Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697647968491.pdf (Bahamas)
PUBLIC HOSPITALS AUTHORITY [CH.234 – 3 CHAPTER 234 PUBLIC HOSPITALS AUTHORITY THE PUBLIC HOSPITALS AUTHORITY (MEDICAL STAFF) BYELAWS, 2003 S.I.92/2003 (SECTION 6) [Commencement 15th December, 2003] PART 1 PRELIMINARY 1.

These Byelaws may be cited as the Public Citation.

Hospitals Authority (Medical Staff) Byelaws, 2003.

2.

In these Byelaws — Interpretation.


“admitting privileges” means admission, attendance, treatment and discharge of a patient to, in or from a hospital in accordance with the physicians hospital rights and privileges; the “Authority” means the Public Hospitals Authority the Public Hospitals under established Authority Act; Ch.234.
“Chief of Department” means the head of a clinical department and includes any person appointed to act as head of a clinical department; “Chief of Staff” means the person appointed to head the Medical Staff and includes any person appointed to act as head of the medical staff, (previously referred to as the Medical Staff Coordinator); “clinic patient” means a person who is admitted and registered in a hospital or who has received treatment at a hospital for a period of less than twenty-four hours; “Council” means the group of physicians who are the the Medical Staff executive officers of Association; “Credentials Committee” means the group of persons who consider applications for appointments by medical personnel; ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– STATUTE LAW OF THE BAHAMAS LRO 1/2006 CH.234 – 4] PUBLIC HOSPITALS AUTHORITY “dental services” means services performed by dental surgeons in the clinical department of dentistry; “Director of Services” means the Consultant with responsibility for a unit within a general speciality area; “Executive Management Committee” means the senior management for overseeing all the day-to-day operations of the hospital; responsible team “in-patient” means a person who is admitted and registered in a hospital or who has received treatment at a hospital for a continuous period exceeding twenty-four hours; “junior staff” means physicians below the rank of Consultant who, with the exception of Senior as registrars, Boarded/Fellowship
 trained in a given medical specialty; include Senior Registrars, Registrars, Senior House Officers and Interns (see also Resident House Staff); are usually not certified these “Locum tenens” means a medical officer who is appointed to perform a specific function for a limited time period only; “Medical Advisory Committee” means the group of senior physicians who advise the hospitals’ Executive Management Committee via the office of the Medical Chief of Staff; “medical or clinical records” means the records of a
 patient compiled in a hospital by medical practitioners, nurses and allied professional persons, relating to their care and treatment, investigations and personal and medical administrative matters; “medical/patient care” refers to activities that are directly related to the care given by a medical practitioner; “medical practice” means the management and treatment of patients at a hospital of the Public Hospitals Authority and includes the practice of dentistry; “medical staff” means physicians who are appointed to the staff of a hospital (including dental STATUTE LAW OF THE BAHAMAS LRO 1/2006 PUBLIC HOSPITALS AUTHORITY [CH.234 – 5 surgeons) who hold the privilege of attending patients in the hospital; “policies and procedures” means the Medical Byelaws, Policy and Practice Guidelines, Physician Reform Document and other rules and the Public Hospitals Authority”; regulations of “private patient” means a person who receives private services at a hospital and who compensates the medical practitioner for his services either directly or by way of private insurance or other non-national insurance coverage or contract; “resident house staff” means a member of the medical staff whose employment in the Public Hospitals Authority requires that they remain in the hospital during their respective hours of duty; “rights and privileges” mean the rights and privileges extended to a member of the medical staff as prescribed by law; “Senior Registrar” means a postgraduate specialty qualified member of the medical staff without ultimate responsibility of a patient; under the supervision of an active Consultant staff member, or head of department; with voting rights in the Medical Staff Association but who will not hold office therein.
PART II 3.

The Medical Staff shall comprise the following categories — Categories of appointments.
(a) active staff-comprising all categories of physicians appointed by the Authority — (i) Consultants; (ii) Senior Medical Officers; and (iii) Junior Physicians – who include, Senior Registrars, Registrars, Senior House Officers and Interns; (b) courtesy staff-comprising all other categories of physicians who are not members of the active staff and who have limited rights and privileges — ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– STATUTE LAW OF THE BAHAMAS LRO 1/2006 CH.234 – 6] PUBLIC HOSPITALS AUTHORITY (i) private practitioners; (ii) part-time consultants; (iii) temporary/visiting staff; (iv) locum tenens; and (v) Honorary Physician staff.
Active Staff.

4.

(1) The active staff refers to physicians applying for appointment as an active staff member and who may be appointed for a probationary period if the Authority so requires.

(2) All active staff members are responsible for ensuring that medical care is provided to all patients in the hospital.
(3) All active staff members shall — (a) perform professional services (treatment and operative procedures) for patients only to the extent permitted by the privileges granted by the Authority; (b) be a member or the chairperson of any committee of the medical staff and hold any position as elected by the medical staff but only in accordance with the privileges granted to their category of appointment as stipulated in these byelaws; (c) if eligible, vote at meetings of the medical staff association or at any committee on which they hold membership; (d) assume the responsibilities and perform the duties of to promote the medical staff appropriate patient care either directly or through committees their category of appointment as provided by these bye-laws; in keeping with (e) act as supervisor of a member of the medical or dental staff, which may include medical students as and when requested by the Chief or Staff or the Chief of Department; (f) attend meetings of the medical staff as required; and (g) abide by procedures.
the Authority’s policies and 5.

(1) The appointment of Senior Medical Officers will be granted to — Senior Medical Officers.
STATUTE LAW OF THE BAHAMAS LRO 1/2006 PUBLIC HOSPITALS AUTHORITY [CH.234 – 7 (a) members of staff who have fulfilled some years of specialist training, although they may not have acquired the specialist certification by one of the Specialist Boards/Fellowships or University graduate degree recognized by the Authority; (b) a senior member of the house staff with a prerequisite number of years in a given specialty department and that specialty by the active consultant medical staff for members for that specialty; judged competent in (c) the Chief of Department or the Chief of Staff must recommend the Medical Advisory Committee must approve it before the recommendation is submitted to the Authority; this application and (d) a Senior Medical Officer will be granted limited private practice within the department under the supervision and permission of the Chief of the Department in accordance with the type of privileges granted by the Authority on the the Medical Advisory recommendation of Committee; (e) a Senior Medical Officer shall work under the supervision of an Active Consultant Medical Staff or the Chief of the Department.
(2) Senior Medical Officers may — (a) perform professional services for patients to the extent permitted by the privileges granted; of the Medical Staff (b) attend meetings Association; (c) not hold office in the Medical Staff Association; (d) sit and vote on committees if required to attend by and on behalf of the Chief of Staff or Chief of Department; and (e) vote at meetings of the Medical Staff Association.

(3) Members shall abide by the Authority’s policies and procedures.
(4) Ensure that appropriate arrangements are made for the ongoing care of patients.

6. for a (1) A Senior Registrar shall work probationary period under the supervision of an active Senior Registrar.

