"Act" means Regional Health Authorities Act (Alberta).

"Articles" means the Articles of Association of the Capital Health Authority.

"Board" means the Board of Directors of the Capital Health Authority.

"Capital Health Region" means Capital Health Region 10 as established by the
Minister pursuant to the Regional Health Authorities Act.

"Capital Health Authority (CHA)" means the Board appointed by the Minister
or elected to govern, organize and deliver health services within the Capital
Health Region and the organization resulting.

"Capital Region Medical Staff (CRMS)" means those physicians who are
members of the Capital Region Medical Staff pursuant to the CRMS Bylaws.

"Capital Region Medical Staff Bylaws (CRMS Bylaws)" means the Capital
Region Medical Staff Bylaws effective July 17, 1997 as amended from time to
time.

"Caritas" refers to the Caritas Health Group, a voluntary operator.

"Category" means any one of the classes of membership in the Medical Staff
referred to in Article 4.2 of the Capital Region Medical Staff Bylaws.

"College" means the College of Physicians and Surgeons of the Province of
Alberta as constituted by Section 2 of the Medical Profession Act (Alberta).

"Continuing Care Facility" means a residential facility that provides for patients
assessed by the Region as needing long term care.

"Dentist" means a member entered upon and in good standing in the register
pursuant to the Dental Professions Act, S.A. 1983, c.D-9.5 and amendments
thereto.

"Director" means a person appointed to the Board.

"Executive Committee" means the senior administrative committee of the CHA.

"Faculty" means the Faculty of Medicine and Dentistry at the University of
Alberta (Edmonton).

"Impact Analysis" means an assessment that estimates the effect on available
resources of a change or proposed change in the Physician Resource Plan or an
individual physician's practice.

"Medical Director" means a physician designated as a Medical Director by the
Vice President, Medical Affairs.

"Medical Staff" means those Physicians, and Honorary Staff who are appointed
members of the medical staff pursuant to the Medical Staff Bylaws

"Medical Student" means a student registered in an approved undergraduate
medical training program.

"Medical Staff Bylaws" means the Capital Region Medical Staff Bylaws adopted
pursuant to Section 32 of the Act.

"Member" means a Physician, or Dentist, appointed to the Capital Region
Medical Staff by the Board pursuant to the Medical Staff Bylaws or the Dental
Staff Bylaws.

"Minor" means a person under the age of majority (18 years of age).

"Personal Directive" means a personal directive of a Patient related to health care
under the Personal Directives Act (Alberta).

"Physician" means a person entered upon and in good standing in the Alberta
Medical Register pursuant to the Medical Profession Act (Alberta) or
successor legislation.

"Physician Resource Plan" means the Physician Resource Plan as defined in the
CRMS Bylaws.

"President" means the President and CEO of the Capital Health Authority.

"Privileges" means the clinical services that a member of the Medical Staff may
provide in Hospital Facilities and the access to Hospital Facilities granted to a

member of the Medical Staff in order to provide specified health care services to
Patients.

"Program and Section" mean organizational units of the Medical Staff that are
established by the President and CEO on the recommendation of the Vice
President, Medical Affairs and to which members of the Medical Staff are
assigned.

"Regional Section Head" means a physician or other health care professional
designated as a Regional Section Head by the Vice President, Medical Affairs.

"Resident" means a trainee registered with the College of Physicians and
Surgeons of Alberta in an approved postgraduate training program.

"Responsible Physician " refers to the single, designated physician who carries
the primary responsibility for care of a patient during an episode of illness.

a. Each Regional Program is responsible for working with the Faculty of Medicine and Dentistry to develop a Physician Resource Plan that identifies physician requirements, both immediate and future. These plans are submitted to the Vice President, Medical Affairs annually and indicate the positions needed in areas of clinical service, teaching, research and administration as well as a list of priorities in terms of recruitment.

c. It is recognized that this process must be flexible enough to respond to urgent unforeseen changes in physician availability as well as to opportunities that arise with exceptional candidates.

a. Each appointment must be consistent with the Physician Resource Plan as defined in the CRMS Bylaws, must meet the needs of the Capital Health Authority and must be made in light of the constraints to the size of the medical staff and after completion of an impact analysis.

i) possess an M.D. or equivalent degree;

ii) be licensed to practice Medicine in the province of Alberta;

a. Renewal of privileges of Members of the Medical Staff, based upon a performance review, will occur every three years except for those members over age sixty-five (65) in which case it will be every year.

