the investigation, as the case may be, the Medical Advisory Committee may either dismiss the matter for lack of merit or determine to have a meeting of the Medical Advisory Committee.

(7) Within twenty-one (21) days after receipt by the Medical Advisory Committee of the request for a recommendation for Mid-Term action, unless deferred, the Medical Advisory Committee shall determine whether a meeting of the Medical Advisory Committee is required to be held.

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(8) If additional time is needed for the investigative process, the Medical

Advisory Committee may defer action on the request. The Medical Advisory Committee must act within thirty (30) days of the deferral.

(9) If the Medical Advisory Committee determines that there is merit to proceed to a Medical Advisory Committee meeting, then the member is entitled to attend the meeting.


(1) At least fourteen (14) days prior to the Medical Advisory Committee meeting the member and the Medical Advisory Committee shall be given written notice of the Medical Advisory Committee meeting. The notice shall include,

(a) the time and place of the meeting;

(b) the purpose of the meeting;

(c) a statement that the member will be provided with a statement of the matter to be considered by the Medical Advisory Committee together with any relevant documentation;

(d) a statement that the member is entitled to attend the Medical Advisory Committee meeting and to participate fully, to answer all matters considered by the Medical Advisory Committee and to present documents and witnesses;

(e) a statement that the parties are entitled to bring legal counsel to the meeting and consult with legal counsel, but that the legal counsel will not be entitled to participate in the meeting; and

(f) a statement that in the absence of the member, the meeting may proceed 67.

(2) The Medical Advisory Committee secretary shall provide the member with a short but comprehensive statement of the matter to be considered by the Medical Advisory Committee, together with any relevant documentation, including any reports and other documentation which will be reviewed at the meeting68.

(3) At the meeting of the Medical Advisory Committee, a record of the proceeding shall be kept in the minutes of the Medical Advisory Committee meeting69.

(4) The member involved shall be given full opportunity to answer each ground as well as to present documents and witnesses if so desired70.

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(5) Where the Medical Advisory Committee determines that the matter has no

merit, this shall be noted in the minutes of the Medical Advisory Committee.

(6) Where the Medical Advisory Committee determines that the matter has merit, the Medical Advisory Committee shall make a recommendation to the Board71.

(7) Where the Medical Advisory Committee considers the matter at a Medical Advisory Committee meeting, then the procedure set out herein at subsections 6.1.1(1) to (9) and 6.2.1(1) to (13) of these By-laws are to be followed.

7.2 INTERMEDIATE MID-TERM ACTION IN AN EMERGENCY SITUATION

7.2.1 Immediate Steps.

(1) Where the conduct, performance or competence of a member exposes, or is reasonably likely to expose patient(s) to harm or injury and immediate action must be taken to protect the patients and no less restrictive measure can be taken, the Chief of Staff or Chief of the Department, or his or here delegate, may immediately and temporarily suspend the member's privileges, with immediate notice to the Chief Executive Officer, or his or her delegate, and pending a Medical Advisory Committee meeting and a hearing by the Board72.

(2) The Chief of Staff or Chief of the Department shall immediately notify the member, the Medical Advisory Committee, and the Board of his or her decision to suspend the member's privileges.

(3) Arrangements, as necessary, shall be made by the Chief of Staff or Chief of the Department for the assignment of a substitute physician to care for the patients of the suspended member.

(4) Within forty-eight (48) hours of the suspension, the individual who suspended the member shall provide the member and Medical Advisory Committee with written reasons for the suspension and copies of any relevant documents or records.


(1) The Medical Advisory Committee shall set a date for a meeting of the Medical Advisory Committee to be held within five (5) days from the date of the suspension to review the suspension and to make recommendations to the Board.

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(2) As soon as possible, and in any event, at least forty-eight (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;

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

(d) a statement that the member is entitled to attend the Medical Advisory Committee meeting and to participate fully, to answer all matters considered by the Medical Advisory Committee and to present documents and witnesses;

(e) a statement that the parties are entitled to bring to the meeting and consult with legal counsel, but that the legal counsel will not be entitled to participate in the meeting; and

(f) a statement that, in the absence of the member, the meeting may proceed73.

(3) The member may request and the Medical Advisory Committee may grant a postponement of the Medical Advisory Committee meeting74.

(4) At the meeting of the Medical Advisory Committee, a record of the proceeding shall be kept in the minutes of the Medical Advisory Committee meeting75.

