these regulations (N.S. Reg. 86/2023) (just regulations regs hamedstaff.htm)

N.S. Reg. 86/2023

Nova Scotia — Regulations

This consolidation is unofficial and is for reference only.

For the official version of the regulations, consult the original documents on file with the Office of the Registrar of Regulations , or refer to the Royal Gazette

Part II .

Regulations are amended frequently.

Please check the list of Regulations by Act to see if there are any recent amendments to these regulations filed with our office that are not yet included in this consolidation.

Although every effort has been made to ensure the accuracy of this electronic version, the Office of the Registrar of Regulations assumes no responsibility for any discrepancies that may have resulted from reformatting.

Nova Scotia Health Authority Medical Staff By-laws

made under Sections 21 and 22 of the

Health Authorities Act

S.N.S. 2014, c. 32

N.S. Reg. 86/2023 (effective May 17, 2023)

Please note: this table of contents is provided for convenience of reference and does not form part of the regulations.

Click here to go to the text of the regulations .

Part A: General Provisions

Citation

Definitions

Purpose

Application

Amendment to by-laws

Part B: Medical Staff and Committees

Organization of medical staff

Authorization

Medical staff categories

Appointment and privileges

Probationary medical staff

Active with admitting medical staff

Active without admitting (facility) medical staff

Community medical staff

Locum tenens medical staff

Assistant medical staff

Affiliated medical staff

Temporary privileges

Temporary medical staff

Leaves of absence

Notice of leave of absence

Extension of leave of absence

Leave of absence longer than 2 years

Member responsibilities during leave of absence

Returning from leave of absence

Leave of absence for Zone Department Head or Zone Division Head

Deemed resignation

Resignation or retirement

Notice of resignation or retirement

VP Medicine

Zone Medical Executive Director

Medical Site Lead

Zone Department Head

Zone Division Head

Assistant Zone Department Head

Nova Scotia Health Authority-Medical Advisory Committee

Zone Credentials Committee

Zone Medical Advisory Committee

Departmental organization

Programs

Zone Medical Staff Association

Continuing professional review and development

Comprehensive performance and development review

Review of community and locum tenens medical staff

NSHA Code of Ethics

Rules and policies

Part C: Appointment, Credentialing and Discipline

NSHA-MAC hearing pool

NSHA-MAC hearing committee

Appointment of Medical Staff

Conditions of appointment to medical staff

Privileges

Change in privileges

Application for appointment

Review of application by Zone Credentials Committee

NSHA-MAC review of Zone Credentials Committee’s recommendation

Board review of Zone Credentials Committee’s and NSHA-MAC’s

recommendations

Reappointment of Medical Staff

Application for reappointment

Zone Department Head recommendation

Recommendation referred to Facilitated Mediation Process

Zone Credentials Committee review of recommendation

Recommendation referred to NSHA-MAC for review

Medical staff member actions after NSHA-MAC review

Decision of Board

Notice of Board’s decision

Cross-Credentialing of Medical Staff Across Zones

Definitions for Sections 63 to 71

Application for cross-appointment

Contents of application

Right to require interview

Zone Medical Executive Director may contact primary zone medical leaders

Cross-credentialing application procedure

Deadline for NSHA-MAC recommendation

Decision of Board

Reappointment and termination of cross-appointments

Discipline

Monitoring patient care

Automatic suspension of privileges

Deemed receipt of notices

Medical staff member obligation to report

Initiating complaint

Notice to medical staff member

Initial determination by recipient

Facilitated Mediation Process to resolve complaint

Immediate action regarding privileges

Facilitated Mediation Process after immediate action regarding privileges

Board’s actions after Facilitated Mediation Process

Facilitated Mediation Process

Appointment of mediator

Parties to Facilitated Mediation Process

Facilitated Mediation Process procedure

Resolution of Facilitated Mediation Process

Hearings

Medical staff member is subject of hearing

Beginning of hearing process

Parties to hearing

Notice of hearing

Deemed receipt of documents

Amendment to notice of hearing

Powers of Hearing Committee

Hearing procedure

Written recommendations of Hearing Committee

Board review of Hearing Committee recommendations

Legal counsel

Appeals

Notice of appeal

Appeal panel

Parties to appeal

Deadline for written submissions

Appeal procedure

Legal counsel

Appeal Panel decision

Part A: General Provisions

Citation

1 These by-laws may be cited as the Nova Scotia Health Authority Medical Staff By-laws .

Definitions

2 In these by-laws,

“Act” means the Health Authorities Act ;

“affiliation agreement” means a Board-authorized written agreement describing the

relationship between NSHA and a university;

“Appeal Panel” means a Board panel, established as provided in

Section 100, to

which the Board has delegated the authority to hear appeals from a Hearing

Committee’s decision;

“Board” means the board of directors of NSHA or, if applicable, an administrator

appointed under subsection 10(2) of the Act;

“Board Chair” means the chair of the Board, or an administrator, as defined in the

Act, if an administrator has been appointed under the Act;

“by-law” means these NSHA medical staff by-laws;

“CEO” means the individual appointed by the Board to be the chief executive

officer of NSHA or a person designated under subsection 4(8);

“College” means the College of Physicians and Surgeons of Nova Scotia, the

Provincial Dental Board of Nova Scotia and any other professional licensing or

regulatory bodies that regulate or govern other prescribed health professionals;

“day”, unless specified as a working day, means a calendar day;

“dentist” means an individual who, under the Dental Act , is registered in the

Dentists’ Register and who holds a current licence to practise dentistry;

“diagnostic services” means diagnostic medical imaging and laboratory services

provided through NSHA, and any other services determined by the Board from

time to time;

“ex officio” means membership by virtue of the office and includes all rights and

responsibilities, or the power to vote, unless otherwise indicated;

“Facilitated Mediation Process” means the mediation process outlined in Sections

83 to 86;

“Hearing Committee” means the NSHA-MAC subcommittee established under

subsection 47(1);

“medical practitioner” means an individual who holds a licence issued under the

Medical Act or its regulations entitling that individual to practise medicine, and

includes hospital-based fellows;

“Medical Site Lead” means an individual appointed by the VP Medicine, after

considering the recommendation of the Zone Medical Executive Director, who is

accountable to the Zone Medical Executive Director, and who co-leads a medical

site for a facility or community with the site administrative lead;

“medical staff” means any medical practitioners, dentists and other prescribed

health professionals who have been appointed to the medical staff and to whom the

Board has granted privileges;

“NSHA” means the Nova Scotia Health Authority established under the Act;

“NSHA-MAC” means the Nova Scotia Health Authority’s medical advisory

committee as defined in

Section 35;

“NSHA-MAC Chair” means the chair of the NSHA-MAC who holds the office ex

officio as the VP Medicine;

“NSHA Representative” means the CEO, who acts as the representative of NSHA

for the purposes of a facilitated mediation process, a hearing process or an appeal

to the Board;

“other prescribed health professionals” means any class of health professionals not

employed by NSHA that are prescribed by these by-laws to constitute medical

staff;

“patient” means any individual who receives care or services under the authority of

NSHA and includes patients, clients and residents receiving care in the place

designated as their home;

“policies” means the policies and procedures, guidance and directives on the

operation of NSHA’s services, programs and facilities established by the Board,

the NSHA-MAC, the Zone Department Head or as otherwise provided under

Section 45;

“program” means a provincial program of care or a clinical service network

operated by NSHA;

“rules” means the rules and policies established under

Section 45;

“university” means Dalhousie University or any other educational institution that

has an affiliation agreement with NSHA;

“University Department Head” means an individual who is appointed by a

university to be the senior medical or dental education and research administrator

in the university faculties of medicine or dentistry and, with the Board’s approval,

has designated clinical education responsibilities under an affiliation agreement at

1 or more of NSHA’s services, programs or facilities;

“VP Medicine” means NSHA’s Vice President, Medicine;

“working day” means a day other than a Saturday, Sunday or a statutory holiday in

the Province;

“zone” means a management zone as defined in the Act;

“Zone Credentials Committee” means a committee of the NSHA-MAC for each of

the zones known as the zone’s credentials committee as further defined in

Section

36;

“zone department” means a clinical organizational unit established under

Section

38 that is structured on a zone-wide basis consisting of medical staff members with

related fields of practice;

“Zone Department Head” means an individual appointed by the VP Medicine,

after considering the recommendation of the Zone Medical Executive Director,

who is accountable to the VP Medicine for medical staff professional-based issues

and to the Zone Medical Executive Director for care and operational issues at the

zone level and who co-leads a zone department with an administrative co-lead;

“zone division” means a clinical organizational unit of a zone department;

“Zone Division Head” means an individual appointed by the VP Medicine, after

considering the recommendations of the Zone Medical Executive Director and the

Zone Department Head, who is accountable to the Zone Medical Executive

Director and the Zone Department Head, and who acts as the senior medical

administrator and co-lead of a zone division with an administrative co-lead, if

applicable;

“Zone Medical Executive Director” means an individual appointed by the CEO,

after considering the recommendation of the VP Medicine, to co-lead a zone with

the Vice President, Zone Operations, and who is accountable to the VP Medicine;

“Vice President, Zone Operations” means an NSHA employee appointed by the

CEO, who co-leads a zone with the Zone Medical Executive Director, and who is

accountable to the CEO;

“ZMAC” means the medical advisory committee for a zone described in

Section

37;

“ZMSA” means the medical staff association for a zone described in

Section 40.

Purpose

3 The purposes of these by-laws are to do all of the following:

(

a) to outline the medical staff structure, including the categories of

appointment and associated privileges, the medical staff committees and the

duties and functions of senior medical leaders appointed by NSHA;

(

b) to define the rules governing the medical staff, including the key elements

of appointment, reappointment, privileging and the orderly resolution of

issues while ensuring the principles of due process and procedural fairness

are maintained;

(

c) to establish clinical criteria and standards to oversee and manage quality

assurance, utilization review, performance evaluation and other medical

staff activities;

(

d) to address processes through which issues respecting the medical staff

relationship with NSHA may be considered and resolved.

Application

(1) These by-laws apply to all NSHA services, programs, facilities and resources.

(2) These by-laws govern all of the following individuals:

(

a) any member of the medical staff;

(

b) any medical practitioner, dentist or other prescribed health professional who

provides services to NSHA under a contract, whether directly or as a

subcontractor, and is expressly subject to these by-laws under the terms of

the contract, which may or may not include the granting of privileges.

(3) For an individual who is governed by these by-laws under clause (2)(b), the

renewal, extension or termination of their contract and, if applicable, the granting,

reappointment, suspension, restriction, variance, non-renewal or revocation of their

privileges must be determined in accordance with the terms of their contract and,

unless expressly provided for in their contract, they are not entitled to access the

provisions of

Part C.

(4) If the only contract governing a medical practitioner’s, dentist’s or other prescribed

health professional’s relationship with NSHA is an agreement under the Health

Services and Insurance Act for alternative funding arrangements to which the

Province and Doctors Nova Scotia are parties, or an agreement made to confirm

the medical practitioner’s, dentist’s or other prescribed health professional’s

agreement with the alternative funding arrangements, then that contract must not

be interpreted as being a contract for the purposes of subsection (3).

(5) Unless these by-laws, or the policies or rules otherwise state, only those medical

practitioners, dentists and other prescribed health professionals who are granted

admitting privileges and those who have been granted that authority under these

by-laws, the policies or rules may admit and discharge patients from NSHA’s

services, programs or facilities.

(6) Nothing in these by-laws limits the authority to discharge patients that is granted

under subsection 12(1) of the Hospitals Regulations made under the Hospitals Act ,

unless the limit is outlined in the policies or rules.

(7) A medical practitioner may authorize a registered nurse to discharge patients under

subsection 12(1) of the Hospitals Regulations made under the Hospitals Act , if

done in compliance with the policies or rules outlining the conditions under which

that authorization can occur.

(8) The CEO may designate an individual to perform any function assigned to the

CEO under these by-laws in place of the CEO.

Amendment to by-laws

5 The Board may recommend amendments to these by-laws to the Minister of Health and

Wellness after consulting with or if recommended by the NSHA-MAC.