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– STATUTE LAW OF THE BAHAMAS LRO 1/2006 CH.234 – 8] PUBLIC HOSPITALS AUTHORITY consultant medical staff member named by the Chief of Staff or the Chief of Department to which they are assigned.
(2) Subject to the provisions of byelaw 7(4) a Senior Registrar may be permitted to have limited private practice.
(3) All Senior Registrars shall — (a) perform professional services (treatment and operative procedures) for patients only to the extent permitted by the privileges granted by the Authority and only under supervision and/or permission of an active staff medical member, Chief of Department or Chief of Staff; (b) be a member, but not the chairperson of any committee of the medical staff and hold any position as elected by the medical staff; (c) vote at meetings of the medical staff or at any committee on which they hold membership; (d) assume the responsibilities and perform the duties of to promote the medical staff appropriate patient care either directly or through committees as provided by these Bye- laws; (e) act as supervisor of a member of the medical or dental staff, which may include medical students as and when, requested by the Chief of Staff or the Chief of Department; (f) attend meetings of the medical staff as required by the rules; (g) abide by procedures; the Authority’s policies and (h) on receipt of an unfavorable report the Medical to the Senior Advisory Committee reserves recommend the Registrar’s appointment.
termination of the right (4) The Medical Advisory Committee shall, on receipt of a complaint regarding a Senior Registrar, refer the matter to the Disciplinary Committee which shall investigate the matter and upon its finding, make its recommendations.

7.

(1) The duties of the junior physician shall apply to both public and private patients.

The junior physician will be expected to respond to the care of all patients attached to their direct attending/Consultant Staff services Junior Physicians.
STATUTE LAW OF THE BAHAMAS LRO 1/2006 PUBLIC HOSPITALS AUTHORITY [CH.234 – 9 and to all patients requiring medical attention during their “on-call”, on the instructions of the Admitting Physician.
(2) A junior physician — (a) shall work under the supervision of senior medical staff members above his/her rank; (b) shall provide medical care to all patients in the hospital who are under the care of their senior staff and undertake such duties in respect of those patients classed as emergency cases as may be specified by the Chief of Staff or the Chief of Department to which they have been assigned; (c) may attend meetings of the Medical Staff Association; (d) with the exception of interns, will have voting privileges and may be elected to the posts of Secretary and Treasurer in the Medical Staff Association; (e) may sit and vote on committees if required to attend by and on behalf of the Chief of Staff or Chief of Department; (f) shall perform all the duties of the medical staff to promote appropriate patient care provided by these Byelaws; (g) abide by procedures; the Authority’s policies and (3) Any junior physician employed after the coming into force of these Byelaws shall not be allowed to engage in independent private practice.
(4) A junior physician who, immediately before these Byelaws came in independent private practice may continue to operate that practice — force, was engaged into (a) during the period of six months commencing from the date of the coming into force of these Byelaws; for permission (b) if within the six months period application is made the independent private practice the junior physician may continue to do so until the application is finally disposed of or withdrawn.
to continue in ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– STATUTE LAW OF THE BAHAMAS LRO 1/2006 CH.234 – 10] PUBLIC HOSPITALS AUTHORITY Courtesy Staff.

(5) For the purpose of this byelaw, “independent private practice” means a practice operated by a physician on his own without any approved on-site supervision.

8.

(1) A Courtesy Staff post may be offered to physicians who have active staff appointments in other regions or jurisdictions.
It shall include physicians who establish consultant clinics or perform itinerant services in any of the Authority’s facilities and physicians who, for geographic reasons, have part of their practice in another region or jurisdiction.

(2) Members of the Courtesy Staff may — (a) perform professional services for patients to the extent permitted by the privileges granted; of the Medical Staff (b) attend meetings Association; Temporary Visiting Staff.
(c) not hold office in the Medical Staff Association; but part-time consultants may vote at Medical Staff Association meetings; (d) sit and vote on committees if required to attend by and on behalf of the Chief of Staff or Chief of Department.

(3) Members of the Courtesy Staff shall abide by the Authority’s policies and procedures and ensure that appropriate arrangements are made for the on going care of their patients.

9.
9.

(1) This category will include all physicians seeking to access Authority’s resources and/or provide patient services and who are not otherwise appointed in accordance with these Byelaws.

(2) Such appointments may be granted to a physician for a defined time and for a specific purpose detailed in the appointment.

Once the specific time or purpose has come to an end, the physician shall cease to be a member of the medical staff.
(3) An appointment to temporary status will not bestow any additional rights, after expiry of that temporary status, other than those that would be available to an applicant on a subsequent application for appointment to become an active member of staff.
(4) Members of the Temporary/Visiting Staff may — STATUTE LAW OF THE BAHAMAS LRO 1/2006 PUBLIC HOSPITALS AUTHORITY [CH.234 – 11 (a) perform professional services for patients to the extent permitted by the privileges granted; (b) not hold office in the Medical Staff Association or be a member of any hospital committee; (c) not vote nor be required to attend meetings of the Medical Staff Association.
(5) Members shall assume all responsibilities and perform all the duties of the medical staff to promote appropriate patient care provided by these Byelaws and abide by the Authority’s policies and procedures.

10.

(1) The Medical Advisory Committee upon the request of a member of the medical staff may recommend tenens as a planned locum the appointment of a 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 counsel and supervision of a member of the active consultant medical staff who has been assigned this responsibility by the Chief of Staff or his/her delegate; Locum tenens.
(c) attend patients assigned to his/her care by the active Consultant medical staff member(s), and shall the professional privileges granted by the Authority on the recommendation of the Medical Advisory Committee; them within treat (d) abide by the rules of the Authority and the Byelaws specified under Temporary/Visiting Medical Staff; (e) assume all responsibilities and perform all the is the physician for whom he duties of substituting.
(3) The locum tenens staff may — (a) perform professional services for patients to the extent permitted by the privileges granted; (b) not hold office in the Medical Staff Association; (c) not vote nor be required to attend meetings of the Medical Staff Association.

11.

(1) The Authority may, on the recommendation the the Medical Advisory Committee and with of Honorary Staff.
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– STATUTE LAW OF THE BAHAMAS LRO 1/2006 CH.234 – 12] PUBLIC HOSPITALS AUTHORITY concurrence of the physician, make an appointment to the honorary staff category.

(2) A physician of the honorary staff ordinarily should no longer be in full active practice and have previously given distinguished service.
(3) Members of the honorary staff may attend meetings of the Medical Staff, but shall not be a member of any committee, have no voting powers, and shall not be eligible to hold elected office on the Medical Staff Association; they will have no assigned duties.

(4) The honorary staff shall not have admitting privileges.

PART III ESTABLISHMENT, FUNCTIONS AND MANAGEMENT OF THE MEDICAL STAFF ASSOCIATIONS OF THE PUBLIC HOSPITALS 12.
There shall continue to exist a Medical Staff Association for each public hospital which shall comprise of physicians appointed to the active staff of the hospital.

13.

The functions of an Association are to — (a) ensure that all patients admitted to the hospitals or treated in an outpatient, emergency service or any department of the hospitals receive the best medical care possible; Establishment.

Functions.
Functions.

(b) provide instruction, maintain standards and promote ethics and research; (c) provide members for the standing hospital educational committees; (d) act as advisors to the Executive Management the Medical Advisory through Committee Committee; Management.

(e) have representation on the Medical Advisory Committee through its President and Secretary who shall sit on this committee.

14.
(1) The Medical Staff Association in each hospital of the Authority shall be managed by an executive council which shall consist of — (a) a Chairperson and Vice-Chairperson who shall be active consultant medical staff; STATUTE LAW OF THE BAHAMAS LRO 1/2006 PUBLIC HOSPITALS AUTHORITY [CH.234 – 13 (b) a Secretary and Treasurer who shall also be active consultant medical staff or a junior physician above the post of intern; (c) the past Chairperson (if any); and (d) four other council members of whom at least two shall be active consultant medical staff and two shall be junior staff members.
(2) Election to these positions will take place at the Annual General Meetings of the Association.

(3) The executive council shall meet at such times as may be necessary or expedient for the transaction of the business of the Association and such meetings shall be held at such places and times and on such days as the executive council may determine, provided that meetings are held no less than twice per year.

15.
15.