The extent of access to Hospital Facilities or other facilities of the CHA and the degree of access to resources granted to any member of the Medical Staff will be defined by the Privileges granted by the CHA to that member.

The CHA reserves the right to transfer clinical services, programs and sections among the region's facilities and to adjust the Privileges of Members accordingly.

Physicians wishing to treat patients residing in continuing care facilities of the CHA or of a Voluntary Operator must advise the Medical Director responsible and conform to any policies that exist for treatment in such facilities.

The granting of delineated clinical Privileges or individual procedures shall be based on CHA need, on the Physician's licensure, specific training, documented experience in categories of treatment areas or specific procedures, current competence, and conclusions drawn from quality assurance activities.

a. Each new Medical Staff member shall be oriented to CHA facilities by the Site Chief of Service or designee of the relevant Program. This orientation will vary depending on the member's prior association with and knowledge of the facilities. In general, it should ensure that the member has been:

a. All Medical Staff other than Emeritus Staff and Honorary Staff shall be subject to an annual performance review after attaining the age of 65 years. Upon any member of the Medical Staff attaining 70 years of age, that member's appointment and privileges will, subject to section 3.6(b) of the Rules, automatically terminate unless specifically confirmed by the Vice President, Medical Affairs, upon consideration of the recommendation of the site Medical Director

b. Notwithstanding section 3.6(a):

a. The Vice President, Medical Affairs, on the recommendation of the Regional Medical Administrative Council (RMAC), has established the following Programs:

b. After consideration of recommendations by the RMAC, the Vice President, Medical Affairs may alter the organization of Clinical Programs by:

c. Each program shall have a Regional Program Council to oversee the activities of the program. The council shall be chaired by the Regional Program Clinical Director if the program has one, or a Chair appointed by the Vice President, Medical Affairs.

c. The Committee will attempt to reach a decision about a successful candidate by consensus. Should consensus not be achieved, the Committee will decide based on double majority vote; that is, the successful candidate will be chosen by independent majority votes by the Committee members who represent the Department involved, and by the other members of the Committee. In the event that the Committee is not able to achieve a double majority selection, the Vice President, Medical Affairs may disband the Search & Selection Committee. The Vice President, Medical Affairs may then strike a new committee or take information to the Executive Committee for direction.

d. Following the Search & Selection, the appointment will be made by the Vice President, Medical Affairs.

The roles and responsibilities of the RCPD's, Regional Section Heads and Site Chiefs of Service are as outlined in their respective Roles and Responsibilities Statements by the Vice President, Medical Affairs.

a. The selection of Medical Directors shall be accomplished through Search and Selection

c. The Committee will attempt to reach a decision about a successful candidate by consensus. Should consensus not be achieved, the Committee will decide based on a simple majority vote of the Committee.
d. Following the Search and Selection, the appointment will be made by the Vice President, Medical Affairs.

a. The roles and responsibilities of the Medical Director are as outlined by the Vice President, Medical Affairs in the Roles and Responsibility Statement, Medical Director.

a. The Regional Medical Administrative Council is advisory to the CHA as outlined in Article 10 of Capital Region Medical Staff Bylaws

b. There will be CHA Medical Committees reporting to the Regional Medical Administrative Council (RMAC). Committees may include the following:

c. The RMAC may establish Ad Hoc sub-committees for specific assignments at its discretion.

Members of the Medical Staff with admitting privileges may admit patients to the CHA facilities in which they are privileged. The category of Medical Staff to which a member is appointed is designated by the Vice President, Medical Affairs in keeping with the Capital Region Medical Staff Bylaws.

Except in an emergency, no patient shall be admitted to CHA facilities without a provisional diagnosis. In the case of an emergency, the provisional diagnosis and history shall be stated as soon after admission as possible, and in no case more than forty-eight (48) hours following admission of the patient.

Physicians admitting patients shall be held responsible for giving such information as may be necessary to ensure protection of other patients or hospital staff, or to ensure protection of such patients from self-harm.

