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)

Table of Contents

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

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

Deadline for written submissions

Appeal procedure

Legal counsel

Appeal Panel decision

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

“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;

“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;

“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-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;

“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;

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

“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 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.

(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.

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

(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.

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.

7 (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;

(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:

(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.

8 (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.

(h) any other categories the Board may determine after considering the recommendation of the NSHA-MAC.

9 (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.

10 (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:

(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.

(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;

(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.

(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.

11 (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;

(d) they have committed to the terms and conditions of their appointment or 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.

(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;

(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.

12 (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;

(2) An active without admitting (facility) medical staff member may treat patients, but not admit patients to NSHA’s facilities.

(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;

(f) must supervise probationary medical staff members as requested by their Zone Department Head;

(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

(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.

13 (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;

(c) they have committed to the terms and conditions of their appointment or 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.

(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.

14 (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.

15 (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.

(a) attend patients and undertake only those medical and surgical treatments approved by the Board;

(c) commit to the terms and conditions of the appointment, including the requirement to participate fully in achieving NSHA’s mission, vision, values, operational priorities and plans, and accreditation activities, and to comply with the terms and conditions of these by-laws, the policies and 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.

16 (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.

(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;

(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.

17 (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:

(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:

(b) for a medical practitioner, membership in the Canadian Medical Protective Association or other equivalent professional liability protection;

(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:

(8) A decision to grant, refuse or revoke temporary privileges is final and there is no right to review or appeal of the decision.

(b) teach learners and conduct research as directed by the University Department Head and approved by the applicable Zone Department Head;

(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.

19 (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.

(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.

20 All of the following must be notified of a medical staff member’s 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.

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.

23 (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.

(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.

25 (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.

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.

27 (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:

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

(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:

(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;

(4) The VP Medicine may delegate any of their day-to-day medical staff oversight responsibilities to the applicable Zone Medical Executive Director.

30 (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:

(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;

(e) participating on pertinent medical, administrative and Board committees, including chairing the ZMAC and the Zone Credentials Committee and participating on the NSHA-MAC;

(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;

(q) duties that are defined in the position description and contractual agreements applicable to the Zone Medical Executive Director;

(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.

31 (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.

(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;

(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.

33 (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;

(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.

34 (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.

35 (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.

(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;

(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.

(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.

(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;

(11) The NSHA-MAC may retain legal counsel to provide independent legal advice in the fulfillment of its responsibilities.

(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:

(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.

(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;

(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:

(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.

(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;

(f) the Vice President, Zone Operations, 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.

(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.

(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;

38 (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.

39 (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.

(a) be responsible for the administration and operation of the program in accordance with the terms and conditions approved by the Board; and

40 (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.

41 (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.

42 (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.

43 (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.

44 (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.

45 (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;

(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.

46 (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

(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.

47 (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.

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

(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:

(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.

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.

49 (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:

(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:

50 (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;

(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.

51 (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:

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

(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;

(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.

52 (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;

(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;

(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.

53 (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:

(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).

54 (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.

55 (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.

56 (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:

(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.

57 (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.

58 (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:

(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;

(e) suggest a variance that is not acceptable to the signatories of the facilitated mediated resolution;

(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.

59 (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:

(c) the recommendations forwarded to the Zone Credentials Committee by the CEO, the Zone Medical Executive Director and the Zone Department Head;

(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.

60 (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:

(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.

61 (1) The Board must consider all of the following when making a decision about a recommendation made under clause 59(2)(a) or (b):

(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.

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:

“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.

64 (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.

(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.

(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.

66 (1) An applicant must meet with the Zone Medical Executive Director or another zone medical leader to assess their application.

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.

68 (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.

(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.

69 (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.

70 (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 appointment, and any terms and conditions of their appointment, must be the same in the zone as in the primary zone.

71 (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.

(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.

72 (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:

(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.

73 (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;

(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:

(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).

(b) if sent by registered mail with receipt requested, 3 working days after the date of posting; or

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:

(d) acting in a manner that exposes, or is reasonably likely to expose, a patient or another individual at NSHA to harm or injury.

“complainant” means a person who makes a complaint and who is any of the following people:

“recipient” means a person who receives a complaint and who is any of the following people:

(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:

(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.

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.

78 (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:

(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.

79 (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:

(b) recommend a change to the resolution that is acceptable to the signatories to the resolution, and approve that change;

(9) Upon receiving notice of the Board’s decision, the CEO must, without delay, inform all of the following of the decision:

80 (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.

81 (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) recommended a change to the resolution that is acceptable to the signatories to the resolution and the NSHA-MAC, and approve that change;

82 (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:

(b) reject the resolution and refer the matter to a Hearing Committee for a hearing.

(3) Upon receiving notice of the Board’s decision, the CEO must inform all of the following of the decision:

83 Upon initiating the Facilitated Mediation Process, the CEO must appoint a mediator who must facilitate the Facilitated Mediation Process as a neutral party.