(5) The member shall be given full opportunity to answer each ground as well as to present documents and witnesses if so desired76.

(6) Before deliberating on the recommendation to be made to the Board, the Chair of the Medical Advisory Committee shall require the member involved, and any other persons present who are not Medical Advisory Committee members, to retire. The Medical Advisory Committee shall not consider any matter or case to which they did not give the member a fair opportunity to answer.

(7) The Medical Advisory Committee shall provide to the member within twenty-four (24) hours of the Medical Advisory Committee meeting written notice of,

(a) the Medical Advisory Committee's recommendation and the written reasons for the recommendation77; and

(b) the member's entitlement to a hearing before the Board.

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(8) The Medical Advisory Committee shall provide to the Board within

twenty-four (24) hours of the Medical Advisory Committee meeting written notice of the Medical Advisory Committee's recommendation.

7.2.3 The Board Hearing

(1) The Board names a place and time for the hearing.

(2) The Board hearing shall be held within seven (7) days of the date of receipt by the member of the Medical Advisory Committee's recommendation and written reasons.

(3) The Board shall provide written notice of the Board hearing to the member and to the Chair (or substitute) of the Medical Advisory Committee at the earliest possible opportunity and in any event, at least seventy-two (72) hours prior to the date of the hearing.

(4) The notice of the Hospital Board hearing shall include,

(a) the date, time and place of the hearing;

(b) the purpose of the hearing;

(c) a statement that the member 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 report, the contents of which will be given in evidence at the hearing;

(d) a statement that the member may proceed in person or be represented by counsel, and that in his or her absence the Board may proceed with the hearing and that the member will not be entitled to any further notice of the proceeding;

(e) a statement that the member may call witnesses and tender documents in evidence in support of his or her case; and

78(f) the time for the hearing may be extended by the Board .

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

(6) The member requiring a hearing before the Board shall be afforded an opportunity to examine, prior to the hearing, any written or documentary evidence that will be produced, or any report the contents of which will be given in evidence at the hearing.

97 TOR_A2G:1733483.7

(7) Members of the Board holding the hearing shall not have taken part in any

investigation or consideration of the subject matter of the hearing before the hearing and shall not communicate directly or indirectly in relation to the subject matter of the hearing with any person or with any party or his or her representative, except upon notice to and an opportunity for all parties to participate79.

(8) The findings of fact of the Board pursuant to a hearing shall be based exclusively on evidence admissible or matters that may be noticed under sections 15 and 16 of the Statutory Powers Procedure Act.

(9) The Board shall consider only the reasons of the Medical Advisory Committee that have been given to the member in support of its recommendation. Where through error or inadvertence, certain reasons have been omitted in the statement delivered to the member, the Board may consider those reasons only if those reasons are given by the Medical Advisory Committee in writing to both the applicant or member and the Board and the member is given a reasonable time to review the reasons and to prepare a case to meet those additional reasons80.

(10) No member of the Board shall participate in a decision of the Board pursuant to a hearing unless he or she was 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 shall be given unless all members so present participate in the decision81.

(11) The Board shall make a decision to either follow or not follow the recommendation of the Medical Advisory Committee.

(12) A written copy of the decision of the Board and the written reasons for the decision shall be provided to the member and to the Medical Advisory Committee Secretary82 within seven days of the receipt by the member of the decision.

(13) Service of the notice of the decision and the written reasons to the member may be made personally or by registered mail addressed to the member at his or her last known address and, where the notice is served by registered mail, it shall be deemed that the notice was served on the third day after the day of mailing unless the person to be served establishes that he or she did not, acting in good faith, through absence, accident, illness or other cause beyond his or her control receive it until a later date.

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8. AMENDMENTS TO MEDICAL STAFF, DENTAL STAFF, MIDWIFERY STAFF AND EXTENDED CLASS NURSING STAFF BYLAWS

8.1 AMENDMENTS TO BY-LAWS

(1) These By-laws may be amended by the process established by the Board for amending its by-laws provided that prior to submitting any amendments to such process,

(a) a notice specifying the proposed amendments to the By-laws shall be posted;

(b) the Medical-Dental-Midwifery Staff and extended class nursing staff shall be afforded an opportunity to comment on the proposed amendments; and

(c) the Medical Advisory Committee shall make recommendations to the Board concerning the proposed amendments.

