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Bylaws and Policies


Letter from Steven Graff, MD
President, TMH Medical Staff Association

November 16, 2012

 

 
Dear Colleague,

I know it wasn’t that long ago that we revised the Bylaws and approved them. However, as discussed during that process, there was always the potential of it becoming necessary to make additional edits as we utilized them. Based on input from the MEC and a review of the Joint Commission standards in the Medical Staff chapter three Non Core Bylaw changes have been recommended. The proposed changes are listed below and can be found on the attached updated version of the Bylaws. These proposed changes will be reviewed by the Medical Executive Committee on 11/27/12 and if recommended, will be reviewed and voted on at the quarterly Medical Staff Association meeting on December 18, 2012 at 7:00 am in the Hurvitz Board Room.

  1. Adding a Department of Plastic Surgery – page 51
  2. Creating staggered MEC terms between the Departments of Family and Community Medicine/Dermatology/Plastic Surgery/Neurology or Neurosurgery (rotating alphabetically for one (1) year terms) – page 53
  3. Adding the Graduate Medical Education Committee to the Rules and Regulations – page 20.

Additionally there are three recent changes in Lifespan and affiliate organizational structure that require rephrasing of the Medical Staff Bylaws and related manuals and do not materially affect the letter or intent of the involved statements. Those proposed changes are listed below and will be reviewed (FYI only) at the quarterly Medical Staff Association meeting on December 18, 2012 at 7:00 am in the Hurvitz Board Room.

I.     Title Change of Hospital President and CEO

On October 1, 2012, the title of the "President and CEO" of our hospital became the "President" of the hospital. Therefore, the definitions and references in the Bylaws and related manuals need to change accordingly. Core Bylaws According to the Bylaws Article X – Amendments (specifically Section 10.1.3), the SBRC may recommend revisions to the core Bylaws articles. Further, Section 10.4 permits the SBRC to merely notify the affiliate MECs of “technical” amendments. Section 10.4 defines these parameters as follows:

The System-wide Bylaws Review Committee shall have the power to adopt such amendments to the core Bylaws that, in its judgment, are technical modifications or clarifications, reorganization of the Bylaws, or amendments made necessary because of errors of grammar, punctuation, or expression. The affiliate Medical Executive Committees will be notified of the amendments, which shall be effective immediately and shall be permanent. Such amendments shall be communicated in writing to the Medical Staff and the Board of each affiliate.

The change in the title of the hospital President is merely a “technical” change since the role/function of the position does not change.

The SBRC voted to revise the core Bylaws to change the title of Hospital President and CEO to Hospital President wherever it appears. The change shall become effective not earlier than November 20, 2012 and notice is hereby sent to each affiliate’s Medical Executive Committee for information and request for action to alter the core Bylaws articles in the Medical Staff Bylaws.

Non-core Bylaws and related manuals

According to the Bylaws Article X – Amendments (specifically Section 10.2), the MEC may recommend revisions to the non-core Bylaws articles and the Bylaws related manuals. Further, Section 10.4 permits the MEC to merely notify the Medical Staff and Board of “technical” amendments. Section 10.4 defines these parameters as follows:

The Medical Executive Committee shall have the power to adopt such amendments to the non-core Bylaws and other related manuals that, in its judgment, are technical modifications or clarifications, reorganization of the Bylaws, or amendments made necessary because of errors of grammar, punctuation, or expression. Such amendments shall be effective immediately and shall be permanent. The action to amend may be acted upon in the same manner as any other business before the Medical Executive Committee. After approval, such amendments shall be communicated in writing to the Medical Staff and the Board.

The change in the title of the hospital President is merely a “technical” change since the role/function of the position will not change.

PROPOSED: Revise the non-core Bylaws and its related manuals to change the title of Hospital President and CEO to Hospital President wherever it appears. The change shall become effective whenever the proposal is affirmed by the MEC. When affirmed, notice shall be sent to the Medical Staff and Board for information. The change shall occur once affirmed.

II.     Board of Trustees Vote to Reconstitute

The recent vote by all Lifespan affiliate Boards to reconstitute the Hospital Boards into mirror boards of the parent corporation’s Board became effective October 23, 2012.

This action does not call for a modification of the Medical Staff Bylaws as each Hospital will continue to have its own Board considering business related to the specific affiliate, including all Medical Staff business. The role of the Hospital Board as it appears in the Bylaws and related manuals is unchanged. Therefore, no changes in verbiage are required.

III.     PAAC Name Change 

The Professional and Academic Affairs Committee which had functioned as a committee of the TMH Board of Trustees was charged with oversight of Credentials, Academic Affairs, Quality and Safety. Under the new Lifespan Board of Directors governance a new Quality and Safety oversight process is being constructed and this committee has voted to change its name to the TMH Quality Oversight Committee to reflect its new charge and reporting structure to the Lifespan QOC. The name change is a technical change to the By Laws and the will be amended with MEC consent.

PROPOSED: Change the name of the PAAC to TMH QOC wherever it appears.