Medical Staff Portal
Medical Staff Bylaws & Rules

Medical Staff Responsibilities
Guide

Covenant Health has established the Medical Staff Bylaws and Medical Staff Rules in order to assist Practitioners work within Covenant Health facilities. An important section in the Covenant Health Bylaws related to patient safety and professional conduct is Medical Staff Responsibilities and Accountability. This section of the Bylaws provides Practitioners with information outlining the respective expectations of Covenant Health and the Medical Staff, as well as the individual Practitioner’s responsibilities and accountability for patient care. This document should not be used as a replacement for the Bylaws; it is simply a concise reference outlining a Practitioner’s patient care, professional conduct and governance responsibilities. 

If you have any questions about Medical Appointments, please contact Covenant Health Medical Affairs. For additional information, please refer to "Part 4 – Responsibilities and Accountability” in the Covenant Health Medical Staff Bylaws.

Medical Staff Responsibilities Guide (PDF) 

As a Covenant Health Practitioner, how am I responsible to Covenant Health?

Upon Appointment to Covenant Health Medical Staff, individual Practitioners are expected to comply with the Covenant Health Medical Staff Bylaws and Rules and such approved amendments as may from time to time be made, and with applicable Covenant Health Policies, the Covenant Health Health Ethics Guide, and the Professional Code of Conduct of the relevant College, and/or the respective code of ethics of the relevant profession. 

Practitioners are also expected to comply with all obligations contained in contracts for service between a member of the Medical Staff and Covenant Health. In keeping with Covenant Health’s focus on creating a respectful workplace, all Practitioners are expected to demonstrate respect, accountability, transparency and engagement in their interactions with Covenant Health staff, colleagues and patients. In addition, Practitioners are expected to participate in quality improvement programs and other mechanisms to maintain and enhance clinical practice standards and professionalism.

What are Covenant Health’s responsibilities?

Practitioners and Covenant Health share joint responsibility and accountability for delivering safe, patient-centered care to Albertans. Covenant Health, subject to legislation and any direction provided by the Minister of Health, and in cooperation with Alberta Health Services has the responsibility to take appropriate actions to assess, enhance and protect the health of Albertans, through the promotion of health generally, and by ensuring reasonable access to appropriate, high quality and safe health services. Covenant Health retains decision making authority with respect to the distribution of resources to meet these responsibilities. 

What are my patient care responsibilities as an Covenant Health Practitioner?

A Covenant Health Practitioner is responsible for ensuring quality and safety in patient care. The individual Practitioner must demonstrate and maintain clinical skills and judgment to provide patient care that meets established professional standards. This includes providing information, expertise, and advice to Covenant Health in assessing health needs and completing health records in an accurate and timely manner.

What about advocating on behalf of my patients?

Covenant Health Practitioners have the right to advocate on behalf of their patients. Advocacy should always be conducted in a manner that is consistent with the values and principles of each Practitioner’s regulatory College, their professional association, and Covenant Health. If a Practitioner advocating on behalf of a patient holds a medical administrative leadership role within Covenant Health, it should always be made clear that they are not speaking as a representative of Covenant Health. Practitioners are encouraged to enquire about the matter internally before making public statements.

How is the on-call schedule determined?

Practitioners and their Facility Chief or Medical Director will jointly establish and maintain reasonable, safe and effective on-call schedules. Disputes related to on-call coverage and/or schedules should be resolved between Practitioners themselves or discussed with the relevant Facility Chief or Medical Director. Any remaining on-call issues can be referred to the Alberta Health Services Zone Clinical Department Head for resolution as required.

What if I am unavailable for on-call duties?

If a Practitioner is unavailable to perform their pre-scheduled on-call coverage, the Practitioner must ensure on-call coverage by another Practitioner(s) with appropriate skills and Clinical Privileges if he/she is unable to provide the coverage assigned to him/her in a previously established on-call schedule. If urgent circumstances limit or prevent the Practitioner from fulfilling this responsibility, the AHS Zone Clinical Department Head or designate(s) shall provide reasonable assistance to make alternative arrangements for coverage of the on-call period in question.

What do I do if I require a short-term leave of absence?

If a Practitioner will be absent from his/her Site(s) of Clinical Activity Coverage for less than 96 hours, patient coverage can be provided through the on-call schedule. If the absence will be greater than 96 hours, formal patient transfer of responsibility is required.

What do I do if I am taking a longer leave of absence?

During an extended leave of absence from a Site(s) of Clinical Activity (more than 96 hours), a Practitioner shall ensure requirements are met for coverage of all his/her responsibilities, and shall identify an alternative Practitioner with appropriate skills and Clinical Privileges, to assume those responsibilities and to serve as Most Responsible Practitioner for his/her admitted patients. For an absence of greater than 45 consecutive days, a formal leave of absence is required and must be approved in advance by the Chief Medical Officer/VP, Medicine or designate.

How is patient transfer of responsibility determined?

Whether a Practitioner is taking an extended absence from his/her Site(s) of Clinical Activity or moving to a new Practice, s/he is required to identify an alternative Practitioner to serve as Most Responsible Practitioner for his/her admitted patients. The Most Responsible Practitioner providing coverage is largely up to the Practitioner’s own choosing. However, the receiving Practitioner must document acceptance of patient responsibility in the patient’s health record. The patient, and/or his/her family and/or the patient’s Legal Representative must also be advised of the transfer. Notification of the Practitioner’s absence and the identity of the Most Responsible Practitioner must also be provided to the relevant Facility Chief or Medical Director(s)  and to the Alberta Health Services Zone Clinical Department Head.

What are my responsibilities for Health Records documentation?

Practitioners and Covenant Health share the responsibility to create and maintain an accurate health record of the care provided to every patient in Covenant Health facilities. To accomplish this, Covenant Health will provide and maintain the appropriate infrastructure and information management systems to create a health record and ensure the proper and timely completion of the health record by all staff including documentation of their role, the care provided, and the relevant events during the patient’s interaction with Covenant Health. For more information on the Practitioner requirements related to proper and timely completion of health records, please refer to section "4C. Documentation, Records and Record Keeping" of the Covenant Health Medical Staff Rules.