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1 Program management combines functional responsibilities (i.e., medicine, surgery, nursing, physiotherapy) with certain programs, such as cardiac, neurosciences, and maternal and child health care programs. Many hospitals have integrated program management with the traditional structure of organizing services around functions. One of the main objectives of program management is to improve coordination between the medical staff and administrative components of the hospital. Such programs generally cut across hospital functions, involving differing components of different departments. Program management includes a multidisciplinary team approach to care, which can include medical, administrative, and departmental representatives so that both clinical and non-clinical issues can be addressed. The team usually comprises a physician-manager (Program Medical Director (PMD)) and administrative director (Administrative Director) who are expected to work together to arrive at a consensus about the management of the program. The PMD and AD report to the Chief Executive Officer. The PMD also reports to the Medical Advisory Committee through the Chief of Staff for matters that are under the authority of the Medical Advisory Committee. Program arrangements result in multiple reporting relationships. Within each program a physician may be accountable to a functional department head and accountable to the physician program medical director for planning and utilization – (i.e., a cardiovascular surgeon may report to the chief of surgery and be accountable to the physician program manager of cardiac). There are many possible methods of incorporating program management in a hospital, and each hospital, if a hospital chooses to use a program management structure, will have to adapt the model to suit its own circumstances. 2 Public Hospitals Act, R.S.O. 1990, c. P.40, ss. 36-39, 41-43. 3 Public Hospitals Act, R.S.O. 1990, c. P.40, s. 37(2). 4 In a non-departmentalised hospital, the Chief of Staff or delegate shall perform this duty. The review should take into account the matters set out in section 2.4.2(2)(c), (2)(d), (2)(e) and (2)(f) of the OHA/OMA Prototype Hospital By-Laws, 2003. 5 Public Hospitals Act, R.S.O. 1990, c. P. 40, s. 36(c). 6 Depending on the number and qualifications of members of the medical staff, all of these staff groups may not be necessary. For other staff groups, see Appendix D. 7 The board may wish to exclude such physicians as radiologists, pathologists and emergency physicians from having admitting privileges. 8 Hospitals, which from time to time have, visiting physicians such as those from a teaching centre who provide a series of consultations, may wish to add a clause (1)(c) "to provide a series of consultations". 9 Some smaller hospitals may wish to add a by-law provision, which allows an honorary member to be appointed to the Credentials Committee. 10 Trillium Gift of Life Network Act, R.S.O. 1990 c. H.20. 11 The Ontario Medical Association (OMA) does not support this open-ended wording and suggests that such duties must be within the normal scope and site of practice. 12 R.R.O. 1990, Reg. 965, s. 2(3)(c) made under the Public Hospitals Act. 13 Each Hospital is structured differently as to whether or not it is divided into departments and whether or not it has a Chief of Staff. Each Hospital must therefore refer to ss. 34(1)-(2) of the

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TOR_A2G:1733483.7

Public Hospitals Act, R.S.O. 1990, c. P.40, and determine which provisions apply and write the By-law accordingly. 14 It may be appropriate to assign the function of reporting of the midwifery staff to another member of the Medical Advisory Committee. 15 R.R.O. 1990, Reg. 965, s. 18 made under the Public Hospitals Act. 16 R.R.O. 1990, Reg. 965, s. 6(1) made under the Public Hospitals Act. 17 An appropriate number to be determined by individual hospitals (for example 10% of the active staff). 18 There is no legal requirement for having a majority of the medical staff members entitled to vote constituting a quorum. This should be determined locally. 19 Supra note 114. 20 There are definite advantages to having a treasurer of the medical staff. See section 2.13.6 of the OHA/OMA Prototype Hospital By-Laws, 2003. 21 The Medical Advisory Committee of every hospital shall be comprised of,

the president, the vice-president, the secretary of the medical staff, the chief of staff, if any, and, in the case of a Group A Hospital, the chief of the dental staff, if any; and

such other members of the medical staff as are elected or appointed in accordance with the by-laws of the hospital.