(1) The funds of the Association shall consist of such monies as may from time to time be paid to the Association for the purposes of the Association in accordance with the Authority’s policy on gifts and gratuities.

Funds.

(2) The Authority shall assist in defraying the costs of the office space and administrative requirements of the Association.

16.
16.

(1) Officers of the Medical Staff Association — (a) shall hold office for a period not exceeding one year and shall be eligible for re-appointment, although no officer shall hold the same post for more than three consecutive years; Duties of officers.
(b) may at any time resign his office by notice in writing addressed to the Chairperson of the executive council and such resignation shall take the effect Chairperson of such notice; the date of receipt by from (c) should a vacancy occur on the executive of the Council, the Chairperson shall select another officer, who shall hold office for the remainder of the period for which the previous officer was elected.
(2) The Chairperson of the Executive Council shall — the Medical Advisory (a) be a member of Committee; ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– STATUTE LAW OF THE BAHAMAS LRO 1/2006 CH.234 – 14] PUBLIC HOSPITALS AUTHORITY (b) report to the Medical Advisory Committee on any issue raised by the medical staff association; (c) be accountable to the medical staff association; (d) advocate fair process treatment of the in individual members of the medical staff; (e) preside at general meetings of the medical staff association; (f) call special meetings of the medical staff association; and (g) be an ex-officio member of all hospital Executive excluding the committees, Management Committee.
(3) The Vice Chairperson shall — (a) in the absence or disability of the Chairperson perform his duties with all powers attaching to his position; and (b) perform such duties as the Chairperson may delegate.
(4) The Secretary of the Executive Council shall — the Medical Advisory (a) be a member of Committee; (b) attend to the correspondence of the medical staff association; (c) give notice of meetings by posting a written notice — (i) in the case of a regular or special meeting of the medical staff association, at least five days before the meeting; (ii) in the case of Annual General Meetings, at least ten days before the meeting; (d) ensure that minutes are kept of all medical staff association meetings; (e) ensure that an attendance record is kept of each Medical Staff Association meeting; (f) perform the duties of the Treasurer and be accountable should a Treasurer not have been elected; and (g) act in the place of the Vice Chairperson, performing his duties and possessing his powers in the Vice Chairperson.
the absence or disability of STATUTE LAW OF THE BAHAMAS LRO 1/2006 PUBLIC HOSPITALS AUTHORITY [CH.234 – 15 Annual general meetings.

(5) The Treasurer of the Executive Council shall — (a) be elected on an annual basis to keep the funds of the medical staff association in a safe manner and be accountable for these funds; and (b) disburse funds on the direction of the general membership as determined by a majority vote of those members present (and entitled to vote) at a medical staff association meeting.
MEETINGS ANNUAL MEETINGS 17.

(1) The annual general meeting of the medical staff shall be held in June of each year and shall be summoned by the Chairperson of the Executive Council who shall preside at these meetings.

(2) Retiring officers must submit a written report on their activities during their term of office at the annual meetings.

(3) Only members of the active consultant medical staff shall be elected or appointed to any position or office.
This also shall include junior physicians who may serve as council members.

(4) A Nominating Committee shall be appointed by the medical staff for each annual meeting that shall consist of three members of the medical staff.

(5) Members of the Courtesy and the Temporary Medical Staff shall not be eligible to hold any position on the Executive Council of the Medical Staff Association.
(6) At least thirty days prior to an annual meeting the Nominating Committee shall post in a designated place a list of the names of persons nominated for posts to be filled by election in accordance with the by-law and the regulations.

(7) Any nomination made after this time shall be put in writing to the Secretary of the medical staff no less than fourteen days after the posting of the names.

(8) Two members of the medical staff who are entitled to vote shall sign all late nominations.
(9) The nominees shall signify in writing their acceptance of the nomination.

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– STATUTE LAW OF THE BAHAMAS LRO 1/2006 CH.234 – 16] PUBLIC HOSPITALS AUTHORITY Regular meetings.

Special meetings.

Attendance at meetings.

(10) Nominations shall then be posted along with the original list.

18.
18.

(1) Regular meetings of the medical staff shall be held once every three months or at such other time as the Advisory Committee may decide.

(2) A member of the medical staff shall not, without reasonable excuse submitted prior to the meeting to the Chairman of the Council, fail to attend a regular meeting.

19.

(1) A special meeting of the medical staff may be summoned at any time by the Chairman of the Council or upon the written request of not less than five members of the active medical staff.
(2) Written notice of the time, date and place of the meeting and of its purpose must be given to members of the medical staff not less than five days prior to the date of the meeting.

(3) No business shall be transacted at a special it was the purpose for which than meeting other summoned.

20.
20.

(1) Members of the Active Medical Staff shall attend meetings of the clinical departments to which they are appointed unless a reasonable excuse for their absence was submitted prior to the meeting to the Chief of their departments.

(2) Where a general clinical meeting of the medical staff is directly related to the medical or surgical practice of the member, the member shall attend that general clinical meeting.
(3) A member of the Honorary Consultant Staff, Temporary/Visiting Medical Staff, Senior Medical Officer and active medical staff shall be notified of any meeting at which a case is to be presented which was treated by that member.

That member shall not, without reasonable excuse, fail to attend such meeting.

(4) Where required by the Chief of a clinical department, members of the Courtesy Medical Staff who admit patients shall attend general clinical meetings.
(5) Members of the Temporary Medical Staff shall not be eligible to vote at any meeting.

STATUTE LAW OF THE BAHAMAS LRO 1/2006 PUBLIC HOSPITALS AUTHORITY [CH.234 – 17 21.

(1) A quorum for a regular or a special meeting of the members of the medical staff shall be thirty three per cent of its membership.

Quorum.

(2) The quorum for a meeting of a clinical department shall be two-thirds of the membership of the department.

22.

(1) The agenda at regular meetings of the Agenda.


medical staff shall be — (a) reading and confirmation of the minutes and of the minutes (where not previously approved) of any special meeting; (b) matters arising; (c) unfinished business; (d) communications; (e) reports of the Advisory Committee and of any standing or special committee; and (f) any new business.
(2) The agenda for meetings of the clinical departments shall be as follows — (a) to review and analyze the clinical work of the hospital; (b) to review the medical care and treatment of patients in the hospital, with special reference to diagnosis, treatment and delayed recovery; selected cases that have been discharged since the meeting immediately preceding; selected cases; deaths; complications error in diagnosis or treatment and analysis of clinical reports; and unimproved infection (c) a discussion of the business related to the department.
(3) The agenda for special meetings of the medical staff shall be as follows — (a) presentation of a topic; (b) discussion; and (c) the making of a decision and action plan.

PART IV MEDICAL STAFF OF HOSPITAL 23.

(1) Every the qualifications criteria as laid out in the specified Policy and physician who satisfies Appointments.
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– STATUTE LAW OF THE BAHAMAS LRO 1/2006 CH.234 – 18] PUBLIC HOSPITALS AUTHORITY Practice Guidelines and Physician Reform Document shall be eligible for appointment to any of the established categories of appointment of a hospital.

