Medical Staff Bylaws

Baystate Medical Center

• BMC Rules and Regulations
• BMC Bylaws
• BMC Bylaws Appendix 1
• BMC Bylaws Appendix 2
• BMC Bylaws Appendix 3

Baystate Franklin Medical Center

• BFMC Rules and Regulations
• BFMC Bylaws
• BFMC Bylaws Appendix 1
• BFMC Bylaws Appendix 2
• BFMC Bylaws Appendix 3

Baystate Noble Hospital

• BNH Medical Staff APS Rules and Regulations
• BNH Bylaws
• BNH Bylaws Appendix 1
• BNH Bylaws Appendix 2
• BNH Bylaws Appendix 3

Baystate Wing Hospital

• BWH Medical Staff Rules and Regulations
• BWH Bylaws
• BWH Bylaws Appendix 1
• BWH Bylaws Appendix 2
• BWH Bylaws Appendix 3

Licensure and Certification Expiration Tracking and Reporting Policy

Policy

Consistent with relevant state, federal law, medical staff bylaws, and to be in regulatory compliance, all practitioners at the time of appointment and continuously thereafter, must have and maintain the current required documents:

• MA license
• MA license renewal application (requirement by the State of Mass.)
• Federal DEA Certification with a Mass. Address listed on it
• MA Controlled Substance Certificate (MCSC)
• Malpractice insurance face sheet (it must list policy number, dates of coverage, amount of coverage and any exclusions)
• Applicable National Certification for Associate Professional Staff
• Applicable departmental certification requirement: examples; BLS, ACLS, PALS, NRC, Moderate Sedation.

Failure of a practitioner to provide copies of the above documents may result in suspension.

Purpose

To ensure applicants continuously meet the qualifications for membership to the Medical Staff and/or Associate Professional Staff without lapse.

Scope

This policy covers all Medical Staff and Associate Professional Staff members upon initial application for privileges, and continuously thereafter to satisfy the qualifications and requirements of Medical Staff membership and privileges and as otherwise consistent with the Medical Staff Bylaws.

Procedure

Sixty days prior to the practitioner’s licensure and/or certification expiration, the Medical Staff Office (MSO) will send a notification to the provider’s contact if applicable otherwise directly to the provider, of the pending expiration.

Thirty days prior to the practitioner’s licensure and/or certification expiration, the Medical Staff Office (MSO) will send a notification directly to the provider of
the pending expiration.

Third and Final Reminder a final reminder will be emailed two weeks prior to the expiration date directly to the provider.

A two-weeks prior pending suspension list will be run to identify the practitioner who failed to submit to the Medical Staff Office a copy of the following:

• MA license renewal application (requirement by the State of Mass.)
• Federal DEA Certification with a Mass. Address listed on it
• MA Controlled Substance Certificate (MCSC)
• Malpractice insurance face sheet (it must list policy number, dates of coverage, amount of coverage and any exclusions)
• Applicable National Certification for Associate Professional Staff
• Applicable National Certification for Associate Professional Staff
• Applicable departmental certification requirement: examples; BLS, ACLS, PALS, NRC, Moderate Sedation.

Note this is a two-week prior to the expiration date of the licensures.

The pending suspension list will include the names of the practitioner, specialty, date of the potential suspension, and identification of the required documentation. The MSO will send email notification of the pending suspension to an established core distribution contact list, this will include Chief/Chair of the Department, MSO Staff to mention a few.

If the required documentation has not been received by 10 am at the end of the business day on the date of suspension, the Medical Staff Office (MSO) will proceed to modify the privilege type relating to the practitioner to suspended (SUM) in the SMS database and the status as (SUS) in the CACTUS database. At the time of suspension, the Medical Staff Office will also send email notification of suspension to an established core distribution contact list including the provider who’s been suspended. If the suspension date fall on a weekend the MSO will proceed to suspend the provider by the Friday at 10 am prior the weekend.

Query steps:

1. Open CACTUS database
2. Select Query option
3. Select Expiration (License & Insurance)
4. Enter dates for the upcoming week
5. Select printer option
6. Run query

The Query will identify the names of any provider with expiration to their Massachusetts license and medical malpractice insurance within the dates provided.