R.R.O. 1990, Reg. 965, s. 7(1) made under the Public Hospitals Act. 22 Where, in a Group A Hospital, there is a Chief of Dental Staff he or she shall be a member of the Medical Advisory Committee. R.R.O. 1990, Reg. 965, s. 7(1)(a) made under the Public Hospitals Act. 23 R.R.O. 1990, Reg. 965, s. 7(2)-(6) made under the Public Hospitals Act. 24 R.R.O. 1990, Reg. 965, s. 7(2)(c) made under the Public Hospitals Act. 25 In a non-departmentalised hospital, the Chief of Staff or delegate shall perform this duty. The review should take into account the matters set out in section Error! Reference source not found.(2)(c), (2)(d), (2)(e) and (2)(f) of the OHA/OMA Prototype Hospital By-Laws, 2003. The Chief of the Department shall communicate with the Program Medical Director, as appropriate. 26 R.R.O. 1990, Reg. 965, s. 18 made under the Public Hospitals Act. 27 In a non-departmentalised hospital, the Chief of Staff or delegate shall perform this duty. The review should take into account the matters set out in section Error! Reference source not found.(2)(c), (2)(d), (2)(e) and (2)(f) of the OHA/OMA Prototype Hospital By-Laws, 2003. The Chief of the Department shall communicate with the Program Medical Director, as appropriate. 28 Supra note 87. 29 Generally, it is desirable that a midwife have an active staff appointment at only one general hospital. 30 In making an appointment to the courtesy staff specific consideration will be given to the granting of privileges to each application, for example, admitting privileges and treatment services on an out-patient basis only, etc. 31 The Department Chief named should be consistent with the Department within which the midwifery staff functions, e.g. Chief of Obstetrics or Chief of Family Practice, etc.

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32 Supra note 136. 33 Each hospital may determine within which Department of the Hospital the midwifery staff will function. This may be the Department of Obstetrics and Gynaecology or Family Practice, etc. 34 Supra note 143. 35 Ibid. 36 Registered nurses in the extended class may practice in a variety of models and settings. In the OHA/OMA Prototype Hospital By-Laws, 2003 and pursuant to Regulation 965 made under the Public Hospitals Act, extended class nursing staff means those registered nurses who are not employed by the hospital and to whom the board has granted privileges to diagnose, prescribe for or treat out-patients in the hospital (Public Hospitals Act, R.S.O. 1990, c. P. 40, s. 1(1)(b)). The extended class nursing staff report through the medical departmental structure via the Chief of Family Practice, to the Chief of Staff, to the Medical Advisory Committee and then to the Board. As prescribed by Regulation 965 made under the Public Hospitals Act, the Board is to pass by-laws that provide for the organization of the extended class nursing staff, set out the duties of the extended class nursing staff and the criteria with respect to appointment and re-appointment of the members of the extended class nursing staff (R.R.O. 1990, Reg. 965, s. 4(1)(c) made under the Public Hospitals Act). The Medical Advisory Committee is to make recommendations to the Board concerning every application for appointment or re-appointment to the extended class nursing staff (R.R.O. 1990, Reg. 965, s. 7(2)(a)(i) made under the Public Hospitals Act), the hospital privileges to be granted to each member of the extended class nursing staff (R.R.O. 1990, Reg. 965, s. 7(2)(a)(ii) made under the Public Hospitals Act), by-laws respecting the extended class nursing staff (R.R.O. 1990, Reg. 965, s. 7(2)(a)(iii) made under the Public Hospitals Act), the dismissal, suspension or restrictions of hospital privileges of any member of the extended class nursing staff (R.R.O. 1990, Reg. 965, s. 7(2)(a)(iv) made under the Public Hospitals Act), the quality of care provided in the hospital by members of the extended class nursing staff (R.R.O. 1990, Reg. 965, s. 7(2)(a)(v) made under the Public Hospitals Act), and the clinical and general rules respecting the extended class nursing staff (R.R.O. 1990, Reg. 965, s. 7(2)(a)(vii) made under the Public Hospitals Act). Every Medical Advisory Committee shall supervise the practice of extended class nursing in the hospital (R.R.O. 1990, Reg. 965, s. 7(2)(b) made under the Public Hospitals Act). Despite subclauses (2) (a) (i), (ii) and (iv), the duties of the Medical Advisory Committee described in those subclauses that relate to the extended class nursing staff of a hospital shall only be performed with respect to those members of the extended class nursing staff who are not employees of the hospital and to whom the board has granted privileges to diagnose, prescribe for or treat out-patients in the hospital (R.R.O. 1990, Reg. 965, s. 7(2.1) made under the Public Hospitals Act). The OHA/OMA Prototype Hospital By-Laws, 2003 provisions have been written in accordance with Regulation 965 made under the Public Hospitals Act. 37 Registered nurses in the extended class may practice in a variety of models and settings. In the OHA/OMA Prototype Hospital By-Laws, 2003 and pursuant to Regulation 965 made under the Public Hospitals Act, extended class nursing staff means those registered nurses who are not employed by the hospital and to whom the board has granted privileges to diagnose, prescribe for or treat out-patients in the hospital (Public Hospitals Act, R.S.O. 1990, c. P. 40, s. 1(1)(b)).