(2) Prior to any appointment a physician shall submit an application as is prescribed, through the Chief of staff, to the respective Executive Management Committee.
(3) The Authority may require an applicant to attend the hospital for an interview with appropriate members of the medical staff and the Hospital Administrator or his delegate.
(4) An application shall be accompanied by — (a) a current curriculum vitae; (b) a list of privileges that are requested; (c) evidence of adequate training and experience for the privileges requested; (d) evidence of satisfactory medical malpractice coverage for physicians applying for privileges which extend to private practice; (f) (e) certification of their professional qualifications and standing; proof of registration with the Bahamas Medical or Dental Councils, together with at least three references; the names of referees, experience, including competence and reputation of the applicant from the Chief of Staff or the Chief of Department in the last hospital in which the applicant trained or held an appointment; three professional report on the a (g) evidence of registration by the appropriate Council; (h) a copy of the applicant’s medical degree; (i) a copy of the applicant’s specialist degree and/or a report from the relevant specialty board or fellowship specialty degree/certification was awarded.
from which the (5) All applications under this section, except those for Senior House Officer and Internship postings, shall be submitted its to consideration.

the Credentials Committee for (6) The Credentials Committee shall consider the application and consult with the Chief of Service and/or the Director of Service of the specialty to which STATUTE LAW OF THE BAHAMAS LRO 1/2006 PUBLIC HOSPITALS AUTHORITY [CH.234 – 19 application relates.
Thereafter the Credentials Committee shall, at one of its general meetings, either recommend appointment to a particular clinical department specifying the procedural privileges to be allowed or not recommend the appointment.

In either case, the Credentials Committee shall then notify the Medical Advisory Committee of its decision.

(7) The Medical Advisory Committee shall decide at a general meeting, whether or not to support the to recommendation recommend appointment to another clinical department.
The Committee shall then forward the application through the Chief of Staff the Executive Management Committee, notifying it of its decision.

appointment, or whether for to (8) The Executive Management Committee in turn shall submit to the Authority headquarters for its approval a statement as to whether or not they support the appointment or appointment to another clinical department, and if recommended, for what period of time.
(9) The Executive Management Committee may recommend the appointment of any person and shall, at the time of such appointment, specify in writing, the clinical department, assignments and hospital rights and privileges which apply in respect of that person.

(10) Persons so appointed shall submit a signed statement to the effect that they understand and accept the rights and privileges granted and will comply with the existing rules and regulations relating to members of the medical staff.
(11) Medical staff who are in the employ of the Authority, shall apply for re-appointment not later than three months prior to the date of expiration of his appointment, or previous re-appointment.

Provisions for re-appointment shall apply, with necessary modification, as they apply for to appointment.
initial applications relation in (12) Notwithstanding the provisions of this byelaw, the Chief of Staff or any person authorized by the Chief of Staff, acting on the recommendation of the Medical in special circumstances, Advisory Committee may, recommend the appointment to the Temporary Medical Staff or Locum tenens staff any person who is eligible for such appointment, for a period not exceeding six months.
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– STATUTE LAW OF THE BAHAMAS LRO 1/2006 CH.234 – 20] PUBLIC HOSPITALS AUTHORITY (13) The Chief of staff or any person authorized by the Chief of Staff acting on the recommendation of the Medical Advisory Committee, may appoint members to the post of Senior House Officer and Intern subject to the approval of the Authority to fulfill the needs of the clinical services in accordance with policies established by the Public Hospitals Authority.
24.

(1) A complaint that any member of the medical staff has been engaged in — (a) any illegal, improper or unethical medical practice; (b) any act prejudicial to the interest of his patient; or (c) any contravention of these Byelaws or any other rule relating to a hospital, may be made to the Chief of Staff in writing by any person and shall bear the date of the complaint and the signature of the complainant but, subject to this, shall be in particular form.
(2) The Medical Advisory Committee, on receipt of a complaint regarding a staff member up to the level of Senior Registrar shall refer the matter to the Disciplinary Committee, which shall investigate the matter and upon its finding, make its recommendations.

(3) Whenever a vacancy occurs on the Disciplinary Committee, the Medical Advisory Committee shall in a special meeting, recommend the Chief Hospital Administrator, the appointment of another person to fill the vacancy.
to (4) Complaints made in respect of Consultants shall be referred to the Authority through the Executive Management Committee.

25.

(1) The Disciplinary Committee summoned under section 24 shall hear all complaints referred to it and in the conduct of the hearing shall ensure — (a) that the person complained about be given not the fourteen days notice of less than proceedings; and Complaints against members of Medical Staff of Hospital.

Procedure on referral of complaint to the Disciplinary Committee.
(b) that the notice specifies the complaint in the form of a charge.

STATUTE LAW OF THE BAHAMAS LRO 1/2006 PUBLIC HOSPITALS AUTHORITY [CH.234 – 21 (2) The date for the hearing shall not be fixed earlier than twenty-eight days after the notice has been served on the person complained about except with his consent.

(3) The notice of hearing shall be served personally or sent by prepaid registered post to the last known address of the person complained about.
A copy of the notice shall be sent to the complainant.

(4) The person complained about shall be entitled to receive free copies of or be allowed access to any documentary evidence relied on for the purpose of the hearing.

After the hearing is completed he shall also be given, upon request, a copy of the evidence including copies of documents entered in evidence.
(5) The person complained about shall have the right to be represented by a counsel or attorney or a representative of the Medical Staff Association in any disciplinary proceedings instituted against him.

He must, however, give the Chairperson of the subcommittee not less than three days notice of his intention to exercise this right.
(6) If a person complained about does not appear at the date fixed for the hearing of the complaint the subcommittee may, if it is satisfied that a notice of hearing has been served on the person, and the Committee is not aware of any mitigating circumstances, proceed with the hearing.

(7) The subcommittee may call witnesses and may adjourn the proceedings from time to time.
(8) If the sub-committee calls witnesses, the person complained about or his attorney shall be given an opportunity to put questions to the witnesses.

(9) No documentary evidence shall be used against the person complained about unless he has previously been supplied with copies or given access to them.

He or counsel of his choice shall be permitted to give evidence, call witnesses and make submissions orally or in writing.
(10) At the conclusion of the hearing the committee shall forward its findings and all the recorded evidence to the Medical Advisory Committee who shall forward their recommendation to the Authority through the Executive Management Committee.

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– STATUTE LAW OF THE BAHAMAS LRO 1/2006 CH.234 – 22] PUBLIC HOSPITALS AUTHORITY Procedure of Medical Advisory Committee on receipt of Disciplinary Committee’s findings.
Immediate suspension of membership.

26.

(1) Where the person complained against is a member of the Active Medical Staff, the Chairperson of the Medical Advisory Committee shall, on receipt of the findings and evidence, forward the complaint, after review, together with the findings and evidence to the Authority through the Executive Management Committee.
(2) Where the person complained against is not a member of the Active Medical Staff, the Medical Advisory Committee may accept, reject or vary the findings of the Disciplinary Committee and may impose any one or any combination of the following penalties — (a) reprimand; (b) deprivation of any hospital rights and privileges to which the person complained against may have been entitled; (c) suspension from membership of the medical staff for a specified period; and (d) revocation of the appointment to membership of the medical staff.
(3) When acting under the provisions of subsection (2), the Medical Advisory Committee must give notice of its recommendations in writing to the person complained about and if aggrieved with any recommendations made against him, may appeal to the Executive Management Committee within twenty-one days of receipt of the recommendation.

such person, (4) The Executive Management Committee may, on appeal affirm, vary or set aside the decision appealed against.

27.
(1) Notwithstanding the provisions of any previous rules if, in the opinion of the Medical Advisory Committee, acting on the advice of the Chief of the Department, it is inexpedient or dangerous or not in the public interest for a person complained about to continue as a member of the medical staff pending an inquiry into the complaint, the Chief of Staff shall — (a) where the person is a member of the active consultant medical staff, order their immediate suspension and forthwith forward the complaint the through to suspension should not normally exceed one week prior the complaint; initial hearing of the authority the EMC; the to STATUTE LAW OF THE BAHAMAS LRO 1/2006 PUBLIC HOSPITALS AUTHORITY [CH.234 – 23 (b) where the person is not a member of the active consultant medical staff, order their immediate suspension until the next sitting of the Medical Advisory Committee for a period not normally exceeding one week prior to the initial hearing of the complaint.
(2) The Chief of Staff shall straightway submit to the Medical Advisory Committee a written report of the complaint in respect of which the suspension was ordered.