A patient requiring admission may be assigned to an appropriate member of the Medical Staff who is on call. No patient shall be admitted to a member of the Medical Staff without that member's agreement. The Site Chief of Service of each Program or designee is responsible for drawing up the call list and distributing it to the members of the Program, Switchboard, Emergency and Nursing Units as appropriate.

e. Patients requiring admission to CHA facilities will be categorized by the Responsible Physician(s) as Emergent or Scheduled. These categories are defined as follows:

f. All members who wish to admit scheduled patients to CHA facilities shall book these admissions according to established site admitting procedures.

g. Temporary curtailing of admitting privileges may be employed if, in the view of the Site Medical Director, the member's use of available beds or other hospital resources is inappropriate.

a. Members of the Medical Staff will ensure coverage for patients for whom they are the designated Responsible Physician, twenty-four (24) hours per day, seven (7) days per week. This may be accomplished individually or by participating in a roster with other physicians privileged at the site. This roster must be made available to all departments in the site that may need to contact the physician on call.

b. Clinical programs/departments and their respective physicians are required to provide on-call coverage to provide medical care to patients presenting in the region and those referred from other regions with conditions requiring their expertise. On-call responsibilities include:

c. It is expected that the referring physician will limit consultations to the on-call physician to urgent or emergent cases. Consults for non-urgent cases should be handled during regular office/clinic hours.

d. Referring and on-call physicians are expected to behave at all times in a professional and collegial manner and to act in the best interest of the patient.

Call rosters must not place work demands on individual physicians that do not allow them to provide safe and timely care. Capital Health will work with programs/medical staff to try to resolve issues where an undue burden of call exists and where resources are not available to meet the emergency need.

Each patient shall receive timely and professional care appropriate to his/her condition. The frequency of attendance will be determined having regard to the condition of the Patient, Program requirements and these Rules

All patients in an acute care hospital except those awaiting rehabilitation or placement in a continuing care facility shall be visited at least daily by the Responsible Physician or designate (not a Resident). Patients awaiting rehabilitation or placement shall be visited at least weekly.

Patients in Continuing Care facilities should be visited at least once every three months by the Responsible Physician or designate (not a resident).

Patients receiving rehabilitation in the Glenrose Rehabilitation Hospital should be visited at least three times per week by the Responsible Physician or designate (not a resident).

a. Members of the medical staff shall provide care within their area of expertise to all patients, including those with potentially transmittable infections. Members of the medical staff shall ensure that appropriate precautions are taken to prevent transmission of these diseases.

It is the duty of all health care personnel including physicians to take appropriate action to protect patients from known or suspected transmittable conditions, including blood and body fluid precautions and compliance with recommendations regarding infection control, including selective job replacement or when necessary, exclusion from work.

The attending medical staff shall be responsible for notifying the Medical Officer of Health of all cases of communicable disease where such notification is required by provincial statute.

It is the responsibility of medical staff to anticipate and begin planning for discharge with nurse managers, social services and others as early as possible during the patient’s stay and, in the case of scheduled admissions, prior to admission. Discharge planning involves the patient and the patient’s family as well as early consultation with receiving facilities and/or the personal or referring physician. It also includes timely transmission of sufficient patient care information to facilitate safe and responsible care after discharge.

The patient shall be discharged only on the order of the Responsible Physician or designate.

The Responsible Physician needs to co-ordinate with and respond to assessment processes that identify suitable alternate arrangements for their patients.

Members of the Medical Staff are requested to discharge patients according to policy set in the institution or, wherever possible, before 11:00 hours. Discharge orders may be written the day prior to discharge in order to vacate beds prior to 11:00 hours.

When a patient, or the guardian of a minor, discharges himself (or the minor) prior to the Responsible Physician's order, the "Refusal of Treatment" part of the "General Treatment Consent" form shall be completed. If possible, the signature of the patient or guardian shall be secured, absolving the doctor and the Capital Health Authority from responsibility. CHA Policy states that if the appropriate form is not signed as outlined above, a statement signed by two members of the nursing staff shall be obtained describing the circumstances of the discharge. The Responsible Physician shall make a notation on the patient’s clinical record regarding the unauthorized discharge by the patient from the facility.

a. Pronouncement of death may be made by any Physician. As soon as practical following the death of a Patient, the Responsible Physician or designate will notify the next of kin and determine whether:

c. The Responsible Physician or designate must complete a death certificate within twenty-four (24) hours, unless directed otherwise by the Medical Examiner.

a. Each Member of the Medical Staff will comply with the regional Corporate Administrative Directive and Procedure 6.2.1. "Completion of Health Records by Medical Staff" and will also comply with the standards as outlined in the "Regional Health Records Documentation Standards". (Appendix 2)

When involved in the education of trainees (Medical Students and Residents), Medical Staff have the responsibility to supervise all procedures. When the trainee has obtained and demonstrated the necessary skills and is considered competent to perform procedures competently and independently, the Member of the Medical Staff responsible for the trainee must always be available to intervene if necessary. In all cases involving supervision of Medical Students and Residents, the Responsible Physician must maintain sufficient knowledge of the patient to ensure they are receiving safe medical care.