Part B: Medical Staff and Committees

Organization of medical staff

6 The medical staff is organized as provided in these by-laws.

Authorization

(1) All of the following individuals are authorized to admit or provide any service to a

patient of NSHA or conduct research in or access any service provided by NSHA:

(

a) employed medical practitioners, dentists or other prescribed health

professionals, if permitted by their terms of employment;

(

b) medical practitioners, dentists and other prescribed health professionals,

who hold an appointment to the medical staff with privileges to do so;

(

c) other individuals who have otherwise been authorized by the Board.

(2) An appointment to the medical staff in any zone constitutes sufficient authority to

do any of the following in any zone, subject to any additional requirements as may

be stipulated by the Province or in the policies or rules:

(

a) access diagnostic services;

(

b) provide written orders;

(

c) provide medical advice virtually to patients, NSHA staff or other medical

staff members.

(3) A medical staff member who is seeking physical access to NSHA infrastructure

must hold appropriate privileges in the zone in which the infrastructure is located.

Medical staff categories

(1) A medical staff member must be appointed to the appropriate medical staff

category as determined by the Board.

(2) If a medical staff member has been appointed to a medical staff category that has

been materially amended or deleted by the Board, the Board may assign the

medical staff member to another medical staff category that is appropriate for the

individual’s qualifications and the Board must inform the medical staff member of

the reassignment.

(3) All of the following are the categories of medical staff:

(

a) probationary;

(

b) active with admitting;

(

c) active without admitting (facility);

(

d) community;

(

e) locum tenens;

(

f) assistant;

(

g) affiliated;

(

h) any other categories the Board may determine after considering the

recommendation of the NSHA-MAC.

Appointment and privileges

(1) A document granting a medical staff appointment must specify all of the

following:

(

a) the zone, service, program and facility that will serve as the primary site for

the medical staff member’s appointment and privileges;

(

b) any other services, programs or facilities to which the medical staff member

may hold any category of appointment and privileges.

(2) A medical staff member must not hold an appointment in more than 1 category at

any 1 service, program or facility at the same time.

(3) In the event of a conflict between the appointment and privileges granted to a

medical staff member to whom the Board has granted privileges at more than 1

service, program or facility in 1 or more zones, the medical staff member’s duties

and responsibilities in their primary category of appointment as set out in the letter

granting privileges take precedence.

(4) Duties, responsibilities, activities and any conditions or limitations relating to

privileges granted to a medical staff member must be further defined by the Board

decision that grants the appointment and privileges and are subject to the

provisions of these by-laws, the policies and the rules.

(5) Duties, responsibilities, activities and any conditions or limitations relating to a

medical staff category may, in the Board’s discretion, be clarified in the policies or

rules.

(6) Medical staff members must comply with these by-laws, the policies and the rules.

Probationary medical staff

(1) An applicant to the active with admitting, active without admitting (facility) or

assistant category must complete a period of probationary membership as outlined

in these by-laws, unless the Board grants an exemption to this requirement under

subsection (3).

(2) The probationary medical staff consists of those individuals who are completing a

period of probationary membership.

(3) The Board may, in writing, exempt an applicant to the active with admitting, active

without admitting (facility) or assistant category from the requirement to complete

a period of probationary membership in exceptional circumstances and if all of the

following conditions apply:

(

a) the VP Medicine and the CEO request the exemption;

(

b) the Board determines that the quality of care, patient and staff safety and the

fulfilment of NSHA’s mission, vision, values and strategy priorities will not

be negatively impacted by the exemption.

(4) A grant of probationary membership is for a period of at least 1 year.

(5) The relevant Zone Department Head must conduct a formal evaluation of each

probationary medical staff member’s clinical competence and compliance with

NSHA’s mission, vision, values, these by-laws, the policies and the rules, no

earlier than 6 months and no later than 8 months after the date probationary

membership is granted, and the zone department head must submit the results of

the evaluation in writing to Zone Credentials Committee and the VP Medicine.

(6) Upon receiving the results of the evaluation, the Zone Credentials Committee, with

input from the VP Medicine, may recommend to the NSHA-MAC 1 of the

following courses of action:

(

a) if the evaluation of the probationary medical staff member is positive,

appointment of the probationary medical staff member to the active with

admitting, active without admitting (facility) or assistant category;

(

b) if the evaluation of the probationary medical staff member is not positive,

(

i) that the medical staff member be required to serve a further period of

probationary membership of up to 1 year, or

(ii) that the medical staff member’s appointment be terminated, without

resort to the Facilitated Mediation Process or referral to a Hearing

Committee.

(7) Unless otherwise provided by the Board, a probationary medical staff member

(

a) must participate equitably in the on-call requirements of their zone division

or department, program or service as set by their Zone Department Head,

except in exceptional circumstances if their Zone Department Head

determines that it is appropriate to allow the member to be exempt from on-call requirements, and that the quality, patient safety, and care needs of

patients of the zone department are otherwise satisfied;

(

b) must attend and participate in the general business of their zone division or

department, program or service and NSHA;

(

c) is entitled to vote at the ZMSA meetings and meetings of the zone division

or department to which they are appointed;

(

d) must participate in administrative matters, including membership on any

committees the Zone Department Head, the Zone Division Head or the VP

Medicine or their designate may request in their reasonable discretion;

(

e) must participate in the educational, accreditation and clinical activities of the

zone department members, the medical staff, other NSHA personnel,

medical learners and clinical trainees in the reasonable discretion of the

member’s Zone Department Head;

(

f) must maintain a satisfactory standard of medical, dental, oral and

maxillofacial surgery or other knowledge and ability in the fields of their

practice as determined by the Zone Department Head in their reasonable

discretion;

(

g) may teach learners and conduct research as may be directed by the

member’s Zone Department Head or, if the probationary medical staff

member holds a university appointment, as may be directed by the

applicable University Department Head;

(

h) must perform any other duties the member’s Zone Department Head, the

VP Medicine or their Zone Division Head may, in their reasonable

discretion, assign to them from time to time and as may be required by these

by-laws, the policies or the rules; and

(

i) is not eligible to be a member of any ZMAC, the NSHA-MAC or any

ZMAC or NSHA-MAC committee.

Active with admitting medical staff

(1) The active with admitting medical staff consists of medical practitioners, dentists

and other prescribed health professionals who meet all of the following conditions:

(

a) unless exempted from the requirement under subsection 10(3), they have

completed the required period of probationary membership;

(

b) they have been appointed by the Board or assigned by contract to this

category;

(

c) they are actively engaged in the practice of medicine, dentistry or another

prescribed profession within the zones, services, programs or facilities of

NSHA;

assignment, as applicable, including the commitment to participate fully in

achieving NSHA’s mission, vision, values and operational priorities and

plans and to comply with these by-laws, the policies and the rules.

(2) An active with admitting medical staff member may admit and treat patients as

provided for by, and within the limits approved by, the Board and as specifically

interpreted by the Zone Department Head and communicated to the member.

(3) An active with admitting medical staff member

(

a) must participate equitably in the on-call requirements of their zone division

or department, program or service as set by their Zone Department Head,

except in exceptional circumstances if their Zone Department Head

determines that it is appropriate to allow the member to be exempt from on-call requirements, and that the quality, patient safety, and care needs of

patients of the zone department are otherwise satisfied;

(

b) must attend and participate in the general business of their zone division or

department, program or service and NSHA;

(

c) is entitled to vote at the ZMSA meetings and meetings of the zone division

or department to which they are appointed;

(

d) must participate in administrative matters, including membership on any

committees the Zone Department Head, the Zone Division Head or the VP

Medicine or their designate may request in their reasonable discretion;

(

e) must participate in the educational, accreditation and clinical activities of the

zone department members, the medical staff, other NSHA personnel,

medical learners and clinical trainees in the reasonable discretion of the

member’s Zone Department Head;

(

f) must supervise probationary medical staff members as requested by their

Zone Department Head;

(

g) must maintain a satisfactory standard of medical, dental, oral and

maxillofacial surgery or other knowledge and ability in the fields of their

practice as determined by the Zone Department Head in their reasonable

discretion;

(

h) may teach learners and conduct research as may be directed by the

member’s Zone Department Head or, if the active with admitting medical

staff member holds a university appointment, as may be directed by the

applicable University Department Head; and

(

i) must perform any other duties the member’s Zone Department Head, the

VP Medicine or their Zone Division Head may, in their reasonable

discretion, assign to them from time to time and as may be required by these

by-laws, the policies or the rules.

(4) The patient service responsibilities of an active with admitting medical staff

member are under the supervision of the Zone Department Head, and any

applicable university-based academic activities of the member are under the

supervision of the applicable University Department Head.

Active without admitting (facility) medical staff

(1) The active without admitting (facility) medical staff consists of medical

practitioners, dentists and other prescribed health professionals who meet all of the

following conditions:

(

a) unless exempted from the requirement under subsection 10(3), they have

completed the required period of probationary membership;

(

b) they have been appointed by the Board or assigned by contract to this

category;

(

c) they are actively engaged in the practice of medicine, dentistry or another

prescribed profession within the zones, services, programs or facilities of

NSHA;

assignment, as applicable, including the commitment to participate fully in

achieving NSHA’s mission, vision, values and operational priorities and

plans and to comply with these by-laws, the policies and the rules.

(2) An active without admitting (facility) medical staff member may treat patients, but

not admit patients to NSHA’s facilities.

(3) An active without admitting (facility) medical staff member

(

a) must participate equitably in the on-call requirements of their zone division

or department, program or service as set by their Zone Department Head,

except in exceptional circumstances if their Zone Department Head

determines that it is appropriate to allow the member to be exempt from on-call requirements, and that the quality, patient safety, and care needs of

patients of the zone department are otherwise satisfied;

(

b) must attend and participate in the general business of their zone division or

department, program or service and NSHA;

(

c) is entitled to vote at the ZMSA meetings and meetings of the zone division

or department to which they are appointed;

(

d) must participate in administrative matters, including membership on any

committees the Zone Department Head, the Zone Division Head or the VP

Medicine or their designate may request in their reasonable discretion;

(

e) must participate in the educational, accreditation and clinical activities of the

zone department members, the medical staff, other NSHA personnel,

medical learners and clinical trainees in the reasonable discretion of the

member’s Zone Department Head;

(

f) must supervise probationary medical staff members as requested by their

Zone Department Head;

(

g) must maintain a satisfactory standard of medical, dental, oral and

maxillofacial surgery or other knowledge and ability in the fields of their

practice as determined by the Zone Department Head in their reasonable

discretion;

(

h) may teach learners and conduct research as may be requested by the

member’s Zone Department Head or, if the active without admitting

(facility) medical staff member holds a university appointment, as may be

directed by the applicable University Department Head; and

(

i) must perform any other duties the member’s Zone Department Head, the

VP Medicine or their Zone Division Head may, in their reasonable

discretion, assign to them from time to time and as may be required by these

by-laws, the policies or the rules.

(4) The patient service responsibilities of an active without admitting (facility) medical

staff member are under the supervision of the Zone Department Head, and any

applicable university-based academic activities of the member are under the

supervision of the applicable University Department Head.

Community medical staff

(1) The community medical staff consists of medical practitioners, dentists and other

prescribed health professionals who meet all of the following conditions:

(

a) they have been appointed by the Board or assigned by contract to this

category;

(

b) they are actively engaged in the practice of medicine, dentistry or another

prescribed profession within the zones, services, programs or geographic

location of NSHA;

assignment, as applicable, including the commitment to participate fully in

achieving NSHA’s mission, vision, values and operational priorities and

plans and to comply with these by-laws, the policies and the rules.