The Medical Advisory Committee shall consider the report as if it were a complaint submitted by a disciplinary subcommittee.

(3) The suspended member should continue to receive full pay until a final decision is made.
(4) Any breach of the terms and conditions of an employment contract shall lead to disciplinary action or termination of service at the discretion of the Authority.

In such cases the Authority’s appropriate policy and procedure and/or the standard labour relations appeals process will apply.

PART V 28.

(1) The Authority shall appoint a member from the Active Consultant Medical Staff to be the Chief of Staff.
Consideration will be given to the recommendations of the Selection Committee on the advice of the Medical Advisory Committee through its Executive Management Committee.

The appointee shall have at least three years experience as a Chief of Department (2) The membership of the Selection Committee may include — (a) the Medical Advisor to the Public Hospitals Authority, who will act as the chairperson; and (b) two Members of Committee.
the Medical Advisory (3) An appointment under this section shall be for a term of three years or, if necessary, until a successor is appointed.

(4) The Chief of Staff shall hold office for a maximum of two terms, provided however that there must be a break of at least one year before the same person may be re-appointed to this post for a third term.

Chief of Staff.
Chief of Staff.

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– STATUTE LAW OF THE BAHAMAS LRO 1/2006 CH.234 – 24] PUBLIC HOSPITALS AUTHORITY Duties of Chief of Staff.

29.
The duties of the Chief of Staff are — (a) to be accountable to the Executive Management Committee of the Hospital; (b) to be responsible for clinical matters to the Medical Advisor of the Authority; (c) to sit as a member on Management Committee; the Executive (d) to organize the medical and dental staff to ensure that the quality of care given to all patients of the hospital is in accordance with policies the Executive management Committees; established by (e) to chair the Medical Advisory Committee; (f) to advise the Medical Advisory Committee and the Executive management Committee with respect to the quality of medical and dental to diagnosis, care and patients of the hospitals; treatment provided (g) to assign, or delegate the assignment of the medical and dental staff; (i) (h) to supervise the professional care provided by the medical and dental staff and ensure that their conduct conforms with the requirements of the Bahamas Medical Dental Council as appropriate; to be responsible to the Executive Management Committee through and with the Administrator for the appropriate utilization of resources by all medical and dental departments; to report to the Medical Advisory Committee on activities of the hospital including the use of resources and quality assurance; (j) (l) (k) to participate in the development of the hospital’s mission, objectives and strategic plan; to work with the Medical Advisory Committee to plan the medical manpower needs of the hospital the hospital’s strategic plan; in accordance with (m) to participate in hospital resource allocation decisions; (n) to ensure a process of regular review of the performance of the Chiefs of Department; STATUTE LAW OF THE BAHAMAS LRO 1/2006 PUBLIC HOSPITALS AUTHORITY [CH.234 – 25 (o) to ensure there is a process for participation in continuing medical and dental education and in collaboration with the Education Committee, Chiefs of Department and Services, coordinate the educational activities of the Medical Staff; (p) to receive and review performance evaluations and the recommendations from the Chiefs of Department on reappointments.
Ensure that the evaluations and recommendations are tabled at the Medical Advisory Committee; (q) to advise the medical and dental staff on current (r) (s) hospital policies, objectives and rules; to delegate appropriate responsibility to the Chiefs of Department; to promote a harmonious relationship among members of the medical and dental staff and other employees of the hospital.

30.
30.

(1) The Deputy Chief of Staff, where applicable, shall be a member of the Active Consultant staff and shall be appointed by the Authority on the advice of the Medical Advisory Committee through the Executive Management Committee.

He shall be responsible to the Chief of Staff in the exercise of such duties as may be approved by the Chief of Staff.

(2) The authority of the Deputy Chief of Staff shall, in relation to the medical staff organization be one of line authority.
(3) An appointment to Deputy Chief of Staff shall be for a term of three years, but the Deputy Chief of Staff shall hold office until a new Deputy Chief of Staff is appointed.

(4) The Deputy will serve for a maximum number of two terms.

31.

(1) The Executive Management Committee, on the advice of the Advisory Committee, after considering the recommendation of the Chief of the department, may divide a department into services when warranted by need and professional resources.
(2) The Authority, on the advice of the Medical Advisory Committee, through its Executive Management Committee and on the recommendation of the Chief of Department, shall appoint a Director to head the services within the clinical departments.

The Director shall be Appointment to Deputy Chief of Staff.

Director of Services.


––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– STATUTE LAW OF THE BAHAMAS LRO 1/2006 CH.234 – 26] PUBLIC HOSPITALS AUTHORITY responsible to the Chief of the Department for the quality of medical care rendered to patients in that service.

(3) A Director of Service shall be appointed for three years, but shall not vacate office until a successor is appointed.
(4) The Director shall hold office for a maximum of two terms provided, however, that there shall be an interval of at least one year before he can be reappointed.

Clinical Departments.

32.
The clinical departments of each hospital are — (a) The Princess Margaret Hospital — (i) Medicine; (ii) Surgery — (a) General Services; (b) Ophthalmology; (c) Emergency medicine; (d) Dental surgery; (e) Orthopaedics; (iii) Obstetrics and Gynaecology; (iv) Paediatrics; (v) Neonatology; (vi) Radiology; (vii) Pathology; (viii) Anaesthesiology; (ix) Intensive Care; (x) Family Practice, any other or the Executive clinical department Management Committee, acting on the recommendation of the Medical Advisory Committee, may from time to time establish.
(b) The Rand Memorial Hospital — (i) Medicine; (ii) Surgery; (iii) Obstetric and Gynaecology; (iv) Paediatrics; (v) Radiology; (vi) Pathology; (vii) Anaesthesiology, STATUTE LAW OF THE BAHAMAS LRO 1/2006 PUBLIC HOSPITALS AUTHORITY [CH.234 – 27 any other or the Executive clinical department Management Committee may from time to time establish, acting on the recommendation of the Medical Advisory Committee.
(c) The Sandilands Rehabilitation Center — (i) Psychiatry; (ii) Community Mental Health; (iii) Gerontology, any other the Executive clinical department or Management Committee may from time to time establish as may be necessary, acting on the recommendation of the Advisory Committee.

33.

(1) The Consultants in a clinical department shall select a candidate from the Active Consultant Medical Staff for appointment to this position, which shall be ratified by the Medical Advisory Committee.
The nominee will in turn be recommended through the Executive Management Committee to the Public Hospitals Authority for formal appointment.

(2) The Chief of Department shall be appointed for a term of three years, but shall remain in office until a successor is appointed.

(3) A Chief of Department shall normally hold office for a maximum of two terms, provided however that there must be a break of at least one year between any re- appointment.
(4) No person shall be recommended for Chiefs of Clinical Departments.

appointment as Chief of a clinical department unless — (a) he is a member of the Active Medical Staff; in (b) holds a certificate or the specialized area of medical practice of that department; and fellowship (c) has at least five years of experience in that area.