When involved in the education or supervision of trainees, Medical Staff must ensure that trainees are aware they have the following responsibilities:

Residents licensed to practice in an acute care facility, as determined by the College of Physicians and Surgeons of Alberta, will refer to the CHA Professional Services Agreement prepared for their specific term of service.

a. In the case of an emergency, the specific procedure recommended by the Responsible Physician may be performed without Informed Consent provided that two physicians attest in writing to the existence of the emergency and the inability of the patient to give informed consent. This would not apply if the patient had previously and competently refused consent to the procedure or if the patient’s Personal Directive provided other direction

b. A health care provider may provide health care to a patient without the patient's consent if:

c. Non-English Speaking Patient

An interpreter shall be used to evidence the consent of a non-English speaking patient, and the interpreter shall attest, in writing, that the contents of the Consent Form have been interpreted to the patient, and the interpreter believes that the patient understands the contents.

d. Patient Admitted under the provisions of the Mental Health Act

Observation, assessment, examination, treatment, detention and control of persons admitted through an admission certificate and of a formal patient shall be as set out in the terms of the Mental Health Act.

e. Matters requiring specific informed consent

Capable adults have a right to provide, refuse or revoke consent to healthcare defined as: anything that is done for a therapeutic, preventative, palliative, cosmetic or other purpose related to health. The following require specific consent, in addition to the Consent to Specific Procedure process outlined in the Corporate Administrative Directive 1.3.4. "Patient Consent":

a. Members of the Medical Staff shall abide by the Corporate Administrative Directive 1.3.6. "Personal Directives" (Appendix 4)

c. The Responsible Physician shall verify and record any Personal Directive on the patient's chart.

d. Wherever possible, the Personal Directive will be honored when prescribing medical treatment.

f. Information transferred to other institutions will include the Personal Directive of the patient.

a. It is the responsibility of all physicians to discuss organ donation with the family where appropriate and to encourage consideration of organ donation when appropriate.

a. Members of the Medical Staff shall acquaint themselves with and adhere to the Capital Health Authority policies regarding drugs and their use. These include:

a. All members of the Capital Region Medical Staff will participate as required in the event of an External/Internal Disaster according to the respective site Disaster Plan Manual. This includes participation in dealing with any major service disruption.

a. Members of the Capital Region Medical Staff will abide by the Corporate Administrative Directive 1.3.1 regarding Conflict of Interest. (Appendix 5)

a. Every patient admitted to a CHA facility will have an identified Responsible Physician. Acceptance as being the Responsible Physician will be documented at the time of admission. The patient should be informed of the name of his/her Responsible Physician by the attending Medical Staff, resident staff or nurse manager. This physician has the duty, responsibility and authority to direct all medical care for that patient while in the facility, and to make reasonable efforts to ensure continuity of care following discharge.

b. The Responsible Physician will see his/her patient as soon as required by the patient's condition but at least within 24 hours of admission in the case of an acute care facility, and within 7 days in a continuing care facility. The Responsible Physician should notify and consult with the patient's family physician and/or other physicians whom the patient identifies as providing continuing care. The Responsible Physician may designate any physician to provide concurrent care where this will provide particular benefit to the patient, however, such designation will not have the effect of transferring ultimate responsibility for the patient from the Responsible Physician.

Responsibility for a patient's care may be transferred from the Responsible Physician to another member of the Medical Staff.

The Responsible Physician shall ensure the following are informed of the transfer: the patient or designate, admitting office, and other physicians involved in providing continuing care.

Dated, formal documentation of both the order to transfer and the acceptance of the new Responsible Physician will serve as evidence of discussion of such a transfer between the physicians involved. A written summary of the current condition and management of the patient at this time is encouraged.

Information transferred will include the health directives of the patient.

The Responsible Physician will make reasonable efforts to inform the patient's physician(s) in the community of that patient's course in hospital and disposition and treatment following discharge.

a. Members of the Medical Staff shall ensure requirements are met for coverage of all medical staff responsibilities and identify an alternate Responsible Physician to provide clinical care for their inpatients during an absence from Capital Health facilities. Notification of the absences and the identity of the covering physician shall be sent to the Regional and site Medical Staff Office.

ii) Absence of Longer than 72 hours