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The extended class nursing staff report through the medical departmental structure via the Chief of Family Practice, to the Chief of Staff, to the Medical Advisory Committee and then to the Board. As prescribed by Regulation 965 made under the Public Hospitals Act, the Board is to pass by-laws that provide for the organization of the extended class nursing staff, set out the duties of the extended class nursing staff and the criteria with respect to appointment and re-appointment of the members of the extended class nursing staff (R.R.O. 1990, Reg. 965, s. 4(1)(c) made under the Public Hospitals Act). The Medical Advisory Committee is to make recommendations to the Board concerning every application for appointment or re-appointment to the extended class nursing staff (R.R.O. 1990, Reg. 965, s. 7(2)(a)(i) made under the Public Hospitals Act), the hospital privileges to be granted to each member of the extended class nursing staff (R.R.O. 1990, Reg. 965, s. 7(2)(a)(ii) made under the Public Hospitals Act), by-laws respecting the extended class nursing staff (R.R.O. 1990, Reg. 965, s. 7(2)(a)(iii) made under the Public Hospitals Act), the dismissal, suspension or restrictions of hospital privileges of any member of the extended class nursing staff (R.R.O. 1990, Reg. 965, s. 7(2)(a)(iv) made under the Public Hospitals Act), the quality of care provided in the hospital by members of the extended class nursing staff (R.R.O. 1990, Reg. 965, s. 7(2)(a)(v) made under the Public Hospitals Act), and the clinical and general rules respecting the extended class nursing staff (R.R.O. 1990, Reg. 965, s. 7(2)(a)(vii) made under the Public Hospitals Act). Every Medical Advisory Committee shall supervise the practice of extended class nursing in the hospital (R.R.O. 1990, Reg. 965, s. 7(2)(b) made under the Public Hospitals Act). Despite subclauses (2) (a) (i), (ii) and (iv), the duties of the Medical Advisory Committee described in those subclauses that relate to the extended class nursing staff of a hospital shall only be performed with respect to those members of the extended class nursing staff who are not employees of the hospital and to whom the board has granted privileges to diagnose, prescribe for or treat out-patients in the hospital (R.R.O. 1990, Reg. 965, s. 7(2.1) made under the Public Hospitals Act). The OHA/OMA Prototype Hospital By-Laws, 2003 provisions have been written in accordance with Regulation 965 made under the Public Hospitals Act. 38 Public Hospitals Act, R.S.O. 1990, c. P. 40, s. 1(1). 39 It is possible that the first group of registered nurses in the extended class who will be applying for an appointment to the Hospital will not have worked with a Chief of Staff or Chief of the Department in a hospital and therefore could not produce a report from the Chief of Staff or Chief of the Department. Therefore, in such circumstances a report from a physician where the physician has had direct knowledge of the registered nurse in the extended class experience, competence and reputation should be required. 40 In a non-departmentalised hospital, the Chief of Staff or delegate shall perform this duty. The review should take into account the matters set out in section 10.2.2(2)(c), 10.2.2(2)(d), 10.2.2(2)(e) and 10.2.2(2)(f) of the OHA/OMA Prototype Hospital By-Laws, 2003. 41 The Department Chief named should be consistent with the Department within which the extended class nursing staff functions, i.e. Chief of Family Practice. 42 Supra note 136. 43 Public Hospitals Act, R.S.O. 1990, c. P. 40, ss. 37(4), 37(6). 44 Public Hospitals Act, R.S.O. 1990, c. P. 40, s. 37(7). 45 Public Hospitals Act, R.S.O. 1990, c. P. 40, s. 37(5). 46 Public Hospitals Act, R.S.O. 1990, c. P. 40, s. 42.