(5) A person appointed as Chief of a clinical department shall be responsible to the Medical Advisory Committee and accountable to the Chief of Staff.
(6) The functions of the Chief of Department are — (a) to supervise the professional care provided by all members of the medical and dental staff in their department; ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– STATUTE LAW OF THE BAHAMAS LRO 1/2006 CH.234 – 28] PUBLIC HOSPITALS AUTHORITY (b) to participate in the orientation of new members of their medical and dental staff; (c) to be responsible for the organization and implementation of a quality assurance program in their department; (f) (d) to advise the Medical Advisory Committee along with the Chief of Staff with respect to the quality of medical and, where appropriate, dental, diagnosis, care and treatment provided to the patients and out-patients of their department; (e) to advise the Chief of Staff of any patient who is not receiving appropriate treatment and care; to be responsible to the Chief of Staff through the Administrator for the appropriate utilization of the resources allocated to the department; (g) to report to the Medical Advisory Committee and to the department on the department’s activities including the utilization of resources and quality assurance; the Medical (h) to make recommendations regarding medical Advisory Committee manpower needs of in the department accordance with the Hospital’s strategic plan following consultation with medical staff of the department, the Chief of Staff and, where appropriate, Heads of Services; to direct the development of the department’s mission, objectives and strategic plan; to direct department decisions; allocation resource (j) (i) to (l) (k) to review or cause to be reviewed the privileges granted members of the department including members of the dental staff for the purpose of making recommendations for changes in the kind and degree of such privileges; to review and make written recommendations in respect of the annual performance evaluations of members of including members of the dental staff and in respect of the re-appointments.
These recommendations must the Medical Advisory be Committee; their department, forwarded to (m) to sit as a member of the Medical Advisory Committee; STATUTE LAW OF THE BAHAMAS LRO 1/2006 PUBLIC HOSPITALS AUTHORITY [CH.234 – 29 (n) to establish a process for continuing medical education related to their department; (o) to advise the members of their department, including members of the dental staff regarding current hospital and departmental policies, objectives, and rules; (p) to hold regular meetings with the staff of their department and, where appropriate, with the Heads of Services within their department; (q) to notify the Chief of Staff of his or her absence, and designate an alternate from within the department; and to delegate appropriate responsibility to the Heads of Services within their department.
(r) 34.

(1) Where an in-patient may require dental services, he may be admitted to the clinical department of surgery by a medical practitioner who is a member of staff.

Chief of Dental Department.


(2) The chief of the department shall ensure that a surgeon is responsible for the medical care and treatment of that patient while in hospital, but the provision of dental services shall be the responsibility of a member of the medical staff who holds hospital rights and privileges in respect of the proposed dental procedure.
(3) The dental surgeon shall hold consultations and shall before performing any dental surgery, write a complete dental history of the patient and obtain from the surgeon responsible for his medical care and treatment, a report of his physical condition.

35.

Every — (a) Chief of Staff; (b) Deputy Chief of Staff; (c) Chief of Department; and (d) Director of Services, shall ensure that all physicians for whom they are responsible comply with the Authority’s policies and procedures.

36.
36.

(1) Members of the medical staff shall come under the administrative jurisdiction, direction and control of the Chief of the Department to which they are appointed.

They must, in addition, comply with all general and departmental staff rules and regulations.

Medical staff.
Medical staff.

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– STATUTE LAW OF THE BAHAMAS LRO 1/2006 CH.234 – 30] PUBLIC HOSPITALS AUTHORITY (2) Except in cases of emergency, members of the medical staff are only allowed to practice medicine in the clinical department to which they have been appointed and in their specialized areas of medical practice in accordance with their hospital rights and privileges.
(3) Members who have been granted privileges in the Clinical Department of Family Practice, may, with the approval of the relevant Chiefs of Department, pursue their medical practice in a clinical department and in a specialized area, to which they have not been appointed.

(4) Honorary Consultant staff shall be comprised of physicians who are not active medical staff members and who are not ordinarily resident in The Bahamas.

Eligibility for this appointment shall be qualifications in a specialty.
(5) Active medical staff consultants will be allowed to have admitting privileges for private patients.

(6) Resident house staff, under the supervision of the relevant Chief of Department, shall attend in-patients and clinics, perform in the department to which they are appointed and carry out such other functions as are assigned to them.

However, they shall not have ultimate responsibility for, or admit private or public patients under their own name without the consent of the Medical Advisory Committee.
(7) Heads of clinical departments to which medical staff are appointed shall be responsible for supervising their work.

The head may designate a member of the active senior staff to whom they shall be immediately responsible.

(8) Non-active medical staff who have been granted admitting privileges to the private wards except where indicated above, shall not be eligible to vote or hold office and shall not be obliged to attend designated meetings of the medical staff and their respective department.
(9) The retirement age of the medical staff shall be in accordance with the relevant section of the Pensions Act.

(10) Notwithstanding subparagraph (9), a person shall be eligible for early retirement after thirty years of service, at which time, such person shall be eligible for appointment under special circumstances.

Ch.

43.
Ch.

43.

STATUTE LAW OF THE BAHAMAS LRO 1/2006 PUBLIC HOSPITALS AUTHORITY [CH.234 – 31 (11) Members of the Active medical staff may be appointed to the courtesy staff on their retirement from public office.

37.

All physicians who have been granted the privilege of private practice shall, prior to employment and thereafter on an annual basis, show evidence of malpractice coverage.

Medical Malpractice.

PART VI STANDING COMMITTEES 38.


The Standing Committees of the hospitals shall consist of any one or more of the following — Standing Committees.
(a) the Medical Advisory Committee; (b) the Credentials Committee; (c) the Medical Records Committee; (d) the Utilization Committee; (e) the Quality Assurance Committee; (f) the Education Committee; (g) the Intensive Care Committee; (h) the Library Committee; (i) (j) (k) the Pharmacy and Therapeutics Committee; (l) (m) the Experimental Medicine and Research the Infection Control Committee; the Tumor Board (Princess Margaret Hospital); the Theatre Committee; Committee; or (n) the Transfusion Practices Committee.
39.

(1) The Medical Advisory Committee members shall appoint the Chairman and members of a standing committee.

(2) Standing Committee members shall appoint a Secretary from among themselves.

(3) The Chief of Staff shall provide the terms of reference and method of operation of a Standing Committee.

(4) Unless otherwise provided in these rules, a the Executive Standing Committee shall submit Management Committee on a quarterly basis report of the work of their respective committees.
to Composition and function of a Standing Committee.

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– STATUTE LAW OF THE BAHAMAS LRO 1/2006 CH.234 – 32] PUBLIC HOSPITALS AUTHORITY (5) Membership of a Standing Committee may vary at each of the hospitals so as to reflect the scope of services offered.

40.
40.

This Committee shall be comprised of the Chief of Staff who shall be the Chairperson each Chief of Department, the Medical Staff the Chairperson of Association Council and the Directors of Services.

41.

(1) The Medical Advisory Committee shall carry out such functions as are required for the promotion of a good the Executive Management Committee and without prejudice to the generality of the foregoing, the Advisory Committee shall — relationship with Medical Advisory Committee.
Functions of Medical Advisory Committee.
(a) acting on the recommendation of a sub- committee appointed for this purpose, appoint the other the Chairman and members of Standing Committees Special Committees; and the (b) give due consideration to and act upon where necessary, reports and recommendations of other committees; (c) gather and disseminate to members of the medical staff all information which in the opinion of the Advisory Committee may be of interest to them; (d) provide advice on the clinical organization and supervision of work carried out in the hospital; (e) advise the Executive Management Committee on matters pertaining to clinical organization, medical equipment and when requested by the Executive Management Committee, on medical matters of an administrative nature; (f) arrange scientific programs for presentation at meetings of the medical staff; (g) arrange, convene and conduct the regular and special meetings of the medical staff.
At every regular meeting it shall submit a report on the work carried out by the Advisory Committee for the information of the Authority.
(h) perform such other duties as may be required by law; (i) provide a structure where the members of the medical staff can participate in the hospital’s planning, policy development and decision- making; STATUTE LAW OF THE BAHAMAS LRO 1/2006 PUBLIC HOSPITALS AUTHORITY [CH.234 – 33 (j) serve as a quality assurance system for medical care rendered to patients in the hospital by the medial staff and to ensure the continuing improvement of the quality of medical care; (k) enact and implement rules and regulations for enforce governance and medical compliance with them.
staff (2) The Advisory Committee shall meet at least once per month and minutes of each meeting shall be kept and a report submitted within a reasonable time to the Executive Management Committee.