(2) A community medical staff member

(

a) has access to diagnostic services, but may not treat patients in or admit

patients to NSHA’s facilities;

(

b) may consult on patients as provided for and within the limits approved by

the Board and as specifically interpreted by the zone department head and

communicated to the member;

(

c) at the request of the applicable Zone Department Head, must participate in

the on-call requirements of their zone division or department;

(

d) may attend and participate in the general business of their zone division or

department, program or service and NSHA;

(

e) is entitled to vote at the ZMSA meetings and meetings of the zone division

or department to which they are appointed;

(

f) may participate in administrative matters, including membership on any

committees the Zone Department Head, the Zone Division Head or the VP

Medicine or their designate may request in their reasonable discretion;

(

g) may participate in the educational, accreditation and clinical activities of the

zone division or department, the medical staff, other NSHA personnel,

learners and clinical trainees as determined by the member’s Zone

Department Head;

(

h) must maintain a satisfactory standard of medical, dental, oral and

maxillofacial surgery or other knowledge and ability in the fields of their

practice as determined by the Zone Department Head in their reasonable

discretion;

(

i) may teach learners and conduct research as may be requested by the

member’s Zone Department Head or, if the community medical staff

member holds a university appointment, as may be directed by the

applicable University Department Head; and

(

j) may perform any other duties the member’s Zone Department Head, the VP

Medicine or their Zone Division Head may, in their reasonable discretion,

request from time to time and as may be required by these by-laws, the

policies or the rules.

(3) The patient service responsibilities of a community medical staff member are

under the supervision of the Zone Department Head, and any applicable university-based academic activities of the member are under the supervision of the

applicable University Department Head.

Locum tenens medical staff

(1) The locum tenens medical staff consists of medical practitioners, dentists and other

prescribed health professionals appointed by the Board to this category who have

been granted privileges or retained to address a temporary vacancy in an approved

position in the active with admitting, active without admitting (facility),

community or assistant medical staff until a qualified individual can be recruited

and appointed to the vacant position, but in any event for no more than 1 year.

(2) A medical staff member who is initially appointed as locum tenens medical staff

but who is successful in achieving a permanent position may be converted to the

probationary category with equivalent credit for time spent in the locum tenens

category.

(3) A locum tenens medical staff member’s appointment must be for a period of at

least 30 days and no more than 3 years, but the appointment may be extended for a

period of no more than 1 year if the Board considers it necessary to address the

applicable medical staff resource needs and if the locum tenens medical staff

member continues to meet all qualifications and criteria for the appointment.

(4) A locum tenens medical staff member must be zone-based and may be NSHA-based, but in that instance a primary zone base for privileges must be defined in the

member’s letter of appointment.

(5) A locum tenens medical staff member must maintain a satisfactory standard of

medical, dental, oral and maxillofacial surgery or other knowledge and ability in

the fields of their practice, as determined by the Zone Department Head in their

reasonable discretion.

(6) A locum tenens medical staff member is accountable to the applicable Zone

Department Head for their performance.

(7) Despite subsection (6), a locum tenens medical staff member is clinically

accountable for services provided in any zone, other than the primary zone base for

privileges, to the applicable Zone Department Head where services are provided.

(8) Despite subsection (7), a locum tenens medical staff member is accountable to

their primary Zone Department Head for virtual services provided in another zone.

(9) A locum tenens medical staff member must follow the same process for obtaining

an appointment and privileges as an applicant to the active with admitting, active

without admitting (facility) or assistant medical staff category and is subject to the

same requirements for probationary membership and processes for professional

development and ongoing oversight as those medical staff members.

(10) Unless otherwise restricted by their privileges, a locum tenens medical staff

member

(

a) may admit and treat patients with the approval of the Zone Department

Head for the member’s primary zone and as approved by the Board, unless

those actions are specifically restricted by the Zone Department Head where

services are being provided;

(

b) may teach learners and conduct research as directed by the University

Department Head and approved by the Zone Department Head for the

members’ primary zone; and

(

c) must participate equitably in the on-call requirements for their applicable

zone division or department call

schedule as determined by the Zone

Department Head.

(11) The patient service responsibilities of a locum tenens medical staff member are

under the supervision of the Zone Department Head for the member’s primary

zone, and any applicable university-based academic activities of the member are

under the supervision of the applicable University Department Head as approved

by their Zone Department Head.

(12) Subject to subsection (13), a locum tenens medical staff member has the same

requirements for attendance, voting and committee obligations as the member for

whom the locum tenens medical staff member is relieving.

(13) A locum tenens medical staff member is not eligible to be a member of any

ZMAC, the NSHA-MAC, any ZMAC or NSHA-MAC committee or the ZMSA.

Assistant medical staff

(1) The assistant medical staff consists of those members who, unless exempted from

the requirement under subsection 10(3), have completed the required period of

probationary membership and who apply for and are granted specifically-defined

medical staff roles within a program, department or

section of a zone or NSHA,

including giving assistance with surgical procedures, and whose appointment and

privileges are approved by the Board.

(2) An assistant medical staff member does not have admitting privileges.

(3) An assistant medical staff member must do all of the following:

(

a) attend patients and undertake only those medical and surgical treatments

approved by the Board;

(

b) attend any medical staff meetings mandated by the policies or the rules;

requirement to participate fully in achieving NSHA’s mission, vision,

values, operational priorities and plans, and accreditation activities, and to

rules.

(4) An assistant medical staff member may be a member of any committee of the

medical staff relevant to their professional designation, but is not entitled to hold

any office or be a voting member on any committee.

Affiliated medical staff

(1) The affiliated medical staff consists of medical practitioners, dentists and other

prescribed health professionals who meet all of the following conditions:

(

a) they hold a PhD or an equivalent combination of education and expertise in

a healthcare profession;

(

b) they perform clinical functions or research functions or both solely for the

purposes of research in collaboration with medical staff or NSHA health

professional staff.

(2) An individual who meets the requirements of subsection (1) may apply for and

receive affiliated medical staff privileges under these by-laws.

(3) An affiliated medical staff member

(

a) must not admit or treat patients but may advise on the care of patients;

(

b) must perform the duties and functions described in their approved position

description or otherwise approved by the Board and must meet the terms of

NSHA employment and any other applicable agreement, NSHA policies

and procedures and the standards associated with their profession in

performing those duties and functions;

(

c) may, subject to NSHA research policies and procedures, act as principal

investigator for research studies or projects;

(

d) may attend but not vote at ZMSA meetings nor hold office in the ZMSA;

and

(

e) may attend but not vote at zone department or zone division meetings or at

the ZMAC or the NSHA-MAC, unless they are appointed to the role of

Zone Division Head or Department Head.

(4) If the education and experience of an affiliated medical staff member meet the

requirements of the position profile or description for a Zone Division Head or

Zone Department Head role, an affiliated medical staff member may apply for and

be appointed to serve in a Zone Division Head or Zone Department Head role.

Temporary privileges

(1) Despite any other provisions in these by-laws, the CEO, the VP Medicine or their

designate or the Zone Medical Executive Director may grant temporary privileges

to a medical practitioner, dentist or other prescribed health professional after

gathering any information they consider appropriate in the circumstances, if either

of the following apply:

(

a) a medical staff member requests a temporary replacement for up to 30 days;

(

b) an application for an active with admitting, active without admitting

(facility), community or assistant staff appointment and privileges cannot be

processed within the time associated with the appointment or reappointment

process outlined in

Part C.

(2) A grant of temporary privileges must specify any limitations, restrictions or special

requirements that it includes.

(3) Before temporary privileges are granted, the applicant must provide proof of all of

the following:

(

a) registration with the relevant College;

(

b) for a medical practitioner, membership in the Canadian Medical Protective

Association or other equivalent professional liability protection;

(

c) for a dentist, the professional liability protection required by the Dental Act ;

(

d) for other prescribed health professionals, the professional liability protection

required under the legislation or standards that apply to their profession or,

in the absence of a requirement, professional liability protection in an

amount satisfactory to the CEO in the CEO’s discretion.

(4) Temporary privileges granted under clause (1)(

b) remain in effect until the next

Board meeting unless revoked under subsection (7).

(5) After receiving a recommendation from the NSHA-MAC, the Board may continue

temporary privileges granted under clause (1)(

b) for a period of time and subject to

any terms the Board determines.

(6) The CEO must report any grant of temporary privileges under this

Section to the

Board at the next Board meeting, whether or not the temporary privileges have

expired or been revoked.

(7) The CEO may revoke temporary privileges at any time, in which case the CEO

must, without delay, notify all of the following people of the revocation:

(

a) the holder of the temporary privileges;

(

b) any relevant Zone Department Head;

(

c) the Zone Medical Executive Director;

(

d) the VP Medicine;

(

e) the Board.

(8) A decision to grant, refuse or revoke temporary privileges is final and there is no

right to review or appeal of the decision.

Temporary medical staff

(1) A person holding temporary privileges may do all of the following:

(

a) admit and treat patients as recommended by the Zone Department Head;

(

b) teach learners and conduct research as directed by the University

Department Head and approved by the applicable Zone Department Head;

(

c) attend ZMSA meetings.

(2) A person holding temporary privileges must participate in the on-call requirements

of NSHA as directed by the Zone Department Head, except in exceptional

circumstances if the Zone Department Head determines that it is appropriate to

allow the person to be exempt from on-call requirements, and that the quality,

patient safety and care needs of patients of the zone department are otherwise

satisfied.

Leaves of absence

(1) A medical staff member who proposes to take a leave of absence for longer than 8

consecutive weeks must apply in writing to the Zone Department Head stating the

duration and purpose of the proposed absence.

(2) A leave of absence may be granted in either of the following circumstances:

(

a) by the Zone Department Head, in the event of extended illness or disability

of a medical staff member; or

(

b) by the Board, in other circumstances acceptable to the Board, upon the

recommendation of the Zone Department Head.

(3) Subject to

Section 21, a leave of absence must not exceed 12 months.

Notice of leave of absence

20 All of the following must be notified of a medical staff member’s leave of absence:

(

a) the ZMAC and the NSHA-MAC, by the Zone Department Head;

(

b) the Board, by the NSHA-MAC.

Extension of leave of absence

21 A medical staff member who is on a leave of absence may, with reasonable notice, apply

in writing to the Zone Department Head for an extension to the leave of absence granted

under

Section 19 for an additional period of leave of no longer than 1 year, but the total

continuous period of time to be granted through leaves of absence must not exceed 2

consecutive years.

Leave of absence longer than 2 years

22 A medical staff member who has taken a leave of absence of longer than 2 consecutive

years must submit a new application for appointment to the medical staff upon their

return.

Member responsibilities during leave of absence

(1) During a leave of absence, the member remains a medical staff member, but is

excused from clinical, teaching, research and committee duties and responsibilities.

(2) The member on leave must keep their file current during the leave by completing

the reappointment application at the usual time.

Returning from leave of absence

(1) Before returning from a leave of absence, a medical staff member

(

a) may be required by the Zone Department Head to produce a medical

certificate of fitness, prepared by a physician and acceptable to the Zone

Department Head; and

(

b) must provide, upon request, an accounting of the member’s activities during

the leave of absence, including proof of good standing in all jurisdictions in

which they practised medicine, dentistry or other [another] prescribed

profession since the leave of absence began, if applicable.

(2) Upon return from a leave of absence, the Zone Department Head may impose any

conditions they consider appropriate on the privileges granted to the member.

(3) Subject to any conditions imposed under subsection (2) and provided all

requirements under subsection (1) are met, upon return from a leave of absence the

medical staff member may resume the status that the member held before the

leave.

Leave of absence for Zone Department Head or Zone Division Head

(1) A Zone Medical Executive Director may grant a leave of absence to a Zone

Department Head or Zone Division Head.

(2) If a Zone Department Head or Zone Division Head is granted a leave of absence,

the Zone Medical Executive Director must appoint an acting head for the zone

department or zone division on the recommendation of the Zone Department Head

and with the approval of the VP Medicine.

Deemed resignation

26 A medical staff member who has failed to apply for or who has been denied a leave of

absence and nevertheless does not access NSHA’s services, programs, facilities or

resources for 6 consecutive months is deemed to have resigned their appointment and

privileges, but may apply for a new appointment and privileges.

Resignation or retirement

(1) A medical staff member who wishes to resign or retire from active practice must,

at least 90 days before the effective date of their resignation or retirement, submit a

written notice to the head of the relevant departments or the CEO or both.

(2) If an individual who should receive notice under subsection (1) does not receive

notice, they must notify all of the following:

(

a) the Head of the relevant departments or the CEO, as the case may be;

(

b) the VP Medicine;

(

c) the Zone Medical Executive Director;

(

d) the chair of the Zone Credentials Committee.