(a) the medical staff member who is the subject of the Facilitated Mediation Process;

(i) in the case of a reappointment, the medical staff member’s Zone Department Head,

(iii) in the case of an immediate action under Section 80, the person initiating the immediate action;

(d) at the medical staff member’s request, a ZMSA member of the zone in which the medical staff member works and who is appointed by the ZMSA Executive.

85 (1) The parties to the Facilitated Mediation Process must seek to develop a resolution that addresses the outstanding issues to the satisfaction of the parties.

(2) A resolution must be approved and signed by the parties to the Facilitated Mediation Process and, if the CEO is not the NSHA Representative, the CEO.

(3) The parties must participate in the Facilitated Mediation Process on a timely basis to either reach a resolution or determine that it is not possible to reach a resolution.

86 (1) If the parties reach a resolution, the resolution must be forwarded by the NSHA Representative to the relevant committee under these by-laws and processed in accordance with the relevant Section.

(2) If a resolution is not reached, the matter must proceed in accordance with the relevant provisions of these by-laws.

(3) If a resolution is not reached and the matter is referred to a Hearing Committee, reference to discussions held during the Facilitated Mediation Process or to a proposed resolution is not allowed in evidence before a Hearing Committee.

87 In Sections 87 to 99, a reference to the medical staff member is a reference to the individual who is the subject of the hearing.

(2) Subject to subsection (3), in a proceeding before a Hearing Committee, the NSHA Representative presents the matter to the Hearing Committee and the medical staff member responds to the matter presented by the NSHA Representative.

(3) If a party does not attend a hearing, the Hearing Committee, upon receiving proof of service on that party of the notice of hearing, may proceed with the hearing in the party’s absence and, without further notice to the party, may take any action it is authorized to take under these by-laws.

90 The chair of the Hearing Committee must give written notice of the hearing to the parties that includes all of the following information:

91 A document required to be served on or provided to either party as part of the hearing process may be delivered personally or by registered mail addressed to the party at their last known address and is deemed to be received when

(a) the intended recipient or their legal counsel acknowledges receipt of the document;

(d) evidence satisfactory to the Hearing Committee that all reasonable efforts to effect service or delivery have been exhausted is provided.

92 (1) At any time before or during a hearing, the Hearing Committee, on its own motion or on receipt of a motion from a party to the hearing, may amend the notice of hearing for any of the following reasons:

(b) to make the notice conform to the evidence, if there appears to be a difference between the evidence and the notice, or if the evidence discloses issues not alleged in the notice.

(2) The parties must be give[n] an opportunity to respond to an amendment to a notice of hearing made by the Hearing Committee.

93 (1) A Hearing Committee may determine rules or procedures for the conduct of a hearing not covered by these by-laws.

(2) The chair of the Hearing Committee may determine whether preliminary motions will be heard independently or at the beginning of a hearing.

(3) An appeal arising from a preliminary hearing must be heard with an appeal of the final decision.

(4) A Hearing Committee may, in its discretion, allow the introduction of evidence that is otherwise inadmissible under subsection 94(4) and may make directions it considers necessary to ensure that the other party has an appropriate opportunity to respond.

(5) Evidence may be given before the Hearing Committee in any manner that the Hearing Committee considers appropriate, and the Hearing Committee is not bound by the rules of law respecting evidence applicable to judicial proceedings.

(6) At any time before or during a hearing, after providing the opportunity for each party to make submissions, the Hearing Committee, acting in good faith and on reasonable grounds, may require the medical staff member to do any of the following:

(a) submit to physical or mental examinations by a qualified person or persons selected by the medical staff member and acceptable to the Hearing Committee and provide a copy of the report [of] the examination to the Hearing Committee and the NSHA Representative;

(b) submit to a review of the medical staff member’s practice by a qualified person or persons selected by the Hearing Committee and provide a copy of the review to the Hearing Committee and the NSHA Representative;

(c) submit to a competence assessment or other assessment or examination, by a person or persons and by any means the Hearing Committee considers appropriate, to determine whether the medical staff member is competent to practise, and provide a copy [of] the assessment or the report of the examination to the Hearing Committee and the NSHA Representative;

(7) If a medical staff member fails to comply with a requirement under subsection (6), the Hearing Committee may order that the medical staff member’s privileges be suspended until the medical staff member complies.

(8) Expenses incurred for a medical staff member to comply with a requirement under subsection (6) must be paid by NSHA.

94 (1) A Hearing Committee must ensure that a hearing is conducted in accordance with the principles of natural justice and procedural fairness.

(2) To protect personal health information and privacy, a hearing must be closed except to the parties, legal counsel and any witnesses, but the chair of the Hearing Committee may permit other people approved by the chair to attend, in circumstances determined by the chair.

(3) In a proceeding before a Hearing Committee, the parties have the right to present evidence and make submissions, including the right to cross-examine witnesses.