(3) Where the Advisory Committee intends to consider any subject which properly lies within the jurisdiction of another committee, the Chairman shall invite and inform that committee’s Chairman of the date, time and place of the meeting at which the subject will be considered.
(4) The functions of the Advisory Committee shall be exercised by a quorum of the Advisory Committee consisting of two-thirds of the members.

(5) The Chairman of the Advisory Committee shall not have an original vote but shall only have a casting vote whenever the voting is equal.

42.

(1) This committee shall consist of not less than three members of the Active Medical Staff, which shall include the Chief of Staff and the Chief of the relevant Departments.

Credentials Committee.


(2) The Credentials Committee shall— (a) carry out all the functions prescribed in Part IV above; (b) review and assess all information related to the qualifications, experience and competence of members applying for appointment the medical and dental staff; and to (c) make to recommendations the Advisory Committee in respect of the procedure for appointment and assignment of persons to clinical departments and respective categories of appointment.

their 43.
their 43.

(1) The Medical Records Committee shall consist of not less than three members of the active medical staff.

Medical Records Committee.

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– STATUTE LAW OF THE BAHAMAS LRO 1/2006 CH.234 – 34] PUBLIC HOSPITALS AUTHORITY (2) The senior Medical Records Officer shall not be eligible to vote at any meeting of the Medical Records Committee.
(3) The committee shall recommend procedures to the Medical Advisory Committee in keeping with hospital regulations and byelaws.
(4) The procedures recommended shall relate to — (a) rules to govern the completion of medical records; (b) the review of medical records for completeness and quality of recording; reports to (c) written the Medical Advisory Committee with respect to — (i) the review of the medical records and the results thereof; and (ii) the names of delinquent members of the medical and dental staff; (d) review and revision of forms as they pertain to medical staff record keeping; and (e) the retention of medical records and notes, charts and other material relating to patient care.
(5) The Medical Records Committee shall perform any other duties pertaining to medical record keeping as may be requested by the Medical Advisory Committee.

44.

(1) The Utilization Committee shall consist of — (a) four members of staff the clinical departments of medicine, surgery, obstetrics and gynaecology, and paediatrics, medical; from Utilization Committee.
(b) one member of the Advisory Committee (who shall be the Chairman of the Admissions and Discharge Utilization Committee); (c) the Chief Medical Records Officer; (d) one senior nursing officer; and (e) the Hospital Administrator or his representative.
(2) The functions of the Utilization committee are — (a) to review utilization patterns in the hospital and identify where improvements can be achieved; (b) to monitor overall trends in admission, length of stay, volumes of day programs and provide reports to management on a regular basis; STATUTE LAW OF THE BAHAMAS LRO 1/2006 PUBLIC HOSPITALS AUTHORITY [CH.234 – 35 (c) to monitor responses committee recommendations that have been approved by the Medical Advisory Committee and Hospital management and the progress achieved; report on to (d) to report appropriate information on an annual basis to Chiefs of Department and Heads of Service; (e) to review each department’s utilization review (f) reports; to ensure that Chiefs of Department are educated about utilization review issues and about their their report to responsibility departments on utilization trends; regularly to (g) to report findings and make recommendations to the Medical Advisory Committee and the medical staff on the Committee’s activities; (h) to comment on the resource implications of proposed additions to the medical staff; and to perform such other duties as may be requested from time to time by the Medical Advisory Committee.
(i) 45.

(1) The Medical Quality Assurance Committee shall consist of a representative from each Clinical Department and Nursing personnel.

Medical Quality Assurance Committee.

(2) The Medical Quality Assurance Committee shall — (a) develop a Medical Quality Assurance Program which includes mechanisms to — (i) monitor trends and activities; (ii) identify potential problem areas; (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 of and monitor the functioning of Medical Staff Committees reporting to the Medical Advisory Committee.
(d) monitor the functioning of the Medical Advisory Committee; ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– STATUTE LAW OF THE BAHAMAS LRO 1/2006 CH.234 – 36] PUBLIC HOSPITALS AUTHORITY (e) review, evaluate and make recommendations on the following matters affecting the medical and dental staff— (i) privileges; (ii) human resource planning, impact analysis; (iii) departmental and service activities; (iv) process for handling complaints; and (v) byelaws, rules and policies of the Hospital.
(f) recommend procedures to the Medical Advisory Committee to establish an ongoing peer review process to assess the quality of patient care.
That is, to study, record, analyze and consider agreements or disagreements between pre- operative diagnoses of the hospital records and the pathology reports on tissues removed from patients, or post mortem reports; (g) regularly review medical records; (h) submit the Medical Advisory Committee and to the appropriate Chiefs of Departments; review all hospital deaths to assess the quality of care that was provided; identify the continuing educational needs of the medical, dental, allied health and nursing staff and ensure that the recommendations of the Committee are acted on; and (i) (j) reports to (k) ensure that medical and dental audits are undertaken as necessary in other Departments; and (l) perform such further duties as the Medical Advisory Committee may direct in relation to the quality and quantity of professional work performed in any department by the medical staff.
Infection Control Committee.

46.

(1) The Infection Control Committee shall consist of — (a) the Chief Consultant or his representative who shall be in charge of — (i) surgery; (ii) medicine; (iii) obstetrics & gynaecology; (iv) pediatrics; and STATUTE LAW OF THE BAHAMAS LRO 1/2006 PUBLIC HOSPITALS AUTHORITY [CH.234 – 37 (v) pathology; (b) the Quality Assurance Risk Manager; and (c) the Director of the Intensive Care Unit or his representative.
(2) The Committee shall — (a) be for the responsible surveillance of nosocomial infections in the hospital and for ensuring the protection of patients and members of the staff of the hospital from such infections; gather and disseminate information relating to nosocomial the hospital and prescribe measures for the control of such infections; infections in (b) make recommendations to the Medical Advisory Committee on Infection Control matters related to — (i) immunization programs; (ii) visitor restrictions or instructions in both special terms and in general circumstances; (iii) patient restrictions or instructions; (iv) educational programs for all persons working in the hospital; (v) isolation procedures; (vi) aseptic and antiseptic techniques; and (vii) environmental sanitation in the Hospital; (c) make recommendations to the Administrator on infection an Occupational Health & Safety and Health Surveillance Programmes; control matters related to (d) follow-up and evaluate the results of each of its the above in respect of recommendations subsections; (e) develop, monitor and evaluate an infection control program that includes a reporting system by which all infections, including post discharge infections will be brought to the Committee’s attention; (f) review reports programs in the hospital; from all departments and (g) meet at least quarterly and as required at the call of the Committee Chair; and ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– STATUTE LAW OF THE BAHAMAS
 LRO 1/2006 CH.234 – 38] PUBLIC HOSPITALS AUTHORITY (h) take the necessary action to prevent or control the spread of infection within the hospital, and with the Executive the permission of Management Committee to — (i) move any patient from one hospital unit to another; (ii) isolate any patient or restrict or prohibit the entry into any hospital unit of any person; or (iii) request cultures from any patient or from any the staff or member of environmental source.
Tumor Board Committee.