Notice of resignation or retirement

28 All of the following must be notified of a medical staff member’s resignation or

retirement:

(

a) the Board, by the VP Medicine;

(

b) the ZMAC, by the Zone Medical Executive Director.

VP Medicine

(1) The CEO must appoint the VP Medicine.

(2) If the VP Medicine is absent or unable to perform their duties for any reason, the

CEO must appoint an acting VP Medicine.

(3) The VP Medicine is accountable to the CEO and responsible for any medical staff

matters arising from the operation of NSHA, including all of the following:

(

a) the effective functioning of the medical staff;

(

b) implementing Board-approved policies for medical staff matters;

(

c) leading the development and implementation of measures to evaluate and

enhance medical staff clinical performance;

(

d) leading the development and implementation of processes for provincial

credentialing, including general and procedure-specific privileging;

(

e) leading the development of leadership development initiatives for medical

staff;

(

f) with other health authorities, the Department of Health and Wellness and

other bodies, as required, participating in and implementing initiatives for

provincial human resource planning, recruitment and retention;

(

g) overseeing the development of appropriate measures to ensure that the

quality of services offered by all medical staff members and compliance

with these by-laws, the policies and the rules are evaluated on a regular

basis and that any required corrective actions are taken;

(

h) monitoring medical staff practices to ensure compliance with these by-laws,

the policies and the rules;

(

i) ensuring mechanisms are in place to monitor and encourage medical staff

involvement in continuing education;

(

j) monitoring the performance and effectiveness of the Zone Medical

Executive Directors, and through the Zone Medical Executive Directors,

ensuring that the performance and effectiveness of Zone Department Heads,

Zone Division Heads and Medical Site Leads is monitored and acted upon

as required;

(

k) serving on relevant medical, administrative and Board committees,

including chairing the NSHA-MAC;

(

l) leading, promoting and ensuring medical staff engagement in quality

improvement and developing and implementing operational priorities and

plans;

(

m) duties that are defined in the position description and contractual

agreements applicable to the VP Medicine;

(

n) any other duties the CEO may assign.

(4) The VP Medicine may delegate any of their day-to-day medical staff oversight

responsibilities to the applicable Zone Medical Executive Director.

Zone Medical Executive Director

(1) The CEO, on the recommendation of the VP Medicine, must appoint a Zone

Medical Executive Director to each of the zones.

(2) If a Zone Medical Executive Director is absent or unable to perform their duties for

any reason, the CEO must, in consultation with the VP Medicine, appoint an acting

Zone Medical Executive Director.

(3) If a Zone Medical Executive Director is unable to perform a specific duty under

these by-laws as a result of a conflict of interest or for any other reason, the CEO

may, in consultation with the VP Medicine, appoint another individual to act on

behalf of the Zone Medical Executive Director to perform that duty.

(4) Subject to any action that may be taken under the applicable terms of appointment

and any contractual arrangement with a Zone Medical Executive Director, a Zone

Medical Executive Director may be appointed for up to 5 years and may be

reappointed for an additional period of up to 5 years.

(5) A Zone Medical Executive Director is accountable to the VP Medicine and

responsible for any medical staff practice-related matters arising from the operation

of NSHA within the applicable zone, including all of the following:

(

a) the effective functioning of the medical staff within their zone;

(

b) implementing Board-approved policies for medical staff matters in their

zone;

(

c) with other Zone Medical Executive Directors, advising the VP Medicine on

and participating in developing and implementing plans for the Provincial

health system, including operational priorities and plans for NSHA within

their zone;

(

d) co-leading with their Vice President, Zone Operations;

(

e) participating on pertinent medical, administrative and Board committees,

including chairing the ZMAC and the Zone Credentials Committee and

participating on the NSHA-MAC;

(

f) addressing zone operational issues that require medical staff input;

(

g) leading the collaboration and cooperation between zones that is required for

effective, quality and safe patient care;

(

h) coordinating learner placement and educational experience for residents and

learners within the zone in accordance with identified needs and affiliation

agreements;

(

i) coordinating and overseeing, with the Vice President, Zone Operations and

Zone Department Heads, the implementation of initiatives related to

programs and the provision of services within the applicable zone;

(

j) working with Zone Department Heads, the VP Medicine and Medical Site

Leads to recruit and retain medical staff required to provide services within

the applicable zone;

(

k) supporting the identification and development of leaders, including Medical

Site Leads, Department Heads, Division Heads and committee chairs within

the zone;

(

l) overseeing the development of appropriate measures to ensure that the

quality of services offered by all medical staff members in the applicable

zone and compliance with these by-laws, the policies and the rules are

evaluated on a regular basis and that any required corrective actions are

taken;

(

m) ensuring mechanisms are in place to monitor and encourage zone-based

medical staff involvement in continuing education;

(

n) monitoring the performance and effectiveness of the Medical Site Leads and

Zone Department Heads and acting on issues identified as may be required;

(

o) leading, promoting and ensuring medical staff engagement in quality

improvement and participation in developing and implementing operational

priorities and plans;

(

p) performing any administrative functions assigned by the VP Medicine;

(

q) duties that are defined in the position description and contractual

agreements applicable to the Zone Medical Executive Director;

(

r) any other duties the CEO or the VP Medicine may assign.

(6) The Zone Medical Executive Director may delegate any of their day-to-day

medical staff oversight responsibilities to a Zone Department Head or Medical Site

Lead.

Medical Site Lead

(1) After consulting with the Zone Medical Executive Director, the VP Medicine must

appoint a Medical Site Lead for each NSHA facility.

(2) If a Medical Site Lead is absent or is unable to perform their duties for any reason,

the VP Medicine, in consultation with the Zone Medical Executive Director, must

appoint an acting Medical Site Lead.

(3) Subject to any action that may be taken under the applicable terms of appointment

and any contractual arrangement with a Medical Site Lead, a Medical Site Lead

may be appointed for up to 5 years and may be reappointed for an additional period

of up to 5 years.

(4) A Medical Site Lead is accountable to the Zone Medical Executive Director and

responsible for any medical staff practice-related matters arising from the operation

of NSHA within the applicable site, including all of the following:

(

a) acting as the Zone Medical Executive Director’s delegate at the applicable

site to perform the obligations outlined in subsection 30(5);

(

b) with their administrative co-lead, being responsible for ensuring the Zone

Medical Executive Director is aware of the perspectives of medical staff at

the applicable site and for bringing information relevant to the site forward

for consideration during the development and implementation of operational

priorities and plans;

(

c) participating in developing and overseeing, with their administrative co-lead, the implementation of NSHA’s operational priorities and plans at the

applicable site;

(

d) supporting and ensuring patient flow and ensuring that timely admissions

and discharges are occurring in line with NSHA policy and direction at the

applicable site;

(

e) duties that are defined in the position description and contractual

agreements applicable to the Medical Site Lead;

(

f) any other duties the CEO, VP Medicine or Zone Medical Executive

Director may assign.

Zone Department Head

(1) Each zone department must have a Zone Department Head.

(2) After consulting with the Zone Medical Executive Director, the VP Medicine must

appoint a Zone Department Head for each zone department from among the

members of the active medical staff of that zone department.

(3) A Zone Department Head must have an academic appointment with the university

unless specifically exempted from this requirement by the Board.

(4) Subject to any action that may be taken under the applicable terms of appointment

and any contractual arrangement with a Zone Department Head, a Zone

Department Head may be appointed for up to 5 years and may be reappointed for

an additional period of up to 5 years.

(5) Subject to any exceptions made by the VP Medicine, a Zone Department Head

must act as both the clinical and academic head for their zone department and the

Zone Department Head may also be appointed by the university as the University

Department Head.

(6) A Zone Department Head is accountable to the applicable Zone Medical Executive

Director and the VP Medicine, and, to the extent applicable, to the Vice President

of Research and Innovation, for any medical staff practice-related matters arising

from the operation of NSHA within the applicable zone department, including all

of the following:

(

a) having authority over and being responsible for the clinical care of patients

within the zone department, including the scheduling of medical staff

members and ensuring appropriate clinical coverage is provided;

(

b) being responsible for the medical administration and functioning of the zone

department;

(

c) working with the leadership of NSHA facilities;

(

d) being a member of the applicable ZMAC and, in that capacity, doing all of

the following:

(

i) advising the ZMAC on the quality of care and treatment provided to

the zone department’s patients,

(ii) advising the ZMAC on the fulfillment of teaching and research

responsibilities within the zone department,

(iii) participating in developing, reporting on and overseeing the zone

department’s objectives, planning, budgeting, resource allocation and

utilization,

(iv) making recommendations on physician resource needs of the zone

department, including the number and type of physicians needed,

after consulting with the Zone Medical Executive Director, the VP

Medicine, the Medical Site Leads and, if applicable, Zone Division

Heads;

(

e) being responsible for organizing and implementing clinical and academic

activities and working with the University Department Head when the Zone

Department Head and University Department Head are not the same

individual for the academic review within the zone department;

(

f) implementing NSHA’s process for continuing professional development

and evaluation related to the zone department;

(

g) ensuring the development of, and, if applicable, implementing NSHA’s

programs to maintain and enforce professional standards in the zone

department and to implement quality assurance and improvement in the

zone department;

(

h) addressing and resolving medical staff issues, including those involving

respectful workplace and interpersonal matters;

(

i) at least annually, reviewing the performance of zone department medical

staff members, with the exception of community medical staff members, for

the purpose of making recommendations for reappointments or contract

renewal in accordance with subsection 41(1);

(

j) holding regular meetings with zone department medical staff members, any

Zone Division Heads within the zone department and Medical Site Leads,

and ensuring consultation on and compliance with current NSHA and zone

department objectives, policies and rules;

(

k) monitoring the performance and effectiveness of the medical staff members

of the zone department and acting on issues identified as may be required,

including issues raised in other zones where medical staff members of the

zone department are providing virtual services;

(

l) supervising residents’ educational requirements if there is no applicable

post-graduate residency training program director;

(

m) working in conjunction with the VP Medicine, Zone Medical Executive

Director and Medical Site Leads for the recruitment and retention of

medical staff required to provide services within the applicable department;

(

n) delegating appropriate responsibility to the Zone Division Heads, as

applicable;

(

o) duties that are defined in the position description and contractual

agreements applicable to the Zone Department Head;

(

p) any other duties the CEO, VP Medicine or Zone Medical Executive

Director may assign.

(7) In the event of a conflict between any of the Zone Department Head’s

responsibilities under subsection (6) that cannot otherwise be resolved, medical

care responsibilities have priority over teaching and research responsibilities.

Zone Division Head

(1) After consulting with the Zone Medical Executive Director and the applicable

Zone Department Head, the VP Medicine must appoint a Zone Division Head for

each zone division from among the members of the active medical staff of that

zone division.

(2) A Zone Division Head must have an academic appointment with the university

unless specifically exempted from this requirement by the Board.

(3) Subject to any action that may be taken under the applicable terms of appointment

and any contractual arrangement with a Zone Division Head, a Zone Division

Head may be appointed for up to 5 years and may be reappointed for an additional

period of up to 5 years.

(4) To the extent applicable, a Zone Division Head must act as both the clinical and

academic head for their zone division.

(5) A Zone Division Head is accountable to the applicable Zone Department Head for

any medical staff practice-related matters arising from the operation of NSHA

within the applicable zone division, including all of the following:

(

a) the clinical care of patients in the zone division, including the scheduling of

medical staff members and ensuring appropriate clinical coverage is

provided;

(

b) the medical administration and functioning of the zone division;

(

c) ensuring the development of programs to maintain and enforce professional

standards in the zone division;

(

d) reviewing the performance of members of the zone division for the purpose

of making recommendations for reappointment or contract renewal;

(

e) holding regular meetings of the zone division and advising medical staff

members in the zone division on current NSHA and zone division or

department policies and rules;

(

f) submitting minutes of regular zone division meetings to the Zone

Department Head;

(

g) liaising with the University Department Head on medical education and

research within the zone division;

(

h) duties that are defined in the position description and contractual

agreements applicable to the Zone Division Head;

(

i) any other duties the CEO, VP Medicine, Zone Medical Executive Director

or Zone Department Head may assign.