(4) Evidence is not admissible before a Hearing Committee unless, at least 10 working days before the date of a hearing, the opposing party has been given

(a) in the case of written or documentary evidence, an opportunity to examine the evidence;

(b) in the case of evidence of an expert, a copy of the expert’s written report or, if there is no written report, a written summary of the evidence; and

(5) The testimony of witnesses at a hearing must be taken under oath or affirmation, administered by a member of the Hearing Committee or other person in attendance authorized by law to administer oaths or affirmations.

(6) Evidence submitted to the Hearing Committee must be recorded by an individual authorized by the Hearing Committee.

(7) The chair of a Hearing Committee is a voting member of the Hearing Committee, and must cast an additional vote in the event of a tie among the remaining members of the Hearing Committee.

(8) The quorum for a Hearing Committee is 3 individuals, 1 of whom must be the chair.

95 (1) No more than 30 working days, or if permitted by the chair of the Hearing Committee 60 working days, after the date the evidence is complete and both parties have had the opportunity to present submissions, the Hearing Committee must issue to the Board and the parties written recommendations with reasons concerning the matters raised in the notice of hearing and any other matter that may have arisen during the hearing.

(i) to approve, reject or vary the appointment or privileges requested by the applicant,

(ii) to impose certain conditions or restrictions on the applicant’s appointment or privileges,

(3) After the hearing, the chair of the Hearing Committee must order a transcript of the hearing and must provide a copy of it, along with all of the following, to the Board:

(b) a record of any preliminary decisions made by the chair or the Hearing Committee.

(4) The chair of the Hearing Committee must provide a copy of the recommendations made under subsection (1) to the NSHA-MAC for information.

96 (1) If the medical staff member does not file a notice of appeal under subsection 99(1), the Board must review the Hearing Committee’s recommendations and the chair of the Hearing Committee must provide any additional information requested by the Board.

97 (1) In a proceeding before a Hearing Committee, the chair of the Hearing Committee may retain legal counsel to advise the Hearing Committee on matters of law and procedure and may approve legal expenses incurred as part of the hearing process.

(2) NSHA may retain legal counsel to present or to assist in presenting the case on behalf of NSHA before the Hearing Committee.

(3) The medical staff member may retain legal counsel to represent the medical staff member at their own expense.

98 A medical staff member may appeal a Hearing Committee’s recommendations made under Section 95 only on the basis of an error of law.

99 (1) A medical staff member requesting an appeal must file a notice of appeal with the Hearing Committee and the Board no more than 10 working days after the date the Hearing Committee’s written recommendations are delivered to the Board.

100 (1) Upon receiving the notice of appeal, the Board Chair must constitute an Appeal Panel that must include all of the following members:

(2) If a single Appeal Panel member is unable, for any reason, to continue to participate on the Appeal Panel, the remaining Appeal Panel members may complete the work of the Appeal Panel and render a decision.

(3) An Appeal Panel must consider written submissions only and not oral submissions by the parties.

102 Upon receiving the notice of appeal, the chair of the Appeal Panel must, without delay, meet with the parties and set a deadline for written submissions by the parties on the grounds of appeal and the remedy sought.

103 (1) An Appeal Panel may determine rules or procedures for the conduct of an appeal not covered by these by-laws.

(2) New evidence is not admissible before the Appeal Panel unless the Appeal Panel directs otherwise.

104 An Appeal Panel may retain independent legal counsel to advise the Appeal Panel on matters of law and procedure.

105 (1) An Appeal Panel must, no more than 30 working days after the date it receives the written submissions, issue a written decision, with reasons, and must provide a copy of the decision to all of the following:

(2) The Appeal Panel may extend the time for issuing a written decision for up to 60 days after the date it receives the written submissions if it considers an extension appropriate.

(3) An Appeal Panel may impose any disposition available to the Hearing Committee.

(4) The decision of an Appeal Panel is the final decision concerning the medical staff member’s appointment and privileges.

The current consolidation of the Nova Scotia Health Authority Medical Staff By-laws made under the Health Authorities Act includes all of the following regulations:

The following regulations are not yet in force and are not included in the current consolidation:

*See subsection 3(6) of the Regulations Act for rules about in force dates of regulations.

N.S. Regulation	Title	In force date	Repealed date

187/2015, 188/2015 & 189/2015	Nova Scotia Health Authority Medical Staff By-laws	Apr 1, 2015	May 17, 2023

Note: Only regulations that are specifically repealed and replaced appear in this table. It may not reflect the entire history of regulations on this subject matter.

N.S. Regulation	In force date*	How in force	Royal Gazette Part II Issue

ad. = added am. = amended	fc. = fee change ra. = reassigned		rep. = repealed rs. = repealed and substituted
Provision affected		How affected
..........................................................

Nova Scotia Health Authority Medical Staff By-laws	N.S. Reg. 86/2023
Health Authorities Act
Note: The information in these tables does not form part of the regulations and is compiled by the Office of the Registrar of Regulations for reference only.