Pharmacy and Therapeutics Committee.

47.

(1) The Tumor Board Committee shall consist of not less than four members of the Active Medical Staff.

The Oncologist or his designate shall act as chairperson.

Other members of the Committee shall be appointed by the Chief of Departments of — (a) Pathology; (b) Surgery; (c) Obstetrics & Gynaecology; and (d) the Oncology nurse of whom shall himself sit on the Committee.
(2) A Registrar for the Tumor Board shall be selected by the Chief of Staff of the hospital after consultation with the Hospital Administrator but that person will have no voting rights on the Tumor Board Committee.

(3) The Tumor Board Committee shall provide advice in respect of — (a) matters relating to neo-plastic disease in the hospital; (b) the composition of the neo-plastic registry; and (c) the functioning of the neo-plastic conference.
(4) The Tumor Board Committee shall meet not less than once per month.

48.
(1) The Pharmacy and Therapeutic Committee shall consist of — (a) the Chief Pharmacist who shall be the Secretary of the Committee; (b) the Director of the Bahamas National Drug Agency; STATUTE LAW OF THE BAHAMAS LRO 1/2006 PUBLIC HOSPITALS AUTHORITY [CH.234 – 39 (c) any six members of staff from the clinical departments of medicine, surgery, obstetrics and gynaecology, dentistry, anaesthesiology, psychiatry, where appropriate; paediatrics, (d) the Principle Nursing Officer or designate; (e) the Hospital Administrator or his designate; and (f) any other representative whom the chairperson may request as deemed necessary.
(2) The committee shall — (a) serve in an advisory capacity to the medical and dental staff by making regular assessments of the appropriateness and adequacy of medication- related policies; (b) make policy recommendations to the Medical Advisory Committee regarding drug utilization to ensure safe, effective and economical use of drugs; (c) evaluate drug utilization, new drugs and current therapeutics and develop a formulary that is suited to the hospital’s needs and periodically assess the effectiveness of and adherence to the formulary; (d) develop a procedure for the use of non- formulary drugs and mechanisms for their evaluation; (e) periodically analyze a summary of medication errors and their causative factors and make regarding recommendations appropriate prevention or error to the medical, dental, nursing and pharmacy staff; (f) develop an adverse drug reaction-reporting program, review reports on them and ensure that a summary is circulated to medical, dental and nursing staff when the need arises; (g) annually review all standing orders, or more often if deemed necessary; (h) develop protocols governing programs such as total parenteral nutrition, investigational drugs, self-medication, or ensure that such protocols have been developed after a quality committee review; identify and arrange appropriate educational programs for the medical, dental and Hospital (i) ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– STATUTE LAW OF THE BAHAMAS LRO 1/2006 CH.234 – 40] PUBLIC HOSPITALS AUTHORITY Theatre Committee.
staff that will enhance their knowledge of drug therapy and practices; (j) perform such other duties as the Medical Advisory Committee may direct; (k) meet quarterly or more frequently at the call of the Committee Chair.

49.
(1) The Theatre Committee shall consist of — (a) the Chief of the Departments of Surgery, and Orthopaedics, Obstetrics/Gynaecology Anaesthesiology, who shall rotate among themselves, every two years, the position of Chairman or their designate; (b) one representative from the active medical staff; (c) the Nursing Area Supervisor; (d) the Nursing Officer-in-Charge of Theatre who shall be the Secretary of the Committee; (e) one representative from Administration; and (f) one representative from the support staff.
(2) The functions of the Committee are — (a) to allocate operating time and space for all respective surgical disciplines; (b) to set policies, rules and guidelines to govern the daily operations of the Theatre; (c) to ensure the efficient functioning of theatres in the Hospitals and for that purpose, ensure compliance with any written law or guideline; (d) to appoint from among the Medical Staff or Senior Theatre Nursing staff, a theatre manager who will be paid and authorized to manage the theatre’s daily flow of activities and recommend and/or affect solutions to problems that may arise in the course of the day; (e) to recommend the Medical Advisory to Committee any necessary changes the operation of the Theatre that would improve efficiency; to review disputes among staff members in Theatres resolved without arbitration; and that cannot be in (f) (g) to perform such other duties as may be assigned from time to time by the Medical Advisory Committee.
STATUTE LAW OF THE BAHAMAS LRO 1/2006 PUBLIC HOSPITALS AUTHORITY [CH.234 – 41 (3) The Theatre Committee shall meet not less than once every three months, but may meet more often if the need demands it.

50.

(1) The Experimental Medicine and Research Committee shall consist of — (a) the heads of the clinical departments; (b) two members of the medical staff; and (c) the Hospital Administrator or his representative.
(2) The functions of the Experimental Medicine and Research Committee are — Experimental Medicine and Research Committee.

(a) to review any research proposal submitted to it review, make and, recommendations to the Advisory Committee in respect of the research proposal; based the on (b) to make recommendations to the Advisory the maintenance of Committee international standards in the medical practice at the hospital.
to ensure (3) The Medical Advisory Committee shall submit such recommendations to the Executive Management Committee for its approval.

51.

(1) The members of the Transfusion Practices Committee shall consist of— (a) six members of representing surgery, obstetrics/gynaecology, pathology and laboratory medicine; the Active Medical staff the departments of medicine, care, anaesthesia/intensive and paediatrics, Transfusion Practices Committee.
(b) a senior from transfusion service a senior nurse; representative the Blood (c) a senior volunteer with public relation skills; (d) such other personnel as deemed necessary in specific areas.
(2) The duties of the Committee are — (a) to develop and implement policy and guidelines on the clinical use of blood; (c) to develop standard operating procedures for the implementation of the guidelines, including procedures for ordering and handling blood and investigating suspected transfusion reactions; ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– STATUTE LAW OF THE BAHAMAS LRO 1/2006 CH.234 – 42] PUBLIC HOSPITALS AUTHORITY (d) to provide education and continuing training of all clinical and blood bank staff involved in the transfusion process; (e) to monitor the use of blood and blood products; (f) to review incidents of suspected transfusion reactions or errors associated with transfusion, and action when necessary; and implement corrective Special Committees.
(g) to monitor the safety and adequacy of the blood implement supply and blood products and corrective action when necessary.

SPECIAL COMMITTEES 52.

(1) The Advisory Committee may appoint special committees which shall consist of members of the medical staff, acting on the recommendation of its chairman, who may see fit to appoint persons to assist medical staff in the execution of their duties.

(2) The members of the special committee shall appoint a Chairman and a Secretary from among themselves.
(3) A special committee shall carry out only those functions for which it was appointed and shall not have a power of action unless so enabled at the time of appointment.

(4) The special committee shall submit to the Advisory Committee a written report of the work carried out by it.

MISCELLANEOUS Retirement.

53.

Members of the active medical staff may be appointed to the Honorary Consultant Staff on their retirement from public office.

Hospital rights and privileges.

54.


(1) Members of the medical staff shall be granted Hospital rights and privileges in keeping with their medical training, experience and competence.

(2) Where a member may wish to be granted additional rights and privileges, consideration will also be given to the views of members of the Active Medical Staff and to the reports of the Credentials Committee.

Medical Malpractice coverage.

55.


(1) All physicians who have been granted the privilege of private practice such as Active Staff, Senior Medical Officers, Temporary/Visiting, Courtesy and STATUTE LAW OF THE BAHAMAS LRO 1/2006 PUBLIC HOSPITALS AUTHORITY [CH.234 – 43 Locum tenens shall, prior to employment and thereafter on an annual basis, show evidence of malpractice coverage.

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– STATUTE LAW OF THE BAHAMAS LRO 1/2006