Assistant Zone Department Head

(1) In consultation with the VP Medicine and the Zone Department Head, the Zone

Medical Executive Director may appoint an Assistant Zone Department Head for a

zone department.

(2) Subject to any action that may be taken under the applicable terms of appointment

and any contractual arrangement with an Assistant Zone Department Head, an

Assistant Zone Department Head may be appointed for up to 5 years, and may be

reappointed for an additional period of up to 5 years.

(3) In addition to any duties prescribed by the Zone Department Head, the Assistant

Zone Department Head must perform the functions of the Zone Department Head

in the Zone Department Head’s absence.

Nova Scotia Health Authority-Medical Advisory Committee

(1) The NSHA-MAC is a committee of NSHA, which advises the Board and the CEO

on matters concerning the provision of quality patient care and service, teaching

and research as prescribed by the mandate of NSHA.

(2) The NSHA-MAC consists of all of the following individuals:

(

a) the VP Medicine, who acts as chair;

(b) 4 medical staff members, as set out in the rules, representing the leadership

of each ZMSA;

(

c) any other medical staff members, as may be outlined in the rules,

representing the leadership of the ZMACs and programs, as determined by

the CEO after consultation with the VP Medicine;

(

d) the Zone Medical Executive Directors;

(

e) the CEO;

(

f) other representatives from the NSHA executive leadership and Medical

Affairs team, as set out in the rules.

(3) The members of the NSHA-MAC described in clauses (2)(

e) and (

f) serve in an ex

officio capacity and do not have a vote in decisions of the NSHA-MAC.

(4) The NSHA-MAC Chair is accountable to the Board through the CEO.

(5) The NSHA-MAC must meet at regular intervals and at least 10 times per year.

(6) The NSHA-MAC Chair may call special meetings, and must give written or oral

notice to all NSHA-MAC members at least 48 hours before any special meeting.

(7) The quorum for a meeting of the NSHA-MAC or any of its committees is 50% of

the voting members.

(8) The NSHA-MAC Chair is entitled to vote.

(9) If there is a tie vote, the motion is considered defeated.

(10) The NSHA-MAC must do all of the following:

(

a) be responsible, through each ZMAC, for all of the following:

(

i) the oversight of the ethical conduct and professional practice of the

respective zone medical staff members,

(ii) the supervision, quality, organization and delivery of all services

provided by the respective zone medical staff, including patient care,

teaching and research;

(

b) consider, coordinate and recommend to the Board the policies and rules as

they apply to the medical staff as a whole or to individual zone divisions or

departments;

(

c) make recommendations to NSHA’s Board concerning appointments,

reappointments, discipline and privileges of the medical staff;

(

d) consider and take appropriate action on all matters and recommendations

forwarded from the NSHA-MAC committees;

(

e) consider and make recommendations on any matters that may be referred to

it by the Board;

(

f) constitute any subcommittees it considers necessary for the proper

governance of the NSHA-MAC and set their terms of reference and appoint

the members and chairs of those subcommittees, including the Zone

Credentials Committee;

(

g) notify the Board of any new subcommittees constituted under clause (f).

(11) The NSHA-MAC may retain legal counsel to provide independent legal advice in

the fulfillment of its responsibilities.

Zone Credentials Committee

(1) There must be a Zone Credentials Committee for each zone.

(2) A Zone Credentials Committee is a subcommittee of the NSHA-MAC, which

consists of all of the following individuals appointed by the NSHA-MAC on the

recommendation of the applicable ZMAC:

(

a) the Zone Medical Executive Director, or their delegate, who acts as chair;

(b) 4 other medical staff members from the relevant zone who are appointed by

the NSHA-MAC and who broadly represent the geographic and medical

staff specialty-based demographics of the zone.

(3) The quorum for a Zone Credentials Committee meeting is 3 individuals, 1 of

whom must be the chair.

(4) Each Zone Credentials Committee must do all of the following:

(

a) undertake detailed investigation and analysis of applications for

appointments, privileges and applications for reappointment for their zone

and make recommendations about those matters to the NSHA-MAC;

(

b) review resolutions arising out of the Facilitated Mediation Processes and as

required under these by-laws;

(

c) perform any other functions set out in these by-laws or in the rules.

(5) The chair of the Zone Credentials Committee is a voting member of the Zone

Credentials Committee, and must cast an additional vote in the event of a tie

among the remaining members of the Zone Credentials Committee.

(6) The NSHA-MAC may at any time appoint or replace Zone Credentials Committee

members for any of the following reasons:

(

a) no quorum is available;

(

b) a conflict of interest may exist;

(

c) a Zone Credentials Committee member is absent or unable to act for any

other reason.

Zone Medical Advisory Committee

(1) There must be a ZMAC for each of the 4 zones.

(2) A ZMAC is a subcommittee of the NSHA-MAC established to advise the NSHA-MAC on matters concerning the provision of quality patient care, teaching and

research within the zone as prescribed by the NSHA’s mandate.

(3) Each ZMAC consists of all of the following individuals:

(

a) the Zone Medical Executive Director, who acts as chair;

(

b) any other medical staff members, set out in the rules, representing the

leadership of the zone departments and programs of care as determined by

the VP Medicine after consultation with the Zone Medical Executive

Director and the Vice President, Zone Operations and as documented in the

rules;

(

c) the Medical Site Leads for the applicable zone;

(

d) a medical staff member designated by the ZMSA;

(

e) any additional representatives of the ZMSA approved by the ZMAC;

(

f) the Vice President, Zone Operations, who is an ex officio, non-voting

member;

(

g) the VP Medicine, who is an ex officio, non-voting member;

(

h) any other non-voting representatives from the zone clinical directors or

managers or Medical Affairs team as may be provided for in the rules.

(4) The members of the ZMAC described in clauses (3)(f), (

g) and (

h) serve in an ex

officio capacity and do not have a vote in decisions of the ZMAC.

(5) The chair of the ZMAC is accountable to the NSHA-MAC through the VP

Medicine.

(6) The ZMAC must meet at regular intervals and at least 10 times per year.

(7) The ZMAC Chair may call special meetings, and must provide written or oral

notice to all ZMAC members at least 48 hours before any meeting.

(8) The quorum for a meeting of the ZMAC or any of its committees is 50% of the

voting members.

(9) The ZMAC Chair is entitled to vote.

(10) If there is a tie vote, the motion is considered defeated.

(11) Each ZMAC must do all of the following:

(

a) be responsible, through the Zone Department Heads, Zone Division Heads

and the Zone Medical Site Leads, for all of the following:

(

i) the oversight of the ethical conduct and professional practice of the

zone medical staff members,

(ii) the supervision, quality, organization and delivery of all services

provided by the medical staff in the zone, including patient care,

teaching and research;

(

b) consider, coordinate and recommend to the NSHA-MAC the policies and

the rules as they apply to the medical staff as a whole or to the zone

divisions or departments;

(

c) consider and, after seeking advice from the VP Medicine, take appropriate

action on all matters and recommendations forwarded from ZMAC

committees;

(

d) consider and make recommendations on any matters that may be referred to

it by the NSHA-MAC;

(

e) constitute any subcommittees it considers necessary for the proper

governance of the ZMAC and set their terms of reference and appoint the

members and chairs of those committees;

(

f) notify the Board of any subcommittee constituted under clause (e).

Departmental organization

(1) The Board may organize the medical staff into zone departments and, if

appropriate, zone divisions and programs of care, after considering the

recommendations of the NSHA-MAC, which must consult with the ZMAC.

(2) The Board must assign medical staff members individually to a zone department

and, if appropriate, to a zone division.

(3) A medical staff member may be assigned to 1 or more zone departments or zone

divisions.

(4) Each zone department and zone division must function in accordance with the

policies and the rules.

(5) After seeking advice from the CEO and the VP Medicine, the Board may change

the status of a zone department or zone division.

(6) A change in the status of a zone department or zone division must be reflected in

the rules in a timely fashion.

Programs

(1) The Board may establish programs on the recommendation of the CEO, and the

Board may outline how those programs interact with the medical staff

organization, the NSHA-MAC and ZMACs under these by-laws.

(2) After consulting with the CEO, the VP Medicine may appoint a senior medical

director for a program.

(3) A senior medical director must

(

a) be responsible for the administration and operation of the program in

(

b) be a member of the NSHA-MAC.

Zone Medical Staff Association

(1) The medical staff members in each zone form a single ZMSA for the zone in

accordance with these by-laws.

(2) A ZMSA must define its own terms of reference, policies and processes, which

must be consistent with these by-laws and the policies.

(3) A ZMSA consists of medical staff members who are eligible for membership

under these by-laws and who have the relevant zone designated as the primary base

for application of their appointment and privileges.

(4) ZMSA membership does not convey, confer or imply any benefits, rights or

privileges of medical staff membership.

(5) The purpose of a ZMSA is to represent the interests of the zone medical staff to the

CEO, the ZMAC and the NSHA-MAC.

(6) A ZMSA must determine the membership dues to be paid to the ZMSA by

medical staff members of the zone designated as the primary base for application

of their appointment and privileges.

Continuing professional review and development

(1) Each active, assistant and affiliated medical staff member must have a review for

the purposes of evaluating their performance and their ongoing appointment to the

medical staff on an annual basis and at any other times as determined by the VP

Medicine or the Zone Medical Executive Director in consultation with applicable

Zone Department Head in the member’s primary zone.

(2) A medical staff member who holds an appointment with a university may also be

subject to the university’s professional review and development process.

(3) A medical staff member’s Zone Department Head or Zone Division Head must

conduct the annual review.

(4) An annual review must include documentation to be delivered from the Zone

Department Head to the Zone Medical Executive Director, including all of the

following:

(

a) confirmation of the medical staff member’s compliance with any continuing

medical education requirements that may be required by the Zone

Department Head;

(

b) confirmation of the medical staff member’s compliance with Code of Ethics

and workplace behaviour requirements as outlined in these by-laws, the

policies and the rules;

(

c) information on any health condition that affects or may affect the medical

staff member’s proper exercise of the necessary skill, ability and judgement

to deliver appropriate patient care and service;

(

d) information on any discipline actions taken by the medical staff member’s

College or NSHA;

(

e) confirmation of the medical staff member’s current membership in the

Canadian Medical Protective Association or proof of other professional

liability protection approved by the Board and in the category appropriate to

the medical staff member’s practice;

(

f) a list of the current appointment and privileges or areas of practice held or

performed by the medical staff member and any additional areas of practice

or privileges requested;

(

g) information on any legal action arising out of the medical staff member’s

professional activity;

(

h) a finding by the applicable Zone Department Head that the medical staff

member continues to meet the requirements for continuing appointment to

the category and level of privileges granted to the medical staff member by

the Board.

(5) The finding described in clause (4)(

h) must be based on the Zone Department

Head’s evaluation of the information required under this

Section and any other

information known by or received by the Zone Department Head in connection

with the medical staff member’s privileges.

Comprehensive performance and development review

(1) A medical staff member must undergo a comprehensive performance and

development review in accordance with this

Section and the requirements

developed by the VP Medicine with input from the NSHA-MAC, which must

include, at a minimum, consideration of the items required under subsection 41(4)

and the additional requirements and considerations outlined in the rules.

(2) A medical staff member must not be reappointed to the medical staff unless, within

the year before their reappointment, the medical staff member undergoes a

comprehensive performance and development review in accordance with this

Section.

(3) A probationary medical staff member must not be appointed to the active with

admitting, active without admitting (facility) or assistant medical staff category

unless, within the year before their appointment, the probationary medical staff

member undergoes a comprehensive performance and development review in

accordance with this Section.

(4) The Zone Department Head must provide a copy of the comprehensive

performance and development review to the medical staff member and a copy

must be stored in the medical staff member’s credentials file.

(5) A medical staff member may provide written input about the comprehensive

performance and development review, a copy of which must be stored in the

medical staff member’s credentials file.

(6) The comprehensive performance and development review and the medical staff’s

member’s written input, if any, must be made available to any NSHA committee

responsible for assessing the credentials of the medical staff member or to the

Board for the purposes of making a decision about the medical staff member’s

privileges.