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47 Public Hospitals Act, R.S.O. 1990, c. P. 40, s. 38. 48 Public Hospitals Act, R.S.O. 1990, c. P. 40, s. 39(1). 49 Pending the Medical Advisory Committee making its recommendation and the ultimate decision of the hospital Board, the member may continue his or her duties at the hospital, but only if the member's conduct does not expose, or is not reasonably likely to expose, patients to harm or injury. 50 Supra note 163. 51 Public Hospitals Act, R.S.O. 1990, c. P. 40, s. 39(2). 52 Public Hospitals Act, R.S.O. 1990, c. P. 40, s. 39(5). 53 Public Hospitals Act, R.S.O. 1990, c. P. 40, s. 39(4). 54 This means that the Chief of Staff, President of the Medical Staff and, in the case of a group A or a group B hospital, the Vice-President of the Medical Staff, who are by law voting members of the hospital Board, and the Chief Executive Officer, where the Chief Executive Officer is a voting member of the hospital Board, will not be eligible to be members of the hospital Board holding the hearing if they were involved in any investigation or consideration of the member's case. The hospital Board may seek legal advice from an adviser independent from the parties and in such case the nature of the advice should be made known to the parties in order that they may make submissions as to the law. At the hearing, the Chair of the hospital Board shall chair the meeting or a substitute appointed or elected in accordance with the by-laws of the hospital. (see section Error! Reference source not found.Board Meeting - Chair of the OHA/OMA Prototype Hospital By-Laws, 2003.) The Chair shall ensure that the hospital Board meeting has been duly called in accordance with the hospital by-laws and that a quorum is continuously present. (refer to Error! Reference source not found. Regular Meetings of the Board – Call and Notice, Error! Reference source not found.Error! Reference source not found. Special Meetings of the Board, and Error! Reference source not found.Quorum - OHA/OMA Prototype Hospital By-Laws, 2003.) When the Chair is counting a quorum, he or she should exclude persons who have investigated or considered the matter. It is important for the hospital Board to have a solicitor present at the hearing independent from the parties, to advise the Chair on, among other things, the granting of an adjournment, the admissibility of evidence, what facts or scientific or technical information and opinions the hospital Board may take into account in making its decision, and, through the Chair, to inform any witnesses of his or her right to object to answer any question under section 5 of the Canada Evidence Act, R.S. 1985, c. C-5. 55 Public Hospitals Act, R.S.O. 1990, c. P. 40, s. 39(6). 56 The procedure at the hearing shall be as follows:

a) First, the Chair shall call on the Medical Advisory Committee's representative to present its case in support of the Medical Advisory Committee recommendation.

b) Then the Chair shall call on the member to reply as to why the hospital Board should not adopt the recommendation of the Medical Advisory Committee.

c) The Chair shall invite the Medical Advisory Committee to present a rebuttal, if any, to the member's reply.

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d) The member shall be given an opportunity to respond to the Medical Advisory Committee rebuttal.

The procedure should follow the practice of a court of law where witnesses are first examined and cross-examined without argument in the four stages and then, in conclusion, argument from each side is heard in the same order. It is usually convenient to allow each side to put questions to witnesses immediately after giving their evidence. The Chair however, may decide whether to permit questions throughout the process and rule that questions may not be addressed by members except to the parties at the conclusion of their case. The Chair should maintain order in the conduct of the proceedings taking particular care not to cut short the member's presentation before he or she has put his or her full case to the hospital Board and been given adequate opportunity to answer the Medical Advisory Committee's case in support of its recommendation.