(7) At any time during or after a comprehensive performance and development review,

the Zone Department Head may recommend to the Zone Credentials Committee

that the medical staff member’s privileges be terminated or changed, and that

recommendation is considered to be a recommendation to reject or vary an

application for reappointment under clause 56(1)(

b) to which

Part C applies.

Review of community and locum tenens medical staff

(1) The VP Medicine or the Zone Medical Executive Director may, in consultation

with the Zone Department Head for a community or locum tenens medical staff

member, direct that a review of the member’s ongoing appointment to the medical

staff be conducted by the Zone Department Head.

(2) After the review under subsection (1), the Zone Department Head may, with the

approval of the VP Medicine, continue, terminate, impose conditions or restrictions

on or otherwise alter the member’s appointment or privileges.

(3) The decision of the Zone Department Head under subsection (2) is final and there

is no right to review or appeal of the decision.

NSHA Code of Ethics

(1) The NSHA Code of Ethics and these by-laws govern the professional conduct of

medical staff members.

(2) In the absence of an NSHA Code of Ethics, or if the NSHA Code of Ethics does

not apply to a matter, the codes of ethics adopted by the applicable College govern

the professional conduct of medical staff members.

Rules and policies

(1) After consulting with the NSHA-MAC, the Board may make any rules it considers

necessary that apply to the medical staff that are consistent with these by-laws

concerning any of the following:

(

a) the management of clinical activities, programs and services provided

through NSHA, education and research;

(

b) patient care and safety;

(

c) the conduct of medical staff members.

(2) After consulting with the NSHA-MAC, the Board may make policies that apply to

the medical staff that are consistent with and that support the implementation of

the rules.

(3) After consulting with the ZMACs, the NSHA-MAC may make policies that apply

to the medical staff that are consistent with these by-laws and the Board-approved

rules and policies.

(4) After consulting with the medical staff members of the zone department, the Zone

Department Head, may make policies that apply to the medical staff of the zone

department that are consistent with these by-laws and the Board- and NSHA-MAC-approved rules and policies.

(5) The Board-approved policy approval framework must be observed in the making

of any policy under these by-laws.

(6) In addition to the rules and policies described in these by-laws, medical staff

members are required to comply with all general NSHA policies that are

designated as applicable to medical staff in accordance with the Board-approved

policy approval framework.

Part C: Appointment, Credentialing and Discipline

NSHA-MAC hearing pool

(1) The NSHA-MAC hearing pool is composed of 8 medical staff members,

including:

(a) 1 individual from each zone who is not a member of the ZMAC for that

zone; and

(b) 1 individual from each zone’s ZMSA.

(2) A member of the NSHA-MAC hearing pool must not serve concurrently on the

Zone Credentials Committee.

(3) NSHA-MAC hearing pool members must excuse themselves from any discussions

at an NSHA-MAC meeting on the credentialing or discipline of medical staff

members who may become a party to a hearing.

NSHA-MAC hearing committee

(1) If the NSHA-MAC receives notice of a referral to a hearing committee in

accordance with these by-laws, the NSHA-MAC Chair must constitute a Hearing

Committee, as a subcommittee of the NSHA-MAC, to hold a hearing.

(2) A Hearing Committee is composed of 4 NSHA-MAC members, including

(a) 2 NSHA-MAC members, appointed by the NSHA-MAC, who are not any

of the following:

(

i) the NSHA-MAC Chair,

(ii) the Zone Medical Executive Director of the medical staff member

who is the subject of the hearing,

(iii) the Zone Department Head of the medical staff member who is the

subject of the hearing; and

(b) 2 members of the NSHA-MAC hearing pool who are not from the zone of

the medical staff member who is the subject of the hearing, 1 of whom must

be a ZMSA member of another zone.

(3) 1 of the NSHA-MAC members listed in clause (2)(

a) must act as chair of the

Hearing Committee.

(4) The NSHA-MAC Chair may exclude any member of the hearing pool from any

discussion at an NSHA-MAC meeting on the credentialing or discipline of a

medical staff member.

(5) The NSHA-MAC may replace 1 or more Hearing Committee members for any of

the following reasons:

(

a) no quorum is available;

(

b) a conflict of interest may exist;

(

c) a Hearing Committee member is not available to act for any other reason.

(6) A Hearing Committee member who replaces another Hearing Committee member

is subject to the same categories, conditions and restrictions that applied to the

replaced member.

(7) If a single Hearing Committee member is unable, for any reason, to participate on

the Hearing Committee, the remaining Hearing Committee members may

complete the work of the Hearing Committee and render a decision.

Appointment of Medical Staff

Conditions of appointment to medical staff

48 A member’s appointment to the medical staff is conditional on the member agreeing in

writing to abide by these by-laws and all applicable NSHA and medical staff policies and

rules, including any limits of the appointment and privileges specified in or determined

under these by-laws and granted to the member.

Privileges

(1) A medical staff member must be granted privileges that are appropriate for their

role and practice, and that specify the extent and limits of the privileges, including

the zone departments, zones, services, programs and facilities in which the member

may use NSHA infrastructure and services and exercise privileges.

(2) A grant of privileges to a medical staff member in accordance with these by-laws

is for 36 months.

(3) Despite subsection (2), privileges granted to a medical staff member may be for a

term less than 36 months for any of the following reasons:

(

a) the medical staff member is appointed to the probationary category;

(

b) a different term is specified in a decision made under these by-laws;

(

c) the privileges are granted as temporary privileges under

Section 17;

(

d) a different term is specified in an initial grant of privileges or a renewal of

privileges;

(

e) an employment contract or another contractual relationship with the medical

staff member specifies a different term;

(

f) a different term is agreed to by the medical staff member and the VP

Medicine;

(

g) the medical staff member has not participated in the annual performance

review, the annual performance review has not been provided by the Zone

Department Head or the Zone Division Head, or the result of the annual

performance review recommends a shorter term of appointment to address

performance concerns.

(4) If a medical staff member has filed an application for reappointment in accordance

with

Section 55 and within the time prescribed by the NSHA-MAC, the current

appointment continues until the member is reappointed or the reappointment is

refused.

(5) Medical staff members must annually, on a date specified by the CEO, provide all

of the following to the CEO:

(

a) proof of appropriate professional liability coverage;

(

b) proof of registration and current licensing with the relevant College;

(

c) a copy of the member’s completed performance review;

(

d) any other record or information that the CEO may require.

Change in privileges

(1) A medical staff member may request a change in privileges or category of

appointment by providing all of the following to the CEO or the applicable Zone

Department Head or both:

(

a) an application on the prescribed form listing the change of privileges or

category of appointment requested;

(

b) proof of appropriate training and competence for the requested privileges or

category of appointment;

(

c) any other record or information that the CEO or the Zone Department Head

may require.

(2) The CEO must forward a request for a change in privileges or category of

appointment to the VP Medicine and relevant Zone Department Chief and the

matter must be processed as if it were an application for reappointment under

Section 55.

Application for appointment

(1) After receiving an inquiry from a medical practitioner, dentist or other prescribed

health professional seeking appointment to the medical staff, the CEO must, after

consulting with the relevant Zone Medical Executive Director, the relevant Zone

Department Head and the VP Medicine, assess the inquiry from the perspective of

need and the availability of resources and not from the perspective of the

individual merit of the applicant.

(2) The assessment required by subsection (1) is to determine whether there is a

position approved by the Board and, to the extent required, by the Department of

Health and Wellness, and resources to support the position.

(3) The assessment required by subsection (1) must be completed within 60 working

days of date of the inquiry.

(4) After completing the assessment under subsection (1), the CEO must inform the

applicant of the result of the assessment.

(5) If the result of the assessment under subsection (1) is positive, the CEO must

provide the applicant with a copy of, or information on how to access, all of the

following:

(

a) an application form;

(

b) these by-laws;

(

c) any applicable policies and rules.

(6) An applicant for appointment to the medical staff must submit all of the following

to the CEO:

(

a) an application in the form prescribed by the CEO;

(

b) proof of registration with the relevant College;

(

c) for a medical practitioner, proof of membership in the Canadian Medical

Protective Association or other equivalent professional liability protection;

(

d) for a dentist, the professional liability protection required by the Dental Act ;

(

e) for other prescribed health professionals, the professional liability protection

required under the legislation or standards that apply to their profession or,

in the absence of a requirement, professional liability protection in an

amount satisfactory to the CEO in the CEO’s discretion;

(

f) proof of up-to-date inoculations, screenings and tests that may be required

by applicable laws or NSHA’s occupational health and safety policies and

practices;

(

g) signed consent to enable NSHA to inquire with the relevant College and

other facilities where the applicant has previously provided professional

services or received professional training to allow NSHA to fully investigate

the qualifications and suitability of the applicant;

(

h) any other information or proof the CEO may require.

(7) No more than 5 working days after the date a completed application form with the

required accompanying documentation is received, the CEO must forward the

application to the Zone Medical Executive Director to administer and coordinate

the credentials process.

(8) No more than 5 working days after the date the material under subsection (6) is

received, the Zone Medical Executive Director must forward the material to the

Zone Credentials Committee.

Review of application by Zone Credentials Committee

(1) When reviewing an application, the Zone Credentials Committee must do all of the

following:

(

a) consult with the appropriate Zone Department Head to assess the

application on its merit;

(

b) verify the accuracy of information provided by the applicant;

(

c) conduct any other inquiries the committee considers necessary;

(

d) interview any individuals the committee considers necessary;

(

e) engage in any other form of investigation it considers necessary.

(2) After completing its review, and no more than 60 working days after the date the

application is received from the Zone Medical Executive Director, the Zone

Credentials Committee must recommend to the NSHA-MAC 1 of the following

actions:

(

a) the NSHA-MAC appoint the applicant to the privileges determined to be

appropriate by the Zone Credentials Committee;

(

b) the NSHA-MAC reject the application;

(

c) a variance of the applicant’s current privileges or category of appointment or

both.

(3) If the Zone Credentials Committee makes a recommendation to appoint the

candidate under clause (2)(

a) or reject the application under clause (2)(b), the Zone

Credentials Committee must review its recommendation with the applicant and

provide the applicant with a reasonable opportunity to provide a written response.

(4) The Zone Credentials Committee must forward its recommendation and any

written response by the applicant to the NSHA-MAC.

(5) The Zone Credentials Committee must inform the appropriate Zone Medical

Executive Director of its recommendation.

NSHA-MAC review of Zone Credentials Committee’s recommendation

(1) After receiving a recommendation from the Zone Credentials Committee, the

NSHA-MAC must review the recommendation and any response by the applicant

and, no more than 30 working days after the date the recommendation is received,

do 1 of the following:

(

a) accept the Zone Credentials Committee’s recommendation;

(

b) reject the Zone Credentials Committee’s recommendation;

(

c) suggest a variance to the Zone Credentials Committee’s recommendation.

(2) The NSHA-MAC must inform the appropriate Zone Medical Executive Director,

the CEO and the applicant of its recommendation.

(3) If a variance to the Zone Credentials Committee’s recommendations is suggested

by the NSHA-MAC, the NSHA-MAC must review the suggested variance with

the applicant and determine the applicant’s position on the variance.

(4) The NSHA-MAC Chair must forward the NSHA-MAC’s recommendations to the

Board, including the applicant’s position on any suggested variance to the Zone

Credentials Committee’s recommendations, no more than 5 working days after the

date the NSHA-MAC made its recommendation under subsection (1).

Board review of Zone Credentials Committee’s and NSHA-MAC’s recommendations

(1) The Board must review all recommendations from the Zone Credentials

Committee and the NSHA-MAC.

(2) If the Board determines that it does not have sufficient information to make a final

decision on the application, the Board may make inquiries of the NSHA-MAC

Chair as it considers necessary to make a decision.

(3) The Board Chair must, without delay, forward the Board’s written decision to the

CEO and the appropriate Zone Medical Executive Director.

(4) No more than 10 working days after the date the Board Chair forwards the Board’s

written decision to the CEO and the appropriate Zone Medical Executive Director,

the CEO must inform the applicant of the decision.

(5) The Board’s decision is final and there is no right to review or appeal of the

decision.

Reappointment of Medical Staff

Application for reappointment

(1) The CEO must provide an application for reappointment form to a medical staff

member at least 100 days before the date their current term of appointment expires.

(2) A medical staff member who wishes to be reappointed to the medical staff must, at

least 85 days before the date their current term of appointment expires, submit to

the CEO a completed application for reappointment form, along with all required

accompanying information and documentation required by the CEO.

(3) A medical staff member who wishes to be reappointed but does not submit an

application for reappointment on or before the deadline specified in subsection

(2) will be subject to the deadlines and consequences provided in the rules, which may

include paying late filing fees, the expiry of their appointment and privileges and a

requirement to apply as a new applicant.

(4) After receiving a completed application for reappointment, the CEO must, without

delay, forward the application to the Zone Medical Executive Director to

administer and coordinate the reappointment process.

(5) No more than 5 working days after the date the application for reappointment is

received, the Zone Medical Executive Director must forward the application and

all accompanying documentation to the medical staff member’s Zone Department

Head.

Zone Department Head recommendation

(1) The Zone Department Head must assess the application for reappointment and

must recommend that the Zone Credentials Committee take 1 of the following

actions:

(

a) recommend the applicant’s reappointment;

(

b) refuse to recommend the applicant’s reappointment or suggest a variance

that is not acceptable to the applicant;

(

c) recommend a variance to the applicant’s current privileges or category of

appointment in a manner that is acceptable to the applicant.

(2) A recommendation by the Zone Department Head to reappoint a medical staff

member under clause (1)(

a) or to vary a medical staff member’s privileges or

category or appointment under clause (1)(

c) must be forwarded to the Zone

Credentials Committee no more than 10 working days after the date the application

for reappointment is received from the Zone Medical Executive Director.

(3) If the Zone Department Head makes a recommendation to refuse to recommend a

medical staff member’s application for reappointment under clause (1)(b), the

Zone Department Head must notify the applicant of the proposed recommendation

no more than 10 working days after the date the application for reappointment is

received from the Zone Medical Executive Director and, no more than 10 working

days after the date the Zone Department Head notifies the applicant of the

proposed recommendation, must refer the proposed recommendation to the CEO

to begin a Facilitated Mediation Process under

Section 83.

Recommendation referred to Facilitated Mediation Process

(1) If a resolution of the member’s application for reappointment is reached after a

Facilitated Mediation Process, the Zone Medical Executive Director must revise

the application for reappointment to reflect the resolution reached and must present

it as a recommendation to the Zone Credentials Committee at its next meeting.

(2) If no resolution is reached after a Facilitated Mediation Process, the Zone Medical

Executive Director must, without delay, refer the matter to a Hearing Committee

for a hearing, and, no more than 2 working days after the date the matter is referred

to a Hearing Committee, notify in writing the Zone Credentials Committee, the

Zone Department Head and the applicant.

Zone Credentials Committee review of recommendation

(1) The Zone Credentials Committee must review a recommendation made by a Zone

Department Head and, after completing its review, may do 1 of the following:

(

a) approve the recommendation made under clause 56(1)(a), (

b) or (c);

(

b) recommend a variance to the recommendation made under clause 56(1)(

a) or (

c) that is acceptable to the medical staff member;

(

c) recommend a variance to the recommendation made under subsection 57(1)

that is acceptable to the signatories to the facilitated mediated resolution;

(

d) reject the recommendation made under subsection 56(1);

(

e) suggest a variance that is not acceptable to the signatories of the facilitated

mediated resolution;

(

f) reject the recommendation made under clause 56(1)(

a) or (c);

(

g) suggest a variance that is not acceptable to the medical staff member.

(2) The Zone Credentials Committee must inform the Zone Medical Executive

Director and the medical staff member of its decision.

(3) If the Zone Credentials Committee makes a recommendation to approve the

recommendation under clause (1)(

a) or to vary the recommendation under clause

(1)(

b) or (c), the Zone Credentials Committee must, no more than 30 working days

after the date the Zone Credentials Committee receives the recommendation of the

Zone Department Head, forward its recommendation to the NSHA-MAC.

(4) If the Zone Credentials Committee makes a recommendation to reject the

recommendation under clause (1)(

d) or (

f) or to vary the recommendation under

clause (1)(

e) or (g), and if the medical staff member advises the Zone Credentials

Committee, in writing, no more than 15 working days from the date they receive

the Zone Credentials Committee’s recommendation, that they wish the matter to be

referred to a Hearing Committee, the Zone Credentials Committee must forward

the matter to a Hearing Committee.

Recommendation referred to NSHA-MAC for review

(1) If the Zone Credentials Committee refers a matter to the NSHA-MAC in

accordance with subsection 58(3), the NSHA-MAC must conduct any inquiries it

considers necessary and must consider all of the following:

(

a) the application for reappointment;

(

b) the recommendation of the Zone Credentials Committee;

(

c) the recommendations forwarded to the Zone Credentials Committee by the

CEO, the Zone Medical Executive Director and the Zone Department Head;

(

d) any information resulting from its inquiries.

(2) After completing its review under subsection (1), the NSHA-MAC must, no more

than 20 working days after the date the matter was referred to the NSHA-MAC by

the Zone Credentials Committee, do 1 of the following:

(

a) approve the application as recommended by the Zone Credentials

Committee and forward its approval to the Board for a final decision;

(

b) recommend a variance acceptable to the medical staff member and forward

its recommendation to the Board for a final decision;

(

c) reject the Zone Credentials Committee’s recommendation or recommend a

variance that is not acceptable to the medical staff member and forward its

recommendation to the Board for a final decision.

Medical staff member actions after NSHA-MAC review

(1) If a recommendation is made under clause 59(2)(c), the medical staff member may

do 1 of the following, no more than 7 working days after the date the

recommendation is made:

(

a) withdraw their application for reappointment;

(

b) advise the NSHA-MAC in writing that they want the matter referred to the

Hearing Committee, in which case the NSHA-MAC must forward the

matter to the Hearing Committee.

(2) If the medical staff member does not take any action under subsection (1), the

application is deemed to be withdrawn without prejudice to any further application

by the member.

Decision of Board

(1) The Board must consider all of the following when making a decision about a

recommendation made under clause 59(2)(

a) or (b):

(

a) the application for reappointment;

(

b) the recommendation of the Zone Credentials Committee;

(

c) the recommendation of the NSHA-MAC.

(2) After considering the recommendation, the Board must, no more than 20 working

days after the date the recommendation was received from the NSHA-MAC, make

a final decision concerning the matter and the Board Chair must, without delay,

forward the Board’s written decision to the CEO.

Notice of Board’s decision

62 The CEO must, no more than 10 working days after the date of receiving the Board’s

decision, notify all of the following, in writing, of the Board’s decision:

(

a) the medical staff member;

(

b) the NSHA-MAC;

(

c) the Zone Credentials Committee;

(

d) the VP Medicine;

(

e) the applicable Zone Medical Executive Director.

Cross-Credentialing of Medical Staff Across Zones

Definitions for Sections 63 to 71

63 In Sections 63 to 71,

“primary zone” means the zone in which a member of the medical staff is

primarily based for the purposes of privileges and their category of appointment;

and

“zone”, except in reference to a primary zone, means the zone to which a member

of the medical staff wishes to be granted privileges as a cross-appointee, and

references to a Zone Medical Executive Director, Zone Credentials Committee and

ZMAC should be read accordingly.

Application for cross-appointment

(1) Upon receiving a written request for cross-appointment from an applicant who has

privileges in a primary zone, the CEO must provide the applicant with an

application in the form prescribed by the CEO.

(2) An applicant may apply for any category of appointment.

(3) Except as provided for the application process set out in this Section, NSHA must

not provide any applicant any preferential treatment with respect to the application

process.

Contents of application

65 An application for cross-appointment must include all of the following:

(

a) the category of appointment and privileges requested in the zone;

(

b) an authorization signed by the applicant to permit the primary zone

(

i) to disclose to the zone’s medical leadership information and

documentation about the applicant’s qualifications, competence,

privileges and practice, and

(ii) to answer any questions about the applicant from the zone’s medical

leadership;

(

i) a declaration by the applicant that all information on file at the

primary zone from the applicant’s most recent appointment or

reappointment is up to date, accurate and unamended as of the date

of the application,

(ii) a description of all changes to the information on file at the primary

zone since the applicant’s most recent appointment or reappointment.

Right to require interview

(1) An applicant must meet with the Zone Medical Executive Director or another zone

medical leader to assess their application.

(2) An interview may be conducted in person, by telephone or electronically.

Zone Medical Executive Director may contact primary zone medical leaders

67 The Zone Medical Executive Director may contact the primary zone’s Zone Medical

Executive Director or other primary zone medical leader if considered necessary or

appropriate by the Zone Medical Executive Director to assess the application.

Cross-credentialing application procedure

(1) Upon receiving a completed application, the CEO must refer the application to the

applicant’s primary zone Department Head who must make a written

recommendation to the primary zone Medical Executive Director.

(2) The primary zone Medical Executive Director must make a recommendation,

which must be sent with the application to the Zone Medical Executive Director.

(3) The Zone Medical Executive Director may confer with the relevant Department

Head in their zone before forwarding the application with the Zone Medical

Executive Director’s recommendation to the applicant’s primary Zone Credentials

Committee for review.

(4) The primary Zone Credentials Committee must review each application, including

the qualifications and experience of the applicant.

(5) After considering the recommendations of the Primary Zone Medical Executive

Director, Primary Zone Department Head and the Zone Medical Executive

Director, the primary Zone Credentials Committee must submit a written report to

the NSHA-MAC.

(6) The primary Zone Credentials Committee must do all of the following:

(

a) review the application to ensure that it contains all the information required

under these by-laws;

(

b) make a recommendation to appoint, appoint subject to conditions or not to

appoint the applicant;

(

c) if the primary Zone Credentials Committee considers it to be appropriate,

make a recommendation for a variance to the application;

(

d) if the primary Zone Credentials Committee considers it to be appropriate,

recommend a list of the clinical responsibilities to be carried out by the

applicant in exchange for being granted the appointment and privileges.

Deadline for NSHA-MAC recommendation

(1) The NSHA-MAC must consider the application and report of the primary Zone

Credentials Committee and forward its recommendation in writing to the Board no

more than 60 days after the date the completed application is received by the CEO.

(2) Despite subsection (1), the NSHA-MAC may make its recommendation to the

Board later than 60 days after the date the completed application is received by the

CEO if, before the end of the 60-day period, it notifies the Board and the applicant,

in writing, that a final recommendation cannot yet be made and provides written

reasons for the delay.

(3) An applicant may, in the application or otherwise in writing, waive the 60-day

response deadline.

(4) If the recommendation of the NSHA-MAC is delayed beyond the 60-day period

specified in subsection (1), the NSHA-MAC must consider any additional

information relevant to an applicant’s application, provided that the additional

information is provided to the applicant and the applicant is given an opportunity

to respond to it.

Decision of Board

(1) The Board may accept or reject the NSHA-MAC’s recommendation or make a

decision that differs from the NSHA-MAC’s recommendation.

(2) Except as ordered by the Board, a member’s privileges and category of

in the zone as in the primary zone.

(3) The Board must give notice of its decision in writing to the applicant.

Reappointment and termination of cross-appointments

(1) A cross-appointment under

Section 70 is renewed automatically by the member’s

reappointment to the medical staff in the member’s primary zone.

(2) [Original text does not include subsection 71(2).]

(3) If a medical staff member’s appointment to the medical staff in the member’s

primary zone expires, is terminated or suspended, the medical staff member’s

cross-appointment to the medical staff in the zone expires, is terminated or

suspended in the same manner.

Discipline

Monitoring patient care

(1) The VP Medicine, a Zone Medical Executive Director or a relevant Zone

Department Head may review any aspect of patient care or medical staff conduct in

NSHA without the consent of the medical staff member responsible for the care or

conduct.