57 Public Hospitals Act, R.S.O. 1990, c. P. 40, s. 39(7). 58 When the hospital Board deliberates to consider a decision following the giving of evidence and representation by the parties, only those members who are eligible to participate in the hearing shall remain, all others shall retire. The solicitor for the hospital Board should stay but must take no part in the deliberations except to advise the hospital Board on matters of law. During the hospital Board's deliberations after the hearing, all members present shall participate in making the decision, with the exception of any who were not present throughout the entire presentation of evidence and argument. The actual wording of the resolution and the reasons for the decision must be that of the hospital Board, not the solicitor for the Hospital board. The solicitor for the hospital Board may assist with drafting of the resolution and reasons. The reasons should be comprehensive yet succinct, having in mind that they will form the basis for the hospital's case before the Hospital Appeal Board in the case of a member of the medical staff should the matter be appealed. (The Public Hospitals Act does not provide for a right of appeal to the Hospital Appeal Board by a dentist, midwife, or registered nurse in the extended class.) 59 Public Hospitals Act, R.S.O. 1990, c. P. 40, s. 41(1). 60 Public Hospitals Act, R.S.O. 1990, c. P. 40, s. 42. 61 It is not necessary to employ the services of a court reporter to record the proceedings of the hearing verbatim. Nevertheless, a secretary should be present throughout the hearing to make, under the guidance of the solicitor for the hospital Board if desired, a memorandum that outlines the proceedings, notates the documents filed, and states the decision. This memorandum should be in a form suitable for submission with the usual minutes of the hospital Board meetings and for the compilation of a record in the event of further proceedings before the Hospital Appeal Board or the courts. (The Public Hospitals Act does not provide for a right of appeal to the Hospital Appeal Board by a dentist, midwife, or registered nurse in the extended class.) Where the privileges of a member of the medical staff of a hospital are restricted or cancelled or where his or her appointment to the medical staff is revoked or suspended by reason of his or her incompetence, negligence or misconduct, the administrator of the hospital shall prepare and forward a detailed report to the College of Physicians and Surgeons of Ontario. (Public Hospitals Act, R.S.O. 1990, c. P.40, s. 33.)

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62 The Chief Executive Officer, Chief of Staff and Chief of the Department as well as the member should be attendees at the interview. At the interview, circumstances prompting the consideration of action may be discussed. 63 The interview and any initial investigation is not a "hearing" as is provided for in these By-laws, the Public Hospitals Act, R.S.O. 1990, c. P.40 or the Statutory Powers Procedure Act, R.S.O. 1990, c. S.22. 64 While it is preferable that the Chief of Staff, Chief of the Department and Chief Executive Officer unanimously agree on whether the situation merits further investigation, any of them can so require further investigation. 65 R.R.O. 1990, Reg. 965 made under the Public Hospitals Act requires that the Medical Advisory Committee is to make recommendations to the hospital Board on the dismissal, suspension or restriction of hospital privileges of any member of the medical staff or, where there is a dental staff, the dental staff, and the quality of medical and dental care in the hospital. 66 The Medical Advisory Committee should establish specific criteria for the external consultant to follow in his or her review. The investigative process is not a "hearing" as is provided for in these By-laws, the Public Hospitals Act or the Statutory Powers Procedure Act. It may involve a consultation with the member involved and with the individuals who may have knowledge of the events involved. 67 The member may consult with counsel, but the legal counsel will not be permitted to testify, put questions or make representations on behalf of the member. If one party intends to have legal counsel present at the Medical Advisory Committee meeting, that party should notify the other party as soon as possible prior to the meeting. 68 This material should be provided at the time the notice is given or as soon as possible thereafter. All relevant documentation is to be made available to the Medical Advisory Committee and the member. In this way, the Medical Advisory Committee will be able to make a well-considered recommendation to the hospital Board. If specific patient cases are involved, the relevant names and dates shall be given. The member shall be permitted to bring any relevant notes and records and any other individual(s) to speak in support of his or her case. Where legal counsel for one party is present at the meeting, the other party should be so advised. 69 The record shall be a concise report in the minutes of the Medical Advisory Committee meeting, prepared by the Medical Advisory Committee secretary. Minutes of the Medical Advisory Committee are to be made by the Medical Advisory Committee's secretary, and are to constitute the permanent record of the Medical Advisory Committee. The proceeding at the Medical Advisory Committee meeting is not a hearing as is provided for in these By-laws, the Public Hospitals Act, R.S.O. 1990, c. P.40 or the Statutory Powers Procedure Act, R.S.O. 1990, c. S-22. An orderly presentation should be made by one or more members of the Medical Advisory Committee. 70 The Chair of the Medical Advisory Committee and anyone else present, other than legal counsel, shall be permitted to ask and answer questions of and from anyone present at the meeting. The Chair of the Medical Advisory Committee may permit adjournments. Adjournments may be permitted, when requested, to allow the member or any Medical Advisory Committee member to

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obtain further information or documents in the interest of a fair and thorough consideration of the grounds of complaint. However, unreasonable delays should not be permitted. Before deliberating on the recommendation to be made to the hospital Board, the Chair shall require the member involved, and any other persons present who are not Medical Advisory Committee members, to retire. The Medical Advisory Committee shall not consider any matter or case to which they did not give the member a fair opportunity to answer. 71 The Medical Advisory Committee may recommend to the hospital Board without limitation:

to warn or provide a formal letter of reprimand;

to require a probationary period with retrospective review of cases but without special requirements of prior or concurrent consultation or direct supervision;

to suspend membership prerogatives that do not affect clinical privileges;

to require individual requirements of consultation or supervision;

to restrict, suspend or revoke clinical privileges;

to reduce the Staff category; or

to suspend or revoke the member's staff appointment. 72 Each hospital should have a mechanism in place which permits it to immediately suspend the member's privileges pending a meeting by the Medical Advisory Committee to settle its recommendation and pending the disposition of the matter by the hospital Board, while at the same time protecting the public interest. Each hospital should address who is empowered to immediately and temporarily suspend a member's privileges pending a Medical Advisory Committee meeting and pending a hearing before the hospital Board. Hospitals may wish to consider an option whereby the Chief of Staff or Chief of the Department, or his or her delegate, may immediately and temporarily suspend the member's privileges, pending notice to and approval by the Chief Executive Officer. 73 Supra note 184. 74 The requirement of five (5) days for the Medical Advisory Committee to hold a meeting is for the benefit of the member. If the member needs more time to prepare for the Medical Advisory Committee meeting or wishes time to prepare and/or to attend with legal counsel and such counsel is not available until a later date, then the Medical Advisory Committee should agree to postpone the matter to ensure the member has time to prepare. If specific patient cases are involved, the relevant names and dates shall be given. The member shall be permitted to bring any relevant notes and records and any other individual(s) to speak in support of his or her case. Where legal counsel for one party is present at the meeting, the other party should be so advised. 75 Supra note 186 and accompanying text. 76 The Chair of the Medical Advisory Committee and anyone else present, other than legal counsel, shall be permitted to ask and answer questions of and from anyone present at the meeting. The Chair of the Medical Advisory Committee may permit adjournments. Adjournments may be permitted, when requested, to allow the member or any Medical Advisory Committee member to obtain further information or documents in the interest of a fair and thorough consideration of the grounds of the complaint. However, unreasonable delays should not be permitted.

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77 The written reasons for the recommendation of the Medical Advisory Committee should be short and to the point but nevertheless reasonably comprehensive. The members of the Medical Advisory Committee should not discuss the matter with any members of the hospital Board in light of the possibility that the physician may later require a hearing by the hospital Board. 78 The member may request a postponement of the hospital Board hearing. The requirement for the hospital Board to hold a hearing within seven (7) days is for the benefit of the member. If the member needs time to prepare for the hospital Board hearing or wishes to attend with legal counsel and such counsel is not available until a later date, then the hospital Board may postpone the matter to ensure that the member has time to prepare. 79 Supra note 169 and accompanying text. 80 Supra note 171 and accompanying text. 81 When the hospital Board deliberates to consider a decision following the giving of evidence and representation by the parties, only those members who are eligible to participate in the hearing shall remain, all others shall retire. The solicitor for the hospital Board should stay but must take no part in the deliberations except to advise the hospital Board on matters of law. During the hospital Board's deliberations after the hearing, all members present shall participate in making the decision, with the exception of any who were not present throughout the entire presentation of evidence and argument. The actual wording of the resolution and the reasons for the decision must be that of the hospital Board, not the solicitor for the hospital Board. The solicitor for the hospital Board may assist with the drafting of the resolution and reasons. The reasons should be comprehensive yet succinct, having in mind that they will form the basis for the hospital's case before the Hospital Appeal Board should the matter be appealed. 82 It is not necessary to employ the services of a court reporter to record the proceedings of the hearing verbatim. Nevertheless, a secretary should be present throughout the hearing to make, under the guidance of the solicitor for the hospital Board if desired, a memorandum that outlines the proceedings, notates the documents filed, and states the decision. This memorandum should be in a form suitable for submission with the usual minutes of the hospital Board meetings and for the compilation of a record in the event of further proceedings before the Hospital Appeal Board or the courts. Where the privileges of a member of the medical staff of a hospital are restricted or cancelled or where his or her appointment to the medical staff is revoked or suspended by reason of his or her incompetence, negligence or misconduct, the administrator of the hospital shall prepare and forward a detailed report to the College of Physicians and Surgeons of Ontario. (Public Hospitals Act, R.S.O. 1990, c. P.40, s. 33.)

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