(2) The relevant Zone Department Head or Zone Medical Executive Director, if they

believe it to be in the patient’s best interests and after notifying the VP Medicine,

may examine the condition and scrutinize the treatment of any patient in their

Department and make recommendations to an attending medical staff member, a

consulting medical staff member involved in the patient’s care and, if necessary,

the NSHA-MAC.

(3) Despite subsection (2), if it is not practicable to notify the VP Medicine in

advance, notice must be given as soon as possible.

(4) If, in the opinion of the VP Medicine or relevant Zone Department Head, a serious

problem exists in the diagnosis, care or treatment of a patient, the VP Medicine or

relevant Zone Department Head must, without delay, discuss the condition,

diagnosis, care or treatment of the patient with the attending medical staff member.

(5) If the attending medical staff member does not change the diagnosis, care or

treatment of the patient in a manner that is satisfactory to the VP Medicine or

relevant Zone Department Head, the VP Medicine or relevant Zone Department

Head must, without delay, assume the duty of investigating the patient’s condition

and diagnosing, prescribing for and treating the patient.

(6) If the VP Medicine or relevant Zone Department Head has reason to take over the

care of a patient, they must do so and they must notify all of the following people:

(

a) the CEO;

(

b) VP Medicine or relevant Zone Department Head;

(

d) the attending medical staff member;

(

e) the patient or the patient’s substitute decision maker.

(7) If the VP Medicine or relevant Zone Department Head takes over the care of a

patient, they must submit a written report to the NSHA-MAC within 48 hours of

their action.

(8) If the NSHA-MAC concurs with the opinion of the VP Medicine or relevant Zone

Department Head who has taken action under this

Section that the action was

necessary, the NSHA-MAC must immediately submit a written report to the CEO

and the Board detailing the problem and the action taken.

(9) If the NSHA-MAC determines that part or all of the action taken under this

Section was not necessary, the NSHA-MAC may substitute its opinion for that of

the VP Medicine or relevant Zone Department Head, and may reverse part or all of

any action taken, as appropriate in the circumstances.

Automatic suspension of privileges

(1) A medical staff member’s privileges will be automatically suspended, without

resort to a Facilitated Mediation Process, if any of the following occur:

(

a) a medical staff member fails to complete a patient’s record in accordance

with the rules within 10 working days of the date they receive notice from

the CEO;

(

b) a medical staff member ceases to be a member of the Canadian Medical

Protective Association or to carry and have in force professional liability

protection as required by these by-laws;

(

c) a medical staff member’s licence has been suspended or revoked by the

applicable College;

(

d) a medical staff member fails to provide acceptable proof of vaccination or a

valid exception to vaccination, in accordance with applicable policy.

(2) A suspension under clause (1)(a), (

b) or (

d) continues until the matter described in

that clause has been corrected.

(3) A suspension under clause (1)(

c) continues until all of the following occur:

(

a) the member’s licence has been reinstated by the applicable College;

(

b) the CEO or VP Medicine or their designate has determined the

circumstances of the suspension no longer pose a concern to the member’s

continued practice at NSHA.

(4) The CEO may require a review of the privileges of a medical staff member who is

suspended under clause (1)(c).

Deemed receipt of notices

74 A notice given under these by-laws is deemed to be received

(

a) if delivered by hand, upon delivery;

(

b) if sent by registered mail with receipt requested, 3 working days after the

date of posting; or

(

c) if sent by e-mail or facsimile transmission, 1 working day after the date of

the transmission.

Medical staff member obligation to report

75 A medical staff member or NSHA staff member who reasonably believes that a medical

staff member is any of the following must, without delay, report that belief to the CEO,

VP Medicine, Zone Medical Executive Director or relevant Zone Department Head:

(

a) incompetent;

(

b) attempting to exceed their privileges;

(

c) incapable of providing a service that they are about to undertake;

(

d) acting in a manner that exposes, or is reasonably likely to expose, a patient

or another individual at NSHA to harm or injury.

Initiating complaint

(1) In Sections 76 to 82,

“complainant” means a person who makes a complaint and who is any of the

following people:

(

i) the CEO,

(ii) the VP Medicine,

(iii) a Zone Medical Executive Director,

(iv) a Zone Department Head;

“recipient” means a person who receives a complaint and who is any of the

following people:

(

i) a Zone Medical Executive Director,

(ii) the VP Medicine.

(2) A complainant may initiate a complaint concerning the privileges of a medical staff

member at any time.

(3) The grounds for a complaint under this

Section include all of the following:

(

a) unprofessional or unethical conduct;

(

b) issues of clinical care or competency;

(

c) behaviour otherwise contrary to NSHA’s values, the policies or the rules;

(

d) failure to meet the requirements of these by-laws, the policies or the rules.

(4) A complaint must be submitted in writing, specifying the grounds for the

complaint, to the Zone Medical Executive Director or the VP Medicine, or both,

and a copy of the complaint must be sent to the Zone Department Head.

(5) A person must not be the recipient of a complaint for which they are the

complainant.

Notice to medical staff member

77 The recipient must notify the medical staff member who is the subject of the complaint

within 24 hours of receiving the complaint and must provide the medical staff member

with a copy of the complaint.

Initial determination by recipient

(1) Upon receiving the complaint, the recipient must make an initial determination as

to whether the complaint should be dismissed or proceed that includes considering

all of the following factors:

(

a) the details of the written complaint;

(

b) any other information that the recipient may deem relevant in making the

initial determination.

(2) If the recipient dismisses the complaint, the recipient must notify the complainant

and the medical staff member that the complaint has been dismissed.

(3) If the recipient determines that the complaint should proceed, the recipient must

consider if it is likely that the parties may reach an agreement, and, if so, whether

the matter can be appropriately addressed informally or if the matter should be

referred to the Facilitated Mediation Process.

Facilitated Mediation Process to resolve complaint

(1) The recipient may initiate the Facilitated Mediation Process by written notice to the

medical staff member and the VP Medicine.

(2) If the complainant is not the CEO, the recipient must notify the CEO of the

complaint within 24 hours of initiating the Facilitated Mediation Process.

(3) If a resolution is not achieved through the Facilitated Mediation Process, the

NSHA Representative must, without delay, refer the matter to a Hearing

Committee for a hearing.

(4) If a resolution is achieved after the Facilitated Mediation Process, the NSHA

Representative must, without delay, forward the resolution to the NSHA-MAC.

(5) If the NSHA-MAC agrees with the resolution, the NSHA-MAC Chair must

forward the resolution and its recommendation to the Board no more than 5

working days after the date the resolution is received by the NSHA-MAC, and the

Board must proceed under subsection (7).

(6) If the NSHA-MAC does not agree with the resolution, the NSHA-MAC Chair

must, without delay, refer the matter to a Hearing Committee for a hearing.

(7) The Board must review the resolution forwarded under subsection (5) and, no

more than 15 working days after the date the proposed resolution is received from

the NSHA-MAC Chair, do 1 of the following:

(

a) approve the resolution;

(

b) recommend a change to the resolution that is acceptable to the signatories to

the resolution, and approve that change;

(

c) reject the resolution with reasons and, without delay, refer the matter to a

Hearing Committee for a hearing.

(8) The Board Chair must notify the CEO of the Board’s decision.

(9) Upon receiving notice of the Board’s decision, the CEO must, without delay,

inform all of the following of the decision:

(

a) the medical staff member;

(

b) the complainant;

(

c) the appropriate Zone Department Head;

(

d) the NSHA-MAC.

Immediate action regarding privileges

(1) In Sections 80 and 81, “the person initiating the immediate action” means the CEO

or a Zone Department Head or their designate.

(2) The person initiating the immediate action may suspend or restrict a medical staff

member’s privileges at any time if the person initiating the immediate action

reasonably believes that immediate action must be taken to protect a patient or any

other individual from harm or injury, and that 1 of the following is true:

(

a) the medical staff member’s conduct, performance or competence is

reasonably likely to expose a patient or any other individual to harm or

injury at NSHA or by services provided through NSHA;

(

b) the medical staff member’s conduct, performance or competence is

reasonably likely to be detrimental to patient safety or to the delivery of care

at NSHA or by services provided through NSHA.

(3) The person initiating the immediate action must inform the NSHA-MAC Chair no

more than 24 hours after the time the suspension or restriction begins, and, no

more than 48 hours after the time the suspension or restriction begins, must

provide the NSHA-MAC Chair with a written report on the action taken, including

all relevant materials and information.

(4) If a person other than the CEO immediately suspends or restricts a medical staff

member’s privileges, they must inform the CEO within 24 hours of the suspension

or restriction.

Facilitated Mediation Process after immediate action regarding privileges

(1) When the CEO is notified of the initiation of a suspension or restriction under

subsection 80(4), the CEO must, no more than 48 hours after the time the CEO is

notified of the suspension or restriction, appoint an NSHA Representative to begin

the Facilitated Mediation Process.

(2) If the CEO initiates the immediate action, the CEO must advise the Zone Medical

Executive Director and the Zone Department Head of the suspension or restriction

and, no more than 48 hours after the time the CEO initiates the immediate action,

must appoint an NSHA Representative to begin the Facilitated Mediation Process.

(3) If a resolution is not achieved through the Facilitated Mediation Process, the CEO

must, without delay, refer the matter to a Hearing Committee for a hearing to

address the issues giving rise to the immediate action.

(4) If a resolution is achieved through the Facilitated Mediation Process, the NSHA

Representative must forward the resolution to the NSHA-MAC in writing no more

than 24 hours after the time the resolution is achieved.

(5) The NSHA-MAC must review the resolution no more than 5 working days after

the date the resolution is received.

(6) If the NSHA-MAC agrees with the resolution, the NSHA-MAC Chair must

forward the resolution and its recommendation to the Board, in writing, no more

than 24 hours after the time the NSHA-MAC reviewed the resolution.

(7) If the NSHA-MAC does not agree with the resolution, the NSHA-MAC must do 1

of the following:

(

a) recommend ed a change to the resolution that is acceptable to the signatories

to the resolution and the NSHA-MAC, and approve that change;

(

b) refer the matter to a Hearing Committee for a hearing.

Board’s actions after Facilitated Mediation Process

(1) The Board must review the resolution received under subsection 81(6) and, no

more than 15 working days after the date the resolution is received, do 1 of the

following:

(

a) approve the resolution;

(

b) reject the resolution and refer the matter to a Hearing Committee for a

hearing.

(2) The Board Chair must notify the CEO of the Board’s decision.

(3) Upon receiving notice of the Board’s decision, the CEO must inform all of the

following of the decision:

(

a) the medical staff member;

(

b) the relevant Zone Department Head;

(

c) the relevant Zone Division Head, if applicable;

(

d) the NSHA-MAC.

Facilitated Mediation Process

Appointment of mediator

83 Upon initiating the Facilitated Mediation Process, the CEO must appoint a mediator who

Document details

Collection	Nova Scotia — Regulations
Citation	N.S. Reg. 86/2023
Date	2023-01-01
Type	regulation
Volume / chapter	just regulations regs hamedstaff.htm
Language	en
Format	htm
Source	PROVINCIAL
Identifier	b2bfa6af282282eab3bd168f6f0ebc03148573af

Source file is stored in the law ingest library (htm).

these regulations (N.S. Reg. 86/2023) (just regulations regs hamedstaff.htm)

Part II .

Table of Contents

Part A: General Provisions

Citation

Definitions

Part B: Medical Staff and Committees

Part C: Appointment, Credentialing and Discipline

Definitions for Sections 63 to 71

Part A: General Provisions

Citation

Definitions

Section 100, to

Section 35;

Section 45;

Section 45;

Section

Section

Section

Section 40.

Part C.

Part B: Medical Staff and Committees

NSHA;

NSHA;

Part C.

Section to the

Section 21, a leave of absence must not exceed 12 months.

Section 19 for an additional period of leave of no longer than 1 year, but the total

Section.

Part C applies.

Part C: Appointment, Credentialing and Discipline

Section 17;

Section 55 and within the time prescribed by the NSHA-MAC, the current

Section 55.

Section 83.

Definitions for Sections 63 to 71

Section 70 is renewed automatically by the member’s

Section that the action was

Section was not necessary, the NSHA-MAC may substitute its opinion for that of

Section include all of the following:

Document details